The tables below set out the advanced foundation trust assessment criteria and board statements, mapped to the Provider Capability Assessment, that all trusts undertake on an annual basis. The assessment criteria and board statements are applicable to all aspiring advanced foundation trusts (including acute, mental health, community, ambulance, and specialist trusts). These statements may be updated periodically to reflect feedback and to maintain alignment with the provider capability framework and other relevant frameworks and guidance.
The wording of the board statements should not be adjusted in any way. Where applicants are unable to sign off one or more of the statements, the memorandum should explain why not and, if applicable, how the trust plans to address this within a reasonable timeframe.
The board memorandum should explain how the board has assured itself that each of the board statements has been met, and should detail or reference the evidence used to support that assurance. To avoid duplication, the memorandum may reference evidence available in separate documents (for example, Provider Capability Assessment submissions, medium-term plans and board and committee papers) or in some cases it may directly set out in narrative form why the statement is met. For example, narrative included in the board memorandum may include the applicant’s vision and ambition for using the advanced foundation trusts freedoms to deliver national strategic goals as set out in the 10 Year Health Plan. Any aspects already set out in other NHS England framework self-assessments or submissions will not need to be re-submitted if the assessment team can be signposted to where this information has already been provided.
The final two columns of the tables below set out examples of the types of evidence that may be expected to underpin the advanced foundation trusts application, separating out business as usual evidence and evidence that specifically supports the assertions made in the board statements. These examples are not exhaustive and do not constitute an information request, which will be provided separately to applicant trusts at the start of the assessment process. Trusts should determine what evidence is most appropriate for their sector and service mix, and consider the evidence required for their own assurance that the board statements have been met.
1. Strategy, leadership and planning
Advanced foundation trust assessment criteria – strategy to deliver national and local priorities and comply with legislation
Provider capability self-assessment requirement:
The trust’s strategy reflects clear priorities for itself as well as shared objectives with system partners.
- Are the trust’s financial plans linked to and consistent with those of its commissioning integrated care board (ICB) or ICBs, in particular regarding capital expenditure?
- Do plans reflect and leverage the trust’s distinct strengths and position in its system?
- Are plans for transformation aligned to wider system strategy and responsive to key strategic priorities agreed at system level?
The board has the skills, capacity and experience to lead the organisation.
- Are all board positions filled and, if not, are there plans in place to address vacancies?
- What proportion of board members are in interim/acting roles?
- Is an appropriate board succession plan in place?
- Are there clear accountabilities and responsibilities for all areas of operations including quality, delivering access standards, operational planning and finance?
The trust is working effectively and collaboratively with system partners and its provider collaborative for the overall good of the system(s) and population served.
- Is the trust contributing to and benefiting from its provider collaborative?
- Does the board regularly meet system partners, and does it consider there is an open and transparent review of challenges across the system?
- Can the board evidence that it is making a positive impact on the wider system, not just the organisation itself – for example, in terms of sharing resources and supporting wider service reconfiguration and shifts to community care where appropriate and agreed?
- Are the trust’s digital plans linked to and consistent with those of local and national partners as necessary?
| Advanced foundation trust board statements Building on its submission for the Provider Capability Assessment, the board has further assured itself that… | Examples of evidence that all boards might use as part of business as usual assurance | Examples of additional evidence that advanced foundation trust applicants may consider to support the approval of their board statements |
|---|---|---|
| 1: The trust has a clear and coherent strategy that aligns with, and supports delivery of, the ambitions of the NHS 10 Year Health Plan. a) The strategy sets out clear priorities and objectives, reflecting the trust’s intended role in the local system and relevant ICB strategies, and is underpinned by appropriate data, analysis and evidence. b) The trust will leverage digital technologies across care settings to improve patient care and experience. c) The trust can demonstrate its commitment and contribution to improving population health outcomes and prevention. | Medium term plan/integrated delivery plan. Provider collaborative and other partnership model plans. A link to clear and effectively cascaded annual objectives for the board. Reports that set out priorities and progress in relation to health inequalities. Plans for delivery of research and innovation. Progress against neighbourhood health guidelines. Digital and data strategy – linked to the ICS strategy and underpinned by a sustainable financial plan. Examples of effective partnership working, such as working to deliver data sharing, joint care records, remote consultations. Digital maturity self-assessment ratings/standards under What Good Looks Like framework, digital inclusion. System wide meeting minutes/forums on digital. Digital exemplar status/awards. Performance indicators relating to the use of digital services. E vidence of compliance with national digital standards. | Data and analysis that substantiates the trust’s strategies. Clear analysis showing how chosen strategic priorities address key risks, trade‑offs and constraints, and why alternative options were not pursued. Additional narrative setting out the trust’s strategy to support the shift from hospital to community, including that the trust has or is developing community infrastructure and workforce to deliver this, and examples of progress and impact to date, as well as data and analysis to substantiate this. Evidence the trust has reserved funds to support non-recurrent transformation costs [specific 10 Year Health Plan ambition]. Examples of previous successful digital programme administration and delivery, for example, Electronic Patient Record, artificial intelligence (AI) diagnostics, electronic prescribing, contribution to the Federated Data Platform. Evidence setting out decommissioning of outdated technologies. Examples of how digital solutions and approach is being co-developed and coordinated with system partners, including evidence of use of technology to support quality improvement, for example, through AI to assess and respond to complaints and real time monitoring of vitals. Evidence the trust understands health needs of both its patients and the communities it serves (including use of Joint Strategic Needs Assessments (JSNAs) and health intelligence). Demonstration of partnership working with local authorities and Health and Wellbeing Boards, including shared plans to address social determinants of health. Evidence of prevention at scale (primary, secondary and tertiary) – including concrete examples, outcomes and learning. Additional examples of impact to date, for example, impact on health inequalities and inequity. Evidence the trust has access to and oversight of population health intelligence. Population stratification/segmentation by outcomes and need, and evidence of targeted interventions for high-risk cohorts. Assessment of data integration and digital maturity to deliver population-level service planning, delivery and evaluation (population health management). |
| 2. The trust demonstrates effective, mature working relationships with system partners, including its ICB, primary care, local authorities and other relevant partners, to support joint working, shared decision‑making and delivery of the ambitions of the 10 Year Health Plan. | Medium term plan/integrated delivery plan. System wide meeting minutes/forums (for example, evidence of active participation in ICB System Quality Group). | Details of system collaboration structures and processes and trusts’ role within these; including evidence of successful implementation, impact and sustainable improvement consequence. Evidence of mature working relationships with local authorities and social care partners supported by joint governance and shared priorities for key populations. Evidence of alignment with environmental sustainability requirements. |
| 3. The trust understands and addresses health inequalities in how people access services, their experience of care and the outcomes they achieve; demonstrating impact on population health overall. | Annual reports on health inequalities. Equality impact assessments (EQIAs). Reports which set out priorities and progress on improving outcomes and experiences related to health inequalities. | Demonstration of partnership working with local authorities and Health and Wellbeing Boards, including shared plans to address social determinants of health. Additional examples of impact to date, for example, impact on health inequalities and inequity. Evidence the trust has access to and oversight of health inequalities intelligence. Evidence of how data and wider intelligence is used to monitor inequalities and service impact on vulnerable and underserved groups. Population stratification/segmentation by outcomes and need, and evidence of targeted interventions for high-risk cohorts. |
| 4. The trust can articulate how the additional freedoms it would gain as an advanced foundation trust would be used deliberately to support its strategic and system priorities, including those set out in the 10 Year Health Plan. | Board papers and minutes demonstrating consideration of autonomy, delegation and managed risk in delivering strategic or system priorities Governance frameworks (for example, scheme of delegation) evidencing the board’s approach to responsible decision‑making and accountability. | Clear articulation of how additional advanced foundation trust freedoms would be used deliberately to innovate and improve patient outcomes in support of strategic or system priorities and delivery of the 10 Year Health Plan. |
Advanced foundation trust assessment criteria – corporate governance arrangements that are effective in practice
| Advanced foundation trust board statements Building on its submission for the Provider Capability Assessment, the board has further assured itself that… | Examples of evidence that all boards might use as part of business as usual assurance | Examples of additional evidence that advanced foundation trust applicants may consider to support the approval of their board statements |
|---|---|---|
| 1. The board has the skills and expertise to deliver its strategy against the ambitions of the 10 Year Health Plan. | History of filling board vacancies and position with interims Robust gap analysis of board skill sets. Approach to succession planning. | Board bios, including information on length of time in post (for example, departures during probation period, history of interims). In its board memo or supporting evidence, the trust may outline a proactive approach to non-executive director (NED) and board development, such as shadow NEDs, induction and onboarding approach for executives and non-executives, ongoing development support for board members. Evidence that succession plans are developed to respond to strategic needs identified. Evidence that indicates the quality of the leadership development programme (for example, successful translation through to appointments to board and level below board). |
| 2. The trust has appropriate succession and talent management plans in place to ensure that Board‑level leadership remains resilient, high‑performing, and incorporates a balanced mix of internal and external skills and experience to deliver the trust’s strategy. | The outputs of board effectiveness reviews for example, undertaken against the Insightful Provider Board guidance. Gap analysis of board skill sets – approach to succession planning. Compliance with the requirements of the fit and proper person test (FPPT) framework. Implementation of the Management and Leadership Framework. Compliance with the forthcoming Code of Practice for NHS Managers. | Gap analysis which specifically considers ability to deliver the three shifts, for example, sufficient public health expertise at board level and embedded through the organisation. Additional narrative (for example, in board memo) that considers how bandwidth and capacity will be balanced between transformation and operational delivery. Board development plan that balances team functionality and subject specific training; and evidence of effective delivery. Funded plans for the continuous professional development of senior management and leadership teams, focusing on strategic capabilities. Evidence that indicates that any tensions are dealt with effectively in a responsive manner. Evidence of NHS IMPACT training and improvement approach to delivery of annual plans. Evidence of independent 360-degree management and leadership assessments that align with the NHS Management and Leadership Framework. |
| 3. The trust has an effective operating model and governance framework that enables the board to recognise when change is required and to adapt arrangements as the organisation evolves. | Operating model overview. Sample of board and committee papers and terms of reference that demonstrate that the robustness, effectiveness and clearly defined roles of committees allow the board the time and space it needs to focus on strategic matters. Board and governance effectiveness reviews. | Where shared leadership arrangements are in place with other providers, the trust can articulate clear and comprehensive arrangements for responsibilities, decision making and conflict of interest management. Principles for business unit operation underpin innovation within clear guardrails – allowing the organisation to be dynamic and agile. Board agendas are followed and not overtaken by reactive management of business as usual. Evidence that demonstrates there are clear arrangements for system engagement, accountability and influence in each of the trust’s systems and geographies. |
| 4. The board sets a culture of curiosity and openness, actively seeking learning from other organisations and encouraging the sharing of the trust’s own learning in support of long‑term system transformation. | Board effectiveness reviews, history of use of internal and external review. Board and committee agendas and papers. | Evidence that reviews are used proactively in a ‘problem sensing’ way and where appropriate include people with lived experience. Evidence of a transparent approach and proactive identification and sharing of issues with regulators. Examples demonstrating how the board seeks, reflects on and applies learning from peer organisations or independent review to improve its own effectiveness. |
| 5. The board receives timely, insightful information at an appropriate level to enable effective board‑level decision‑making and oversight, including in relation to delivery of the three strategic shifts set out in the 10 Year Health Plan. | Board effectiveness reviews Integrated performance report (IPR). Board and committee agendas and papers. | NED engagement approach demonstrates that information is shared with NEDs in a way that allows effective challenge. Tangible examples of triangulation of staff-related data with lived experience from front-line teams and staff networks. Evidence of outcome-based metrics to demonstrate impact. |
| 6. The Board has a clear understanding of the key risks to delivering the trust’s strategy and ensures these are appropriately assessed and mitigated in the trust’s plans. | Board assurance framework (BAF). Risk registers. Medium-term plan and integrated delivery plan. Action and mitigation plans in relation to key risks and regulatory requirements. | Evidence of proactive scenario and contingency planning (see also finance domain). |
Advanced foundation trust assessment criteria: effective mechanisms in place to meaningfully engage with staff and local communities, ensuring involvement influences decisions
| Advanced foundation trust board statements Building on its submission for the Provider Capability Assessment, the board has further assured itself that… | Examples of evidence that all boards might use as part of business as usual assurance | Examples of additional evidence that advanced foundation trust applicants may consider to support the approval of their board statements |
|---|---|---|
| 1. The board demonstrates it actively seeks to be held to account by its people, patients and public; supported by public reporting of outcomes and performance. Staff and local communities meaningfully shape and inform the boards strategy development and decision making, leading to decisions which improve experiences and outcomes. | Evidence of patient voice, service user and staff voice flowing through to the Board and of active debate (for example, level of co-production interrogated; outcomes and experience data debated). Appointment of patient safety partners (PSPs), medication safety officers and medical device safety officers. Medium-term plan and integrated delivery plan. Staff feedback. Engagement plans, for example, in relation to new strategies and transformation proposals. Self-assessment against experience of care framework. Staff survey. Evidence of engagement with Council of Governors, where this is in place. Evidence of engagement with Local Healthwatch or equivalent local community representative bodies. Evidence of board and committee papers and minutes, both private and public. External review reports or audits on quality of reporting. Any publication, reports or audits shared widely across the organisation and beyond. | Additional clarity on how decisions have been shaped as a result of hearing this feedback. Examples of co-produced outcome measures. Where patient stories are used, it is clear what the impact/effect is. Evidence of organisational wide approach to the trusts’ strategy development and improvement planning, with input from staff, patients, carers, local public, charities, communities, and stakeholders; with clear systems in place to support improvement at all levels of care delivery. |
2. Quality of care (including quality governance)
Advanced foundation trust assessment criteria – quality of care
- A “good” or “outstanding” Care Quality Commission (CQC) rating from the trust’s most recent trust level CQC assessment, with no site or service rated inadequate by CQC. If the most recent CQC rating is more than 3 years’ old and “requires improvement” this will be permitted, but the trust will be required to commission and complete an independent, targeted governance review to provide assurance historical issues have been addressed. The scope of the review will need to be agreed with NHS England and the trust will need to share the review with both NHS England and the CQC.
- A score of 3 or better in the quality domains within the NHS Oversight Framework (currently these are the effectiveness and experience of care domain and patient safety domain) for the last 2 consecutive quarters
- Not being subject to support from the Maternity and Neonatal Improvement Support team.
Provider capability self-assessment requirement:
Having had regard to relevant NHS England guidance (supported by Care Quality Commission information, its own information on patient safety incidents, patterns of complaints and any further metrics it chooses to adopt).
- ensure required standards are achieved (internal and external)
- investigate and develop strategies to address substandard performance
- plan and manage continuous improvement
- identify, share and ensure delivery of best practice
- identify and manage risks to quality of care
- there is board-level engagement on improving quality of care across the organisation
- board considers both quantitative and qualitative information, and directors regularly visit points of care to get views of staff and patients
- Board assesses whether resources are being channelled effectively to provide care and whether packages of care can be better provided in the community
- Board looks at learning and insight from quality issues elsewhere in the NHS and can in good faith assure that its trust’s internal governance arrangements are robust
- Board is satisfied that current staff training and appraisals regarding patient safety and quality foster a culture of continuous improvement
The trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients.
- Is the board satisfied that it receives timely information on quality that is focused on the right matters?
- Is the board satisfied it is equipped with the right skills and experience to oversee all elements of quality and address any concerns?
- Does the board triangulate qualitative and quantitative information, including comparative benchmarks, to assure itself that it has a comprehensive picture of patient experience?
- Does the board consider variation in experience for those with protected characteristics and patterns of actual and expected access from the trust’s communities?
- Is the board satisfied that the trust has a clear system to both receive complaints from patients and escalate them?
Systems are in place to monitor patient experience, and there are clear paths to relay safety concerns to the board.
- Does the board consider volume and patterns of patient feedback, such as the Friends and Family Test or other real-time measures, and explore whether staff effectively respond to this?
- How does the organisation involve service users in quality assessment and improvement and how is this reflected in governance?
| Advanced foundation trust board statements Building on its submission for the Provider Capability Assessment, the board has further assured itself that… | Examples of evidence that all boards might use as part of business as usual assurance | Examples of additional evidence that advanced foundation trust applicants may consider to support the approval of their board statements |
|---|---|---|
| 1. The trust’s Provider Capability Self-Assessment and any relevant accompanying self-certification provides assurance that any CQC actions resulting from regulatory assessments have been addressed, assured and closed; quality assurance mechanisms are in place to maintain/achieve good or outstanding. | Committee and Board meeting minutes. Trust documents of delivery of CQC action plans and governance arrangements. Any assurance reports or external reviews, including national statutory and non-statutory inquiries, that demonstrate that actions have been addressed and compliance has been sustained. Quality Committee and board meeting minutes. Internal audit. Learning from prevention of future deaths reports including national statutory and non-statutory inquiries. Outcomes of quality (including safety) visits/reviews including walkarounds and ward accreditations. Processes and systems used by the board to ensure there is sustainable quality assurance. | For trust level ‘requires improvement’ ratings more than 3 year’s old, an independent targeted governance review which evidences that all historical recommendations and requirements from the previous CQC assessment have been actioned and closed with assurance gained on sustained improvement. The scope of this review will have to be agreed with NHS England. Evidence of any actions and progress resulting from independent reviews, internal clinical audit outlier alerts and national statutory and non-statutory inquiries. Evidence that action plans address the real drivers of failure and are aligned to transformational plans. Evidence that the trust is consistently working toward accreditation as part of its improvement strategy and response to learning from investigations and other safety learning responses, including national statutory and non-statutory inquiries. Evidence of implementation of the Patient Safety Incident Response Framework (PSIRF) including a well-developed Patient Safety Incident Response Plan (PSIRP). Evidence of annual quality strategy and delivery plans and improvement programmes. Evidence that the board can demonstrate a balance between compliance and improvement – striving to drive quality outcomes further than expected targets. |
| 2. The trust has developed clinical quality plans driven by data and analysis; that actively progress delivery of the 3 shifts as outlined in the 10 Year Health Plan and the trust’s own clinical quality strategy. | Board Assurance Framework, IPR and risk registers. Quality committee papers. Quality and delivery metrics. Quality account. | Evidence that risk appetite and risk approach supports opportunities as well as managing challenges resulting in pathway redesign programmes for improvement and delivering the 3 shifts. Evidence that the quality strategy balances local and national priorities and quality plans demonstrate progress and improvement. Evidence of plans to deliver the national quality strategy (once published). |
| 3. The trust is actively engaged with system partners in managing actual or emerging quality concerns and working collaboratively with people who use services, carers and with the wider community to reduce risk and impact for patients. | Clinical and quality strategies. System wide quality meeting and forums minutes. Contribution or leadership in any system wide quality improvement programme. Participation in and action resulting from clinical audits. System wide quality improvement programmes demonstrating co-productive and collaborative working arrangements. Participation in ICB System Quality Groups. | Evidence that there is monitoring for early warning signs. Evidence that systems identify poor quality care with system wide improvement programmes with demonstrable delivery and impact on patient care and treatment. Evidence of how the interface between primary and secondary care is being improved. Evidence from clinical and quality strategies of system partners including provider collaboratives. |
| 4. Service delivery reflects national guidance, accreditation, and best practice, and seeks to innovate and go further to improve and address unwarranted variation within the trust and across the local system. | Examples of sharing best practice, notes in board meeting minutes or divisional level meeting notes. Evidence of Board knowledge and discussion of national guidance and best practice and accreditation such as clinical audits, Experience of Care Improvement Framework, Getting It Right First Time (GIRFT), clinical senate and application of national frameworks. Staff and patient surveys, feedback, complaints and other insight reports to board. Evidence of systems to monitor patient and carer experience with clear mechanisms to relay feedback to board. Staff training and development update and performance reports to board. Any relevant third-party evidence for example, Royal Colleges, other regulatory bodies and progress on accreditation. Compliance with all relevant National Patient Safety Alerts. Evidence from relevant provider collaboratives associated with unwarranted variation. | Emerging clinical and quality strategy to reflect the ambitions of the 10 Year Health Plan and shifting resources into community, neighbourhood and place care settings (where this is relevant). Strategy and plans should reflect all domains of care quality, including experience, and align with the national Quality Strategy, as well as the 10 Year Health Plan. Examples of application of national best practice and peer learning, including modern service frameworks as they evolve. |
Advanced foundation trust assessment criteria – quality governance arrangements are effective in practice
| Advanced foundation trust board statements Building on its submission for the Provider Capability Assessment, the board has further assured itself that… | Examples of evidence that all boards might use as part of business as usual assurance | Examples of additional evidence that advanced foundation trust applicants may consider to support the approval of their board statements |
|---|---|---|
| 1.The trust demonstrates a visible impact on quality performance and improvement through distributed leadership and an open, transparent culture where quality is everyone’s responsibility. | National patient surveys. Staff feedback including pulse survey. Staff networks. People strategy. Freedom to Speak Up (FTSU). Complaints data and reports. Coroners reports or ombudsman. Cultural development assessments and work at board level. Workforce development programmes and delivery plans. Quality focussed learning and development approach and programmes. Evidence from papers and minutes from performance and quality reviews. External reports or audits on quality of reporting. Appointment and training of patient safety specialists, medication safety officers and medical device safety officers. IPR. Any publication, reports or audits shared widely across organisation and beyond, for example, clinical audit outliers and action plans. Board and Quality Committee meeting minutes. Board development work plan. Board member leadership of improvement or innovation projects. | Evidence that the trust can identify pockets of adverse culture to ensure psychological safety in its workforce and has action plans to address concerns. Board member visits to clinical areas with action plans and follow up. Evidence that strategic objectives linked to quality are being implemented successfully. Evidence of organisational wide approach to its improvement with input from staff, patients, carers, local public, communities and stakeholders on quality, and with clear systems in place to support improvement at all levels of care delivery including actions to address unwarranted variation and inequity. |
| 2. The trust continuously reviews its quality governance arrangements to ensure these support changes to the operating model of care in the context of delivering the 3 shifts outlined in the 10 Year Health Plan. | Quality governance (QG) architecture including structure and reporting approach. Quality governance framework. Internal or external QG reviews or audits. Internal or external QG or Well Led reviews that have included governance elements and/or audits with progress on any actions identified. Analysis uses statistically appropriate tools which identify and focus on relevant issues, for example, Statistical Process Control (SPC), Pareto. | Evidence that learning has been identified through internal and external reviews of governance, including actions taken as a result. Evidence that learning from national inquiries have been considered and reviewed, including recommendations that have been implemented. Evidence of dynamic changes to quality governance arrangements over time and any plans for strengthening governance to support the requirements of the advanced foundation trust moving forward and at place or system. Evidence that the trust has appropriate quality governance architecture to support their quality governance and reporting. |
| 3. The trust uses insightful triangulation and interrogation of information (including feedback from stakeholders) to inform systemic learning and decision-making and ambitious target setting, leading to improvement in outcomes for patients and population health. There are effective systems for improvement that drives prioritisation, and action to address unwarranted variation and inequity. | IPR. Board and quality committee meeting minutes. Service level performance reporting. Improvement programmes. Organisational strategy. Quality strategy. | Evidence of how the IPR informs decisions and target setting, which has led to demonstrable improvements in population health. Evidence that patient safety and quality information is reviewed by board through an inequalities lens. A good quality PSIRP with clear, evidence based and patient-informed safety improvement priorities. Evidence of outcome-based metrics to demonstrate impact. Evidence of the trust’s development journey in population health, prevention, and health inequalities outcome measures in the context of the 10 Year Health Plan. |
3. People and culture
Advanced foundation trust assessment criteria: Highly engaged workforce that is committed to quality improvement
Provider capability self-assessment requirement:
Staff feedback is used to improve quality of care provided by the trust.
- Does the board look at the diversity of its staff and staff experience survey data across different teams (including trainees) to identify where there is scope for improvement?
- Does the board engage with staff forums to continually consider how care can be improved?
- Is the trust an outlier on staff surveys across peers?
- Can the board evidence action taken in response to staff feedback?
- Does the board engage effectively with information received via FTSU channels, using it to improve quality of care and staff experience?
- Are all complaints treated as serious and do complex complaints receive senior oversight and attention, including executive level intervention when required?
Staff have the relevant skills and capacity to undertake their roles, with training and development programmes in place at all levels.
- Does the trust regularly review skills at all levels across the organisation?
- Does the board see and, if necessary, act on levels of compliance with mandatory training?
Staff can express concerns in an open and constructive environment.
- Is there a clear and streamlined FTSU process for staff and are FTSU concerns visibly addressed, providing assurance to any others with similar concerns?
- Is there a safe reporting culture throughout the organisation? How does the board know?
| Advanced foundation trust board statements Building on its submission for the Provider Capability Assessment, the board has further assured itself that… | Examples of evidence that all boards might use as part of business as usual assurance | Examples of additional evidence that advanced foundation trust applicants may consider to support the approval of their board statements |
|---|---|---|
| 1. All staff understand the importance of quality, are empowered to report concerns and are actively involved in delivering sustainable and innovative improvements to quality of care. | Workforce reporting to the board. Staff survey results and trends, both national and local. Staff forum feedback which has led to improvements by the board. FTSU reporting. Duty of Candour. Complaints reporting. PSIRF / PSIRP demonstrates staff input. CQC views and whistleblowing. FTSU intelligence. Applicant’s own in-house staff check-ins, surveys and feedback results. QI training and methodologies. Patient safety specialists, medication safety officers and medical device safety officers appointed and trained. | Evidence of staff involvement in transformation and improvement plans, using NHS IMPACT or any other QI methodology of choice. Evidence of proportion of staff at all levels trained in continuous improvement, QI methodology and patient first. Evidence of implementing Management and Leadership Framework. Evidence from staff survey results that staff appraisals are taking place which are meaningful. Evidence of a talent management strategy at all levels. |
| 2. The trust has fair, just, compassionate, and transparent mechanisms and processes that encourage staff at all levels to recognise and acknowledge where services are not meeting organisational expectations of high-quality delivery. | Skills analysis. Performance management. Mandatory training. Sickness and retention. PSIRF and PSIRP demonstrate a just culture. Quality Improvement programme. | Evidence of embedded organisational wide improvement approach with evidence of continuous improvement projects delivering benefits where performance requires attention. Evidence of mechanisms for gathering and acting on feedback from all clinical and staff groups. Evidence of ‘you said, we did’ feedback loops demonstrating that staff views have led to concrete changes in working conditions, culture and support offers. High numbers of staff trained in QI who act as improvement champions and drive the delivery of change. Evidence that service level clinically led improvements are the norm. Evidence that expectations and support to staff are hardwired into the culture, organisational values, and ways of working. Evidence of an evaluated and effective leadership development programme. Tangible examples of triangulation of staff-related data with lived experience of front-line teams and staff networks. |
| 3. The trust is working with system partners to develop workforce models that support 10 Year Health Plan ambitions and deliver neighbourhood health services. | Workforce strategies and plans for coordination and collaboration and delegation of clinical tasks. Partnership plans (transition of care) across pathways. | Evidence of how workforce strategies and plans are aligned to those across the system, and where developments in workforce models will support the ambitions at neighbourhood level, linked to the strategy as an advanced foundation trust. |
| 4. The trust actively identifies and addresses workforce inequalities which impact a fair and inclusive culture and works towards improving equality and equity for its people. | Workforce Race Equality Standard (WRES). Workforce Disability Equality Standard (WDES). NHS People Promise Indicators. Any other appropriate workforce data available. Board and People Committee minutes. Equality, diversity and inclusion (EDI) workforce analysis. | Evidence of the trust’s understanding of the variation in staff experience between different staff groups, locations and services, and how the trust is addressing any inequities. Talent and leadership programmes. Staff networks and other feedback from staff survey. Examples of EDI initiatives that have resulted in specific improvements identified through analysis of workforce data. |
| 5. Staff have appropriate skills, and capacity, supported by an inclusive education and training programme, that values and develops its workforce across all professions to deliver safe high quality and effective care, now and into the future. | Educator Workforce Strategy and alignment to the Educator Workforce Planning Framework. Local models for education and training. Skills audits. Staff surveys. | Local implementation plans that link to ICB workforce plans. Career structure frameworks. Evidence of how models of education are evolving. Evidence of how plans promote aspirations to improve EDI. Evidence of how plans drive improvements in quality through education. Plans for the continuous professional development of senior management and leadership teams, focusing on strategic capabilities. Evidence of independent 360-degree management and leadership assessments that align with the NHS Management and Leadership Framework. Evidence of digital literacy of staff. |
4. Access and delivery of services
Advanced foundation trust assessment criteria: Performance against NHS Oversight Framework metric scores in line with and aiming to exceed planning guidance priorities. Clear improvement plans in place where metrics are not being met. A proven track record of performance recovery and system level working.
Provider capability self-assessment requirement:
Plans are in place to improve performance against the relevant access and waiting times standards.
- Is the trust meeting the relevant national standards in the NHS planning guidance? If not, is the trust taking all possible steps towards meeting them, involving system partners as necessary?
The trust can identify and address inequalities in access and waiting times to NHS services across its patients.
- Where waiting time standards are not being met or will not be met in the financial year, is the board aware of the factors behind this? Is there a plan to deliver improvement?
Appropriate population health targets have been agreed with the ICB.
- The board can track and minimise any unwarranted variations in access to and delivery of services across the trust’s patients and population and plans to address variation are in place
- Is there a clear link between specific population health measures and the internal operations of the trust?
- Do teams across the trust understand how their work is improving the wider health and wellbeing of people across the system?
| Advanced foundation trust board statements Building on its submission for the Provider Capability Assessment, the board has further assured itself that… | Examples of evidence that all boards might use as part of business as usual assurance | Examples of additional evidence that advanced foundation trust applicants may consider to support the approval of their board statements |
|---|---|---|
| 1. The trust has a proven track record of recovering performance against national standards and targets in a timely way. | Performance against NHS Oversight Framework metric scores which relate to planning guidance priorities (NHS Oversight Framework access domain and sub-domains). IPR. Clinical audits. | Recovery action plans, where applicable, showing a track record of performance improvement and delivery turnaround in IPR. Evidence that the trust is on plan against relevant national recovery plans |
| 2. The trust balances the delivery of operational performance against national priorities (such as elective, cancer, urgent and emergency care, mental health) and responds to any changes to these as outlined in national planning guidance. | Performance against NHS Oversight Framework metric scores which relate to planning guidance priorities (NHS Oversight Framework access domain and sub domains). IPR. | Evidence that across the national priority targets, the trust is balancing operational performance with experience and outcomes, ensuring that there is equal parity across services performance. |
| 3. The trust sets itself ambitious plans to exceed national targets in relation to access and waiting times and supports and identifies initiatives that enable system partners to deliver outcomes for patients. | IPR. Operational plans. | Evidence that the trust can demonstrate plans to, or delivery of, accelerated performance improvements in national priority areas, for example, 18 weeks. Examples of emerging plans showing co-production and transformation of clinical services to deliver ambition to shift care from hospital to community and focus on prevention rather than just treatment. Evidence of system level working and leadership on improvement programmes to create solutions to address challenges being faced in care delivery. Examples of continuous improvement projects and outcomes. |
| 4. The trust explores and shapes system wide solutions to challenges to care delivery that impact inequity of access, unwarranted variation and overall performance. | IPR. Operational plans. | Examples of emerging plans showing co-production and transformation of clinical services to deliver ambition to shift care from hospital to community and focus on prevention rather than just treatment. Evidence of system level working and leadership on improvement programmes to create solutions to address challenges being faced in care delivery. Evidence of involvement and support for system level diagnosis of challenges, for example, population health analysis, demand and capacity modelling. Evidence of audits and improvement programmes that demonstrate that the trust is addressing [any inequalities] of access to the trust’s services. |
5. Productivity and value for money
Advanced foundation trust assessment criteria: the applicant demonstrates a clear understanding of productivity opportunities and actionable plans to deliver improvements, including through use of technology and national digital services.
Provider capability self-assessment requirement:
Plans are in place to deliver productivity improvements as referenced in the NHS Model Health System guidance, the Insightful board and other guidance as relevant. Indicative evidence or lines of enquiry are:
- Board uses all available and relevant benchmarking data, as updated from time to time by NHS England, to:
- review its performance against peers
- identify and understand any unwarranted variations
- put programmes in place to reduce unwarranted negative variation
- The trust’s track record of delivery of planned productivity rates
| Advanced foundation trust board statements Building on its submission for the Provider Capability Assessment, the board has further assured itself that… | Examples of evidence that all boards might use as part of business as usual assurance | Examples of additional evidence that advanced foundation trust applicants may consider to support the approval of their board statements |
|---|---|---|
| 1. The trust has a proven and consistent track record of delivering measurable productivity and sustained improvements, and has mechanisms and plans in place to achieve further productivity improvements. | Measurable productivity improvements over the past 12 months, evidenced through cost improvement plans (CIP) delivery reports or efficiency programme updates. Planning processes show the trust has actively identified and addressed unwarranted variation when setting cost reduction and service improvement plans. | Sustained productivity gains over multiple years, through transformation programmes or service redesign. Productivity improvements are embedded within operational and financial planning cycles, showing alignment between strategic transformation goals, quality and delivery outcomes. |
| 2. The board and its sub-committees routinely use all available and relevant benchmarking data, to drive and balance both quality and financial improvement. | Board and sub-committee papers routinely reference national benchmarking resources and the latest available guidance. This might include NHS Model Health System, Patient Level Information Costing System (PLICS), NHS Spend Comparison Service, productivity packs and other relevant data to support financial and operational decision-making. The Insightful Provider Board guidance includes examples of relevant indicators and measures. | Clear demonstration that trust is using this data to inform detailed analysis of opportunities and actively improve on these. Productivity planning is underpinned by robust demand, capacity, and utilisation modelling. This may consider workforce, physical assets, and enabling factors such as digital infrastructure and care pathway design, including emerging models of care and alignment to the 10 Year Health Plan. Productivity insights are triangulated with national benchmarking tools and local intelligence (for example, NHS England regional teams, ICS data, GIRFT reviews) as well as wider system factors to identify risks, prioritise opportunities, and inform strategic improvement actions. |
6. Financial performance and oversight (including financial governance)
Advanced foundation trust assessment criteria:
- Trust has historically delivered its plan and is on track to deliver its agreed planned outturn for the current financial year (of at least break-even)
- Medium-term plan – applicant demonstrates that the trust, unless there are exceptional circumstances, has a high likelihood of:
- projecting an adjusted position of at least break-even (excluding non-recurrent deficit support funding – as aligned to the measure used in the NHS Oversight Framework) in year 1 and year 2, and achieving this recurrently by year 3 of the projected period.
- maintaining a reasonable cash position including sufficient working capital to meet its operational and financial requirements for at least the next 12 months.
Provider capability self-assessment requirement:
The trust engages with its system partners on the optimal use of NHS resources and supports the overall system in delivering its planned financial outturn.
- Is the board contributing to system-wide discussions on allocation of resources?
- Does the trust’s financial plan align with those of its partner organisations and the joint forward plan for the system?
- Would system partners agree the trust is doing all it can to balance its local and organisational priorities with system priorities for the overall benefit of the wider population and the local NHS?
| Advanced foundation trust board statements Building on its submission for the Provider Capability Assessment, the board has further assured itself that… | Examples of evidence that all boards might use as part of business as usual assurance | Examples of additional evidence that advanced foundation trust applicants may consider to support the approval of their board statements |
|---|---|---|
| 1. The trust has historically delivered its plan and is on track to deliver its agreed planned outturn for the current financial year (of at least break-even). | Historical financial performance of the organisation. Year-to-date performance against plan, and risks and mitigations to the reported financial position. | Updated year-to-date performance against plan, and risks and mitigations to the reported financial position prior to approval as an advanced foundation trust. |
| 2. There is a robust medium-term forecast financial plan, and can confirm the following: – the financial plan was developed using reasonable (evidence-based) or published assumptions and is aligned with national and local priorities, including enabling the 3 shifts outlined in the 10 Year Health Plan. – the financial plan aligns with and is being developed in conjunction with the system plan, and the ICB. – the financial plan projects an adjusted position of at least break-even (excluding non-recurrent deficit support funding – as aligned to the measure used in the NHS Oversight Framework) in year 1 and year 2, and it achieves this recurrently by year 3 of the projected period. – it has undertaken a sensitivity analysis to evaluate risks and model reasonable downside scenarios and their mitigations for testing the financial plan. – the trust maintains a reasonable cash position, including sufficient working capital to meet its operational and financial requirements for at least the next 12 months. | A medium-term financial plan, including a rolling 12 months cash flow forecast to ensure a reasonable cash balance is maintained. The financial modelling assumptions (including capex) applied in the medium-term plan are aligned with the NHS England published guidelines and aligned with the system strategy. Workforce, activity and financial plans are aligned, showing consistency in operational costs and activity (such as workforce plans, financial reports, cost-per-activity analysis). Details of how the trust is collaborating with local partners to contribute to local priorities. A sensitivity analysis demonstrating downside scenarios to the base case, and mitigations. Overall efficiency plan and detail behind significant individual efficiency schemes. Project initiation documents (PIDs) for efficiency schemes that demonstrate consideration of realistic phasing. | Progress against medium-term financial plan. If there are any material changes that have come to light since the agreement of the medium-term financial plan, the trust will need to set out how this impacts the assumptions and medium-term outlook. Rolling 12 months cash flow forecast to ensure a reasonable cash balance is maintained post advanced foundation trust assessment. Financial planning is fully integrated with strategic objectives and clearly reflects national and local priorities, including the 3 shifts in the 10 Year Health Plan. Evidence of review and challenge by Finance Committee and Board of medium-term financial plan. Underpinning plans for efficiencies for at least the first two years of the medium-term plan, including minimal high-risk plans in year one, and credible thematic outline plans for year three efficiencies. |
Advanced foundation trust assessment criteria: financial governance and capital scheme delivery arrangements that are effective in practice
Provider capability self-assessment requirement:
The trust has a robust financial governance framework and appropriate contract management arrangements.
- Trust has a work programme of sufficient breadth and depth for internal audit in relation to financial systems and processes, and to ensure the reliability of performance data?
- Have there been any contract disputes over the past 12 months and, if so, have these been addressed?
- [Potentially more appropriate for acute trusts] Are the trust’s staffing and financial systems aligned and show a consistent story regarding operational costs and activity carried out? Has the trust had to rely on more agency and bank staff than planned?
Financial risk is managed effectively and financial considerations (for example, efficiency programmes) do not adversely affect patient care and outcomes.
- Does the board stress-test the impact of financial efficiency plans on resources available to underpin quality of care?
- Are there sufficient safeguards in place to monitor the impact of financial efficiency plans on, for example, quality of care, access and staff wellbeing?
- Does the board track performance against planned surplus/deficit and where performance is lagging it understands the underlying drivers?
| Advanced foundation trust board statements Building on its submission for the Provider Capability Assessment, the board has further assured itself that… | Examples of evidence that all boards might use as part of business as usual assurance | Examples of additional evidence that advanced foundation trust applicants may consider to support the approval of their board statements |
|---|---|---|
| 1. The trust operates within a strong financial control environment and has a robust financial governance framework, underpinned by clearly defined roles, responsibilities, and accountabilities for all key financial matters, including the management of financial risk, performance, capital scheme delivery and the timely submission of audited accounts. This is proactively reviewed to ensure it remains robust, including through internal audit, value for money and other independent assessments. | Approved financial governance framework, including standing financial instructions (SFI), standing orders (SO) and scheme of reservation and delegation. Terms of reference for relevant committees. Timely submission of audited accounts. A current estates strategy (or equivalent plan). Internal audit programme covering key financial systems, processes, and performance data reliability (such as audit plans, reports, and follow-up actions). Action plan to address recommendations from external audit report. Counter fraud annual report and progress reports. | Clear accountability mapping from board to operational teams, with evidence of ownership at all levels. Documented continuous improvement cycle for governance framework and evidence of regular governance effectiveness reviews with documented improvements and action tracking. Benchmarking reports comparing financial governance maturity against peers. A board-approved estates strategy and development control plan (DCP) setting out an affordable, realistic long-term capital programme aligned to NHS constitutional standards and reduction of the Cost Improvement Requirement (CIR). |
| 2. The Board and Finance Committee possess the necessary skills and experience to provide effective leadership, challenge and oversight of financial matters and all aspects of financial delivery, including the achievement of CIPs. The trust has an effective quality impact assessment (QIA) process and considers the impact of all financial and operational changes on the quality of care, supporting both current service delivery and long-term sustainability. | Board and committee training records and induction packs. Quality impact assessments are completed for major financial and operational changes. | Skills gap analysis, a structured board development programme, and succession planning to ensure the right mix of skills and capabilities for effective oversight of financial delivery, risk management, and capital scheme delivery. Forward planning of agendas for Finance Committee. Minutes showing challenge and meaningful discussion of financial matters and key financial risks, with clear timely decisions taken to address financial risks and performance issues. Quality impact assessments are embedded in planning cycles, with evidence of board-level oversight and feedback loops to adjust plans based on quality outcomes. |
| 3. The Board and Finance Committee receive timely, clear, and comprehensive reporting on the organisation’s financial performance and risks to support triangulation of board-level information, informed decision-making and responsiveness to early warning signs. | Finance reports provided to the board (for example, monthly IPR and CIP delivery reports). Exception reports highlighting financial risks and actions. Financial risks linked to operational and quality risks in the Board Assurance Framework. Minutes showing discussion of financial performance and risks. | Integrated performance reports (IPR) that enable effective triangulation of financial, operational, productivity, quality, and workforce data to inform decision-making. The Insightful Provider Board guidance provides high-level principles on presenting relevant and insightful information to the Board. Early warning indicators embedded in board reporting (such as liquidity, run-rate, CIP delivery risk). Reports demonstrating in-house and/or outsourced estates planning and delivery arrangements operating at sufficient scale for sustainability and high quality. Reports demonstrating how budgets will be used, how priorities for investment will be set, and how the impact of spending decisions on outcomes and inequalities will be monitored. Reports demonstrating successful delivery of recent major capital schemes, including project outcomes, timelines, and benefits achieved. |
Publication reference: PRN02325iv