More than 500 senior NHS managers across the UK are now earning more than the Prime Minister, according to new research, with Wales's highest-paid health board executive working for the troubled Betsi Cadwaladr University Health Board.

The findings, published by the TaxPayers' Alliance, are likely to reignite debate over NHS leadership pay in Wales, where both Betsi Cadwaladr University Health Board and Hywel Dda University Health Board continue to face intense pressure over waiting times, staffing challenges and service delivery.

The report found that Carol Shillabeer, chief executive of Betsi Cadwaladr, received a salary of £262,500 in 2024-25, the highest salary of any senior NHS manager in Wales. The health board was ranked sixth out of seven Welsh health boards for referral-to-treatment waiting times and last for A&E waiting times.

Betsi Cadwaladr serves north Wales and has faced years of scrutiny over performance, governance and financial management. The latest figures are likely to raise further questions about whether executive pay is sufficiently linked to patient outcomes.

The TaxPayers' Alliance report argues that large remuneration packages continue to be paid even where health boards are struggling to meet key performance targets. Across the UK, it found 574 senior NHS managers earned more than the Prime Minister's £172,153 salary entitlement in 2024-25, a rise from 512 the previous year.

At Cardiff and Vale University Health Board, which was ranked last in Wales for referral-to-treatment waiting times, executive director of therapies and health science Emma Cooke received total remuneration of £367,500 during 2024-25.

The report also highlights salaries within Hywel Dda University Health Board, which serves Ceredigion, Carmarthenshire and Pembrokeshire.

Former Chief executive Mark Henwood received a salary of £232,500 during 2024-25, placing him among the highest-paid NHS leaders in Wales. The report also lists chief executive Phil Kloer with a salary of £227,500 and a total remuneration package of £472,500, one of the largest overall remuneration packages awarded to any senior Welsh NHS executive

The figures emerge at a time when health boards are being asked to make savings while maintaining frontline services. Critics argue that executive pay must be justified by tangible improvements in patient care, while supporters contend that running large, complex healthcare organisations requires experienced leaders who can command salaries comparable with senior public sector roles elsewhere in the UK.

The TaxPayers' Alliance said taxpayers would be "appalled" by rising executive pay at a time when patients continue to face long waits for treatment. Researcher Anne Strickland called on ministers to fulfil pledges to link performance more directly to pay, arguing that failing managers should be held more accountable for results.

The report's publication places renewed focus on how Welsh health boards measure success and reward senior leadership. For communities served by Betsi Cadwaladr and Hywel Dda, the debate is likely to centre on a simple question: when waiting lists remain stubbornly high and emergency departments continue to face pressure, should six-figure executive salaries continue to rise, or should remuneration be more closely tied to improvements experienced by patients?