Life after authorisation will present new and unusual challenges for many foundation trust executives. Phil Kenmore and Simon Bird have four tips to help them with their survival - and look toward a successful future.

Foundation trusts remain consistently in the news. Recent stories include how they might borrow more; opportunities presented by the lifting of the private income cap; pressure to open board meetings to the public; and the most current debate – the emerging failure regime.

As possible permutations of the consequences of failure are developed and debated, it seems that foundation trust executive teams have no choice but to carry on with the job in hand and hope that the final decisions taken will not adversely affect their organisation.

These will ultimately be policy decisions, and many executives unsurprisingly feel that the distance between the day-to-day delivery of care at their trust and the policy debates is too great to engage with meaningfully.     

Ask an executive at a non-FT to describe their priorities for the year ahead, and it is almost certain that they will include “achieve FT status”. The national ambition for full FT coverage remains clear, and even though the deadline has been relaxed slightly, there is no doubt that most executive teams feel a sense of responsibility and pressure to achieve this. But what happens after that?

Post-authorisation, top teams must consciously and deliberately shift their mindset to a new environment. Experienced executives will be able to tell stories about what it is they wish they had known.

Here we offer four areas which we believe present particular challenges to FT executives – and indeed, whole boards – and are essential if they are to be successful as they either move on from authorisation or cope with the current context.


For some FTs the vision has been more or less defined by their authorisation process. The mistake some of them make is by failing to evolve the vision in light of FT status and the changing environment. Can the executives articulate how their FT autonomy has enabled them to develop different services, more responsive caring or more integrated care?

Authorisation should be shown as the enabler and vehicle for ultimately delivering a better experience for patients and their families. There is a risk for some that the journey will feel like it is over at authorisation when it should feel like it has just begun.


The freedom granted to FT boards means the top team should take the opportunity to consciously and continually reframe the responsibilities that come with FT status. Executives should be able to articulate how the organisation is ready to respond to the new contextual challenges such as clinical commissioning groups, the quality, innovation, productivity and prevention programme, and the potential failure regime.

One of the biggest changes – and perhaps challenges – of being an FT is developing and maintaining meaningful relationships with a diverse membership of thousands through the council of governors.

Organisations take very different approaches to this. There are examples of chief executives who see the governors as simply another committee to be held at bay as much as possible – with most of the activity in this area being left clearly with membership officers and negligible executive involvement or debate. On the flip side, some see this as a real opportunity to get closer to their communities and understand how best to respond to them. 

FT executives have a choice to make in terms of how they reframe their own roles to reflect this shift in accountability. Another example is where there has been vertical integration of community services. The board needs to work through what this means for the whole organisation – or there is a risk that the new staff and services simply become bolt-on additions, as opposed to being integrated into the culture and direction of the organisation for the benefit of patients.

Commercial management

Entrepreneurialism is a key competence for outstanding FT executives, but this comes with a health warning. There is no point in being entrepreneurial if it makes no commercial sense for the organisation.

There is some evidence that some newly authorised FTs and even more established ones feel compelled to chase or develop business opportunities without real analysis of whether or not this makes sense, or is indeed sustainable, for the organisation.

It is the job of all executives to engage with, and understand, the commercial decision making process – and to challenge or drive it as necessary. FT boards need to know the questions to ask and how to help their executive teams select the opportunity to develop. Given the risks of over-reaching, and potential implications of failure, this is a vital discipline.

Intellectual agility

There is a difference between executives having the required intellect and how agile they are with this. Intellectual flexibility has long been recognised as an essential behaviour for successful leaders, and at times of flux in the environment, the need for such flexibility really comes to the fore.

An example would be the ongoing changes in the commissioning world. The reforms are difficult to keep up with at the best of times, but FT executives must ensure they have enough collective intelligence and input as possible in this area to enable them to be commercially relevant and well placed to respond to the emergence of new commissioning bodies, leaders and requirements. It won’t be enough to leave it to one or two individuals or push it down the organisation.

FT executives face a range of new and significant challenges both after they gain authorisation and through the current climate of rapid change. Keeping a focus on delivering quality care and pushing the organisation forward in difficult times will require a step change in leadership from both their pre- and immediately post-authorisation periods.