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 advanced foundation trust assessment assessment process seeks to avoid duplication and will draw upon existing evidence as far as possible. The process will take into consideration a variety of supporting evidence that will include:
a) evidence that the trust already holds as part of business as usual, to assure itself that it is compliant with good practice and regulatory frameworks, such as the Insightful Board, Provider Capability Assessment, Medium Term Planning and NHS financial oversight
b) limited additional evidence and submissions that aspiring advanced foundation trusts will need to develop specifically for the advanced foundation trusts application process
c) interviews with trust staff and leadership
d) interviews and supporting submissions from third parties, such as CQC, ICBs and system partners and stakeholders
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 detail or reference the evidence the board has used to assure itself that it is in a position to sign off the board statements. To avoid duplication, the memorandum may reference evidence available in separate documents (for example, 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 2 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. Trusts should themselves consider what evidence is appropriate for their own assurance that the board statements have been met.
The NHS England assessment team will provide a detailed core information request list to inform trusts of evidence submission requirements once they have received support from the NHS England regional team to proceed with preparing their application. The NHS England assessment team may ask for submission of additional specific evidence to support some or all of the assertions made in the board statements, based on consideration of the memorandum, core submissions and an initial assessment of risk and trust performance.
Strategy, leadership and planning
Advanced foundation trust assessment criteria – strategy aligned to key priorities and 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 foundation trust applicants may consider to support the approval of their board statements |
|---|---|---|
| 1. It can explain how its existing strategies will deliver the ambitions of the 10 Year Health Plan. | Medium term plan/integrated delivery plan. Provider collaborative 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. | |
| 2. The trust can evidence its commitment and contribution to date in developing community-based care and neighbourhood working (including in partnership with social care and primary care). | Medium term plan/integrated delivery plan. Progress against neighbourhood health guidelines. | Additional narrative setting out the trust’s strategy to support the shift from hospital to community and examples of progress and impact to date. |
| 3. The trust will leverage digital technologies across care settings to improve patient care and deliver the ambitions in the 10 Year Health Plan. | Digital and data strategy – linked to the ICS strategy and underpinned by a sustainable financial plan. Examples of effective partnership, 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. | Evidence that organisation has reserved funds to support non recurrent transformation costs [specific 10YHP ambition]. Examples of previous successful digital programme administration and delivery, for example, Electronic Patient Record, AI diagnostics – dermatology electronic prescribing and medicine 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 co-ordinated with system partners, including evidence of use of technology to support quality improvement, for example, through AI to assess and respond to complaints, real time monitoring of vitals. |
| 4. The trust can demonstrate its commitment and contribution to date in enabling and delivering improved outcomes for population health and prevention. | Medium term plan / integrated delivery plan. System wide meeting minutes/forums. Annual reports on health inequalities. | Additional examples of impact to date, e.g. impact on health inequalities and inequity |
| 5. The trust’s plans have been developed with system partners, including social care and primary care and align to ICB strategies on delivering a neighbourhood health service. | Medium term plan/integrated delivery plan. System wide meeting minutes/forums (e.g. evidence of active participation in ICB System Quality Group). Reports which set out priorities and progress in relation to health inequalities. | Details of system collaboration structures and processes and trusts’ role within these; including evidence of successful implementation, impact and sustainable improvement consequence. |
| 6. The trust has a clear understanding of the causes and presentation of health inequalities and its plans recognise the factors that need to be tackled to address these, with demonstrable impact to date. | Annual reports on health inequalities. Equality impact assessments (EQIAs). | Additional examples of impact to date, for example, impact on health inequalities and inequity. |
| 7. The trust has adopted a credible and recognised corporate improvement methodology, which is actively applied across the organisation. | Reports and evidence that set out clear strategic improvement programmes (including effective spread through the organisation and sustained evidence of improvement). | Examples of applied quality improvement (QI) approaches and their impact (provided as narrative in board memo). QI approach and progress toward a Quality Management System (QMS) with clear strategic delivery frameworks. NHS IMPACT self-assessment framework. Evidence of engagement with population and the data used to inform plans. |
| 8. The trust actively seeks and applies best practice from elsewhere in the delivery of its corporate and clinical support services and disseminates its own learning to other organisations who may benefit from this insight. | Narrative on contribution to system redesign and active membership of networks. | Examples of best practice and learning shared with other organisations provided as narrative in board memo. Examples of best practice and lessons learnt from other organisations being applied provided as narrative in board memo. |
Advanced foundation trust assessment criteria – effective corporate governance arrangements
| 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 foundation trust applicants may consider to support the approval of their foundation trust board statements |
|---|---|---|
| 1. The trust has an effective approach to succession planning and successful development of future leaders which has led to substantive appointments to the board. | History of filling board vacancies and position with interims. Robust gap analysis of board skill sets. Approach to succession planning. | Board bios, including additional 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 the skills and expertise to deliver its strategy against the ambitions of the 10 Year Health Plan. | The outputs of board effectiveness reviews for example, undertaken against Insightful Board – 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 (once published). | Gap analysis which specifically considers ability to deliver the 3 shifts. 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. Evidence 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. |
| 3. The trust’s operating model and governance framework is proportionate and responsive to the size and complexity of the organisation and allows the board to govern the organisation effectively. | 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 stuck to and not overtaken by reactive management of BAU. |
| 4. It role models a culture of openness and transparency, proactively using peer and independent review. | 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. |
| 5. It receives timely information in a format that allow board members to appropriately understand and interrogate performance. | 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. |
| 6. It understands the key risks to achieving the trust’s strategic plans and the potential impact has been modelled and reflected in trust plans appropriately. | 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 pro-active 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 foundation trust applicants may consider to support the approval of their board statements |
|---|---|---|
| 1. Staff and local communities meaningfully shape and inform the board’s strategy development and decision -making, leading to decisions that improve experiences and outcomes. | Evidence of patient voice, service user and staff voice flowing through to board and of active debate (for example, level of co-production interrogated; outcomes and experience data debated). Appointment of patient safety partners (PSPs) Medium-term plan and integrated delivery plan. Staff feedback. Engagement plans, for example, in relation to new strategies, transformation proposals. Self-assessment against experience of care framework. Staff survey. | Additional clarity on how decisions have been shaped as a result of hearing this feedback. Examples of co-produced outcome measures. Where patient stories used, clear what the impact/effect is. |
Quality of care (including quality governance)
Advanced foundation trust assessment criteria – quality of care
CQC* – with ‘Good’ or ‘Outstanding’ rating prior to referral with no site or service rated inadequate by CQC and no issues raised by CQC from its latest intelligence immediately prior to approval as an advanced foundation trust.
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 foundation trust applicants may consider to support the approval of their board statements |
|---|---|---|
| 1. Its 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 and quality assurance mechanisms are in place to maintain 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 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. 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. | Evidence of any actions resulting from independent reviews and internal clinical audit outlier alerts. 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. Evidence of implementation of the Patient Safety Incident Response Framework (PSIRF) including a well-developed PSIRPPatient 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 clinical quality plans that actively progress delivery of the 3 shifts as outlined in the 10YHP and the trust own clinical quality strategy. | BAF and 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. |
| 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 minutes and forums. 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 (once published), as well as 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 foundation trust applicants may consider to support the approval of their board statements |
|---|---|---|
| 1. The trust has a visible impact on quality performance and improvement. There is a distributed leadership approach and cultural tone that is open and focussed on high quality care delivery where quality is everyone’s responsibility. | 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 the performance and quality reviews. Appointment and training of patient safety specialists. IPR. 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. Evidence of engagement with local communities to inform plans. Board member visits to clinical areas with action plans and follow up. |
| 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 plan. | Quality governance (QG) architecture including structure and reporting approach. Quality governance framework. Internal or external QG reviews or audits. Analysis uses statistically appropriate tools which identify and focus on relevant issues, for example, SPC, Pareto. | Evidence that learning identified through internal and external QG reviews and following any inquiry recommendations are or have been implemented and audits are or 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. |
| 3. The trust uses insightful triangulation and interrogation of information to inform systemic learning and decision-making and ambitious target setting, leading to improvement in outcomes for patients and population health. | 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 have 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 Patient Safety Incident Response Plan (PSIRP) with clear, evidence based and patient-informed safety improvement priorities. |
| 4. The trust is transparent and open about all quality outcomes and experiences with a strong reporting culture and clear systems in place to support improvement at all levels of care delivery. Outcomes are made public and feedback and input from stakeholders is evident leading to active improvement in prioritisation, planning and delivery, including action to address unwarranted variation or inequity. | Board meeting minutes demonstrate routine consideration of patient, carers, staff and volunteer experience data and insights, and actions and monitors improvement. IPR. Board committee papers both private and public. External reports or audits on quality of reporting. Public board meeting minutes demonstrate quality and performance is discussed. Any publication, reports or audits shared widely across organisation and beyond. | Evidence of active patient, public, staff and carer involvement for example, in improvement programmes, in recruitment of NEDs, in trust learning events. Any relevant evidence from Healthwatch or patient engagement groups or forums. Evidence that experience leads design and production of quality plans. Evidence that strategic objectives linked to quality are being implemented successfully. Evidence of improvement in prioritisation, planning and delivery including action to address unwarranted variation or inequity. 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. |
People and culture
Advanced foundation trust assessment criteria: culture and people – 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 Freedom To Speak Up (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 foundation trust applicants may consider to support the approval of their board statements |
|---|---|---|
| 1. All staff understand the importance of quality; they are empowered to report concerns and are actively engaged in quality improvements and driving sustainable solutions. | Workforce reporting to the board. Staff survey results both national and local. Staff forum feedback which has led to some improvements by the board. FTSU reporting. Duty of Candour. Complaints reporting. Patient Safety Incident Reporting. PSIRP demonstrates staff input. CQC views and whistleblowing and FTSU intelligence. Applicant’s own in-house staff check-ins, surveys and feedback results. | 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 (once published). 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. 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. 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 is hardwired into the culture, organisational values, and ways of working. Evidence of an evaluated and effective leadership development programme. |
| 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. Staff have appropriate skills, and capacity and they are actively involved in delivering sustainable quality improvements and innovation to shape transformational initiatives to improve quality of care. | Skills audits. Staff surveys. QI training and methodologies. Patient safety specialists appointed and trained. | Evidence of examples of successful QI programmes of work including outputs. |
| 5. 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). Any other appropriate workforce data available. Board and People Committee minutes. Equality, diversity and inclusion (EDI) workforce analysis. | 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. |
| 6. It has an inclusive education and training programme that values and develops its workforce across all professions to deliver safe and effective care now and into the future | Educator Workforce strategy. Local models for education and training. | 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. |
Access and delivery of services
Advanced foundation trust assessment criteria: performance against standards and targets – satisfactory score against NOF and action plans to improve performance
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 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 NOF metric scores which relate to planning guidance priorities (NOF 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 and can demonstrate plans to, or delivery of, accelerated performance improvements in national priority areas, for example, 18 weeks. |
| 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 NOF metric scores which relate to planning guidance priorities (NOF access domain and sub domains). IPR. | Evidence that across the national priority targets the trust is balancing operational performance with experience and outcomes. |
| 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. | 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. | 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. |
Productivity and value for money
Advanced foundation trust assessment criteria: The applicant demonstrates a clear understanding of productivity opportunities and presents actionable plans to deliver improvements.
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
- 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 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 | Measurable productivity improvements over the past 12 months, evidenced through cost improvement plans (CIP) delivery reports or efficiency programme updates. This may include reference to NOF metrics where relevant. 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, with clear attribution to transformation programmes or service redesign. Productivity improvements are embedded within operational and financial planning cycles, showing alignment between strategic transformation goals 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 Finance Committee papers routinely reference national benchmarking resources (for example, NHS Model Health System and trust-specific productivity packs, Patient Level Information Costing System, Insightful Board, Spend Comparison Service) to support financial and operational decision-making. | Productivity improvements are underpinned by robust demand, capacity, and utilisation modelling across workforce, physical assets, and enabling factors such as digital infrastructure and care pathway design. Insights from this modelling are triangulated with both national benchmarking tools and local intelligence (for example, NHS England regional teams, ICS data, GIRFT reviews) to identify risks, prioritise opportunities, and inform strategic improvement actions. |
Financial performance and oversight (including financial governance)
Advanced foundation trust assessment criteria: Medium-term plan – applicant demonstrates that the trust, unless there are exceptional circumstances, has a high likelihood of:
- projecting an adjusted surplus position excluding non-recurrent deficit funding in year 1 and achieving a sustainable adjusted surplus position excluding non-recurrent deficit funding by year 3 of the projected period, (as defined under the NOF).
- maintaining a reasonable cash position including working capital for the next 12 months
Provider capability self-assessment requirement:
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?
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 foundation trust applicants may consider to support the approval of their board statements |
|---|---|---|
| 1. There is a robust medium-term forecast financial plan, and can confirm the following: – the financial plan is developed using reasonable (evidence-based) or published assumptions. – the financial plan aligns with the system transformation strategy and is being developed in conjunction with the system plan, and it is agreed upon with the ICB. – the financial plan projects an adjusted surplus position in year 1, and it achieves a sustainable adjusted surplus position by year 3 of the projected period, excluding deficit support funding (as defined under the NOF). – 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. – it has undertaken a sensitivity analysis to evaluate reasonable downside scenarios and their mitigations for testing the financial plan. – the trust will achieve its financial forecast outturn for the current financial year. | Historical financial performance of the organisation. A medium-term financial plan, including rolling 12 months cash flow forecast to ensure reasonable cash balance is maintained. The financial modelling assumptions (including capex) applied in the medium-term are aligned with the NHS England published guidelines and aligned with the system transformation strategy. Current trading analysis and performance against plan, and risks and mitigations to the reported financial position. Analysis on overall efficiency plan and individual efficiency scheme, project initiation documents (PIDs) that demonstrate consideration of realistic phasing. System financial performance, and the organisation’s contribution to system breakeven. | Updated medium-term financial plan, including rolling 12 months cash flow forecast to ensure reasonable cash balance is maintained post advanced foundation trust assessment. Financial modelling assumptions, including (capex), in the updated medium-term plan aligned with the NHS England’s published guidelines and the system transformation strategy, as well as the intentions outlined in the Board’s self-certification memo. A sensitivity analysis demonstrating downside scenarios to the base case, and mitigations. Updated current trading analysis and performance against plan, and risks and mitigations to the reported financial position prior to approval as an advanced foundation trust. Process to ensure the accuracy of the financial reporting procedures. |
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?
| 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 foundation trust applicants may consider to support the approval of their board statements |
|---|---|---|
| 1. The Trust 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 reporting of audited accounts. | Approved financial governance framework document with role descriptions and delegated authority schedules. Evidence of timely submission of audited accounts (for example, audit sign-off letter). Financial risks linked to operational and quality risks in the Board Assurance Framework. A current estates strategy (or equivalent plan) . | Evidence of regular governance effectiveness reviews with documented improvements and action tracking. Clear accountability mapping from board to operational teams, with evidence of ownership at all levels. 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). Reports demonstrating successful delivery of recent major capital schemes, including project outcomes, timelines, and benefits achieved. |
| 2. Within this framework, they and Finance Committee: possess the necessary skills and experience to provide effective leadership and oversight of financial matters; receive timely, clear, and comprehensive reporting on the organisation’s financial performance and risks to support informed decision-making; operate within a strong financial control environment that enables effective assurance and challenge across all aspects of financial delivery, including the achievement of Cost Improvement Plans (CIPs). | Board and committee training records and induction packs. Finance reports provided to the board (for example, monthly IPR, CIP delivery reports). Minutes showing discussion of financial performance and risks. | 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. Annual forward planning and minutes showing focused challenge and for meaningful discussion of financial matters and key financial risks with clear timely decisions taken to address financial risks and performance issues. Integrated performance reports (IPR) that enable effective triangulation of financial, operational, productivity, quality, and workforce data to inform decision-making. |
| 3. The trust proactively reviews its financial governance framework to ensure it remains robust and supports long-term sustainability. This is demonstrated by regular assessment of value for money, responsiveness to early warning signs – such as inadequate financial information and weak escalation of financial risks – through mechanisms such as in-year reporting, triangulation of board-level information, exception reporting, and assurance from internal audit and other independent reviews. | Internal audit programme covering key financial systems, processes, and performance data reliability (such as, audit plans, reports, and follow-up actions). Exception reports highlighting financial risks and actions. | Documented continuous improvement cycle for governance framework (such as, lessons learned log, action tracker). Early warning indicators embedded in board reporting (such as, liquidity, run-rate, CIP delivery risk). Benchmarking reports comparing financial governance maturity against peers. Reports demonstrating in-house and/or outsourced estates planning and delivery arrangements operating at sufficient scale for sustainability and high quality. |
| 4. Financial planning processes are aligned with national and local priorities, including enabling the 3 shifts outlined in the 10 Year Health Plan | Workforce and financial plans are aligned, showing consistency in operational costs and activity (such as, workforce plans, financial reports, cost-per-activity analysis). | 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. |
| 5. The trust considers the impact of all financial and operational changes on the quality of care, supporting both current service delivery and long-term sustainability. | Quality impact assessments are completed for major financial and operational changes. | Quality impact assessments are embedded in planning cycles, with evidence of board-level oversight and feedback loops to adjust plans based on quality outcomes. |