Date published: 10 June, 2026
Date last updated: 10 June, 2026
10 Year Health Plan, Integrated care

Response to NHS England consultation on the Advanced Foundation Trust Programme – guide for applicants

Introduction

This document summarises the themes in the feedback we received on the draft Advanced Foundation Trust Programme guide for applicants and how we have responded.

As set out in the Government’s 10 Year Health Plan, strengthening local leadership and creating the conditions for earned autonomy are central to delivering a more responsive and empowered NHS. The reinvigorated and reinvented foundation trust model is one of the mechanisms identified to help achieve this ambition by rewarding high performing, capable providers with greater freedoms.

Our consultation ran for 8 weeks from 12 November 2025 to 11 January 2026. We worked closely with stakeholders in the development of these proposals and held a series of events attended by trust and system leaders as part of the consultation.

We received 32 direct responses to the consultation from:

  • 17 NHS providers (12 NHS foundation trusts and 5 NHS trusts)
  • 6 national bodies
  • 9 individuals not representing an organisation

Overall, they expressed support for the policy aims and direction of travel set out in the guide.

In developing the final policy and guidance, we have split the content into two complementary documents to improve useability, informed by analytics insight into how users engaged with the materials:

This consultation response should be read alongside the above publications.

The consultation response covers questions 1 to 12 on the Advanced Foundation Trust Programme. We intend to respond to the feedback to questions which relate to integrated health organisations (IHOs), when we publish the updated IHO assessment framework. This allows us to incorporate learning from the first wave of designation alongside the consultation feedback and co-production of the IHO contractual model with wave 1 trusts, ensuring that the final IHO assessment framework aligns to the capabilities required to deliver the contract.

Consultation feedback and our responses

1. Freedoms and flexibilities

Question 1: Paragraphs 13 to 22 of the guide set out the freedoms and flexibilities that advanced foundation trusts will benefit from. To what extent do you agree or disagree with the broad freedoms for advanced foundation trusts? Please add any additional reflections.

Your feedback

  • Strongly agree: 0%
  • Agree: 53%
  • Neutral: 38%
  • Disagree: 9%
  • Strongly disagree: 0%

Respondents broadly welcomed the increased freedoms and viewed them as appropriate where they would drive innovation and improvement. However, they emphasised that additional autonomy should be meaningful, sustainable and conditional on demonstrable improvements in outcomes, underlining the importance of linking autonomy to evidence of strong organisational performance, effective leadership and delivery, and sustained improvements in population health.

Respondents were clear that increased autonomy must be underpinned by strong guardrails and accountability arrangements. These included expectations around collaboration with system partners and responsibilities to improve population health and reduce health inequalities. Maintaining strong local accountability was seen as essential, including mechanisms for local voice and stakeholder engagement, with some respondents noting that any changes to existing arrangements would need to be at least as robust as those currently in place.

Some respondents asked for greater clarity on how advanced foundation trust status would operate in practice. This included clearer milestones for the introduction of increased autonomy, greater detail on what ‘light-touch’ oversight would mean and clarity on how advanced status would apply within group structures.

Our response

We have revised the guide content on freedoms and flexibilities to provide greater clarity and coherence. The strengthened framing now sets out our underlying principles for how autonomy and accountability operate together and ensures that the policy is applied in a consistent and transparent way. The revised approach clarifies the expectations, safeguards and accountability arrangements that accompany increased autonomy. These changes are described in more detail in the response to question 3 below.

We have also added detail to better describe how advanced foundation trust status will be implemented in practice. This covers the annual planning process and oversight approach and, more fully, how we expect a capability-based regulatory approach to work over time. The guide now also reflects the importance of patient and public voice, stakeholder engagement and collaboration, system working and population health improvement as part of the annual planning process for advanced foundation trusts.

The guide now makes it clear that where trusts operate as part of a group, they will continue to be assessed as individual legal entities. This means group structures can have a mix of trusts that are and are not advanced foundation trusts.

Question 2: What freedoms should be considered within the areas of strategic and operational autonomy, greater financial flexibility and a capability-based regulatory approach and what additional freedoms should be considered to help advanced foundation trusts deliver better organisational performance and to support delivery of the 10 Year Health Plan?

Your feedback

There was general agreement that advanced foundation trusts require strategic and operational freedoms to improve organisational performance and contribute to the delivery of the 10 Year Health Plan. As part of this, respondents highlighted the importance of multi-year planning cycles, fewer routine central approvals and a lighter reporting burden. Additionally, some commented that a more proportionate, capability-based approach would allow high performing trusts to focus more on improvement and long-term outcomes, rather than compliance activity.

Financial flexibility was a strong theme throughout the responses. Some respondents felt the current capital regime can restrict investment in estates, equipment and digital infrastructure. They advocated for wider reforms to capital finance and payment models to ensure that trusts’ surpluses and borrowing capacity translate into tangible improvements in estate and equipment. There were also queries about whether granting these freedoms could inadvertently reduce the capital available for other providers. Some respondents asked for freedom to use their wider cash reserves to support modernisation, community-based services and digital upgrades. Several highlighted the value of enabling trusts to ringfence investment for prevention or tackling inequalities, and some supported shared savings or gain share arrangements to strengthen partnership working on prevention and long-term outcomes.

Workforce autonomy and wellbeing also featured prominently in feedback. Respondents emphasised that high organisational performance relies on a supported and well-equipped workforce. Some asked for greater flexibility to invest in staff wellbeing, occupational health and psychological support programmes, and for freedom to redesign workforce models, skill mix and reward and recognition approaches where this benefits staff experience, continuity of care or recruitment and retention. Respondents also saw an important role for advanced foundation trusts in leading innovation, prevention and system transformation. Some asked for the freedom to act as testbeds for new models of care, digital pathways and preventative interventions, with flexibility for trusts to develop solutions that respond to population needs.

Our response

Our targeted changes to the guide reflect this feedback on advanced foundation trust freedoms. There is now a greater emphasis on a more strategic approach to annual planning, alongside lighter-touch, capability-based oversight and less duplication in reporting, reflecting respondents’ views on the importance of freeing up management capacity and giving trusts clearer space to focus on long-term improvement and delivery of the 10 Year Health Plan. Together, these changes are intended to provide greater strategic and operational autonomy for advanced foundation trusts in practice. Over time, this will be further embedded through the NHS operating framework.

Additional financial freedoms have not been introduced at this stage. Many suggestions related to wider reforms of the overall public spending framework. These issues sit beyond the scope of the Advanced Foundation Trust Programme. Financial freedoms for advanced foundation trusts will be managed nationally in line with broader financial frameworks and approaches to capital allocation, to avoid adverse impacts on other providers who are not advanced foundation trusts. In relation to the broader feedback on the value of flexibility to invest in prevention and reducing inequalities, trusts already have scope for this within the existing financial framework, and the capital and revenue flexibilities that will be available to advanced foundation trusts can further support this through investment in estates, digital infrastructure and other enablers of improved population health.

We have strengthened the guide to reflect more clearly the leadership expected of advanced foundation trusts in improving population health and their contribution to system transformation and innovation. This includes clearer articulation of how advanced foundation trusts can use their leadership role locally and nationally in these areas. On workforce, trusts already have some discretion within existing national frameworks to redesign workforce models, support staff wellbeing and develop new roles where this enhances service delivery. For this reason, the Advanced Foundation Trust Programme does not introduce any additional workforce freedoms.

Question 3: Paragraph 17 of the guide for applicants sets out the capability-based regulatory approach advanced foundation trusts will be subject to. Are there any views or reflections you would like to share on the proposed approach? And what other approaches, if any, should be considered to help advanced foundation trusts deliver their objectives?

Your feedback

Respondents welcomed the aspiration to reduce duplication and adopt a capability-based approach to regulation and oversight, noting that this could encourage organisations to take greater ownership of improvement and support more constructive interactions between regulators and NHS organisations. There was strong support for a risk-based approach and the commitment to avoid micromanagement. Respondents also emphasised the importance of building on existing frameworks, including alignment with the NHS Oversight Framework (NOF), for a coherent and proportionate approach.

There were requests for clearer information on how the capability-based approach would operate in practice, including how concerns would be identified and how and when reviews would be triggered. Some respondents also highlighted the importance of leadership quality in the context of capability, and the insight from examining culture, workforce sustainability and staff experience as indicators of organisational capability, alongside operational and financial performance.

In terms of wider support for advanced foundation trusts to deliver their objectives and promote capability, respondents highlighted the value of peer support, alongside sharing good practice and exemplars to avoid trusts having to reinvent approaches independently.

Our response

Our overall approach is designed to align with existing oversight arrangements, including the NOF, to reduce duplication and provide a joined-up and coherent approach to regulation and improvement. We have added detail in the guide on the capability-based approach to regulation and how it will operate in practice. This includes setting out the key principles that will underpin the approach, alongside how oversight will flex in response to risk. The NOF provides further information.

The importance of leadership and culture as part of organisational capability is reflected in these being core components of the provider capability assessment. Consideration of organisational culture, workforce and staff experience is also embedded in the advanced foundation trust assessment criteria. To further strengthen the assessment criteria in relation to this, we have updated the examples of evidence for statement 2 in the effective corporate governance arrangements section of the strategy, leadership and planning domain, as well as statement 4 in the people and culture domain.

In response to feedback on wider support, we have placed greater emphasis on the role that advanced foundation trusts can play in sector-wide improvement through peer working. Their role in providing and participating in peer support is now explicit, recognising the value of shared learning and peer challenge. While we have no current plans to establish a formal peer support network, we encourage advanced foundation trusts to work with peers to support improvement as part of their greater local and national leadership role.

2. Approach to eligibility and assessment

Question 4: The assessment criteria and process (set out in paragraphs 33 to 98) are intended to avoid duplication with our published frameworks and trust submissions while retaining the rigour and developmental aspects of the original foundation trust assessment approach. Are there any changes to the proposed assessment criteria and process that might help meet these goals?

Your feedback

Respondents strongly supported the alignment of the advanced foundation trust assessment process with existing frameworks and want it to be a proportionate, robust, yet efficient process that minimises the bureaucratic and administrative burden on trusts, including by avoiding unnecessary duplication. Respondents were keen for NHS England to draw lessons from the first wave of assessments and the previous foundation trust programme, ensuring scrutiny in key areas, where existing frameworks are perceived to not provide adequate assurance.

Concern was expressed that the advanced foundation trust assessment adds to the already complex monitoring landscape as it overlays the longer-term aspirations of the 10 Year Health Plan and Medium Term Planning Framework. This multi-layered approach could impact on the bandwidth of trusts and cost of external assurance and was felt to run counter to the government’s commitment to streamline bureaucracy and remove non-value adding processes from the system. There were suggestions that the advanced foundation trust assessment could be subsumed within or at least more structurally aligned to existing assurance and capability assessments such as the NOF, drawing as far as possible on the data and narratives that trusts already provide.

Respondents were keen that the guide is and remains consistent with other regulatory processes. They asked for clearer mapping to existing frameworks, avoiding duplication with existing processes in an already complex regulatory landscape and consolidating the evidence asks across domains. Some respondents considered the assessment criteria extensive for consistently high-performing providers (those that have maintained NOF segment 1 or 2 performance for a sustained period) and that a more streamlined approach for these trusts would reduce the risk of an unnecessary administrative burden on them. It was suggested that these trusts could be automatically designated as advanced foundation trusts.

Clarity was requested on the practicalities of submitting evidence: the acceptable formats, timeframes for evidence, criteria for sufficiency and expectations about the length and level of detail of submissions.

One repeated piece of feedback was that Healthwatch England, local Healthwatch organisations and councils of governors should be added to the list of key stakeholders that may be interviewed as part of the assessment. The 10 Year Health Plan sets out plans for dissolving Healthwatch and removing councils of governors from the foundation trust model, but while these are still in existence, they remain an important source of information.

Our response

While the advanced foundation trust process aligns to the provider capability assessment, it is designed to be additive but not duplicative wherever possible. It tests the governance processes for trusts that are delivering good outcomes and provides more in-depth scrutiny than the provider capability assessment process. The assessments will be risk-based and therefore lighter-touch where there are no clear concerns.

While trusts that are consistently demonstrating strong performance in a range of metrics are assigned NOF segment 1 or 2, as highlighted in feedback to other questions, the NOF does not cover all aspects relevant to designation as an advanced foundation trust, in particular the delivery of longer-term priorities and system working. The guide is now clear that processes will be kept under review and that the board statements may be updated periodically to reflect feedback and maintain alignment with the provider capability framework and other relevant frameworks and guidance. Over the longer term, as these frameworks become more embedded, their alignment will become closer.

We have incorporated what we have learnt from the first wave of assessments in the guide. This includes making the requirements for the board memorandum clearer. We have retained the most useful aspects of the previous foundation trust assessment process that are not covered to the same extent by other existing frameworks (such as quality governance, financial governance, board and committee observations), and given system working much greater consideration than in the provider capability assessment or the previous foundation trust assessment. Councils of governors and local Healthwatch are now listed as stakeholders that the assessment team may engage with as part of the advanced foundation trust process, for as long as they remain part of the statutory framework.

We will minimise the burden on trusts of the advanced foundation trust process as much as possible. The guide is now clear that trusts will not need to re-submit information they have already provided to NHS England and that we will rely on information from recent regulatory reports and findings. As the assessment will draw on existing evidence, the amount of preparation required by applicant trusts, should not be significant.

The only specific request for applicant trusts for the advanced foundation trust assessment process is a short memorandum to support the board statements the board is signing off. In most cases, we will only request existing third-party reports and external assurance, not specially commissioned evidence for the advanced foundation trust process. For added clarity, Annex 1 of the guide now more fully lists examples of evidence that advanced foundation trust applicants may consider for approval of each board statement.

To make the application process easier for applicant trusts, the assessment team will provide applicants starting the process with a consolidated information request list and supplementary guidance and advice on expectations around submissions.

Question 5: Are the eligibility criteria to apply for advanced foundation trust status, described in paragraphs 29 to 32 in the eligibility criteria section, sufficient to ensure that only high-performing, capable and financially sustainable trusts delivering high quality care are chosen?

Your feedback

  • Yes: 47%
  • No: 34%
  • Don’t know: 19%

The most significant area we received feedback about was in relation to the Care Quality Commission (CQC) eligibility criteria. Respondents were concerned that many trusts have not been re-inspected for several years and as they cannot influence the timings of inspections, their ratings may not reflect current performance.  

This means trusts with older ‘Requires Improvement’ ratings may have made significant improvements and addressed previous issues but will be ineligible to apply until they have been re-inspected. There were concerns this may disproportionately affect acute trusts, restricting the number and type of trusts that may be considered to become advanced foundation trusts. We also heard the CQC ratings ‘Good’ or ‘Outstanding’ may be based on out-of-date information for trusts that have not been re-inspected for a while. Suggestions to address the concern about dated CQC ratings were: requiring a letter of assurance from the CQC at the eligibility stage, using a recent external well-led review or potentially fast tracking a CQC inspection for a trust meeting all other eligibility criteria.

Concern was also raised about the quality of care eligibility criteria linking directly to the CQC’s well-led domain when this is not intended as a measure of quality of care.

In relation to the NOF eligibility criteria, some respondents questioned whether a requirement to be in segment 1 or 2 for 2 consecutive quarters was sufficient on its own to demonstrate sustained high performance and a reliable track record of delivering the public’s priorities and value for money.

Respondents also noted that the NOF was developed primarily as an oversight and improvement framework, not a test of readiness for advanced foundation trust status. They argued that NOF segmentation should be considered alongside a wider range of evidence including planning for the delivery of the longer-term objectives set out in the 10 Year Health Plan, such as system working, population health improvement and the shift from hospital to community.

Feedback from some mental health, community and ambulance trust leaders was that the 2025/26 NOF metrics do not provide an accurate or reliable view of operational and financial performance for their trust types.

Concerns were also raised about the lack of clarity surrounding the relationship between a provider’s ability to apply for advanced foundation trust status (requiring NOF segment 1 or 2), the expectation that all providers will achieve advanced foundation trust status by 2035 and the fact that the NHS oversight framework segments currently assume roughly equal numbers of providers will be in each, as opposed to reaching a required performance level. In addition to this, we received feedback that noted that the current model of segmentation has limits to the number of organisations that can be in segment 1 or 2 which could restrict the advanced foundation trust future pipeline.

Suggestions were made for what other information could be considered as part of the eligibility criteria: ‘leading’ indicators of future success, key staff metrics, patient experience and satisfaction, public engagement, accountability to the population served, access to high quality public health expertise, evidence of effective system leadership and collaboration, strong partnerships and demonstrable capability in population health management.

Our response

We understand the concerns many respondents raised regarding the proposed CQC eligibility criteria. We have amended the criteria to allow applications from trusts with a ‘Requires Improvement’ rating that is more than 3 years old, but with a requirement to commission and complete an independent, targeted governance review to provide assurance that 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.

To strengthen the quality of care eligibility criteria, in addition to the CQC rating (and, where relevant, targeted governance review), all trusts will also now need 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. Trusts will also need to not be subject to support from the Maternity and Neonatal Improvement Support team. The current quality of care and quality governance of the trust will be reviewed for all trusts, as part of the assessment criteria.

We have confirmed that trusts will need to continue to meet the eligibility criteria (in the absence of exceptional circumstances) throughout the assessment process to be approved as an advanced foundation trust. The eligibility criteria only require a trust to be in NOF segment 1 or 2 for 2 consecutive quarters to apply, but once it has met the eligibility criteria, NHS England will decide whether it should be shortlisted to apply and, if it is, the trust will need to prepare its submission and apply, and then be assessed and approved. The trust will need to remain in NOF segment 1 or 2 for the duration of this period before potentially being approved as an advanced foundation trust.

We understand the feedback that the 2025/26 NOF may be seen as focused on short-term performance. This reflects its development as a single-year framework ahead of publication of the 10 Year Health Plan. We committed to review the framework in 2026/27 to support a more long-term, strategic approach aligned to the 3 shifts set out in the 10 Year Health Plan.

The 2026/27 NOF metric refresh will improve the representation of mental health, community and ambulance trust metrics and we have already worked with providers and relevant networks to consider their representation.

NOF segmentation will continue to improve, both in terms of the make up of metrics, which will be reviewed annually to ensure they continue to accurately reflect national ambitions, and methodology design, including setting defined segment boundaries to ensure that all organisations are clear on the level of performance required to reach segment 1 or 2. NOF methodology design is shaped by statistical expert, NHS user and public feedback.

Many of the additional indicators suggested for consideration as eligibility criteria will be assessed as part of the assessment process.

3. Assessment criteria

Question 6: Are the advanced foundation trust assessment criteria set out in Annex 1 appropriate to determine suitability for advanced foundation trust status?

  • Yes: 63%
  • No: 28%
  • Don’t know: 9%

Question 7: Are the expectations of the advanced foundation trust board statements set out in Annex 1 appropriately stretching yet achievable for high-performing and well-led trusts?

  • Yes: 63%
  • No: 6%
  • Don’t know: 31% 

Question 8: Are there any key omissions that applicant boards should certify?

We have consolidated the feedback and responses to the above 3 questions to avoid repetition.

Your feedback

Some feedback was that the expectations set out in Annex 1 for high-performing and well-led trusts may be more detailed than necessary. There was also feedback that while the criteria are comprehensive and appropriate, they could be applied with local review and regional discretion.

Respondents also noted that elements of the assessment process will necessarily require subjective judgement. Some asked for clear guidance and examples to support consistent interpretation across boards in making and evidencing the board statements set out in Annex 1.

There was strong feedback that the focus on population health outcomes, prevention and tackling inequalities should be clearer and more consistent, with these embedded as golden threads across all domains.

A significant level of feedback highlighted uncertainty about where existing public accountability responsibilities will sit following proposed changes to governance arrangements and how these would be assessed as part of the advanced foundation trust assessment process. This feedback was especially in regard to the responsibilities currently held by local Healthwatch and the councils of governors, which are intended to be removed from the foundation trust governance model (subject to the will of Parliament).

We also received feedback that the assessment criteria should include a commitment to quality improvement (including patient experience), noting the correlation between this and high performance and financial sustainability.

In relation to some specific statements, we received feedback that people who use services and third sector organisations should be explicitly referenced as key stakeholder groups for advanced foundation trusts in the production of their plans.

In relation to the financial performance assessment criteria, we received feedback that the expectation for year 2 was a little unclear and that clarification of expectations would be helpful.

Our response

We intend to update the guide for applicants during 2027/28 to reflect the learning we gain from undertaking advanced foundation trust assessments for a range of trusts. We recognise that exemplars would support consistent interpretation by boards and our intention is to develop these in time, informed by that learning.

We will also keep the guide under review to update it should other related frameworks and regulatory processes change.

Our assessment will be risk-based, but we recognise that, where there is no definitive threshold, an element of judgement will be required on whether statements are being met. It will be for the trust board to decide what evidence they consider sufficient to be able to sign off on the relevant statements. We will provide advice to applicants when they start the process on expectations around submissions.

Some elements of the assessment will look at the applicant trust’s commitment to and contribution in enabling and delivering improved outcomes. We will apply considered judgement and internal check and challenge to ensure consistency of approach. Views will be reached in a collaborative way, using subject matter experts where relevant. We will maintain a dialogue with the relevant NHS England region throughout the review and also engage integrated care boards to ensure that local knowledge is used as far as possible.

The guide is now clear that population health, prevention and reducing health inequalities will be a focus throughout the assessment and a priority in considering a trust’s application overall. These are only explicitly mentioned in a limited number of statements to avoid duplication in the assessment. We have also added more examples of evidence that applicant trusts may consider to support their approval of board statements in relation to these areas.

We recognise the strength of feedback around uncertainty about where existing public accountability responsibilities will sit following proposed changes to governance arrangements and how these will be assessed as part of the advanced foundation trust assessment process. As any change to Healthwatch and the potential removal of the requirement for foundation trusts to have a council of governors are subject to new legislation, we cannot cover these areas in this version of the guide for applicants. Whether these changes come into effect and the timetable for this will depend on the passage of the Bill and the will of Parliament. We will consider if any amendments to our assessment criteria are required in relation to this when we next update the guide.

A commitment to quality improvement is a key part of our assessment process against all relevant domains, including through our committee and board observations; in recognition of the correlation between quality improvement, financial sustainability, continuously learning and being informed by patient experience.

With respect to changes to specific assessment criteria, we have amended the examples of evidence for the board statement around having effective mechanisms in place to meaningfully engage with staff and local communities ensuring involvement influences decisions, to explicitly reference that people who use services and third sector organisations should be key stakeholder groups for advanced foundation trusts in the production of their plans. We have also adjusted the wording of the financial performance assessment criteria to make the expectation for year 2 clearer.

Question 9: Are the board statements requested in Annex 1 to support assessment applicable and workable across different trust types (mental health, community, acute, ambulance and specialist)?

Your feedback

  • Yes: 60%
  • No: 6%
  • Don’t know: 31%
  • N/A: 3%

While respondents were broadly supportive that the board statements are applicable and workable across mental health, community, acute, ambulance and specialist trusts, some concerns were raised regarding the evidencing of statements for non-acute trusts. Respondents also noted that statements relating to neighbourhood working may have limited relevance for tertiary specialist trusts or ambulance trusts operating across large geographies.

Respondents requested additional guidance by trust type to support proportionality and relevance, including examples of evidence tailored to non-acute providers. They also requested good practice guidance for trusts that are not yet meeting all the eligibility and assessment criteria, but are on an improvement journey to reach those standards.

Our response

The statements and examples of evidence have been developed to reflect all sectors and trust types. However, we recognise the concerns that some respondents have about how the board statements for non-acute trusts may be evidenced. In response we have strengthened the guide to clarify that applicant trusts should determine what evidence is most appropriate to their sector and service mix when assuring themselves that the board statements have been met.

In time we will seek to develop good practice guidance to provide additional support to applicant trusts.

Question 10: Annex 1 gives examples of evidence that may be used by trust boards to assure themselves that the board statements can be certified. Is the evidence set out reasonable and appropriate?

Your feedback

  • Yes: 56%
  • No: 9%
  • Don’t know: 32%
  • N/A: 3%

Respondents welcomed the inclusion of illustrative examples and the ability to submit existing evidence, noting this would be helpful to applicant trusts. However, many emphasised the importance of avoiding unnecessary burden and duplication. Respondents suggested that applicant trusts should be able to cross-reference evidence already submitted through other assurance and oversight processes, such as provider capability assessment submissions, NOF data and audit reports.

Some respondents expressed concern that the evidence requirements appeared extensive for already high-performing trusts with good assurance processes in place and questioned whether they were sufficiently proportionate and streamlined.

Feedback also highlighted that the list of examples of evidence focused predominately on process measures (for example, plans and strategies) with less emphasis on outcomes and demonstrable impact. Respondents also highlighted the need for clearer examples of patient experience data and explicit reference to the trust’s progress on improving outcomes and experiences related to population health, prevention and reducing health inequalities.

Respondents further highlighted the need for greater emphasis on intelligent use of existing staff-related data, incorporating qualitative insight and encouraging triangulation of assurance with lived experience from staff networks and frontline teams. They also stressed the importance of referencing the forthcoming Code of Practice for NHS managers, including the management and leadership assessments that align with the NHS Management and Leadership Framework, and funded plans for the continuous professional development of senior management and leadership teams.

A consistent view was that Healthwatch and councils of governors for NHS foundation trusts remain important sources of insight while they continue to operate and should therefore be recognised as sources of evidence. Feedback also emphasised the importance of engagement with, and support from, wider system partners.

Our response

We recognise respondents’ concerns about the importance of avoiding unnecessary burden and the guide is clear that the advanced foundation trust assessment process seeks to avoid duplication and, wherever possible, will draw on existing evidence, including evidence trusts have already submitted through other NHS England self-assessments or submissions, which will not need to be re-submitted if the assessment team can be signposted to where this information has already been provided.

We have strengthened some of the evidence requirements set out in Annex 1 of the guide for applicants, including, but not limited to:

  • examples of outcome-based metrics to demonstrate impact, including audits and improvement programmes
  • evidence demonstrating the trust’s commitment and contribution to population health, prevention and reducing inequalities
  • evidence of compliance with the forthcoming Code of Practice for NHS managers and leadership assessments aligned with the NHS Management and Leadership Framework, as well as funded plans for the continuous professional development of senior management and leadership teams
  • tangible examples of the triangulation of staff-related data
  • evidence of engagement with local Healthwatch and council of governors (for NHS foundation trusts) while these remain in place.

4. Health inequalities

Question 11: Do you have any comments about the advanced foundation trust proposal and the impact on advancing equalities and/or reducing health inequalities?

Your feedback

Respondents emphasised the importance of ensuring the Advanced Foundation Trust Programme supports efforts to reduce inequalities and avoids creating a two-tier system in which advanced foundation trusts operate with greater freedoms than trusts without this status. To help do so, some respondents proposed that advanced foundation trusts should demonstrate visible and measurable contributions to system-level health inequalities objectives. Feedback also reinforced the expectation that greater autonomy should be used to tackle health inequalities and improve equity between organisations and geographies.

Respondents highlighted the need to maintain strong mechanisms for patient, staff and community voice, particularly if current statutory arrangements such as councils of governors are removed. They supported flexible and innovative approaches to representation, provided these demonstrate meaningful engagement and accountability.

Concerns were raised that the different organisational statuses, some advanced foundation trusts and others not, could disrupt system cohesion and collaborative working. Some emphasised that advanced foundation trust autonomy must reinforce, not weaken, collective efforts to improve population health and reduce inequalities.

Feedback also called for clearer expectations around evidence and impact measurement, with a stronger focus on outcomes. Some respondents requested more examples of appropriate forms of evidence, including for prevention activities and proactive care.

Our response

We have updated the policy framework and guide for applicants to set out a clearer and more explicit expectation that advanced foundation trusts should actively contribute to tackling health inequalities and improving population health across their system. These documents now set out the important role advanced foundation trusts are expected to play as system partners and clarifies that their autonomy and local leadership role should be used to tackle health inequalities and improved outcomes, putting patients and the public at the heart of all they do.

We have also made amendments to place greater emphasis on collaborative working in the context of a more differentiated system. This includes references to the potential role of advanced foundation trusts in providing peer support to other local providers, and the importance of them working constructively with system partners to tackle health inequalities and improve population health (for example, by leading collaborative initiatives or taking a greater role in designing, co-ordinating or delivering programmes to reduce inequalities across populations). This reinforces the expectation that advanced foundation trusts operate as part of a wider system and contribute visibly to collective priorities rather than working in isolation.

In addition, in the guide we have expanded the examples of the types of evidence applicants may submit as part of the assessment process. The additions illustrate how advanced foundation trusts can demonstrate their contribution to reducing inequalities and improving population health, including by using data, insight and wider intelligence to identify and monitor disparities, assess service impact on vulnerable and underserved groups and inform strategic and operational decision-making. The expansion of the examples will help applicants understand the breadth of evidence that can strengthen their submission and support a more transparent and robust assessment process.

5. Other comments

Question 12: Do you have any other comments about the guide for applicants?

Your feedback

Respondents welcomed the attempt to provide a coherent framework for the implementation of the Advanced Foundation Trust Programme and highlighted that this represents a positive shift towards trust, autonomy and system leadership.

Many recognised the ambition of the approach, while noting that successful implementation will depend on the proportionality and consistency of the approach to oversight. Some feedback highlighted that we could place greater emphasis on involvement with local communities, including clearer expectations around public engagement.

Respondents asked practical questions about assessment criteria, definitions of financial metrics such as ‘sustainable surplus’ and the risk of an acute-centric approach, with calls for clearer recognition of the role of community and mental health providers.

Several respondents shared views about the proposed removal of councils of governors, highlighting their role in public voice and accountability, and sought greater clarity on how equivalent assurance and engagement would be maintained going forward.

Our response

We have placed greater emphasis in the policy framework and guide on patient voice and involvement. Linked to this, local Healthwatch and councils of governors have been explicitly included as stakeholders that assessment teams may engage with as part of the advanced foundation trust process, while they remain part of the statutory framework.

We have given a fuller definition of surplus in the final documents and made edits to reflect that the assessment approach is applicable to all trusts and sectors.

PRN02325ii

Date published: 10 June, 2026
Date last updated: 10 June, 2026