Executive summary

1. This document is written for existing NHS foundation trusts and NHS trusts who wish to apply to become advanced foundation trusts under our revitalised Advanced Foundation Trust Programme. It has been developed with input from the sector and is being released for consultation.

2. Advanced foundation trusts will be the new marker of excellence used by high-performing foundation trusts and NHS trusts which pass an updated assessment process and benefit from substantial additional freedoms. Freedoms will include a fundamentally different relationship with the centre, greater strategic and operational autonomy, a capability-based approach to regulation, and greater financial flexibilities.

3. Only highest performers will be able to apply for the advanced foundation trust status. To be eligible providers will need to show: 

• That they are delivering the public’s priorities and value for money (as measured by the NHS Oversight Framework)
• That they are providing high quality care to patients (as measured by the Care Quality Commission (CQC) ratings) 
• That they have excellent leadership (as per their Provider Capability Assessment) 

4. NHS England will assess providers that meet these criteria and have NHS England Regional team and integrated care board (ICB) support. As this is a reinvention of the Foundation Trust model for modern time, our process will look at how well a trust works with others and their plans to help deliver the three shifts set out in our 10 Year Health Plan. It will also examine in more depth leadership, quality governance, and financial sustainability. We will work with the CQC as part of this process, with decisions supported by an independent panel. All advanced foundation trusts will be re-assessed every 5 years at a minimum. 

5. Through the revitalised Advanced Foundation Trust Programme we hope to lift standards across the NHS.

6. The rest of this document sets out: 

• why we are revitalising the foundation trust model through the Advanced Foundation Trust Programme and what this means for existing foundation trusts and NHS trusts 
• what freedoms and flexibilities advanced foundation trusts will exercise 
• the eligibility and assessment criteria to apply to become an advanced foundation trust  
• the assessment process, including the responsibilities of both applicants and assessors  
• the possible outcomes of the application and what they mean for the applicant  
• the regulatory arrangements of advanced foundation trusts  
• the arrangements for advanced foundation trusts seeking designation to be able to hold integrated health organisation (IHO) contracts

7. Throughout this document, the term ‘trust(s)’ refers collectively to both existing NHS foundation trusts and NHS trusts. Eligible trusts interested in advanced foundation trust status should contact their NHS England regional team. We will update this guide to reflect learning from the assessments we undertake during 2027/28. 

Rationale for the Advanced Foundation Trust Programme

8. As set out in the government’s 10 Year Health Plan, we will get the NHS back on its feet is by redistributing power to the frontline: to providers, clinicians, staff, and most importantly, patients and local communities. We will reward and incentivise good performance and re-establish the principle of earned autonomy, which drove substantial improvements in the 2000s. 

9. At the forefront of this will be a reinvigorated and reinvented foundation trust model. Advanced foundation trusts will make use of the foundation trust legal form and maintain the core philosophy of the original policy: that well-governed, capable and entrepreneurial boards are best placed to respond to the needs of their communities and deliver improved care, but the focus and ethos of advanced foundation trusts will be different. 

10. Becoming an advanced foundation trust will not be about exercising greater autonomy for its own sake. Instead, advanced foundation trusts will be excellent organisations because of how effectively they use their freedoms to work with their patients, staff and communities, partners to improve the broader health of their population and tackle health inequalities. This will include playing a leading role in delivering the 3 shifts: from hospital to community, from analogue to digital, and from sickness to prevention.  

11. Trusts which engage in narrow, organisationally focused behaviours or prioritise status over care quality and what is best for local communities will not pass our advanced foundation trust assessment. It is important we learn the lessons from the original foundation trust programme, including the appalling failures at Mid Staffordshire NHS Foundation Trust and Liverpool Community Health NHS Trust where organisations lost sight of their core purpose. We must ensure that quality is not compromised in the pursuit of becoming an advanced foundation trust. Our expectations, regulation and assessment of advanced foundation trusts reflects this. This is a new model for the 21st century.

12. Our intention is that by 2035 all trusts have become advanced foundation trusts so that all communities, including those with the highest needs and inequalities, are served by highly capable, innovative, and people-focused organisations. We are therefore committed to supporting multiple waves of applicants in the coming years.

Advanced foundation trust freedoms and flexibilities

13. Advanced foundation trusts will benefit from 3 core freedoms: strategic and operational autonomy, a capability-based regulatory approach from NHS England and greater financial flexibility. They may also play a more substantial leadership role locally and nationally, supporting improvement in challenged organisations.

14. On strategic and operational autonomy, advanced foundation trusts will continue to follow the medium term planning framework and core national policies and frameworks.  

15. Beyond this, our approach to advanced foundation trusts will be characterised by a different relationship with the centre and regions, which will be driven by our confidence in the leadership and capability of the provider. This approach will look to free up and preserve advanced foundation trust management bandwidth to focus on delivery, local priorities and innovation. We have heard loud and clear from trusts how performance management and new asks from the centre can eat into precious management and leadership bandwidth. This will need to change, and we will look to ingrain this new way of working into our future operating model.

16. An example of this will be a new, more strategic approach to annual planning. While regions will still agree annual plans with advanced foundation trust boards, these conversations will be primarily strategic in nature. Subsequent oversight will be light touch and, while regions will monitor delivery, plans will not be revisited unless significant issues suddenly emerge or there is longer term deviation from agreed plans requiring a reforecast or replan. Regions will continue to engage advanced foundation trust in broader discussions about transformation and system-wide change. Over time we expect providers to have significant autonomy from the centre, with much greater emphasis on local accountability.  

17. Our capability-based regulatory approach to advanced foundation trusts will be built around 3 principles.

• Consistency with the broader NHS: The NHS Oversight Framework (NOF) and league tables will continue to apply to advanced foundation trusts, as well as being core to both eligibility and assessment criteria. They will be also subject to the same core national expectations as other trusts, as well as their contractual requirements with ICBs. They will be overseen by NHS England regional teams.
• More time to address performance issues where they arise: advanced foundation trusts will demonstrate strong leadership and a track record of delivery with a green or amber-green capability rating. Learning from the approach adopted by Monitor, our view of capability will subsequently play a greater role in our regulatory approach towards advanced foundation trusts. For instance, where performance issues arise (for example, an advanced foundation trust moves from Segment 1 to 3), we will generally allow advanced foundation trusts greater time and flexibility to address issues prior to requesting further assurance, monitoring or intervention. Our approach will seek to avoid micromanagement, empower boards and grant leadership teams the space needed to manage operational challenges. Advanced foundation trusts will be expected to be transparent about emerging issues, for example, with regulators and the public.
• Dynamic and rules-based: Building on lessons from the original foundation trust policy, we will also give boards greater clarity on what is expected of them, including our triggers of capability concerns and the processes by which we will escalate them. Where necessary, evidence-based judgement will inform our response to any potential intervention or restrictions on advanced foundation trust freedoms. Advanced foundation trust status will also not be static, with the possibility of removal where standards and, critically, provider capability drop.

18. All advanced foundation trusts will be subject to re-assessments every 5 years to incentivise continuous improvement, or earlier if triggered by a material and ongoing deterioration in delivery, capability, or both. Further details including our rules-based regulatory approach will be outlined as part of the 2026/27 oversight framework (see note 1 below).

Note 1: advanced foundation trusts will continue to be responsible for delivering their contractual obligations set out in NHS Standard Contracts, national primary care contracts or other contracts with local authorities, including the terms of payment in accordance with the NHS Payment Scheme and NHS Business Rules.

19. On financial flexibilities, advanced foundation trusts will benefit from:

• capital flexibility: the ability to retain and reinvest aggregate revenue department expenditure limit (RDEL) surplus (excluding any Deficit Support Funding) accumulated since 2024/25 in future capital projects
• capital autonomy: this will be supported by greater capital autonomy for all NHS Oversight Framework (NOF) segment 1 and 2 trusts, with no need for business case approval for up to £100m capital department expenditure limit (CDEL) spend, where trusts are using their own operational capital,  and/or capital flexibility
• revenue flexibility: revenue flexibilities limited to non-recurrent spending to support implementation costs linked to capital investment and transformation. As with capital, this will allow the reinvestment of aggregate RDEL surpluses, excluding deficit support, accumulated since 2024/25, subject to the provider having corresponding cash reserves

20. Advanced foundation trusts will be required to set out as part of financial planning what use they intend to make of capital and revenue freedoms each year, with agreement dependent on demonstrating a recurrent underlying break-even or surplus position, and to report on forecast use of freedoms in monthly reporting.

21. Furthermore, as highly capable organisations, we also expect advanced foundation trusts to benefit from a greater leadership role locally and nationally. This may mean:

• consideration for holding an integrated health organisation (IHO) contract, as set out in Annex 2
• playing a lead role at system level, where appropriate and in keeping with the strategic commissioning plan of their ICBs – at neighbourhood level or in leading strategy, transformation or improvement programmes, for example, across pathways or across several providers (ICBs will retain a legal duty to instigate major service change)
• working locally, regionally and nationally to share best practice and innovation
• supporting improvement work at other local providers where appropriate

22. These freedoms and flexibilities will be a starting point as of 2026/27, with our ambition to embed them into our new operating framework and to expand this over time.

Assessment criteria

23. Given the greater freedoms and responsibilities, and associated risks, that come with fully exercising advanced foundation trust freedoms and holding an IHO contract, only high-performing and capable trusts will be considered.

24. As with the original foundation trust process, we have distinguished between:

• the eligibility criteria trusts are required to meet to apply and be considered for approval as an advanced foundation trust (covered in paragraph 29 below)
• the “bar” for approval which trusts will be assessed against during the subsequent advanced foundation trust assessment process (criteria in Annex 1)  

Meeting the bar for approval: implications for legal status

25. An existing foundation trust that meets the eligibility criteria to apply to become an advanced foundation trust and successfully meets the “bar” for approval, tested through the assessment process set out in this publication (criteria in Annex 1), will be approved as an advanced foundation trust and gain the associated freedoms.

26. An NHS trust that meets the eligibility criteria and successfully undergoes the advanced foundation trust assessment process will gain access to the same advanced foundation trust freedoms and flexibilities as set out in this publication. They will subsequently be expected to apply under the legislation formally to convert to foundation trust legal form, subject to meeting the legal requirements set out in the Approval section below. Once they convert to foundation trust legal form, they will be able to benefit from the additional freedoms and flexibilities for foundation trusts as set out in the legislation.

27. Under the proposed legislative changes outlined in the 10 Year Health Plan, subject to the will of Parliament, the requirement for foundation trusts to have councils of governors will be removed. We want to avoid NHS trusts being authorised as foundation trusts with councils of governors in place to meet current legislative requirements, only for these to be removed when the legislative changes as proposed. Therefore, NHS trusts that are assessed and approved under the advanced foundation trust policy prior to the proposed legislative changes coming into effect, will not be authorised immediately. NHS trusts will receive confirmation that they have been assessed as having met the requirements to be approved as an advanced foundation trust, but they will not be expected to make their applications under the legislation to become authorised as a foundation trust until a later date, following the proposed new legislation coming into force. When they make their applications to be authorised as a foundation trust under the new legislation, NHS trusts will need to submit further information, including an appropriate proposed constitution (aligned to a model constitution which has been updated to align with the new legislation). There will need to be confirmation that there has been no material reduction in performance or capability concerns identified which mean that the authorisation is not appropriate.  

28. Organisations seeking to become an advanced foundation trust, as well as a designation to hold an IHO contract in the future, will undergo additional tests to assess readiness to take on an IHO contract. Advanced foundation trusts may also choose to undergo the additional IHO assessment at a later stage.

Eligibility criteria to apply to become an advanced foundation trust

29. Both high-performing NHS trusts and existing high-performing foundation trusts can apply to become advanced foundation trusts if they can demonstrate:  

• that they are delivering the public’s priorities and value for money: In the top 2 segments of the NHS Oversight Framework for 2 consecutive quarters
• that they are providing high quality care to patients: A “good” or “outstanding” Care Quality Commission (CQC) rating from the trust’s most recent CQC Well Led assessment, with no site or service rated inadequate by CQC 
• that they have excellent leadership: A provider capability score of at least amber-green

30. CQC assessments of trusts are currently focused on trust-level leadership through assessment of the Well Led key question at trust level, alongside their view of quality and performance across an organisation. CQC do not currently award an aggregated rating to trusts for their safety, effectiveness and responsiveness or how caring they are, but CQC still publishes those ratings for the services they provide. CQC have been consulting on changes to their assessment framework and methodology; the eligibility criteria above relating to CQC assessment will be kept under review to reflect any future changes to CQC’s approach, including assessment timescales.

31. Trusts seeking to apply for assessment as an advanced foundation trust will need to demonstrate that their application is supported by their local ICB(s) and NHS England region system leaders, as detailed in the assessment process below.

32. Trusts that are part of a group model, which can potentially include shared leadership and shared governance, will need to demonstrate eligibility and apply as separate legal entities to be approved as advanced foundation trust. However, the NHS England assessment team will seek to minimise duplication and, where relevant, will not replicate work already carried out on shared leadership and group governance.

Assessment criteria for approval as an advanced foundation trust

33. The assessment process builds on existing NHS England regulatory frameworks, in particular the NHS Oversight Framework, Assessing Provider Capability self-assessment and the Planning Framework, and adds to these to reflect expectations for the most high-performing trusts, including contribution to national priorities in the 10 Year Health Plan and effective plans to use the expected autonomy and freedoms that will be available to advanced foundation trusts.

34. The assessment process is intended to be collaborative and supportive. It incorporates learnings from the original foundation trust process and will take a more streamlined approach, recognising sectoral differences where relevant and seeking to avoid an overly bureaucratic process. We aim to minimise duplication for applicants by relying on information from existing frameworks, evidence and knowledge wherever possible. 

35. Applicants for advanced foundation trust status will be assessed against the 3 fundamental questions set out below, underpinned by more detailed assessment criteria structured around the 6 domains set out in The Insightful Provider Board guidance and the Assessing Provider Capability guidance.

Table 1: Summary of key assessment criteria

36. Applicant boards will need to certify that they meet the assessment criteria using the detailed board statements set out in Annex 1. Alongside this, trusts will be required to submit a supporting memorandum setting out how the board has assured itself that each of the statements has been met. The supporting memorandum may refer to available evidence set out elsewhere, to avoid duplication, or detail evidence itself where this is not otherwise available.  

37. Assessment will involve a core approach for all applicants and based on an initial assessment, may require targeted further work in certain areas. It is intended to be fair, proportionate and developmental, encouraging providers to improve to meet the bar for approval.

38. The assessment team will review core evidence and hold core meetings for all applicants. This will include:

• board statements and memorandum
• interviews and information provided by the ICB, CQC and NHS England regional teams
• underlying NOF and performance data, model hospital and staff survey
• review of existing information, including board and committee papers, risk registers, governance structures
• medium-term plan and financial submission
• provider capability self-assessment and digital maturity assessment
• board and committee observations
• “board to board” meeting between applicant board and senior NHS England and Department of Health and Social Care (DHSC) leadership.

39. The assessment team will provide a detailed information request list to inform trusts of core evidence submission requirements and enable them to prepare their application once they have met eligibility criteria and their application is supported by NHS England’s regional team.

40. Further work will be carried out where the core review indicates it may be needed, and the assessment team may request additional evidence referred to in the board memorandum as required.

41. Annex 2 sets out the additional review requirements for applicants seeking IHO designation in 2026/27 with regards to the capabilities specifically linked to holding an IHO contract. We plan to revise these criteria following the development of the first IHO contracts to incorporate early learnings and reflect evolution of the model.

42. The diagram below sets out how the advanced foundation trust assessment process and the assessment process for IHO designation will build on existing NHS England regulatory frameworks.

Assurance approach for advanced foundation trusts assessment and IHO designation

Download a PDF of the above diagram.

Assessment process

Applicant responsibilities

A. Initiating the application

43. NHS England regional teams will confirm which trusts have met the eligibility criteria set out in paragraph 29 and will be responsible for assessing a trusts readiness to apply to become an advanced foundation trust, taking into consideration:

• the details of the NOF segmentation and underpinning metrics, CQC view and provider capability assessment
• existing local knowledge, including patient and local community feedback and third-party information on board capability; governance; quality of care; financial sustainability; productivity and efficiency; and commitment to partnership working, population health, reducing health inequalities, and neighbourhood health services (see note 2)

Note 2: The neighbourhood health service is outlined further in chapter 2 of the 10 Year Health Plan and is marked by moving care outside of hospital settings and convening professionals into patient-centred teams to reduce fragmentation.

44. For potential IHO designations, regional teams should also consider whether the trust has the organisational maturity and necessary leadership and relationships to take on responsibility for improving population health outcomes and driving the shift of care into the community. They should also consider the trust’s capability to manage financial risks and the likelihood of support from system partners across health and local government.

45. Once they have received support from the NHS England regional team, trusts will need to submit the following to the NHS England assessment team to activate their application:

• an application letter from the trust chief executive
• statements of support from relevant ICB(s)
• medium-term financial plan submission, setting out how a sustainable surplus will be delivered within 3 years, as agreed with the relevant ICB(s) and NHS England region and reflecting the latest planning guidance
• signed board statement (see Annex 1) and supporting memorandum setting out or referencing the evidence the board has used to assure itself that each of the statements has been met

46. As set out above, subject to the passage and coming into force of the proposed legislation changes, NHS trusts will also need to provide the proposed constitution of the advanced foundation trust, based on the requirements for the constitution set out in the NHS Act 2006 which may be amended by the proposed legislative changes (in particular this may include the removal of the need for a council of governors). A model draft constitution will be available from the NHS England assessment team, which will reflect any revised requirements that are passed through Parliament.

47. Potential advanced foundation trust applicants that are also contemplating a statutory transaction should let the NHS England assessment team know early in the planning of the transaction. As there is likely to be significant overlap in the areas being reviewed, and the same team within NHS England will carry out the reviews, we will seek to align the transaction assurance and advanced foundation trust assessment processes where possible, to reduce the burden on providers. Trusts considering undertaking a statutory transaction should consult our transaction guidance.

B. Providing documentary evidence

48. In addition to the specific submissions listed above in paragraph 43, the assessment team will request relevant core pre-existing supporting documents (including where in draft form) as described in Annex 1, many of which trusts will also use for their provider capability self-assessment and planning guidance submission. The examples below are illustrative of the type of evidence the assessment team will look at:

• internal audit reports
• board or board committee papers
• the Board Assurance Framework
• reports from any relevant externally commissioned reviews (for example, external Well Led assessments, independent reviews or patient safety investigations – such as Academy of Medical Royal Colleges invited reviews – and assurance actions taken against clinical audit, including prevention of future death report actions and staff survey reports)

49. Applicants will need to provide a board-approved letter of representation before NHS England makes its decision on whether to approve the trust as an advanced foundation trust, which will confirm that the trust has provided all relevant information to NHS England (see Annex 1).

50. As part of our evidence review, the assessment team will also use existing data from other sources, including, for example, model health system data and insight and qualitative intelligence from regional quality meetings and ICB system quality groups.

51. Trusts will be provided with a detailed information request list and informed of the procedure for submitting the required evidence once an assessment slot and team have been confirmed.

C. Working with NHS England 

52. The NHS England assessment team will endeavour to work with applicants in a collaborative and flexible way. This will include giving appropriate notice for meetings and information requests. To allow the process to run in a timely and efficient way, applicants will need to meet agreed deadlines for submissions and respond to additional information requests in a timely manner.

53. The assessment process will require the involvement of trust senior management. Trust staff (including executive and non-executive directors) will need to make themselves available to attend and participate in meetings with NHS England as required. This includes participation in a meeting of the trust board with the senior leadership of NHS England (see board-to-board meeting section below). It is advised that trusts plan and prepare accordingly to ensure they have sufficient resources to cope with these extra demands.

54. Applicants must inform the NHS England assessment team of any changes that occur during the assessment process that significantly change your:

• financial plan assumptions
• financial viability
• governance arrangements
• material changes to services

Examples may include (but are not limited to) changes in key personnel, never events or any other significant quality concerns with services or the delivery of care, deterioration in the financial position or a loss of contracts.

Assessor responsibilities

Prioritisation of applications based on capacity

55. It is the intention that by 2035 all providers will have become advanced foundation trusts. There will therefore be an ongoing programme of work to assess trusts’ readiness to be approved as an advanced foundation trust. We expect regular assessment slots using this guidance to be available from 1 April 2026 onwards.

56. If there is an available slot, the assessment will start immediately upon receipt of application by an eligible candidate. If significant issues arise, NHS England may postpone the assessment to allow the trust sufficient time to address those issues.

57. If the number of applicants exceeds the available assessment slots, it may be necessary to batch applicants to inform the assessment timetable. This will aim to identify any issues that may delay the assessment process and could lead to deferral, or rejection (see outcomes section below) based on the main drivers of these outcomes in the past.

58. Interviews will be carried out with the chief executive and selected directors of each applicant, and with third parties as required (for example, commissioners, CQC and others).

59. This process will result in a letter to the applicant confirming the timetable for assessment. If a delay is required, NHS England will include details of any potential issues identified. We will aim to minimise delays to the start of an assessment.

Planning the process timetable

60. The overall timetable will vary depending on the organisation. However, it should be assumed that the process from the time of application by the trust to a decision being made will take a minimum of 4 months. An indicative timeline has been set out in Table 2 below.

61. The NHS England assessment team will maintain regular contact with applicants throughout the assessment process. If we do not receive the required standard of documentation by the agreed timescales, the assessment team may need to pause its assurance work until this is addressed.

62. NHS England will meet with the applicant’s board to discuss key risks approximately 3 months after the assessment starts if, based on an analysis of the outstanding issues, we believe we will be able to make a decision on the application within a month of that meeting (see board-to-board section below).

Table 2: Indicative timeline for the advanced foundation trust assessment process

Preparation period

Assessment process (approximately 3 months)

Approval (approximately 1 month)

Download a PDF of the above timeline.

Assigning a team

63. NHS England will assign an assessment team to each applicant. This team will be the first point of contact for queries.

Risk assessment and scoping

64. The NHS England assessment team will scope the assurance work of each review according to an initial assessment of risk and trust performance. The team may ask for submission of specific evidence and perform focused pieces of detailed assurance work to support some, or all the assertions made in the board statements (see Annex 1) based on consideration of the detail included in the supporting memorandum. 

Reviewing submissions

65. During the assessment process the team will review the applicant’s submissions, triangulating with third-party data and following up with targeted activities such as board and committee observations, staff and stakeholder meetings, and a final board-to-board meeting. The assessment team may request further information to support our conclusions.

66. The assessment team will seek assurance that applicants’ plans are closely aligned with relevant ICB strategies, system working, quality and population health plans, financial plans and national strategies and frameworks.

67. For NHS trust applicants, NHS England will review the trust’s draft constitution and determine whether it meets the necessary requirements prior to authorisation as a foundation trust.

Interviewing trust personnel

68. During the assessment process, key personnel from the trust may be interviewed (a high-level agenda will be provided in advance). The assessment team will contact the applicant at the beginning of the assessment process to indicate who they wish to interview. This may include:

• board
• finance team
• quality and patient experience leads
• governance leads
• clinical directorate leads
• focus groups with consultants and senior clinicians

69. The assessment team may also observe the board and main committees, such as the quality, people and finance committees.

Engagement with key stakeholders

70. Fundamental to the review, the assessment team will seek to understand the trust board’s arrangements in relation to active engagement with patients and service-users, carers (including unpaid), staff, volunteers, and the local community. For existing foundation trusts, this should include plans for how arrangements will change if proposals to remove the requirement for foundation trusts to have a council of governors are enacted, subject to the will of parliament. The assessment team will consider whether their views and feedback on experience of care are listened to and acted upon, to co-produce delivery of improvements on an ongoing basis, including during the design of new pathways and processes.

71. The review will include assessment of how regularly and how intelligently patient and service-user feedback, including complaints, is interrogated and then acted upon by the applicant working in partnership with people and communities. The assessment team will also look at the approaches the board is using to “bring patients into the board room”, for example, face-to-face patient stories and discussions, video diaries, board member service visits and patient shadowing.

72. The assessment team will engage with other relevant external bodies and other parties, including but not limited to:

• CQC
• relevant ICB(s)
• other significant commissioners, integrated care systems (ICS) partners and wider stakeholders
• internal auditors
• local system partners
• relevant local patient focus or engagement forum and groups
• Members of Parliament and other relevant elected officials

The assessment team may also gather feedback on applicants through existing information sharing arrangements, for example the National Quality Board and regional clinical and quality improvement groups.

Taking account of CQC’s judgement

73. The assessment team will place reliance on CQC’s regulatory judgement as part of the criteria trusts are required to meet to apply for approval as an advanced foundation trust (see paragraph 27).

74. Prior to the start of our assessment, the assessment team will ask the CQC if they are aware of any reason a trust should not be considered for approval as an advanced foundation trust.

75. The assessment team will discuss the applicant with CQC during the assessment process, review CQC reports and consider CQC’s continuous intelligence monitoring of the provider. The assessment team will receive a letter of assurance from CQC prior to deciding on whether to approve the trust as an advanced foundation trust, which will set out CQC’s overall view and risks regarding the applicant. For applicants where site or service level CQC reports are significantly dated or rated ‘Requires Improvement’, the letter of assurance will include CQC’s view based on continuous intelligence monitoring of the provider.

76. If any issues are raised in the assessment process or through the CQC’s feedback that may impact quality or add risk relating to the decision to approve a trust as an advanced foundation trust, the assessment team may decide to postpone this decision until the specific matters are satisfactorily addressed.

Reviewing third-party reports

77. The assessment team will request from the applicant trust access to relevant third-party reviews, for example, well-led reviews or quality governance assessments. This includes reports at the draft stage.

Convening the board-to-board meeting 

78. Each applicant will be given the opportunity to discuss the key risks found by the assessment process with NHS England at a board-to-board meeting. This meeting will allow the applicant trust to present its perspective on the gathered information, helping to inform the decision NHS England reach.

79. The assessment team will advise the trust of the key areas for discussion before the meeting. These will be issues that have the potential to lead, in their own right or together with other issues, to concerns around the approval of a trust as an advanced foundation trust.

80. The board-to-board meeting will give the applicant’s board the opportunity to respond to the issues raised. It is also a forum for NHS England to ask questions about the applicant’s medium-term strategy.

Presentation at the board-to-board meeting

81. At the start of the meeting, applicants will be asked to make a brief presentation that summarises the trust’s external opportunities and challenges, linked to clear objectives, its internal strengths and weaknesses and how the trust intends to use its advanced foundation trust freedoms. This should include:

• the trust’s local health landscape, including key patient, health inequalities and population drivers, other providers in the local health economy and how the trust is working in partnership with them
• the trust’s assessment of its own position with regard to financial and clinical sustainability
• the trust strategy, including showing how it will contribute to the 3 shifts in the 10 Year Health Plan (from hospital to community, from analogue to digital and from sickness to prevention) using their advanced foundation trust freedoms

82. The presentation will be followed by questions, in relation to the areas of concern shared with the applicant before the meeting.

Attendees at the board-to-board meeting

83. The applicant’s executive and non-executive board members are expected to attend, including non-voting executives who normally attend the trust board meeting and any associate non-executive directors. One observer from the trust may also attend, for example, the board secretary or project manager. The assessment team will also attend but will not participate.

84. Representatives at the board-to-board meeting will include the director in charge of advanced foundation trust assessment, NHS England executives and individuals drawn from the panel of independent members referred to below.

Decision making

85. Towards the end of the process, the assessment team will make a recommendation to a panel of independent members that will formally consider the application. When making a recommendation to approve the applicant as an advanced foundation trust, the assessment team will consider conclusions against all board statements in the round and in the context of an overall assessment of whether a trust is ready to be approved as an advanced foundation trust. A decision may be made to approve, defer or reject an application.

Possible outcomes

86. The possible outcomes for the advanced foundation trust assessment process are:

• approval (for NHS trusts this means approval as a prospective advanced foundation trust and they will be able to benefit from the advanced foundation trust freedoms set out in this document. As set out in paragraphs 26 to 27, they will subsequently be expected to apply under the legislation to convert to foundation trust legal form).
• deferral
• rejection

Approval

Approval of existing foundation trusts

87. If an existing foundation trust is approved as an advanced foundation trust, NHS England will confirm this to the applicant formally by letter and send a copy to the relevant ICB. Once the foundation trust has been approved through the assessment process set out in this document, the advanced foundation trust will be able to exercise the freedoms and flexibilities set out above.

Approval of NHS trusts

88. An NHS Trust that meets the eligibility criteria and successfully undergoes the advanced foundation trust assessment process will gain access to the same advanced foundation trust freedoms and flexibilities set out above. As set out in paragraphs 26 to 27, they will subsequently be expected to apply under the legislation formally to convert to foundation trust legal form, subject to meeting the legal requirements to become a foundation trust (including a proposed constitution that meets the requirements set out in Schedule 7 of the NHS Act 2006 and is otherwise appropriate).   

89. If it is decided, following the new legislation coming into effect (assuming passage through Parliament), that an NHS trust meets the legal criteria to become a foundation trust and a decision is taken to authorise an NHS trust as a foundation trust, the applicant trust will be:

• notified formally by letter and a copy will be sent to the relevant ICB
• issued with an authorisation confirming that it has attained foundation trust status. This letter will be accompanied by a single schedule, which will be the trust’s constitution as approved
• issued with a new provider licence in the name of the foundation trust

Side letters

90. Sometimes an applicant will satisfy the requirements to be approved as an advanced foundation trust, but the application process may uncover some matters that need to be addressed quickly. In these cases, NHS England will approve the applicant and may send a side letter detailing the matters that it must address, within a specified timeframe where appropriate.

Deferral

91. Where neither approval nor rejection is appropriate, NHS England may decide to defer an application. We will only do this if the outstanding issues preventing a successful application can be satisfactorily resolved by the applicant within a reasonable timeframe.

92. NHS England will set the length of a deferral and give the end date of the deferral period in the decision letter to applicants, along with the actions or conditions that need to be met before the application can be approved. The deferral period will usually not exceed 12 months.

93. If the applicant believes it will not be able to reactivate its application on or before the specified end date of its deferral, it should discuss this with the NHS England assessment team as soon as possible. The assessment team may treat an application as withdrawn if it is not reactivated in time and the delay has not been discussed.

94. When deferred applicants believe they are in a position to request a reconsideration of their application, they should write to the NHS England assessment team. They will need to demonstrate that the issues triggering the deferral have been satisfactorily resolved.

95. On receiving a reactivation request, the assessment team will let the applicant know what information it needs to submit, and what further meetings are required. This will depend on the issues identified in the decision letter and the timing of reactivation.

Rejection

96. If NHS England decide to reject an application, the applicant will be formally notified by letter and a copy will be sent to the relevant ICB. The letter will set out the areas where the application fell short of the assessment criteria.

97. The assessment team will also give a formal debrief to the trust of the reasons for the rejection.

98. If an unsuccessful applicant wishes to reapply at a future date, it will need to meet the criteria set out in this guide and will have to go through the application process from the beginning, starting with:

• gaining NHS England regional support for the new application
• making a new application to NHS England

Annex 1: Assessment criteria, board statements and supporting evidence

This annex sets 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 advanced foundation trust assessment process seeks to avoid duplication and will draw upon existing evidence as far as possible. 

• Assessment criteria, board statements and supporting evidence

Annex 2: Advanced foundation trust status and applicants seeking integrated health organisation contract

This annex outlines the additional criteria and evidence that will be required to support advanced foundation trusts wishing to be assessed and designated as an integrated health organisation (IHO) so that they can take on an IHO contract.

• Advance foundation trust status and applicants seeking integrated health organisation contract

Publication reference: PRN02168i