Endnotes

[i] NHS Providers NED network and company secretary network members contributed their views via bespoke sessions during July 2025, and in-depth feedback was provided by six members (chairs, NEDs and company secretaries) in early August. Their role and trusts are not included since the feedback was provided on condition of anonymity.

[ii] Of course, creating the conditions for high autonomy for public sector organisations is inherently challenging. NHS provider boards do not have full control of many the levers which an autonomous commercial corporation would have, such as their wage bill, income/price point, staffing levels and skill mix, or in many cases their estate and other capital assets.

[iii] A simple overview of the unitary board model is available here: Single-Tier Board: Governance Model | Financial Terms Explained. And this paper contains more in-depth academic discussion about the structure of boards: thestructureoftheboardofdirectorsboardsandgovernancestrategiesintheustheukandgermany.pdf

[iv] Legislation will be required to amend Schedule 7 of the NHS Act 2006 which establishes and defines the powers and duties of councils, and establishes the foundational governance of current FTs as organisations with legal personality. In our view, the removal of local accountability mechanisms and powers over appointments, as set out above, is significant enough to mean that new FTs are a different type of organisation: they can no longer be considered public benefit corporations as set out in the 2012 Act.

[v] Albeit likely to be undertaken in practice by the regions.

[vi] In particular, the ability to make chair and other NED appointments and set their remuneration, terms and conditions, which while the case in law are regularly subject to intervention by NHSE, not least artificially restricting NED remuneration since 2019. Financial freedoms are of less use to FTs in practice, as discussed elsewhere.

[vii] The alternative, having a separate set of performance measures against which to remove restrictions on legal freedoms, would introduce further complexity.

[viii] Although provider capability self-assessments are being undertaken in late 2025, the outcome of these will not affect NOF segmentation, which we expect to be published alongside public facing dashboards (league tables) in mid-September 2025.

[ix] We understand CQC well-led assessments are being revised to ensure they are more focused on indicators that assess the capability and capacity of boards. In our view, this type of assessment is more suited to underpinning earned autonomy. However, timeliness of review is important, and so an ongoing, relationship-manager style of oversight is preferable to irregular point-in-time assessments: as a member commented, “CQC well-led assessments… can be quite out of date to the point of describing leadership of a previous version of the Board, given turnover of Execs and NEDs.”

[x] “Trusts and FTs applying for, or seeking reauthorisation as, FT status will need to have demonstrated excellent delivery on waiting times, access, quality of care and financial management, as well as higher levels of productivity than their peers. This will also need to demonstrate a proven track record of, and commitment to, working in partnership to improve health outcomes.” Fit for the future: 10 Year Health Plan for England p.81. We assume ‘reauthorisation’ here applies to existing FTs, rather than future reauthorisation as a new FT having once been deauthorised.

[xi] Monitor, the independent regulator of FTs, was established under the Health and Social Care (Community Health and Standards) Act 2003 and authorised the first wave of FTs in 2004. It was merged into NHS Improvement in 2016, which itself was merged into NHSE by the 2022 Act. The number of authorisations tailed off in the mid-2010s for complex reasons, including financial instability across the NHS, and a change in policy towards integration and system working.

[xii] Mid Staffordshire NHS FT was the only trust to go through the trust special administration process, which was enacted to secure essential services, transferring them to other providers before Mid Staffs was dissolved.

[xiii] The likely approach to short-term variation against NOF metrics will involve enhanced or reduced oversight and direction from the regulator based on performance against the NOF. It will not be feasible to withdraw foundational freedoms (e.g. capital freedoms or the ability to retain surpluses) if performance and NOF segmentation slips temporarily, since this would make it impossible for new FTs to plan, invest, or build. Clearly, to protect patients, there must be consequences if those held to account consistently fall short. But for patients to benefit from a reinvigorated provider landscape, we need clarity and consistency about which circumstances trigger what degree of intervention and direction, and about what is required to remove restrictions. Organisations revert to compliance, risk aversion and looking upwards to the centre for guidance if they suspect freedoms can be removed quickly and often. Autonomy should be the norm unless an organisation is subject to regulatory oversight and intervention.

[xiv] See for example: Bringing NHS England back under political control… Health Foundation (2025); Culture should be a strategic priority… BMJ (2025); Is England’s NHS too ‘top down’? BMJ (2022) Local reform undermined Nuffield Trust (2017).

[xv] As proposed by the English Devolution and Community Empowerment Bill (2025)