Sometimes It is hard to be an NHS manager. Other times, you get almost twice the pay increase you were promised - and still you are not happy.
A survey of trust chief executives found they had secured an average pay rise of 6 per cent for the financial year 1999-2000.
This hike was despite the fact that in February 1999, then chief executive Sir Alan Langlands had stressed that 'the government does not expect to see senior managers being awarded increases out of line with the rest of public service'.
In 1998-99, chief executives received an average pay rise of 5 per cent. In October 1999 Sir Alan set out a clear position on senior managers' pay.
'I am asking you to ensure that within the overall cash envelope you have for managers in your organisation, you take all practical steps to ensure that pay rises for senior managers in 1999-2000 should not exceed a pay envelope of 3.2 per cent of your managerial pay bill. Within the overall limit you have some room to vary individual pay rises according to performance.'
Yet a new survey of pay and conditions reveals all is not well in the boardroom. The survey by employment analysts Incomes Data Services suggests that while a trust chief executive earns an average of£78,000 a year they have all the job security of an England football manager.
And the message from the top is that, like Sven Goran Eriksson, trust chief executives will increasingly have to look to improved performance to determine pay levels.
The IDS survey says the rate of attrition of senior posts 'continues to run at a high level'. Around 30 trusts have disappeared as a result of mergers and 52 chief executives have either left or were replaced.
And the bonus scheme is also becoming a thing of the past, with less than a quarter of chief executives receiving a salary top-up last year.
Andrew Foster, policy director for human resources at the NHS Confederation, says that the private sector is still offering better financial opportunities for experienced managers.
'NHS chief executives have relatively poor job security and this is becoming more and more of a problem. The combination of frequent service reorganisation and a growing factor of personal accountability for the millions of events in their organisations mean that there is an increasing risk of the job not being attractive enough to the really good candidates.'
'NHS chief executives still earn significantly less than their counterparts with similar responsibility in the private sector. The NHS is incredibly complex and difficult to manage. It must offer fairly competitive salaries to attract talented managers.'
And Mr Foster says the top-line results of the IDS survey needs clarification.
'Chief executives will have received cost-of-living increases of no more than 3.2 per cent.
What would make the total up to 6 per cent would be incremental performance-related scales. This is a common feature of pay for the vast majority of NHS staff.'
He says that while trusts in England have freedoms to set and control pay levels, in Scotland, where this has been taken back under central control, the normal annual increase is 6 per cent.
In the light of the survey's results a Department of Health spokesman is at pains not to chastise trusts for awarding their chief executives almost double the pay rise urged by Sir Alan and reinforced by health secretary Alan Milburn.
'It is misleading to look at the figures in isolation. There have been a lot of trust mergers, and taking them into account there has been a total fall of 1.4 per cent in management expenditure as we looked to reduce overall management costs in the last financial year. At present management costs account for less than 4.5 per cent of the total budget.'
But pressed on the fact that trusts are still paying double the rate ordered by the government - and almost double the pay rise for GPs and nurses - the spokesman said: 'I appreciate what you are saying. In future we will be looking a lot more at the link between pay and performance in management.'
Tom Jones, the NHS spokesman for the Association of Chartered Certified Accountants, is sceptical that, faced with a barrage of initiatives and deadlines, chief executives can be performancemanaged any harder.
'It is easy for the DoH to say pay should be linked to performance, but we are looking at a turnover of 14 per cent here.
'I know some is as a result of mergers and reorganisation, but that is too high when you consider that it costs money to keep staff turning over.'
But he says that if chief executives are receiving an average of 6 per cent, then other director-level posts are 'taking a big hit' to keep overall management costs down.
IDS also notes that earnings information disclosed by trust annual reports 'lags behind' the standards of disclosure common in the private sector. 'Few trusts do more than meet the minimum statutory requirements for information on salaries and remuneration.'
Ruth Lea, director of policy at the Institute of Directors, says chief executives are becoming 'demoralised by being forced to jump through endless hoops'.
'What they really want to do is get on with the job of managing, but they are increasingly being given responsibility without real power and that is the worst position to be in - no wonder they want to vote with their feet.'