Advanced Foundation Trust Programme: guide for applicants consultation submission

Key points

• We strongly support the government’s commitment to empower and enable NHS organisations to deliver, and understand the advanced FT (AFT) programme and introduction of Integrated Health Organisation (IHO) contracts is part of implementing that commitment.

• We support the focus throughout the guidance on capabilities and welcome the balance of factors relating to readiness to support the three shifts and integration alongside core corporate and quality governance, workforce and other considerations.

• The guide does not address any implications for organisations sharing leadership and/or governance arrangements seeking AFT status individually or as a partnership. The government should also clarify how it plans to transition from awarding AFT status to a small number of high performing trusts to all trusts being an AFT by 2035.

• Given current operational and financial pressures and the need to improve services and transform models of care, it is essential that the AFT programme and IHO contracts deliver tangible benefits - for providers, for the taxpayer and most of all for patients.

• We have some concerns that within the current constrained fiscal environment, the proposed financial freedoms may be symbolic rather than practical and therefore may not sufficiently incentivise improvement.

• Beyond the guidance, DHSC and NHSE must confront the cultural challenge of designing and operating a system that enables the innovation and experimentation needed to transform NHS care, while still working in an environment that has historically prioritised standardisation and consistency. We have welcomed recent changes to the capital regime, but NHS leaders would welcome wider reforms to ensure capital funding is invested as effectively as possible.

• We strongly believe that a capability-based regulatory approach is the optimal arrangement for all. However, as we have argued in our joint response to the recent CQC consultation and publications on AFTs and IHOs, improvements must be made to the NHS Oversight Framework metrics and CQC’s assessments so they can provide a more accurate picture of performance and capability so that organisations that would most likely benefit from AFT status are eligible. Given the operational challenges facing the CQC, we believe NHSE’s assessment of provider capability and quality should be given adequate weight in the assessment until CQC’s ratings are more regular and robust.

• We strongly support plans to introduce additional criteria to guide the designation of IHO host providers. We also support the criteria outlined, including the emphasis on collaboration and working across organisational boundaries, driving the left shift and contracting and commissioning skills. But we believe the guide should include clearer expectations that governance models include a robust process for collective problem-solving and conflict resolution. Population health and inequalities expertise should also become explicit criteria for IHO designation. We strongly agree with the proposal to review and revise criteria after the first IHO contract is developed.

• Healthcare leaders are concerned that the current IHO designation process may fail to identify the most capable host organisations. They argue that the AFT only eligibility route is too narrow, that ICBs and system partners should have a stronger role in identifying local need and suitable hosts, that systemwide capabilities – especially those of ICBs – are not sufficiently considered, and that inconsistent language about IHOs creates confusion by implying they are organisational forms rather than contractual mechanisms.