Dr Richard Dune

30-06-2025

What are NHS Trusts?

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Your guide to NHS Trusts - Understanding governance, compliance, and their evolving role in Integrated Care Systems (ICSs)

The National Health Service (NHS) is one of the most iconic institutions in the United Kingdom, representing a cornerstone of public service, health equity, and universal access. At the heart of this vast system are NHS Trusts, public sector organisations responsible for delivering day-to-day healthcare services, including hospitals, mental health units, community care, and ambulance services.

In the post-COVID integrated care era, NHS Trusts are no longer just care providers; they are strategic leaders and anchor institutions within their communities. Whether you're an independent provider, commissioner, regulator, or system leader, understanding NHS Trusts is crucial to navigating the future of healthcare in England.

In this comprehensive blog, Dr Richard Dune explores what NHS Trusts are, their role, governance, regulation, and how they differ from NHS Foundation Trusts. We also examine how they are evolving within Integrated Care Systems (ICSs) and the implications for providers and partners in 2025 and beyond.

What is an NHS Trust?

An NHS Trust is a legally constituted public body that provides healthcare services within the NHS in England. As of 2025, there are approximately 212 NHS Trusts, including both standard NHS Trusts and Foundation Trusts.

NHS Trusts are commissioned to provide services by NHS England (now overseen directly by the Department of Health and Social Care (DHSC) following the abolition of NHS England in 2025) or by Integrated Care Boards (ICBs) within ICSs. They are accountable to both national regulators and their local communities.

Types of NHS Trusts

NHS Trusts can be categorised by their specialist service areas:

1. Acute Trusts

• Run large general hospitals or specialist centres
• Provide emergency, surgical, maternity, and diagnostic services.

2. Mental health Trusts

• Deliver services including inpatient psychiatric care, community mental health teams, crisis services, and talking therapies.

3. Community health Trusts

• Provide out-of-hospital services, including district nursing, community rehabilitation, health visiting, and community hospital care.

4. Specialist Trusts

• Focus on specific clinical areas (e.g., cancer, cardiology, eye care, orthopaedics).

5. Ambulance Trusts

• Deliver emergency response, patient transport, and out-of-hours urgent care.

NHS Foundation Trusts - What are the key differences?

NHS Foundation Trusts (FTs) were introduced under the Health and Social Care (Community Health and Standards) Act 2003 to allow for greater autonomy, accountability, and local responsiveness.

Key differences from NHS Trusts:

Table 1 - Key differences from NHS trusts for NHS Foundation Trusts: How Are They Different?

Foundation Trusts operate with more localised control over strategy, operations, and investment, which can lead to more tailored and responsive care in their communities.

Governance structures and accountability

Board of Directors

All NHS Trusts and FTs are governed by a Board of Directors, comprising:

• Executive directors - Chief Executive, Medical Director, Chief Nurse, Director of Finance, and others
• Non-Executive Directors (NEDs) - Appointed for their expertise in governance, finance, strategy, and community representation
• Chairperson - Oversees board conduct and represents the Trust at the system level.

The Board is collectively responsible for:

• Ensuring safe and effective services
• Meeting financial and operational standards
• Responding to regulatory inspections
• Engaging with staff, service users, and the public.

Foundation Trusts and council of governors

In addition to the Board, Foundation Trusts must have a Council of Governors, elected by staff, patients, and public members. Governors help set priorities, approve major decisions, and provide grassroots accountability.

Oversight and regulation

All NHS Trusts and Foundation Trusts are subject to stringent oversight by national bodies.

Department of Health and Social Care (DHSC)

Since the abolition of NHS England in 2025, the DHSC is directly responsible for:

• Allocating budgets
• Setting strategic direction
• Overseeing NHS Trust performance.

Care Quality Commission (CQC)

CQC regulates care quality via the Single Assessment Framework (SAF). Trusts are rated on five key domains: Safe, Effective, Caring, Responsive, and Well-led.

CQC powers include:

• Unannounced inspections
• Enforcement action
• Suspension or removal of registration.

Other regulatory bodies

• Freedom to Speak Up Guardian (via the National Guardian’s Office): Supports whistleblowers and cultural change
• Information Commissioner’s Office (ICO): Oversees GDPR and data protection compliance
• Health and Safety Executive (HSE): Enforces non-clinical workplace safety
• Professional regulators (e.g. NMC, GMC, HCPC): Ensure staff meet professional standards.

The role of NHS Trusts in Integrated Care Systems (ICSs)

In 2025, Trusts are anchor organisations in England’s 42 Integrated Care Systems.

Key Functions in ICSs:

• Place-based leadership - Co-lead health strategy in their geographical area.
• Provider collaboratives - Join with other Trusts to reduce variation and share expertise.
• Workforce development - Collaborate on regional training, retention, and leadership pipelines.
• Innovation and digital integration - Lead deployment of shared care records, virtual wards, and AI pilots.
• Reducing inequalities - Use data and population health tools to improve access and outcomes.

Trusts are expected to align closely with ICB priorities and co-produce services with the Voluntary, Community and Social Enterprise (VCSE) partners and communities.

Performance expectations and compliance

NHS Trusts are held accountable to multiple performance benchmarks, including: 

Clinical access targets:

• Emergency Department (A&E): 4-hour wait standard
• Referral to Treatment (RTT): 18-week target
• Cancer Pathways: 62-day wait from referral to treatment.

Quality metrics:

• Patient safety incidents
• Infection prevention (MRSA, C. diff)
• Patient experience (via Friends and Family Test).

Financial and operational:

• Balanced budgets and value for money
• Annual audit and governance reports
• Sustainability: Green plans and carbon reduction.

Workforce:

• Staff survey results
• Equality, Diversity & Inclusion metrics
• Training, CPD, and supervision audits.

Trust performance is published on NHS England dashboards and used to determine funding, contracts, and improvement actions.

Independent and voluntary providers - What you need to know

If you’re a provider working in partnership with NHS Trusts, be it through subcontracting, integration hubs, or care pathways, you must meet the same governance, compliance, and quality standards.

Expectations include:

• CQC registration and inspection readiness
• NHS-aligned safeguarding, infection control, and incident reporting
• Clinical audits and information governance (UK GDPR compliance)
• Participation in multidisciplinary team (MDT) and system-wide forums
• Timely response to adverse events and Serious Incident Reviews (SIRs).

Being “NHS-trusted” means demonstrating not just competence, but cultural alignment, risk awareness, and system contribution.

Risks of non-compliance

Non-compliance can have serious consequences:

• Contract suspension or termination
• Referral to regulators (e.g. CQC, ICO)
• Public exposure through poor inspection ratings
• Legal liability and reputational damage.

Trusts themselves can be escalated under the NHS Oversight Framework, triggering:

• Intervention by Improvement Directors
• External reviews and audits
• Restructuring of executive teams.

For Foundation Trusts, the Council of Governors may demand explanations or propose changes to leadership if public confidence is lost.

NHS Trust priorities in 2025 and beyond

Trusts are now leading the transformation of care across six key areas:

Final thoughts

NHS Trusts, whether standard or Foundation, are no longer just “hospitals” or “service providers.” They are leaders of population health, custodians of public trust, and collaborators in system transformation.

Their accountability extends beyond their own walls, into homes, communities, and digital front doors. They shape how care is delivered, how staff are trained, how data flows, and how inequalities are tackled.

For external providers, engaging with NHS Trusts is not just about contracts; it’s about culture, compliance, and contribution. Understanding their governance, meeting their expectations, and aligning with their goals is essential for sustainable partnership and system impact.

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