1. This document provides practical information for trusts considering applying to the Advanced Foundation Trust Programme. It sets out:

• the eligibility criteria to apply to become an advanced foundation trust
• the assessment criteria to be met to be approved as an advanced foundation trust
• the assessment process, including the responsibilities of both applicants and NHS England
• the possible outcomes of the application and what they mean for the applicant

2. We will update the guide for applicants during 2027/28 to reflect learning from the assessments we undertake and any relevant framework and regulatory process changes. 

Eligibility criteria to apply to become an advanced foundation trust

3. Both high-performing NHS trusts and high-performing foundation trusts can apply to become advanced foundation trusts if they can demonstrate the following:

a. That they are delivering the public’s priorities and value for money, measured by being in the top 2 segments of the National Oversight Framework for the last 2 consecutive quarters.

b. That they are providing high quality care to patients, defined as:

1. 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 trust level 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.
2. 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.
3. Not being subject to support from the Maternity and Neonatal Improvement Support team.

c. That they have excellent leadership, measured by having a provider capability score of at least amber-green.

4. When we refer to a trust’s most recent trust level CQC assessment, this may have taken place under CQC’s current, future, or previous assessment frameworks. CQC have consulted on possible future changes to their assessment framework and methodology, including a return of aggregated quality ratings. The eligibility criteria above relating to CQC assessment will be kept under review to reflect any future changes to CQC’s approach. As set out in paragraph 41, NHS England will also verify with CQC if there are any material substantiated concerns in relation to a trust before a trust is invited to apply for assessment as an advanced foundation trust. Trusts must continue to meet all the eligibility criteria set out in paragraph 3 throughout the assessment process (in the absence of exceptional circumstances), to be approved as an advanced foundation trust.

5. Trusts seeking to apply for assessment as an advanced foundation trust will also need to demonstrate that their application is supported by their local integrated care board (ICB) and NHS England regional leads, as detailed in the assessment process below.

6. 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 trusts. However, the NHS England assessment team will seek to minimise duplication and, where relevant, will not replicate recent work already carried out on shared leadership and group governance.

Assessment criteria for approval as an advanced foundation trust

7The assessment process builds on existing NHS England regulatory frameworks and guidance, in particular the NHS Oversight Framework, Assessing Provider Capability self-assessment and the NHS Planning Framework. It is designed to test expectations for 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, putting patients and local communities at the heart of all they do.

8. 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, risk-based 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 recent regulatory reports and findings, existing frameworks, and other relevant existing evidence and knowledge wherever possible.

9. Applicants for advanced foundation trust status will be assessed against the 3 fundamental questions set out below, underpinned by more detailed assessment criteria as set out in annex 1, which is structured around the 6 domains set out in The Insightful Provider Board guidance and the Assessing Provider Capability guidance. These statements may be updated periodically to reflect feedback and to maintain alignment with the provider capability framework and other relevant framework and regulatory process changes.

10. In addition to meeting the assessment criteria, trusts are expected to maintain (in the absence of exceptional circumstances) performance against the eligibility criteria for applying to the Advanced Foundation Trust Programme, throughout the assessment period.

Assurance approach for advanced foundation trust assessment and integrated health organisation designation

11. The diagram below sets out how the advanced foundation trust assessment process will build on existing NHS England regulatory frameworks.

Assurance approach for the advanced foundation trust assessment

* i. “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. 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.

ii. 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

iii. Not subject to support from the Maternity and Neonatal Improvement Support team.

12. Organisations seeking to be designated as eligible to hold an integrated health organisation (IHO) contract, in addition to becoming an advanced foundation trust, will undergo further tests to assess readiness to take on an IHO contract. The additional review requirements which are set out in Advanced Foundation Trust Programme – guide for applicants: Annex 2 – advanced foundation trust status and applicants seeking integrated health organisation contracts will be further revised following the lessons learned from the first wave of IHO assessments. This revision will take into account consultation feedback. Advanced foundation trusts may also choose to undergo the additional IHO designation at a later stage.

Assessment process

Applicant responsibilities

A. Initiating the application

13. NHS England will monitor which trusts have met the eligibility criteria set out in paragraph 3. Trusts who believe they may be eligible and are interested in being considered for advanced foundation trust status should speak to their NHS England regional team. Regional teams will be responsible for considering any other relevant information to form a view of an eligible trust’s readiness to apply and will support national prioritisation of applicants for assessment.

14. For potential IHO designations, regional teams will also consider whether the trust has the organisational capabilities 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, including primary care, and ensure support from the ICB.

15. As set out in paragraphs 28 – 30 below, in some cases the assessment process may not start immediately.

16. Once they have received confirmed support from the relevant NHS England regional team and a confirmed start date for the assessment, trusts will need to submit the following to the NHS England assessment team to activate their application:

• signed board statement (see annex 1) and supporting memorandum setting out how the board has assured itself that each of the statements has been met, referencing the evidence the board has used
• statements of support from relevant ICB(s)

17. The assessment team will consider the medium-term financial plan submission already provided to NHS England, setting out how a recurrent position of at least break-even will be delivered within 3 years, as agreed with the relevant ICB(s) and NHS England region and reflecting the latest planning guidance. Depending on the timing of the assessment, if there are any material changes that have come to light since the agreement of the plan, the trust will need to set out how this impacts the assumptions and medium-term outlook.

18. As set out above, NHS trusts will not be expected to make their applications under the legislation to be authorised as a foundation trust until the proposed new legislation comes into force. Subject to the passage and coming into force of the proposed legislative changes, NHS trusts will 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.

19. 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 evidence

20. 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 where this is set out elsewhere, to avoid duplication.

21. The advanced foundation trust assessment process will be risk-based, seeking to avoid duplication and draw upon existing evidence as far as possible. The assessment team will review core evidence and hold core meetings for all applicants. This will include, but is not limited to:

• board statements and memorandum
• interviews and information provided by the ICB, CQC and NHS England regional teams
• underlying NHS Oversight Framework and performance data, model health system and staff survey
• review of existing information, including board and committee papers, risk registers, governance structures, internal audit reports
• reports from any relevant externally commissioned reviews, including where in draft form (for example, external Well Led assessments, independent reviews or patient safety investigations)
• assurance actions taken against clinical audit, including prevention of future death report actions, and staff survey reports
• medium-term plan submission
• provider capability self-assessment and digital maturity assessmentboard and committee observations
• “board to board” meeting between applicant board and senior NHS England and Department of Health and Social Care (DHSC) leadership.

22. Trusts will be provided with a detailed core information request list and informed of the procedure for submitting the required evidence via an online portal once an assessment slot and team have been confirmed. Further supporting evidence may be required where material risks are identified in specific areas during the course of the assessment.

23. Information that has already been provided to other teams in NHS England will not need to be re-submitted. The NHS England assessment team will obtain routinely submitted trust performance information from NHS England regional teams.

24. Prior to approval, applicants will need to provide a management 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.

C.  Working with NHS England

25. The NHS England assessment team aims 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.

26. 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.

27. Applicants must inform the NHS England assessment team of any changes that occur during the assessment process that significantly impact:

• leadership arrangements
• material changes to services
• governance arrangements (including finance and quality)
• financial plan assumptions
• financial viability

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 material contracts.

NHS England responsibilities

Prioritisation of potential applicants based on capacity

28. 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.

29. If the number of eligible trusts exceeds the available assessment slots, it may be necessary to batch applicants to inform the assessment timetable.

30. NHS England will confirm to an applicant the timetable for assessment. We will aim to minimise delays to the start of an assessment.

Planning the process timetable

31. 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.

32. The NHS England assessment team will maintain regular contact with applicants throughout the assessment process. If the assessment team 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.

33. 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)

34. 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, with a focus on population health, prevention and reducing health inequalities.

35. For NHS trust applicants, post the planned legislative change, 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

36. During the assessment process, key personnel from the trust may be interviewed (a high-level agenda will be provided in advance). This may include:

• board
• finance team
• quality and patient experience leads
• governance leads
• clinical directorate leads
• focus groups with consultants and senior clinicians
• where applicable, for existing foundation trusts, representative(s) from the Council of Governors  

37. The assessment team may also observe the board meeting and main committee meetings, such as the quality, people and finance committees.

Engagement with patients, the public and other key stakeholders

38. 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 existing arrangements with their membership and Council of Governors and 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.

39. The review will include assessment of how the trust seeks to understand and respond to patient and service-user feedback (including complaints), and then acts upon it, in partnership with people and communities, for example, through face-to-face patient stories and discussions, video diaries, board member service visits and patient shadowing, with regard to relevant national frameworks and good practice guidance.

40. As above, the assessment team will engage with the CQC and relevant ICB(s) and may engage with other relevant external bodies and other parties, including but not limited to:

• other significant commissioners, integrated care system (ICS) partners and wider stakeholders, including where applicable, local Healthwatch
• internal auditors
• local system and provider collaborative 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.

Engagement with CQC

41. The assessment team will include consideration of 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 3). NHS England will also verify with the CQC if there are any material substantiated concerns in relation to a trust before a trust is invited to apply for assessment as an advanced foundation trust.

42. The assessment team will discuss the applicant with CQC during the assessment process, review CQC reports and consider the most current information CQC hold about the provider, which includes patient feedback. The assessment team will receive a letter from CQC prior to deciding on whether to approve the trust as an advanced foundation trust. The CQC letter will detail the information that the CQC currently holds on the provider based on its regulatory activities and will make clear the significance of that information in the context of the application.

43. If any issues are raised in the assessment process or through our engagement with CQC 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

44. 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

45. 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.

46. 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.

47. 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

48. At the start of the meeting, applicants will be asked to make a brief presentation that may 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 works in partnership with them
• the trust’s key opportunities, challenges, strengths and weaknesses linked to the trust’s key objectives, clinical and financial sustainability and approach to continuous improvement
• how the trust successfully puts patient and public voice, and staff involvement and experience at the heart of its decision-making
• 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

49. 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

50. The applicant trust’s executive board members and a subset of its non-executive board members will be expected to attend. One observer from the trust may also attend, for example, the board secretary or project manager. The assessment team will also attend.

51. Representatives at the board-to-board meeting will include the director in charge of advanced foundation trust assessment and a subset of NHS England Board members. Post-abolition of NHS England, it will include individuals drawn from a panel of independent members, as described in paragraph 52.

Decision making

52. The NHS England Board will decide the outcome of applications on the advice of a panel, which will be a subset of Board members, who will have received a recommendation from the assessment team towards the end of the assessment process. Post-abolition of NHS England, subject to the will of Parliament on the new legislation, decisions will be made by Ministers on the advice of a newly established panel of independent members. 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

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

• approval – for NHS trusts, this means approval as a prospective advanced foundation trust. They will be able to benefit from the advanced foundation trust freedoms set out in the Advanced Foundation Trust Programme Policy Framework. As set out in paragraphs 26 to 27 of the policy framework, 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

54. 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 guide, the advanced foundation trust will be able to exercise the freedoms and flexibilities set out in the Advanced Foundation Trust Programme Policy Framework.

Approval of NHS trusts

55. 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 in the Advanced Foundation Trust Programme Policy Framework. As set out in paragraphs 26 to 27 of the policy framework, 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).

56. 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

57. 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

58. 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.

59. 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.

60. 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.

61. 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.

66. 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

67. 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.

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

69. 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 assessment criteria and board statements are applicable to all aspiring advanced foundation trusts (including acute, mental health, community, ambulance, and specialist trusts). 

• Assessment criteria, board statements and supporting evidence

Publication reference: PRN02168iii