NHS Managers' Pay & the Very Senior Managers (VSM) Framework
Last updated: 28 September 2026 · Figures verified against the NHS Employers 2026/27 pay circular.
The key fact: two pay systems for managers
Searches like "NHS managers salary" and "NHS bosses salaries" usually come from people picturing trust chief executives — but "NHS manager" covers two completely different pay worlds, and the numbers only make sense once you know which one you are looking at.
- Managers on Agenda for Change: ward managers, matrons, service managers, departmental heads and most operational managers are on standard AfC bands — typically Band 6 (£39,959–£48,117 in 2026/27), Band 7 (£49,387–£56,515), Band 8a (£57,528–£64,750) and above, up to Band 9 (£112,782–£129,783). They get national pay awards, pay-step progression, overtime or TOIL rules, unsocial-hours enhancements and the annual AfC uplift (3.3% in 2026/27) exactly like clinical staff. The vast majority of people with "manager" in their NHS job title are in this group.
- Very Senior Managers (VSMs): chief executives, executive directors reporting to the chief executive, and a small number of other board-level roles sit outside Agenda for Change entirely. Their pay is set individually under the national VSM pay framework. This is the group behind the headline "NHS bosses' salaries" figures.
The dividing line is deliberate: NHS England's own guidance says that if a role can be accommodated under Agenda for Change, that route should be considered first — VSM status is reserved for roles at the highest levels of organisational leadership that genuinely fall outside the AfC system.
Who counts as a Very Senior Manager?
NHS England defines VSM roles as those at the highest levels of organisational leadership, including:
- Chief executives of NHS trusts, foundation trusts and integrated care boards (ICBs)
- Executive directors who report directly to the chief executive — chief operating officers, finance directors, nursing directors, medical directors, chief people officers and equivalents
- Other senior roles that fall outside Agenda for Change — typically board-level posts in the largest organisations
Two important carve-outs. Medical directors can choose whether to move to a VSM contract or stay on medical and dental terms and conditions with a management allowance — many stay on medical terms because consultant pay plus the allowance can exceed the VSM range. Medically qualified chief executives appointed after 1 April 2025 are offered VSM terms only, with flexibility to be paid further up the range if the VSM rate would otherwise cut their previous medical pay.
The framework applies to all integrated care boards and NHS provider trusts (acute, mental health, community and ambulance trusts, plus foundation trusts) from 1 April 2025. It was jointly produced by NHS England and the Department of Health and Social Care, and the policy itself is owned by DHSC.
Source: NHS England: The NHS very senior managers pay framework.
How the VSM pay framework works
Instead of national pay bands with fixed spine points, the framework sets pay ranges linked to organisational size:
- Provider trusts: five pay bands, A to E, determined by annual turnover — from up to £250m (Band A) to over £1 billion (Band E).
- Integrated care boards: four pay bands, A to D, determined by weighted population — from under 1 million (Band A) to over 2 million (Band D).
Within each band there are three role levels — Level 1 (chief executives), Level 2 (executive directors reporting to the chief executive) and Level 3 (other senior VSMs) — and each level/band combination has a minimum, an operational maximum and an exception zone above the operational maximum. Spot salaries should normally fall between the minimum and the operational maximum; the exception zone is for genuinely exceptional cases (for example, appointing from a larger organisation to lead a challenged provider) and needs a formal pay case approved by NHS England, which may refer it to DHSC.
Three design features are worth understanding:
- Spot salaries, not steps. There is no automatic progression. Pay is set once, reviewed by the remuneration committee, and can be withheld — for example, if an incumbent's salary sits above the range, the committee can freeze awards until pay moves back into range.
- "Comply or explain". Organisations are expected to comply with the framework; if they do not, they must explain why in their annual report and accounts.
- Annual uprating. The ranges are uprated each financial year in line with the government's pay award decision, so the published numbers move over time.
VSM pay ranges: the published bands
The pay ranges below are those published by NHS England at the framework's launch (May 2025, provisional pending the 2025/26 pay award). They are uprated annually with government pay decisions, so treat them as the structure — check the current NHS England publication or a trust's annual report for the latest numbers.
Chief executives — provider trusts (by turnover)
| Turnover | Band | Minimum | Operational max | Exception zone to |
|---|---|---|---|---|
| Up to £250m | A | £140,595 | £194,670 | £210,000 |
| £250m–£499m | B | £151,410 | £216,300 | £236,250 |
| £500m–£749m | C | £173,040 | £237,930 | £252,000 |
| £750m–£1bn | D | £216,300 | £248,745 | £278,250 |
| Over £1bn | E | £237,930 | £270,375 | £299,250 |
Executive directors reporting to the chief executive — provider trusts
| Turnover | Band | Minimum | Operational max | Exception zone to |
|---|---|---|---|---|
| Up to £250m | A | £97,335 | £151,410 | £178,500 |
| £250m–£499m | B | £108,150 | £162,225 | £189,000 |
| £500m–£749m | C | £118,965 | £173,040 | £199,500 |
| £750m–£1bn | D | £129,780 | £183,855 | £210,000 |
| Over £1bn | E | £151,410 | £200,078 | £220,500 |
Other senior VSMs (Level 3) — provider trusts
| Turnover | Band | Minimum | Operational max | Exception zone to |
|---|---|---|---|---|
| Up to £250m | A | Agenda for Change or equivalent | ||
| £250m–£499m | B | Agenda for Change or equivalent | ||
| £500m–£749m | C | £108,150 | £129,780 | £131,250 |
| £750m–£1bn | D | £113,558 | £135,188 | £141,750 |
| Over £1bn | E | £118,965 | £146,003 | £152,250 |
ICB chief executives (by weighted population)
| Weighted population | Band | Minimum | Operational max | Exception zone to |
|---|---|---|---|---|
| Under 1 million | A | £183,750 | £207,375 | £231,000 |
| 1–1.5 million | B | £199,500 | £223,125 | £246,750 |
| 1.5–2 million | C | £231,000 | £252,000 | £273,000 |
| Over 2 million | D | £262,500 | £283,500 | £304,500 |
Note the overlap: the minimum of some VSM ranges sits close to the top of Agenda for Change (Band 9 tops out at £129,783 in 2026/27), which is why the framework advises similar consideration when a VSM was previously in a Band 9 role earning more than the VSM band minimum.
Source: NHS England: VSM pay framework — provider and ICB pay ranges (May 2025). Ranges uprated annually; check the current publication for latest figures.
How an individual salary is set
Every VSM appointment goes through the organisation's remuneration committee, which sets a spot salary within the range. The committee must justify its decision against published factors and keep auditable records. The factors include:
- The market value of the post and geography — national and regional data, especially where there is evidence of recruitment difficulty in an area. Cherry-picking one high-paying local comparator is explicitly discouraged.
- The appointee's current salary and experience — new-in-post VSMs are normally placed at or near the minimum of the range. There is no expectation that a like-for-like move brings a pay rise.
- Challenged providers — trusts in the recovery support programme can offer a recruitment premium to attract leaders to the toughest jobs.
- Additional responsibilities — temporarily covering another VSM role (3–18 months) can attract a non-consolidated, non-pensionable premium of up to 10% of base pay; permanent extra responsibility across two or more organisations can attract a pensionable premium of up to 10%.
Then comes the national backstop: any proposed VSM salary above £170,000 must be submitted to NHS England as a pay case (for ICB chief executives, the trigger is exceeding the operational maximum instead). Cases that do not comply with the framework go to the Department of Health and Social Care for final approval. This is the mechanism behind the headlines whenever a trust board proposes a salary that Whitehall considers excessive.
Why NHS bosses' salaries are published
If you have ever wondered why a trust chief executive's pay appears in the news every year, this is why: it is a legal and regulatory requirement, not a leak.
- Annual report remuneration reports: every NHS trust, foundation trust and ICB must publish a remuneration report in its annual report and accounts, naming its senior managers (typically executive directors) and disclosing salary bands, pension-related benefits and any performance-related pay.
- Comply-or-explain: the VSM framework requires remuneration committees to include their VSM pay decision-making in the annual report, explain any non-compliance with the framework, and submit an annual pay report to NHS England.
- Foundation trust openness: foundation trust boards publish board papers and annual reports as a matter of course, so proposed salaries surface in public documents long before appointment.
This transparency is the direct answer to "NHS bosses salaries" searches: the figures are public by design, as a condition of spending public money. It also explains why pay disputes at the top play out in public — a proposed salary above the range or above £170,000 leaves a paper trail through NHS England and potentially DHSC.
What NHS senior managers actually earn on average
Ranges describe what can be paid; the Department of Health and Social Care's evidence to the Senior Salaries Review Body describes what is paid. For the 12 months to March 2025:
- Average VSM basic pay: £150,290 per full-time equivalent (£142,420 per person), with total earnings averaging £155,152 per person.
- Chief executives: mean basic pay of around £211,988 per FTE and mean total earnings of around £231,355 — the highest of any VSM group, reflecting the weight of the role.
- Executive directors: finance directors averaged around £156,739 basic; medical directors around £153,892 basic (but £188,087 in total earnings, reflecting clinical work paid on top); directors of nursing around £143,714.
These are mean averages across all trusts, so individual salaries vary widely with organisation size — a chief executive of a small community trust and one running a £1bn-plus teaching hospital group sit at opposite ends of the published ranges. For any specific organisation, the annual report and accounts give the actual figure.
Source: DHSC written evidence to the Senior Salaries Review Body, pay round 2026–27 (NHS England earnings statistics).
Named individuals: how to find a specific salary
Searches for named individuals — for example, the salary of a particular trust chief executive or the NHS England chief executive — are best answered the same way every time: check the organisation's annual report and accounts. The remuneration report names senior managers and discloses their pay; it is the authoritative, audited source, and it is free to download from every trust's website.
A few cautions for interpreting what you find:
- Salary bands, not exact pounds: disclosure is usually in £5,000 bands (e.g. £210,000–£215,000), so press figures derived from them are approximations.
- Total remuneration vs basic pay: reports separate salary from pension benefits and any bonuses — a "£300,000 package" headline may include pension accrual, not take-home salary.
- NHS England roles differ: national-body chief executives are not covered by the trust/ICB framework in the same way; their pay is disclosed in NHS England's own annual report.
We do not publish individual salary figures on this page because they change with each annual report and each appointment — the annual report is always the current source of truth.
VSM vs Agenda for Change: the differences that matter
| Feature | Agenda for Change (incl. most managers) | VSM framework |
|---|---|---|
| Pay structure | National bands 1–9 with pay steps | Spot salaries within size-linked ranges |
| 2026/27 ceiling (illustrative) | Band 9: £129,783 top | Up to £299,250 (exception zone, largest trusts) |
| Progression | Automatic steps with appraisal | Remuneration committee decision; can be frozen |
| Overtime | Bands 1–7: time-and-a-half; bands 8–9: TOIL | None — all-inclusive salary |
| Unsocial hours | Section 2 enhancements; WTD averaging in leave | None |
| Annual pay award | Pay Review Body recommendation (3.3% in 2026/27) | Ranges uprated with government pay decisions |
| Pay disclosure | National scales published; individuals not named | Named individuals disclosed in annual reports |
| Notice periods | Contractual — typically 1 month (bands 1–7), 3 months (bands 8–9) | Individual contracts — see NHS notice periods by band |
One more distinction with practical bite: AfC staff build unsocial-hours and overtime into WTD-averaged leave pay under Section 13.9. VSMs have no enhancements to average — the spot salary is the whole package, and performance-related elements, where they exist, are disclosed separately.
Frequently asked questions
Are NHS managers on Agenda for Change?
Most are. Ward managers, service managers and departmental heads are usually on AfC bands 6 to 8. Only the most senior leaders - chief executives and executive directors - sit outside AfC on the Very Senior Managers (VSM) pay framework with individually set spot salaries.
What is the NHS Very Senior Managers pay framework?
The VSM pay framework, applying to all NHS provider trusts and integrated care boards from 1 April 2025, sets pay bands linked to organisation turnover or weighted population. Each band has a minimum, an operational maximum and an exception zone, with spot salaries set by the local remuneration committee.
How much does an NHS chief executive earn?
It depends on the size of the organisation. Under the published VSM framework, chief executive pay ranges run from a £140,595 minimum in the smallest trusts to a £270,375 operational maximum in trusts with turnover over £1 billion. Actual salaries are published in each trust's annual report.
Why are NHS bosses' salaries published?
Every NHS trust and integrated care board must publish a remuneration report in its annual report and accounts, naming senior managers and disclosing their salary bands, pension benefits and any bonuses. The VSM framework adds a comply-or-explain duty on top.
What is the £170,000 NHS pay scrutiny threshold?
Under the VSM framework, any proposed VSM salary above £170,000 must be submitted to NHS England for review as a pay case, and cases that do not comply with the framework go to the Department of Health and Social Care for approval.
Do NHS managers get overtime or unsocial-hours pay?
Managers on Agenda for Change bands 1 to 7 get standard overtime and unsocial-hours enhancements, and bands 8 to 9 get time off in lieu instead of overtime pay. Very senior managers are on all-inclusive VSM spot salaries with no overtime or unsocial-hours payments.
What is the difference between Band 9 and VSM pay?
Band 9 is the top of Agenda for Change (£112,782 to £129,783 in 2026/27) with national pay steps. VSM pay starts above AfC: even the lowest VSM pay band minimum (£97,335 for some executive directors) sits near the top of AfC, and salaries are individually negotiated spot rates, not steps.
How do I find a specific NHS director's salary?
Check the trust's or integrated care board's annual report and accounts, which must disclose senior managers' remuneration. Our page on NHS notice periods by band covers how senior contracts differ from AfC terms.
Keep exploring
See the top of the AfC scale with Band 9 pay 2026/27, understand NHS notice periods by band for senior contracts, or check how the 2026/27 AfC pay rise compares with VSM uprating.
Sources and independence
Source: NHS England: The NHS very senior managers pay framework.
Source: NHS England: VSM pay framework — provider and ICB pay ranges (May 2025).
Source: DHSC written evidence to the Senior Salaries Review Body, pay round 2026–27.
NHS Bands Pay is an independent information website. It is not affiliated with, endorsed by, or acting on behalf of the National Health Service. VSM ranges shown are the published launch ranges and are uprated annually — confirm current figures in the NHS England publication or the relevant trust's annual report and accounts.