The proposal to introduce an advanced foundation trust tier was intended to create a new space for high-performing providers to innovate, flex their financial levers and drive improvements across their systems. Yet the policy has reached an early moment of introspection, with the interim national finance lead openly acknowledging that it remains difficult to articulate any concrete benefit for the organisations expected to earn this elevated status.
The admission is significant. Foundation trust freedoms have been progressively eroded over the last decade as the government and NHS England sought tighter control of spending, capital, performance and workforce deployment. Against that backdrop, the advanced model was positioned as a potential return to greater autonomy for those that meet the highest operational and financial standards. But the national director’s comments exposed a gap between aspiration and reality. There is still no clear pathway to meaningful flexibilities, no convincing offer on capital, and no settled view on how these trusts would operate differently within an increasingly centralised architecture.
The core tension is structural. The NHS wants a set of providers that exemplify excellent governance and delivery while also acting as engines of improvement for their wider systems. Yet the national frameworks on finance, workforce and performance have tightened rather than loosened. It is therefore difficult to see what additional freedoms an advanced foundation trust could exercise without unpicking the very controls introduced to stabilise the service.
Financial directors across the country have already questioned whether the model risks becoming a badge without substance. Without new levers on capital allocation, earned autonomy, revenue retention or a clearer relationship with integrated care boards, the designation risks offering recognition but little practical value. Trust leaders are wary of taking on extra responsibilities if the balance of risk and reward is not materially different from the status quo.
For NHS England, the challenge is now philosophical as much as technical. If the service believes in earned autonomy, the framework must provide real tools and real discretion. If not, then the advanced trust concept will struggle to gain traction among providers that are already navigating severe financial constraints and unprecedented performance pressures.
The frankness of the interim CFO reflects a wider shift. The service is reviewing long-standing governance assumptions, reconsidering how autonomy can sit alongside system working, and taking a more realistic view of what can be delivered within the current fiscal envelope. Whether the advanced foundation trust model survives that scrutiny will depend on one test. Can it offer something that genuinely changes how a high-performing trust can plan, invest and innovate. Until that answer becomes clearer, the policy remains more theoretical than transformative.
