The new era of strengthened NHS foundation trust governance

The NHS 10-year plan is a resounding endorsement for good governance at a local level. The many structural changes will depend on local unitary boards steering the rapid development of the new style NHS FTs and IHOs. Professor Andrew Corbett-Nolan tracks what we know thus far.

The NHS 10 Year Health Plan for England, published in July 2025 under the title Fit for the Future, marked a pivotal moment in the evolution of England's health service, aiming to shift from crisis management to sustainable, community-focused care.

At GGi we have been at the vanguard of NHS governance transformations for more than 15 years, advising boards on everything from integrated care system (ICS) implementations to developmental reviews that enhance accountability and resilience. Our unique vantage point—gleaned from prodigious work across the whole of the NHS (Wales and Scotland as well as England) and more broadly with other public-purpose sectors, including local authorities, regulators, third-sector organisations, community interest companies (CICs), and universities—positions us to dissect the plan's ambitious proposals for all NHS trusts and existing foundation trusts (FTs) to undergo a new FT authorisation process, with high-performers advancing to integrated health organisations (IHOs).

This article delves into what we currently know about these reforms, with a sharp focus on governance arrangements. We explore the authorisation criteria and processes for the new ‘advanced’ NHS FTs, drawing on informed commentators' views as well as our own insight for both factual depth and new thinking.

A key governance shift—the optionality of councils of governors—will be examined, alongside imaginative ways to reframe them for better community connection in a neighbourhood-focused era. We also address the plan's abolition of local Healthwatch, its implications for providers to absorb patient voice functions, and the enhanced partnerships new FTs must forge particularly with revitalised Health and Wellbeing Boards (HWBs).

As someone deeply invested in governance excellence, my interest lies in the challenges organisations will need to address to navigate all this and emerge with something that is better. Boards need to be thinking now how they need to up their game and make sure they are equipped with robust frameworks, clear delegation and effective assurance to thrive in this new landscape.

The 10 Year Plan's vision

The plan has no chapter describing the end state for the reforms, but it clearly envisions a radical reconfiguration. By 2035 every NHS provider will become a foundation trust, empowered with greater autonomy to drive local improvements in patient care, productivity and population health. This builds on three core shifts—from sickness to prevention, hospital to community, and analogue to digital—while addressing waiting lists and financial sustainability. High-performing FTs can then apply for IHO status, holding integrated contracts to manage local budgets and lead system-wide transformations. The rationale? To devolve power to frontline providers, fostering innovation and efficiency in a system strained by centralisation.

From a governance perspective, this demands boards to recalibrate their roles, emphasising strategic oversight, risk management, and stakeholder engagement. The plan explicitly notes that governance structures will evolve, with councils of governors becoming optional under proposed legislative changes. Originally introduced in the early 2000s to enhance community voice and accountability, governors' track record has been patchy. Many senior NHS colleagues privately express delight at the prospect of dispensing with them, viewing councils as resource-intensive without commensurate value. However, I firmly believe that, like any governance element, you reap what you sow.

Poorly resourced and underdeveloped governors underperform, but with proper support and training – some of which is currently very poor indeed – clear roles and integration into assurance processes, they can significantly bolster an organisation's governance, providing diverse perspectives on community needs and authentically holding their boards to account for the performance of the trust.

Imaginative restructuring could revitalise this model, particularly for vertically integrated IHOs tackling population health challenges. For instance, public constituencies could mirror neighbourhoods, fostering direct connections to local populations. Neighbourhood reference groups—comprising residents, patients, and stakeholders—could link into governor membership, ensuring grassroots input while maintaining scale.

Extending staff governors to include primary care workers (e.g., GPs, pharmacists) would enhance cross-sectoral collaboration, aligning with the plan's emphasis on integrated neighbourhood services. At GGi, our experience with universities and local authorities shows how such adaptive structures promote both connection and accountability turning potential burdens into assets for population health management.

What we know so far about the new FT authorisation criteria and process

Details of the Advanced Foundation Trust Programme emerged in November 2025 with NHS England's draft Guide for Applicants, open for consultation until 11 January 2026. This ‘rules-based’ approach targets existing FTs and NHS trusts, with assessments starting in early 2026.

Eligibility criteria: Applicants must be in NOF segments 1 or 2 for two quarters, hold a CQC ‘good’ or ‘outstanding’ Well-Led rating (no inadequate areas), achieve amber-green capability, and gain ICB/regional endorsement. Commentators like NHS Providers note this as a ‘revalidation’ for FTs and ‘pre-validation’ for trusts, ensuring only mature organisations advance. Lawyers Bevan Brittan highlight consultation opportunities to refine these, warning of ICB veto risks that could politicise approvals.

Assessment bar: Evaluation spans three pillars:

• well-led for population health/inequalities
• high-quality services with governance
• financial sustainability

Boards will submit certified statements, evidence memoranda (audits, risks), and three-year financial plans projecting surpluses. Our colleagues at Carnall Farrar praise this as ‘shifting power to the frontline’, but urge clarity on subjective elements such as partnership commitment. Others add insight on flexibilities, like using revenue surpluses for capital (up to £100m without approval), which demands robust financial governance to avoid misuse.

Process: A four-month collaborative timeline (which seems short to me): submission, evidence review, interviews, observations, stakeholder input (including CQC) and board-to-board decision. For trusts, approval grants interim freedoms pending legislation. NHS Providers critiques potential duplication with existing oversight (NOF, CQC), suggesting streamlining to reduce burden.

The King's Fund questions evidence for such models, advocating for pilots to test governance in practice. Governance-wise, this process mirrors rigorous peer reviews requiring boards to demonstrate ethical leadership and delegation—principles GGi adapts from King V for NHS contexts.

Support needs are clear: regional readiness guidance, internal audits for evidence alignment and significant board development. GGi's reviews often reveal gaps in risk assurance or community engagement, which could derail applications.

Advancing to IHOs: governance for integration

IHOs build on FTs, but we see them as fundamentally different organisations. The authorisation process will involve assessments evaluating maturity factors within integrated contracts—population health leadership, community shifts, financial risks, and partnerships. Criteria emphasise cross-sectoral governance, potentially integrating with FT processes.

Commentators see IHOs as testing beds for devolution but warn of governance strains in managing budgets across providers. There is learning to be had from Scotland and Wales where local authorities already nominate to NHS boards.

For vertically aligned IHOs, imaginative FT models could shine. Using optional governors for neighbourhood connections while addressing population health would align the community voice in a meaningful way with the organisation’s governance. Boards must oversee devolved responsibilities, demanding enhanced assurance and succession planning.

Scotland – proof of concept?

With IHOs so dependent on local partnerships and high-functioning neighbourhoods, where can we learn lessons about implementing such structures elsewhere? Scotland's Integration Joint Boards (IJBs) offer a compelling proof of concept for England's emerging place-based partnerships and neighbourhood governance models.

Established under the Public Bodies (Joint Working) (Scotland) Act 2014, IJBs integrate health and social care by bringing together nominees from NHS health boards and local authorities to oversee joint strategic planning and budgeting for adult services. With equal voting membership from both sectors, plus non-voting stakeholders such as professionals, carers, and service users, IJBs exemplify collaborative governance that reduces duplication, pools resources, and focuses on population health outcomes—mirroring the aims of England's IHOs and place-based partnerships.

At GGi, we played a key role in developing IJBs in Tayside (NHS Tayside) and Edinburgh (NHS Lothian and City of Edinburgh Council), supporting the design of assurance frameworks and integration schemes that ensured effective delegation while maintaining accountability. Early evidence from Scotland shows IJBs have improved care coordination, such as through shared care pathways and reduced hospital admissions, though challenges like restricted autonomy (e.g., IJBs control significant budgets but operate within parent body constraints) highlight the need for clear boundaries.

These are lessons directly applicable to England's reforms. As HWBs and neighbourhood arrangements gain prominence, adopting IJB-like structures could provide a tested model for local empowerment, fostering resilient partnerships that prioritise prevention and equity.

The first wave

The initial cohort, announced in November 2025, focuses on community/mental health: Berkshire, Dorset, Central London, Northamptonshire, Northumbria, Alder Hey, Norfolk, and Cambridgeshire. Trusts like Berkshire express optimism, tying selection to autonomy for patient benefits.

Lessons: Emphasis on non-acute aligns with prevention; strong Well-Led ratings underscore governance as gatekeeper. Commentators suggest these could pioneer IHOs, highlighting need for adaptive boards.

Abolition of local Healthwatch

The plan abolishes Healthwatch England and 152 local bodies, transferring functions to DHSC and local authorities to streamline patient voice. Critics, including petitions and Healthwatch responses, argue this erodes independent advocacy, potentially silencing vulnerable voices. For FTs and IHOs, this creates a vacuum: providers must pick up functions such as gathering feedback and escalating concerns, integrating into authorisation evidence for community engagement. Optional governors could fill this, with neighbourhood-linked structures ensuring independent scrutiny. This will be vital for population health legitimacy.

Locally driven partnerships

New FTs must cultivate links with HWBs, now with an enhanced role in the operating model as ICPs are abolished. They will have a key role in developing evidence-based neighbourhood health plans and fostering cross-sector integration. With ICBs shifting to strategic oversight and reducing costs, HWBs become key for local accountability, aligning with FTs on preventive care and more.

Most current HWBs are not yet fit for this purpose and local authorities, stripped out as they are of developmental capacity, will find achieving this a challenge. Thoughtful ICBs with staff who have many of the skills required should be joining up with local authorities right now as they go through their own defenestration plans to get down to the new ICB running costs model.

The last chance to get this right

I have previously described the 10 Year Plan as ‘very good old wine in new bottles’. The aims of the plan are nothing new and they are essential to implement if there is to be an NHS in 2035. These reforms are the last chance to achieve this before the system collapses under a tsumani of need driven by demographics. The reforms will work if implemented swiftly and work they must.

However, getting this done is not simple – particularly in just one political cycle. The reforms represent a true quantum shift, demanding boards to embody principles like King V's ethical leadership and delegation. IHOs themselves are the very epitome of King’s meaningful outcome of value creation.

All NHS boards need to be working on this right now, whatever authorisation wave they aspire to. Many find themselves struggling with the challenges of today rather than building up resilience, or worse still waiting to be told what to do.

As an enthusiast, I see the 10 Year Plan's FT and IHO pathway as a promise of genuine empowerment but this hinges on exemplary governance. Boards should be thinking this through now and moving beyond an approach to governance that amounts to little more than keep the regulator happy.

As we always have when major changes are heralded, GGi will continue to track this new FT and IHO odyssey, and through our publications, webinars, networks and direct work, we will share what we learn as the journey progresses.