NHS England has launched a review of trust and integrated care board chair positions amid growing concerns that the roles have become financially unappealing and operationally unmanageable. The internal assessment is examining responsibilities, time commitments and pay structures attached to some of the health service's most significant governance positions.

The review covers chairs of NHS trusts and the integrated care boards established under the 2022 health service reorganisation. Both sets of roles carry substantial accountability, spanning financial oversight, clinical governance and system-wide integration across regional health networks. NHS England's assessment is intended to determine whether those responsibilities are currently matched by appropriate remuneration and clearly defined remits.

At the centre of the review is a widening gap between what these positions demand and what they pay.  Senior figures within the health service have raised concerns that chair roles have become increasingly difficult to fill with experienced candidates, partly because remuneration has not kept pace with the scale of accountability now attached to them. NHS trust and ICB chairs are non-executive appointments, and their pay is set against public sector frameworks that have not been substantially revised to reflect the expansion of duties following recent structural changes.

The 2022 reorganisation that created integrated care boards merged functions previously held by clinical commissioning groups and introduced new system-level responsibilities. Practically speaking, this has resulted in a far higher workload for individuals selected to chair ICBs without a corresponding modification to position criteria or pay ranges. As health care confronts ongoing financial shortfalls and performance demands, trust chairs have been under similar pressure to operate within an increasingly rigorous regulatory environment.

The concern among senior NHS officials is that these conditions are narrowing the field of candidates willing to take on the positions. Non-executive roles in the private sector at comparable levels of responsibility typically offer higher remuneration and clearer boundaries around time commitment. For individuals weighing the two options, the public sector proposition has become harder to justify, particularly where the reputational and personal risks attached to NHS governance are factored in.

This is not a new problem, but it has sharpened in the past two years as financial pressures across the health service have intensified scrutiny of board-level leadership. Several trusts and ICBs have faced extended periods without a permanent chair, and in some cases roles have been filled on an interim basis at additional cost to the organisation. NHS England's review reflects an acknowledgement that the current framework is not functioning as intended.

The findings are expected to inform future policy on remuneration frameworks and role specifications. Whether that results in substantive changes to pay bands will depend in part on negotiations with the government, given that increases to non-executive remuneration in the public sector require approval beyond NHS England's own authority. The review may also recommend clearer delineation of what the roles are expected to deliver, reducing the scope creep that has contributed to the workload problem.

Board-level leadership has a direct bearing on organisational performance. Board governance issues have historically preceded some of the most significant institutional failures in the health sector, and trusts and ICBs with stable, experienced chairs are better equipped to handle the operational and financial pressures put on them. NHS England's decision to examine how these roles are structured and rewarded is, in that context, overdue.

The outcome of the review is unlikely to resolve all the pressures facing NHS governance, but addressing the basic question of whether chair positions are coherent and competitive is a necessary step if the health service is to attract the leadership capacity it needs at regional and organisational level.