The government’s decision to withhold pay awards from very senior managers at poor-performing NHS providers might look like accountability in action. But beneath the surface, it risks deepening the very leadership and performance challenges it claims to solve.

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A letter being circulated in the press reveals that executives at trusts and integrated care boards currently in the national recovery support programme, or those who fail to meet local eligibility criteria, will not receive this year’s uplift. While local leaders have been authorised to implement the 2025–26 pay rise, they must first await the outcome of the new NHS England oversight regime, which will introduce a fifth “segment” to categorise struggling organisations.

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In theory, withholding pay aligns financial reward with organisational results. In practice, it could undermine morale and deter the best leaders from taking on the hardest jobs. Twenty-one trusts and ICBs now sit in the lowest rung of oversight. Many are precisely the institutions that need skilled, courageous executives willing to turn things around.

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Early signs already suggest unintended consequences. One senior leader revealed that they will not receive the uplift because their salary sits outside the range for medium-sized district general hospitals: despite moving from a large, high-performing provider five years ago. “This effectively penalises that decision,” they said. It’s a cautionary example of how rigid pay frameworks can discourage mobility and punish those who step forward to help struggling organisations.

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The question now is whether experienced executives will continue to volunteer for difficult turnarounds if they risk losing pay or recognition for doing so. Accountability must not morph into deterrence. The NHS needs a leadership culture that rewards improvement and courage, not one that punishes those who take on the toughest challenges.

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