NHS England » Advanced Foundation Trust Programme

Overview

1. This policy framework sets out the overarching policy intent and principles of the Advanced Foundation Trust Programme. Trusts wishing to apply to the programme should read this framework alongside the Advanced Foundation Trust Programme guide for applicants, which provides practical information on the application process and requirements. These documents have been developed with input from the sector and reflect feedback received through public consultation.

2. Advanced foundation trust status will be the new marker of excellence used for high-performing foundation trusts and NHS trusts which pass an updated assessment process and benefit from substantial additional freedoms and flexibilities. Advanced foundation trust status will be characterised by a fundamentally different relationship with the centre, involving greater strategic and operational autonomy. This will be founded upon the 3 pillars of a new more strategic approach to annual planning, a capability-based approach to regulation, and greater financial flexibilities.

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

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 Care Quality Commission (CQC) ratings and the quality domains within the NHS Oversight Framework)
that they have excellent leadership (as per their Provider Capability Assessment).

4. NHS England will assess providers that meet these criteria and have the support of the relevant NHS England regional team and integrated care board (ICB). Our process will look at how well a trust listens to patients and the public, works with others and their plans to help deliver the three shifts set out in the 10 Year Health Plan. It will also examine in more depth providers’ leadership, quality governance, and financial sustainability. We will work with the CQC as part of this process. Decisions will initially be made by the NHS England Board, on the advice of an expert subset of the Board’s members, post-abolition of NHS England an independent panel will be established. Once approved, the advanced foundation trust status will be reviewed at least every five years to ensure that they continue to meet the standard required of them. The level of this review will be risk-based and proportionate, reflecting the performance and capability of the advanced foundation trust.

5. We expect the Advanced Foundation Trust Programme to support improved 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, what freedoms and flexibilities advanced foundation trusts will be able to exercise, and what this means for existing foundation trusts and NHS trusts.

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 and follow the guidance set out in the Advanced Foundation Trust Programme guide for applicants.

Rationale for the Advanced Foundation Trust Programme

8. The Government’s 10 Year Health Plan sets an ambition to get the NHS back on its feet by redistributing power to the frontline: to providers, clinicians, staff, and most importantly, patients and local communities. The aim is to 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, communities and 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 patients and 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, regulatory approach and assessment of advanced foundation trusts reflects this.

12. Our intention is that by 2035 all trusts will 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. Our approach to advanced foundation trusts will be characterised by a different relationship with the centre, driven by confidence in the leadership and capability of the provider. The key principles of this relationship are summarised below.

Advanced foundation trusts

Will give:

Strong local leadership and a commitment to delivering the three shifts
Detailed annual plans covering finance, service delivery, local engagement and innovation
Early warning of any issues on a ‘no surprises’ basis.

Will get:

Freedoms that, once won, are retained unless there is significant fall-off in capability
Time to plan and deliver investments to improve services and deliver transformation.

The centre

Will give:

Operational autonomy, with advanced foundation trusts provided with time to address all but the most significant concerns
Financial freedoms as set out in paragraph 19.

Will get:

Assurance that capable providers are aware of and addressing issues, with ability to escalate swiftly where there are serious quality, finance or delivery concerns
Continuing visibility of performance via NOF segments, league tables
Regular updates on contribution towards 10 Year Health Plan delivery via a deep-dive annual review

14. Through this new relationship we will look to free up and preserve advanced foundation trust management bandwidth to focus on delivery, local priorities and innovation for the benefit of patients and local communities. 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 look to increasingly embed greater strategic and operational autonomy for advanced foundation trusts into our new operating model.

15. As a starting point, advanced foundation trust freedoms and flexibilities will be founded upon 3 key pillars: a new, more strategic approach to annual planning, a capability-based regulatory approach from NHS England and greater financial flexibility. They may also play a more substantial leadership role locally and nationally, including supporting improvement in challenged organisations, collaborating with system partners, driving improvements in population health and in tackling health inequalities.

16. Pillar 1: While advanced foundation trusts will continue to follow the medium-term planning framework and core national policies and frameworks, they will benefit from 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 and will:

reflect our views of the prior year’s performance, the provider’s capability and financial and operational plans
look to understand the advanced foundation trust’s plans to deliver the three shifts, be a local leader and engage with stakeholders
consider the trust’s plans to improve quality of care and collaborate with system partners to improve population health and reduce health inequalities.

17. Subsequent oversight will be proportionate and light touch and, while NHS England regions will monitor performance, 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 trusts in broader discussions about transformation and system-wide change. Over time we expect providers to have growing and significant autonomy from the centre, with much greater emphasis on local accountability.

18. Pillar 2: Our capability-based regulatory approach toadvanced foundation trusts will incorporate the successful elements of the previous FT oversight approaches and be built on:

Consistency with the priorities of the broader NHS: the NHS Oversight Framework ( 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: We will grant highly capable leadership teams the space needed to manage operational challenges. Learning from previous foundation trust oversight approaches, our view of capability will subsequently play a greater role in our regulatory approach towards advanced foundation trusts. Having demonstrated higher capability through passing the assessment process, advanced foundation trusts will generally have more time to address issues as they arise before triggering a response. This notwithstanding, as with all providers the boards of advanced foundation trusts will be expected to be transparent with us about emerging serious issues – regarding, for example, emerging quality issues or deviating from financial plans. In addition, where serious issues requiring immediate attention arise – for example, a significant quality failing or a material adverse deviation from planned financial performance – we will be involved much sooner
Our rules-based regulatory approach to advanced foundation trusts will be outlined in due course. Note that advanced foundation trusts will continue to be responsible for delivering all their contractual obligations, including as set out in NHS Standard Contracts, national primary care contracts or other contracts with local authorities, and the terms of payment in accordance with the NHS Payment Scheme.

19. Pillar 3: 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 segment 1 and 2 trusts, with no need for business case approval for up to £100 million 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 take on a greater leadership role locally and nationally. This may mean:

consideration for holding an integrated health organisation (IHO) contract
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)
going further in work with system partners (including local authorities and voluntary and community sector organisations) to tackle health inequalities and improve population health – for example leading collaborative initiatives or taking a greater role in designing, coordinating, or delivering programmes to reduce inequalities across populations
working locally, regionally and nationally to develop and share best practice and drive innovation, including through acting as early adopters and exemplars
supporting improvement work and providing peer support at other local providers where appropriate.

22. These advanced foundation trust freedoms and flexibilities will be a starting point as of 2026/27, with our ambition to embed them, and then increasingly ingrain greater strategic and operational autonomy into our new operating model over time.

Meeting the bar for approval and implications for legal status

23. Given the greater freedoms and responsibilities, and associated risks, that come with advanced foundation trust status, 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
the ‘bar’ for approval which trusts will be assessed against during the subsequent advanced foundation trust assessment process.

25. For existing foundation trusts, if they meet the eligibility criteria to apply to become an advanced foundation trust, maintain (in the absence of exceptional circumstances) the criteria for eligibility while undergoing assessment and successfully meet the ‘bar’ for approval (tested through the assessment process set out in the guide for applicants), the foundation trust will be approved as an advanced foundation trust and gain the associated freedoms.

26. For existing NHS trusts, if they meet and maintain (in the absence of exceptional circumstances) the eligibility criteria while undergoing assessment and successfully complete the advanced foundation trust process, the NHS trust 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 referred to in the approval of NHS trusts section within the guide for applicants [note for web team: add link to section in guide]. 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, and (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 legislation 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 further tests to assess readiness to take on an IHO contract and the responsibility for managing a whole population budget. Advanced foundation trusts may also choose to undergo the additional IHO assessment designation at a later stage. Draft assessment criteria set out these additional criteria and evidence required. This criteria will be further revised in line with the development of the first IHO contractual model.