Applying for NHS foundation trust status

We assess NHS trusts before they become foundation trusts to ensure they are well led so they can deliver good quality care for patients on a sustainable basis. This section provides an overview of the NHS foundation trust assessment process.

Trusts need the support of the NHS Trust Development Authority (NHS TDA) to apply for foundation trust status

Before beginning their formal foundation trust application, NHS trusts must work with the NHS TDA to make sure they are ready. The NHS TDA will provide development and support, alongside its routine oversight, to help them prepare.

The Care Quality Commission’s (CQC) Chief Inspector of Hospitals will then conduct a thorough inspection of each trust. We will not grant foundation trust status without the CQC’s assurance that the quality and safety of the services an NHS trust provides meet the required quality threshold.

CQC inspections

Once the CQC fully rolls out its new ratings system, NHS trusts that achieve an overall rating of “Good” or “Outstanding” will be able to pass to the next stage of the assessment process. In the meantime, an interim arrangement is in place until the CQC is in a position to issue formal ratings.

If the NHS TDA Board is satisfied that the trust is ready to proceed then it will offer its support, on behalf of the Secretary of State, for the trust’s application to be passed to Monitor to be assessed.

Trusts already with Monitor for assessment will receive their CQC inspection during the Monitor phase and will not be required to go back to the NHS TDA for approval.

More details can be found in our update on changes to the process for developing and assessing NHS trusts on their journey to FT status (November 2013).

Trusts must write to Monitor to begin the next stage of their assessment

Once we receive confirmation that an applicant trust has the NHS TDA’s support, we write to the trust explaining that they need to:

  1. send us a covering letter from the NHS trust chief executive; and
  2. send us a copy of the:
  • letter confirming the applicant has the support of the NHS TDA;
  • proposed constitution of the NHS foundation trust; and
  • integrated business plan as submitted to the NHS TDA.

More details can be found in the Guide for Applicants.

Monitor’s assessment process

Once an NHS trust has formally applied for foundation trust status, we write to confirm when its assessment will happen. Details of how we prioritise applications can be found in the Guide for Applicants.

Monitor assesses trusts against three criteria

When we assess trusts for foundation status there are three main elements to our work:

  1. testing whether a trust meets the required quality performance threshold (working closely with the Care Quality Commission to determine this);
  2. assessing how well run the trust is; and
  3. assessing the financial viability of the trust to ensure it can continue to deliver high quality care on a sustainable basis.

More information is available in the Guide for Applicants.

Trusts will need to give Monitor a range of documents and attend meetings

The Guide for Applicants gives details on the information that trusts must submit to us during the assessment process.

Our assessment team spends a number of days visiting the trust to conduct interviews and analysis. Our team will also meet key stakeholders, such as commissioners, and will seek views on the trust’s application from members ofand local Healthwatch organisations. The assessment process generally takes around 4 months to complete.

Each trust is given the opportunity to present its business plan to us at a meeting which takes place once the majority of the assessment work has been completed.

The trust executive and non-executive board members will be expected to attend this meeting. We will ask questions and provide challenge on the application. This meeting allows the applicant board to demonstrate that it is aware of the risks facing the trust and to provide details on how these can or have been managed and mitigated. It also gives us the opportunity to question the non-executive directors of the trust to determine whether they have the skills they need to challenge the executive team effectively.

Monitor may decide to authorise, defer or reject an application

Towards the end of the process, our assessment team will formally consider the application. We may authorise, defer or reject a trust’s application. Details about the implications of these outcomes are available in the Guide for Applicants.

Being authorised

If we decide to authorise an applicant trust, we will formally notify the trust and issue it with an NHS provider licence.

The licence sets out the conditions under which an NHS foundation trust is required to operate.

Find out more about how we regulate foundation trusts here.

Being deferred

We have discretion to defer an application where we feel outstanding issues can be solved within a reasonable period of time. We will expressly define and explain the matters needing attention. Deferred trusts are not required to restart the application process with the NHS TDA.

Being rejected

If we reject an application, we will formally notify the trust. If the trust wishes at some future date to reapply to become an NHS foundation trust, it will have to restart the application process with the NHS TDA.

A trust may postpone or withdraw its application

NHS trusts may withdraw from the assessment process or postpone their application until a later date under certain circumstances. Detailed information is available in the Guide for Applicants.


If issues arise during the assessment process that a trust must resolve before we can make a decision, it may write to us to request a period of postponement. We consider the reasons put forward by the applicant on a case-by-case basis and the decision whether to accept a request is at our discretion. Where we accept a request, the applicant trust will not need to regain NHS TDA support before restarting the assessment process.


We will treat an application as withdrawn if the applicant trust requests to be withdrawn from the process or if the trust does not reactivate its application in the timeframe set out in either the deferral letter or letter confirming a period of postponement.

If a trust withdraws its application and later wishes to reapply for authorisation as an NHS foundation trust, it will have to regain NHS TDA support.