Dr Jenny Dean says NHS managers may well have to bite the bullet and accept a pay freeze in the coming year, but if it is executed in the right way and shown to benefit the NHS it may not demotivate staff. The right leadership is key to implementing such top down decisions that directly impact on people's pay, lifestyles and pensions, she says, but if NHS leaders engage with managers to make them see the longer term benefits it will make any freeze easier to shoulder.