We also convened a focus group of VSM/ESM members to discuss current working conditions, morale, workload and pay frameworks. This year, we also asked members for views on recent announcements by government on reforming VSM pay, the reintroduction of NHS league tables and how they’ll impact senior managers, transparency around pay and accountability. 

The high workload VSM and ESMs are expected to produce was further highlighted as two-thirds of respondents (67%) reported they ‘often’ or ’always’ have to deal with unrealistic time pressures – no respondents said they ‘never’ have unrealistic time pressures. 

From our survey, it seems that VSM and ESMs are dealing with unmanageable workloads by doing increasing amounts of unpaid overtime. 9 in 10 of our respondents (92%) indicated they regularly work unpaid overtime in an average week. Just under half work at least over 11 extra hours in an average week, with a quarter working more than 20 unpaid additional hours in an average week. 

Such high workloads without support are taking a considerable toll on senior managers. Of our respondents, 57% reported to feeling unwell due to work related stress in the last year. 66% of respondents stated they had shown up for work in the last 3 months despite not feeling well enough to perform their duties. 

MiP is concerned that these unrealistic workloads are impacting our members ability to do their jobs effectively. Our executive-level members recognise that their roles, by their very nature, are high pressure and the majority seem to thrive in these fast-paced environments. However, as they are continually being asked to do more with less, it is clearly becoming more and more unmanageable, impacting on their health and wellbeing. 

If the health and wellbeing of VSMs and ESMs is being negatively impacted due to work-related pressures, there is an increased risk that it will have a negative impact on services provided to patients. 

In light of the pressures faced, 36% of respondents, worryingly, did not agree that the care of patients is their organisation’s top priority due to ongoing pressures from above. Many members that spoke to us believed that financial performance was taking precedence over patient care. 

Recognition for the work that managers do came up in both our survey and our focus group, and we are concerned that this alongside the intense workload will only lead to further burnout for the remit group. 

78% of respondents said that politicians do not value their work and 36% of respondents do not believe their work is valued by their organisation. Members of our focus group stated they were not necessarily needing a pat in the back, but a simple recognition of the context VSM/ESMs are operating within, dealing with financial pressures, increasing demands and a multitude of performance targets. It can be incredibly demotivating when you are working excessively long hours in challenging circumstances to receive no recognition the work you are doing.  

These issues are leading to burnout among the remit group. 41% of our respondents said they ‘often’ or ‘always’ feel burnt because of work, with only 5% saying they ‘never’ feel burnt out due to work. 

High levels of burnout are nothing new for the remit group, but from our survey it seems to be going in the wrong direction. The result of this burnout is large numbers of staff reporting they are considering leaving their jobs. 58% of our respondents stated they often think about leaving their job, and just under half (49%) said they will probably look for another job in the next 12 months. 

Over a third (35%) stated they will leave as soon as they find another job. 

MiP knows how challenging it already is to recruit to these posts in the NHS and are concerned if high workloads, low recognition and growing levels of burnout are not addressed then it will further exacerbate the NHS’s ability to hire the talent it requires. 

It will also make the Secretary of State for Health and Social Care’s aim of encouraging talented leaders to take on the most challenging trusts even harder. 

 We asked our members for views specifically on the recent reforms announced by the Health Secretary including: the reintroduction of league tables measuring performance of providers, proposed changes to the VSM pay framework and linking senior manager pay to performance. 

Our survey respondents and focus group included both VSMs and ESMs and there was confusion around if the changes to VSM pay would also apply to ESMs. Further clarity is required when making announcements on senior managers to ensure the staff it applies to understand it. 

The prospect of new league tables of providers created unease among both VSM and ESM members. While monitoring the performance of trusts to identify areas where managers need further support was supported in principle, creating very public league tables feels more like an unwelcome return to a name and shame culture according to our focus group. 

All members of our focus group had concerns that the league tables, although framed as a tool to give patients more choice, will offer very little information of value to patients especially as the metrics determining the ranking of trusts will incorporate factors such as financial performance which will not provide any indication of the quality of care provided. 

What is more likely to happen as a result of league tables, we were told, is that it will simply further put off talented executives from taking on struggling trusts. 

One VSM told us that he often hears colleagues discussing about avoiding these types of trusts, saying things like ‘I wouldn’t go there it is career suicide’. League tables would further exacerbate this. 

We also heard from an ESM who highlighted how league tables would discourage senior managers from taking calculated risks: ‘if the Secretary of State is looking for transformational change driven by senior managers, then why create something that will make them more risk averse?’. 

This feeling was compounded by changes to VSM pay that the Secretary of State also confirmed in November. Plans to lock out senior managers from pay rises based on their performance risks making an already difficult post to recruit for even harder. We were told that previous experiences of performance related pay in the NHS was ‘torturous’ and rarely has the desired impact. 

While our focus group were more sympathetic to interventions aimed at individual performance if required, they cautioned that even the best senior managers can only impact so much if there are wider problems in the system or organisation. 

We heard how many issues, especially financially, are outside of VSMs control. Some trusts, for example, own their estate which brings significant savings to a trust who does not. The availability of staff and therefore the reliance on agency staff and the costs associated are also not something a VSM can control. 

MiP believes it is wrong to punish individual managers who are working hard to cut a deficit while maintaining high standards of care. Any future VSM framework that links performance to pay must consider this. 

As we were told from our focus group: ‘Managers should be accountable, but you need freedom to operate. You can’t hold me accountable for things I can’t control.’ 

Our survey respondents also disagreed that performance related pay was a good tool to improve overall performance. 82% said barring senior managers from pay rises is not a good tool to improve performance, and 75% said that linking performance and budget discipline will not improve overall performance. 

We heard how there is a risk that it will have the opposite effect as it can lead to managers focussing on the wrong issues: ‘performance related pay is ineffective, in fact counter-productive as it distorts decision making and undermines teamwork.’ 

Another respondent told us that it would not be applied fairly as it has ‘no regard for context and subject to bias’. 

There was support for more autonomy for VSMs, including greater flexibilities on spending capital budgets, which the Health Secretary stated would be forthcoming if they are performing well. No one knows their local health systems like the managers within them and MiP supports more autonomy for these managers. However, if a senior manager is to be encouraged to take on a role at a struggling organisation, will they have the freedom to make the difficult decisions needed to turn things around? More clarity on how this will work in practice is needed. 

The focus group was clear that the introduction of league tables and linking pay rises to performance will make it much more difficult for the NHS to recruit the right managers in the places they are needed most. There will be increased personal risk associated with roles at struggling providers – to your finances, your career and your ability to do their your job if central grip is tightened at these organisations. 

We ask that the SSRB considers the impact of these new measures on the NHS’s ability to attract senior leaders to the places it needs most. 

We heard how AfC 8d’s at the top of their band are now paid slightly more than the bottom of ESM band 1. The overlap with AfC band 9 is even more prominent as AfC band 9s can command a higher salary than the operational max of ESM band 1. This is before High Cost Area Supplements (HCAS) are incorporated, which are reserved only for AfC staff. 

This ongoing issue demotivates ESMs, many of whom leave the AfC pay scale at band 9 to become an ESM. We were told by a member of our focus group who recently left an AfC job to take on a role at ESM band 1 had to take a pay cut as they lost their HCAS. They were unaware until starting the role that they would not be entitled to HCAS and despite taking on more responsibility in their new role, they would actually earn less than they did at AfC. 

The pay overlap is further exacerbated with staff who are part of an on-call rota. We heard how ESMs receive no payment for their time on-call compared to AfC staff, which means the pay overlap in practice is likely much higher than the pay ranges suggest. 

We were told by members that when they query their pay with line managers or HR there is a culture of simply ‘get on with it and stop complaining’. All members we spoke to appreciate that they are paid well relative to overall economy, but it is extremely demotivating when they are paid less than the staff who report into them. This extremely important staff group works under intense pressure in a very challenging operating environment. ESMs know the skills they have means they can command much higher salaries in the private sector, likely in less demanding roles, but chose to work in the NHS due to their commitment to public service. This only gets you so far however, so without action on the ESM pay framework we risk losing more and more staff at this level. 

For the first time, MiP asked a group of members on senior AfC terms and conditions who indicated they are currently open to, or have previously considered, applying for roles at VSM/ESM level, to better understand their perception of board level roles in the NHS. 

73% of members who responded said the demands at board level make them worried about working at this level. 69% said they believe bord level roles carry more risk than any other role in the NHS. Despite this, less than half (44%) indicated that these roles are paid well enough to justify the higher demands and responsibility. 

It is clear that senior AfC staff recognise the increased pressure and responsibility of these roles and that the majority of them do not feel the salary justifies it. MiP is concerned that this will result in less AfC band 8 and 9 staff applying for roles at VSM and ESM levels as the risk is deemed not worth it for current levels of pay. Further, only 11% of AfC staff we surveyed stated they have had or can access the training and development needed to progress to VSM/ESM roles. The NHS needs a strong pipeline of talent coming through to ensure staff are ready to step up at this level which will only happen if they have the right tools to take on these roles.  

Without action on pay overlap, this will only get worse. 

We are concerned that uplifting VSM/ESM pay alone is not enough to address this. We were told by our focus group that ESMs would only be entitled to a consolidated pay rise of 5% (as recommended by the SSRB) if this would not put their salary above the exception zone figure for their respective band. If it exceeded this, the pay would be non-consolidated and the ranges of the bands would not be uplifted as is the case with AfC. This means without action on pay frameworks, the overlap issue will continue to get worse as AfC pay ranges increase while ESMs, regardless of what their pay award is, will still have to remain within their respective ESM pay band. 

This was especially frustrating for ESM members, who only found out about it from their employer in late November. Delays to awards being paid is a consistent issue for members. There is an understanding that these delays will mostly be down to government, however employers should communicate with staff much earlier about pay awards, including if the award will consolidated or not. 

MiP recognises that the SSRB has previously made recommendations on addressing pay overlap issues with AfC, however from our discussions with members over the last two years these interventions are having very little impact without action the frameworks themselves. 

As the Secretary of State confirmed the new VSM pay framework will be published before the end of the financial year, we expect the pay overlap issue to be addressed. We strongly recommend that the Department for Health and Social Care undertakes a similar exercise on the ESM framework to ensure that the overlap issue with AfC is also addressed here. We recommend that the government involves staff and their unions to ensure all overlap issues are properly addressed and pay for VSMs/ESMs is fair and transparent. 

There is still a lack of understanding for both senior AfC staff and VSM/ESMs themselves on how pay at this level is set. Less than half (40%) of respondents on AfC terms indicated they understood how VSM and ESM pay was set. A similar proportion of current VSM/ESMs (38%) indicated they were unsure how their own pay was set. 

One ESM described the pay setting process as ‘very secret squirrel’, saying it is very difficult to get answers from HR or line managers on the pay process and when / how pay awards will applied. 

MiP believes that further transparency is required when setting the pay of VSMs/ESMs, including at interview stage and that conversations on pay continue when staff are in post. 

Recommendations 

MiP would welcome recommendations from the SSRB addressing the following issues: