Under pressure from political demands and relentless organisational change, many board-level NHS managers are feeling the effects of burnout and contemplating leaving the NHS, according to MiP’s ’Sounding Board’ of senior members and the union’s evidence to the pay review body.

“One step forward, two steps back” was how MiP chief executive Jon Restell summed up the sentiments coming out of MiP’s Sounding Board of executive level members, which met in February to reflect on the past year and inform the union’s evidence to the Senior Salaries Review Body (SSRB). Board members agreed the progress made last on pay year was offset by a number of unresolved issues and the emergence of new pressures on senior staff.

While an increase of 5% in base pay and changes to pension tax rules in 2023 had a “morale boosting effect”, according to board members, reorganisations, cuts driven by productivity programmes and increased political pressure had all contributed to increased burnout among board-level NHS managers.

Each year, the SSRB makes recommendations on the pay of very senior managers (VSMs) working for NHS trusts and ICSs in England, and executive senior managers (ESMs) working for arm’s-length-bodies such as NHS England. As with the pay review body for Agenda for Change staff, the government may accept, reject, or amend the SSRB’s recommendations. MiP, as the trade union for senior managers, contributes evidence to the review body.

Reflecting on last year’s award

A series of 0% awards for executive staff was finally ended in 2022 by a 3% pay rise, followed by the much welcomed 5% award last year. Changes to pension tax rules, introduced in 2023, were also received well. Our Sounding Board felt that these changes have helped slow down, although not completely stop, the stream of executive grade managers considering early retirement or leaving the public sector due to the potential impact on their pensions. Several participants were concerned that the problem would resurface if an incoming government restored punitive annual allowance levels or the lifetime allowance.

Despite these positives from last year, the focus group were concerned about the delay in implementing the pay award. This has become a theme in recent years and there was no sign of improvement last year. We heard that most executive managers did not receive their pay uplift, due in April 2023, until November. Whether the delays arose in the Department of Health Social Care, NHS England or both, they were an “own goal”, said Restell, especially as the government had accepted the SSRB recommendations in July and Agenda for Change colleagues had received their pay rise in April.

In recent years, the SSRB has recommended protected funding to deal with pay overlaps between VSMs/ESMs and Agenda for Change Band 9 staff, which mean some executive level managers are paid less than staff they’re managing. MiP has previously welcomed this funding, but our focus group could offer no insight on how the funding is accessed or what impact, if any, it’s having. We need clarity on how this funding is being used to ensure it’s having the desired effect.

“Brutal and demoralising”

We asked our focus group to reflect on levels of morale, workload and capacity during 2023. They told us the relentless pressure to deliver “more with less”, driven by efficiency programmes and organisational change is being felt throughout providers and arm’s-length bodies.

Vast swathes of the NHS in England have been dealing with some form of organisational change in the last year. NHS England has slimmed down drastically, ICBs are going through similar processes and many trusts have merged with neighbours creating single leadership structures.

But there is no let up on the priorities demanded of these slimmer organisations, our Sounding Board told us. MiP supports work to make the NHS more productive and efficient, and believes that managers and leaders have a crucial role to play here, but government-mandated efforts to improve productivity seem to be about asking staff to increase workloads rather than exploring how to deliver work more efficiently. As Jon Restell puts it: “You can’t cut your way to a productive NHS”.

One ESM told us that reorganisations are “brutal and demoralising” and most staff feel happy just to “survive it”. Some executives told us how they have taken on a whole new portfolio which they fear they they won’t be able to deliver on with their existing priorities: staff will often take on extra work in the hope that it puts them at less risk of redundancy, we heard. It’s another short-term fix, one that Restell describes as a “blunt instrument” that will probably “have the opposite effect on productivity in the long run”.

Executive staff are also under intense political pressure, the board told us. Many feel they are working to political cycles and in many cases, political priorities, limiting their ability to plan for the long term. This has a huge impact on morale, especially as staff feel they are often made scapegoats for problems caused by politicians themselves.

Burning out

Our focus group reported increasingly high levels of burnout among colleagues as the efficiency drive ramped up over the last year. “A lot of younger staff are leaving”, said one VSM working in a trust, often at a critical juncture in their NHS careers – just below executive level. As demands get more intense and the terms on offer are less attractive, the pipeline of talent below deputy director level seems to be dwindling. “We need to make it attractive for the next generation of staff coming through,” if we’re to avoid “massive recruitment challenges in the future,” our VSM said.

Another VSM told us that older, more senior staff, are “sticking it out” but still feeling the effects of burnout: many are considering flexible retirement options, at least to cut down their hours, while others are contemplating retiring from the NHS entirely.

The board also warned that a lack of clarity over government proposals for professional regulation were fuelling concerns that any new framework could become another cause of burnout.

“It’s not the principle of management regulation. Many of our colleagues are already regulated through their clinical and professional qualifications,” said one senior manager working for a trust. “It’s about being put in impossible positions where you’re being regulated to unreasonable standards without having the tools to do the job.”

Many executive staff fear that regulation could become another blunt instrument to hold them to unrealistic demands from politicians. MiP suggests that any new regulatory framework is designed with managers and senior leaders to ensure it’s transparent and that people being regulated see it as fair, proportionate and independent. Building trust will be key if regulation is to have the desired effect.

Building on small successes

Drawing on these insights, MiP’s evidence to the SSRB recommends tackling delays in the payment of awards, action on growing levels of burnout and consideration of the impact organisational change is having on the morale, motivation and capacity of executives. The union has also asked for clarity on how the funding set aside to tackle pay anomalies is being used and for senior managers to be engaged on the design and implementation of any future regulatory framework.

Summing up MiP’s evidence submission, Jon Restell said: “Let’s build on the small successes of last year and deliver a meaningful pay rise for VSMs and ESMs, ensuring the total reward package is at least in line with Agenda for Change to prevent further pay overlap issues. By doing this and addressing the shortfalls highlighted by our Sounding Board, we can take a real step towards tackling the ongoing recruitment and retention challenges for this extremely important staff group”.