Advanced Academy - Part Two: The Advanced Foundation Trust Application and Assessment Process

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In our first article, we reviewed the key freedoms the Advanced Foundation Trust status would afford to those NHS Trusts and Foundation Trusts who are successfully promoted, and we started to consider the eligibility requirements. In this article, we focus on the mechanics of the application and assessment process to become an Advanced Foundation Trust. We will refer to ‘Trusts’ throughout this article to refer to both NHS Trusts and NHS Foundation Trusts.

NHS England has created a process that optimises the use of information that Trusts are already collecting and monitoring for existing regulatory frameworks, such as the NHS Oversight Framework. NHS England has also flagged that the any Trust that is contemplating a statutory transaction should inform the NHS England assessment team early in the transaction planning, as there would be a significant overlap in the materials prepared and reviewed for both approval processes.

NHS England has considered that the application and assessment process will elicit the relevant answers to three fundamental questions which justify the promotion to Advanced Foundation Trust status and has also linked these three questions to the six domains from the Insight Provider Board guidance and the Assessing Provider Capability guidance. The three questions (and related domains) are:

1. Is the Trust well led, collaborating with system partners to improve population health and tackle inequalities, and responsive to local communities? (Related domain: Strategy, leadership and planning)
2. Does the Trust provide high-quality services with robust quality governance in place? (Related domains: Quality of care and quality governance; people and culture; and access and delivery of services)
3. Is the Trust financially sustainable with a focus on productivity improvement? (Related domains: Productivity and value for money; and financial performance and oversight).

Following the NHS England guidance “Advanced Foundation Trust Programme – guide for applicants”, the overall process for applying for Advanced Foundation Trust status can be broken down into four key stages:

Stage 1: Pre-application

An NHS England regional team will notify eligible trusts who have met the eligibility criteria to begin the application process. To recap from our first article, the eligibility criteria is: 

• In the top 2 segments of the NHS Oversight Framework for 2 consecutive quarters.
• A “good” or “outstanding” Care Quality Commission (CQC) rating from the Trust’s most recent CQC Well Led assessment, with no site or service rated inadequate by CQC.
• A provider capability score of at least amber-green.

The NHS England regional team may also consider “existing local knowledge” when assessing a Trust’s eligibility which extends to community feedback and other information available that is relevant to the shift from hospitals to communities under NHS England’s 10 Year Health Plan. 

This additional community focused evidence will be most relevant for considering the timing for allowing a Trust to begin the application process. As the application and assessment process is highly collaborative between the relevant Trust and NHS England regional team, NHS England has foreseen that not all eligible Trusts will be able to complete the assessment process simultaneously. NHS England will also want to give Trusts the chance to address any issues that existing evidence identifies that may not affect the eligibility criteria directly but may cause problems for the Trust completing the application or assessment further down the line. 

Therefore, Trusts should communicate well with their NHS England regional team as the same NHS England regional team becomes the assessor team for the duration of the Trust’s application and assessment process.

Trusts should wait to commit resources to preparing the application and participating in the assessment process until their NHS England regional team provides a clear timetable for the overall process and a detailed information request list. 

Stage 2: Application

NHS England will invite the Trusts to prepare and submit a package of documents and other evidence to make up the core Advanced Foundation Trust application. 

The application evidence package comprises of:

• an application letter from the Trust’s chief executive
• statements of support from relevant ICB(s) (and NHS England region leaders)
• medium-term financial plan submission, setting out how a sustainable surplus will be delivered within 3 years, as agreed with the relevant ICB(s) and NHS England region and reflecting the latest planning guidance
• a signed board statement certifying that the Trust meets the assessment criteria using the detailed board statements set out in Annex 1 of the “Advanced Foundation Trust Programme – guide for applicants”
• a supporting memorandum setting out or referencing the evidence the board has used to assure itself that the Trust has met each of the statements in Annex 1 of the “Advanced Foundation Trust Programme – guide for applicants”.
• Plus, if the Trust is an NHS Trust, the proposed constitution of the Advanced Foundation Trust (the NHS England assessment team will provide a model draft constitution)

The statement and memorandum component will make up most of the Trust’s application. While the statements themselves are unique, the detailed board statements in Annex 1 are like the statements posed as a part of the annual Provider Capability self-assessment. The wording of the statements must remain unamended from what is stated in Annex 1. Where a Trust cannot certify a statement, the Trust should explain why it cannot certify the statement in the supporting memorandum and should include the Trust’s plan to address this gap within a reasonable timeframe.

As with the Provider Capability statements, the Annex 1 statements provide suggestions for the types of supporting evidence to accompany each of the Trust’s certified statements. Trusts should incorporate all relevant third-party information as the NHS England regional team is likely to request this information if not received. Type of additional supporting evidence which NHS England regional team may request includes internal audit reports, board or board committee papers, the Board Assurance Framework, and reports from any relevant externally commissioned reviews (for example, external Well Led assessments, independent reviews or patient safety investigations – such as Academy of Medical Royal Colleges invited reviews– and assurance actions taken against clinical audit, including prevention of future death report actions and staff survey reports).

The 10 Year Health Plan has introduced a new medium term planning approach which will require all NHS Trusts and Foundation Trusts to submit medium-term financial plans regardless of their intention to apply for Advanced Foundation Trust status.

Stage 3: Assessment 

Once the Trust has submitted its application, the NHS England regional team will assess the trust’s suitability to becoming an Advanced Foundation Trust reviewing the contents of the application and gathering its own firsthand evidence of from conducting meetings, observations and interviews with relevant members of the trust and third parties. 

NHS England regional team will review the application evidence package and assess the trust’s capabilities to assure itself that it is compliant with good practice and regulatory frameworks. Upon reviewing the application, the NHE England regional team may request further supporting evidence. The further supporting evidence will most likely be in the form of existing third-party information. For example, the most recent provider capability self-assessment and digital maturity assessment; the underlying NOF and performance data, any staff survey results, board and committee papers, risk registers, governance structures, model health system data, and insight and qualitative intelligence from regional quality meetings and ICB system quality groups. In limited situations, NHS England regional team may request for the trust to develop additional evidence and submissions specifically for the application and assessment process.

NHS England regional team will also collect its own first-hand information from the following sources and methods:

• Interviews with senior Trust staff: board (including possible board and committee observations), finance team, quality and patient experience leads, governance leads, clinical directorate leads, focus groups with consultants and senior clinicians.
• Engaging with key stakeholders: including CQC, ICB, system partners, patients and service-users, carers (including unpaid), staff, volunteers, and the local community.
• Meeting between Trust and NHS England: “board to board” meeting between the Trust’s board and senior NHS England and Department of Health and Social Care (DHSC) leadership. 

NHS England will notify the trust at the beginning of the assessment process of who NHS England wants to interview. At approximately 3 months after the assessment starts, NHS England will assess the outstanding issues related to the Trust’s application. If NHS England considers that it can decide on the outcome of the Trust’s application within one month, NHS England will arrange for the “board to board” meeting to discuss the outstanding key risks. 

Engaging with key stakeholders will form a fundamental part of the Advanced Foundation Trust assessment. The purpose of engaging with stakeholders is for NHS England to understand the trust board’s arrangements in relation to active engagement in the community. Given the importance of this information, and the likely weight NHS England will attribute to community related evidence, we would recommend that Trusts consider their community engagement now. That way, a Trust has time to actively improve where needed and can gather evidence in advance of the assessment process to front-foot NHS England’s requests for engagement.

Key areas of community engagement highlighted in the “Advanced Foundation Trust Programme – guide for applicants” for Trusts to focus on performing to a high quality include:

• the quality of the trust’s arrangements for collecting, considering and responding to regular patient and service-user feedback.
• the approaches the Trust’s board is using to “bring patients into the board room”, for example, face-to-face patient stories and discussions, video diaries, board member service visits and patient shadowing.
• how arrangements will change if proposals to remove the requirement for foundation trusts to have a council of governors are enacted (subject to the will of parliament).

Stage 4: Outcome

There are four possible outcomes for a Trust once the application and assessment process is complete:

• Approval: Where a foundation trust’s application is approved, NHS England will confirm the approval via letter (copied to the relevant ICB) and the approval is effective immediately. Where an NHS trust’s application is approved, the trust is expected to formally apply to convert to a foundation trust first. Once an NHS trust is authorised as a foundation trust, NHS England will confirm the new foundation trust’s approval as an Advanced Foundation Trust via letter (copied to the relevant ICB including a schedule with the trust’s constitution). The new foundation trust will also receive a new provider licence in the name of the foundation trust.
• Entering a “side letter” arrangement: If NHS England uncovers matters during the assessment process that it requires the trust to address in the short term before the assessment can be concluded, NHS England will issue a side letter to the Trust setting out the matters the trust needs to address. The side letter will include an updated timetable.
• Deferral: If there are still outstanding issues or based on the nature or volume of issues identified, NHS England may defer an application for a longer period (but usually within 12 months). NHS England will specify the length of the deferral and the actions or conditions that must be met before the application can be approved. A deferred application must be activated before the specified end date of the referral, otherwise the application will be treated as withdrawn. Once reactivated, the assessment team will confirm what information should be submitted and what further meetings are required.
• Rejection: Where an application is rejected, NHS England will confirm the rejection via letter (copied to the relevant ICB) which will set out the reasons for the rejection criteria. The relevant NHS England assessment team will also discuss these reasons at a formal debrief meeting. The Trust may reapply in future by restarting the application process in full. 

In the next addition of our Advanced Academy series, we will examine the additional tests that an NHS Trust or NHS Foundation Trust could undergo during the Advanced Foundation Trust assessment process to apply to hold an Integrated Health Organisation (IHO) contract.

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