Very senior managers at 28 struggling NHS trusts will not receive this year's pay rise, NHS England has confirmed, in a move that ties top managers' pay directly to the performance of their organisations.

The decision, announced in a letter to providers on 5 November 2026, means very senior managers, known as VSMs, working in the affected provider trusts will be excluded from the 2026/27 pay award. The award is worth 3% this year, according to the Health Service Journal.

Which trusts are affected

The pay freeze applies where a trust spent at least three of the four quarters of 2025/26 in segment 4 of NHS England's National Oversight Framework and also holds an amber-red or red capability rating. Segment 4 covers organisations receiving intensive support because of serious concerns about their performance.

The 28 trusts span every region of England. Eight are in the North West, including Liverpool University Hospitals, Lancashire Teaching Hospitals, Greater Manchester Mental Health and the Northern Care Alliance. Six are in the Midlands, including Nottingham University Hospitals, Birmingham and Solihull Mental Health and Worcestershire Acute Hospitals.

Five are in the South East, among them Medway, Portsmouth Hospitals University and University Hospitals Sussex. Four are in the East of England, including the East of England Ambulance Service and the Queen Elizabeth Hospital in King's Lynn, and four are in the North East and Yorkshire, including Hull University Teaching Hospitals and York and Scarborough Teaching Hospitals. Royal United Hospitals Bath is the single affected trust in the South West.

Exemptions and a possible way back

There are limited exemptions. A manager who has taken up a new appointment in an organisation where the award is being withheld, or who works for a trust acquiring an organisation that is ineligible for the award, can be exempted for up to 24 months.

NHS England also said it is exploring whether some or all of a withheld pay award could be earned back if a trust shows demonstrable and sustained improvement. That would give managers at struggling trusts a route to recover the lost uplift, but only if performance genuinely turns around.

Managers in commissioning bodies spared

The withholding does not apply to very senior managers working in integrated care boards, the bodies that plan and fund local health services. NHS England said ICBs will not face national organisational performance-based withholding of the 2026/27 award, ahead of the full introduction of ICB performance and capability assessments in 2027/28.

The move is part of a wider push to link senior NHS pay to results. Ministers have argued that pay rises and bonuses for health service leaders should be earned through performance rather than awarded automatically, and that leaders of failing organisations should face consequences when services fall short.

For the trusts affected, the decision adds to the pressure already on their boards. Many are working through recovery plans under close oversight from NHS England, and the loss of the pay award for their most senior managers is a further signal that improvement is expected, and that it is expected soon.