Trust leaders’ perspectives on advanced foundation trust freedoms and population health

The 10-year health plan (10YHP) set out an ambition to give high-performing NHS providers greater autonomy and financial flexibility to support an ambition that they take a more active role in improving population health. To encourage this shift, the Advanced Foundation Trust (AFT) programme introduces a new organisational status offering enhanced strategic and operational freedoms.

To understand trust leaders' views on the new freedoms for AFTs, we hosted a virtual peer learning event, Shaping population health: The strategic role of Advanced Foundation Trusts, in March 2026. We also held eleven one-to-one insight discussions with board members, including finance directors, strategy directors and chiefs of staff, to understand the key opportunities and practical considerations in using the new AFT freedoms. 

Context

The AFT programme aims to enable high performing providers to retain surpluses, invest in prevention and expand place based, community focused services. It introduces a new organisational status with enhanced strategic and operational freedoms, supported by capability-based oversight, to bring decision-making closer to clinicians, patients and local communities. Working with ICBs, AFTs are expected to hold a leadership role in systemwide transformation across neighbourhoods and care pathways, using these flexibilities to reduce inequalities, strengthen prevention and improve long-term population health outcomes. 

NHS Providers’ population health event was structured to enable peer-to-peer learning. It brought together a diverse mix of NHS provider leaders, including chairs, chief executives, nonexecutive directors, strategy directors and development leads from acute, mental health, ambulance and community trusts. The programme featured case studies from Andy Snell, consultant in public and emergency medicine at Barnsley Hospital NHS Foundation Trust and Barnsley Metropolitan Borough Council, and Dr Richard Brown, chief of population outcomes and governance insight at Surrey and Sussex Healthcare NHS Trust, highlighting practical steps taken to improve population health. Breakout sessions provided an opportunity for trust leaders to reflect on how the proposed AFT freedoms can support their work in improving population health outcomes and discuss the practical implications of the AFT model. 

This briefing summarises trusts leaders’ views on how AFT flexibilities can support population health improvement and neighbourhood level integration and sets out recommendations for how NHS England and the Department of Health and Social Care (DHSC) can help to ensure these freedoms enable place based, prevention focused care. 

Improving population health will require measures of success focused on outcomes, equity and access. The current activity and acute focused metrics will not support the desired improvement. Trust leaders emphasised the need to identify underserved groups, redesign services around local population need and use both quantitative and qualitative measures to assess progress. 

Delivering this shift depends on stronger neighbourhood level integration across primary, community, mental health and acute services, backed by sustained investment in prevention, collaborative working and better use of data and research.

Progress is constrained by significant financial, structural and cultural barriers. Limited surpluses, misaligned incentives, rigid contracting arrangements and single-year planning cycles restrict investment in prevention. Workforce pressures entrenched organisational cultures and gaps in digital and data infrastructure also inhibit place-based working and the development of new care models. 

AFT freedoms have the potential to support population health improvement, particularly through greater organisational autonomy, flexibility to innovate and a stronger convening role in systems. Financial flexibilities could enable longer-term investment and more integrated neighbourhood level delivery. Yet many participants stressed that these activities are already possible within the current system and whether AFT status has an additional impact will depend on how freedoms are implemented.

There is still uncertainty about what AFT autonomy means in practice, how it aligns with the proposed integrated health organisation (IHO) contractual model, and whether financial freedoms will be meaningful in a constrained environment. Greater autonomy can help systems focus on local needs and outcomes. However, without national incentives and infrastructure that support integration and a shift of investment towards earlier intervention, there is a risk that autonomy could inadvertently lead to the consolidation of power among larger providers. Clearer national intent, aligned incentives, and multiyear financial planning will be crucial if AFT status is to drive prevention, integration and reductions in health inequalities.

Experience from the foundation trust model shows that granting autonomy only works when national bodies are clear about their intent and consistently committed to enabling local freedoms over time. Without this sustained commitment, those freedoms risk being eroded. 

Redefining success through outcomes and equity

Improving population health requires the system to adopt a different definition of success, one focused on long-term outcomes rather than short-term pressures, as well as redesigning how services are planned and delivered. 

Participants emphasised that traditional metrics, such as waiting times or activity volumes, are insufficient and often too focused on acute care. Instead, success should be understood in terms of measurable improvements in population outcomes, reductions in health inequalities and reduced variation in access. Assessing performance therefore needs a longer-term timeframe that reflects the nature of population health improvement. Where progress has been made, it has typically been supported by services designed around patient need and by improved access to specialist care through integrated delivery models.

For many trust leaders, improving population health depends on identifying groups who are not currently accessing services, such as disadvantage or underserved populations, and redesigning care to meet their needs. Providers are seen as having an important strategic and convening role in bringing partners together to redesign pathways and coordinate care. However, measuring progress remains challenging, particularly as many organisations lack experience in using population-level outcomes data. Participants noted that success measures may also need to include qualitative indicators such as improved wellbeing, community engagement and patient experience. 

Integrating services at neighbourhood level

Delivering better outcomes for populations requires a shift toward prevention and community-based care, supported by stronger neighbourhood health systems and better integration between primary care, community services, mental health and acute providers. Leaders stressed that supporting this left shift would need more collaborative systems with increased investment in prevention and health education, stronger links with universities and industry, and greater use of data and life sciences to address population health challenges. 

Revenue investment and prevention

However, members noted that structural change alone will not deliver these improvements. Progress depends on sustained revenue investment, cultural change across organisations, strong system leadership and alignment of incentives and performance frameworks. Lessons from the foundation trust model highlight that autonomy must be clearly defined and consistently supported by the centre, and that financial incentives must reinforce prevention and collaboration rather than hospital activity growth. 

Financial reality often limits the scope for investment

Participants identified a range of structural, cultural and financial barriers that limit progress toward population health and place-based working. A major constraint is the current financial context facing NHS providers, with many organisations able to deliver minimal or no surpluses, while experiencing rising demand and increasing operational pressures. Even where financial flexibilities exist in principle, there is often insufficient headroom to invest in prevention or population-level initiatives and any additional funding is frequently absorbed by existing deficits. 

Funding and contracting arrangements were also highlighted as key barriers, as they often reinforce organisational boundaries and create disincentives to shift activity away from hospitals, making it difficult to move resources into community settings. Annual planning cycles focused on achieving in year financial balance further restrict the ability to invest in long-term prevention. Leaders also noted that risk and funding frequently sit with different organisations, complicating joint decision-making and hindering neighbourhood-based approaches. In this context, ICBs face their own financial constraints and operational pressures, limiting their ability to use commissioning and contracting levers strategically. Strengthening the commissioning role of ICBs and enabling them to contract in ways that support system outcomes rather than organisational activity, will be essential for enabling the shift to prevention and integrated community-based care.  

Cultural and structural barriers to place-based working

Cultural and organisational factors also play a significant role. Some leaders noted that entrenched ways of working, strong organisational identities and a persistent “us and them” culture between providers continue to inhibit collaboration. Historical commissioner–provider divides still shape behaviour, while workforce pressures and infrastructure gaps, particularly in community and mental health services, limit the capacity to deliver new models of care. Performance management regimes remain heavily focused on acute care, reinforcing hospital-centric models and making it difficult to prioritise prevention and community-based services.  

Capital investment and infrastructure

Gaps in digital capability and data infrastructure continue to pose a major barrier. Many community services lack integrated patient records or reliable technology, limiting their ability to support population health management. While capital investment could address some of these issues, leaders cautioned that capital alone is insufficient without sustained revenue funding for staff and services. 

AFTs as conveners and system partners

Participants saw potential for the proposed freedoms associated with AFT status to support population health improvement, particularly through increased organisational autonomy and financial flexibility. Greater autonomy could enable trusts to prioritise local needs, innovation and service delivery, supported by a lighter-touch relationship with national bodies. This may allow organisations to shift resources towards prevention and community-based care, develop more integrated commissioning arrangements and tailor services to the needs of their populations. 

Leaders agreed that AFTs could also play an enhanced system role by convening partners, sharing improvement expertise and supporting innovation across organisations. Larger providers, in particular, may be well placed to act as demonstration sites for new models of care and to support workforce development, research collaboration and quality improvement across systems. 

Future opportunities and long-term outcomes

Financial flexibilities, if realised, could support longer-term investment in prevention and community initiatives, particularly in areas of high deprivation. Participants highlighted the importance of enabling multi-year financial planning, aligning financial decision-making with population health outcomes and developing governance frameworks that support partnership-based decision-making. 

There is also potential for AFT freedoms to support better integration at neighbourhood level, including shared use of community estates, integrated clinical pathways, improved data sharing and stronger relationships with primary care and voluntary sector partners. These sectors were seen as critical to prevention and reducing inequalities due to their reach into local communities. 

However, participants emphasised that many of these activities are already possible within the current system and that the extent to which AFT freedoms represent a meaningful shift remains to be seen. The effectiveness of these freedoms will depend heavily on how they are implemented, the degree of genuine flexibility afforded and whether financial and regulatory frameworks come to align with population health objectives. 

Uncertainty about what autonomy actually means

A central concern across the discussions we held was the lack of clarity about what AFT autonomy actually means in practice. Participants questioned whether it represents “freedom from” central oversight, “freedom to” use resources differently, or a combination of both. Without clearer definitions, organisations may struggle to understand how AFT status will materially change how they work or the decisions they can make. Trust leaders emphasised the need for greater clarification on how AFT freedoms align with the proposed IHO contracts, including whether AFT status will be required for trusts to hold IHO contracts in the medium- and long-term. 

Similar uncertainty exists around financial freedoms. Some leaders observed that the proposed flexibilities appear similar to those available under the original foundation trust model, raising questions about whether AFT status represents a substantive change. Others noted that financial freedoms have eroded over time, suggesting that AFTs may simply restore previous levels of autonomy rather than introduce new capabilities. 

There were also concerns about whether financial flexibilities would be meaningful in practice, given the constrained financial environment. Even if freedoms exist on paper, many organisations lack the resources to invest in prevention or innovation, limiting the impact of these freedoms, and the progress that can be made quickly. 

Risks of concentrating power within large providers 

Another concern relates to the potential concentration of power within large provider organisations. If system partners such as ICBs, reduce their operational role at place level, there is a risk that large AFTs could become dominant local actors. This could create tensions with other trusts, primary care, local authorities and the voluntary sector, and undermine trust and collaboration. Participants stressed that population health must remain a shared system responsibility rather than being associated with a single organisation. There are also risks that AFTs could be perceived as being too dominant in system decision-making. Leaders emphasised the importance of partnership-based leadership approaches to avoid hierarchical control and maintain collaborative relationships. 

More broadly, participants questioned whether autonomy alone is sufficient to deliver the scale of change required. Lessons from the foundation trust model suggest that freedoms are only effective when the centre is clear about its intent and remains committed to enabling autonomy over time. There is a risk that, without this commitment, freedoms could be diluted. 

National governance frameworks and financial decision-making

Leaders highlighted the need to ensure that financial and governance frameworks align with long-term population health goals. Without this alignment, there is a danger that short-term operational pressures will continue to dominate, limiting the ability of AFTs to drive meaningful improvements in prevention, integration and health inequalities. They called for governance changes to give local areas greater flexibility over resources, align national rules with local needs, strengthen commissioning levers and ensure regulation supports partnership working. 

This includes addressing rigid funding conditions around how money is spent and enabling local areas to vary how resources are deployed, so they can focus investment where it delivers the greatest population benefit. 

Members also stressed the need to create headroom, supported by more flexible financial targets, to enable a genuine shift towards long-term financial planning. Short-term financial pressures and limited commissioning powers were seen as major barriers, underscoring the importance of strengthening the ICB commissioning role, including through payment mechanisms and contracting frameworks aligned with system outcomes. 

Although trust leaders supported the principles of AFT status, they stressed that meaningful improvements in population health will only occur if these freedoms are accompanied by wider system reforms. Some key recommendations following discussions with members include: 

Provide clear definition and purpose for AFT freedoms

NHSE should consider:

• Clearly articulating what freedoms AFTs will have that differ from existing foundation trust powers. 
  
  
• Defining whether AFT autonomy represents reduced central oversight (“freedom from”), greater local decision-making authority (“freedom to”), or both. 
  
  
• Explaining why AFT status is required to deliver the proposed IHO contracts, including whether AFT status will remain a prerequisite for holding them. 

Without this clarity, trusts risk seeing AFT status as primarily symbolic or procedural, rather than a meaningful mechanism for enabling system change. 

Align national incentives and performance frameworks with population health goals

NHSE should consider:

• Reviewing and strengthening national and provider level outcome frameworks so that performance metrics consistently support prevention, neighbourhood level health and the reduction of health inequalities, thereby driving the ‘left shift’. 
  
  
• Prioritising long-term population health in incentives while still supporting the government’s need to show visible improvements in core NHS services. 

Participants repeatedly highlighted that organisations respond to the incentives and metrics they are measured against. Current frameworks remain heavily focused on activity, waiting times and financial balance. This alignment will be critical if AFTs are expected to prioritise population health alongside operational performance. 

Enable multi-year financial planning and protect prevention investment

NHSE should consider: 

• Allowing multi-year financial planning frameworks for AFTs to support long-term transformation. 
  
  
• Providing mechanisms to protect prevention funding from short-term operational pressures. 
  
  
• Supporting double-running periods, where new community models are developed while existing hospital services remain operational. 

Trust leaders emphasised that short-term financial planning cycles and annual financial balance requirements limit investment in prevention. While these remain, financial flexibilities may have limited practical impact on prevention or health inequalities. 

Strengthen system governance and clarify roles across organisations

NHSE should consider: 

• Clarifying the system convening role in population health and neighbourhood transformation. 
  
  
• Defining how AFT roles interact with ICBs, health and wellbeing boards and local authorities. 
  
  
• Providing guidance on shared accountability frameworks for population health outcomes across organisations. 

Participants expressed uncertainty about where system leadership and decision-making responsibility sits, particularly between trusts, ICBs and other local structures. Clear system governance and accountability arrangements will help ensure AFTs support system collaboration rather than inadvertently concentrating power. 

Support resource flows to primary care and voluntary sector partners

NHSE should consider: 

• Enabling funding mechanisms that allow resources to flow more easily from NHS providers to community and voluntary sector partners. 
  
  
• Supporting longer-term funding arrangements for voluntary organisations to sustain prevention programmes. 
  
  
• Encouraging collaborative commissioning models that involve primary care and community partners from the outset. 

Trust leaders consistently emphasised that primary care and voluntary/community organisations are central to delivering prevention and addressing inequalities. This will help ensure prevention investment reaches the organisations closest to local communities. 

Learn from the experience of the foundation trust model

NHSE should consider: 

• Setting out a clear, long-term intent for local autonomy and maintaining an ongoing commitment to enabling provider and system level freedoms. This clarity and consistency are essential to prevent the dilution of autonomy and to ensure that freedoms translate into meaningful improvements. 
  
  
• Reviewing how previous incentives drove organisational growth over collaboration in some cases, and ensuring the AFT model avoids incentives that prioritise organisational performance at the expense of system outcomes. 

Members highlighted important lessons from the foundation trust reforms. Applying these lessons will help ensure the AFT model supports system-wide improvement rather than organisational competition. 

Conclusion

NHS provider boards are committed to shifting towards prevention and improving population health. It is essential that the legal framework, new operating model, commissioning approach, financial flows, incentives and performance management systems fully support and recognise organisations in delivering this.