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Government oversight of underperforming NHS trusts

A Westminster Hall debate has been scheduled for 14 October 2026, on government oversight of underperforming NHS trusts. This debate will be opened by Marie Goldman MP.

This briefing covers the overs the oversight of NHS trust (and foundation trust) performance. It does not cover the regulation of individual NHS managers – please see the further reading section for information relating to this.

What are NHS trusts and foundation trusts?

Most hospital, community, mental health, ambulance and specialist NHS care in England is provided by NHS trusts and foundation trusts (the term NHS trust is sometimes used to refer to both trusts and foundation trusts). These organisations account for the large majority of NHS spending.

All NHS trusts and foundation trusts have a Chief Executive and management board and are accountable to NHS England. NHS foundation trusts are self-governing bodies that have greater financial and operational freedom than NHS trusts, although there are also many similarities in how they operate. They also have a board of governors and members. Foundation trusts’ greater financial freedoms include the ability to borrow commercially and generate surpluses to reinvest in services.

Oversight of performance of NHS trusts

The NHS Oversight Framework sets out how NHS England assesses and oversees the performance of NHS trusts and foundation trusts (referred to collectively in the framework as ‘providers’) and integrated care boards (ICBs).

NHS England is responsible for setting overarching oversight policy and ensuring its consistent implementation. It assesses a provider's delivery against defined metrics, such as performance against national waiting time standards and measures of patient experience, to assign it a “segment” that sets out how it is performing.

The process of “segmentation” involves calculating an average metric score for the trust, which is then benchmarked against the rest of the country, to translate the score into a segment of 1-4 (with organisations in segment 1 performing most highly). Any organisation in financial deficit cannot be allocated to segments 1 or 2. Segmentation is used to rank trusts in league tables.

NHS England also monitors leadership, governance and delivery capability to give a capability rating. The segmentation and capability rating are used to decide an oversight response.

Organisations in segment 3 or 4 with amber-red or red capability ratings are subject to the most intense level of scrutiny. Interventions for these providers may include mandated support or enforcement action (such as undertakings or discretionary requirements). Providers with longstanding issues may be entered into an intensive recovery programme (see below). There may also be pay restrictions for very senior managers or limits applied to operational freedoms.

NHS England’s NHS Oversight Framework 2025/26 included a segment 5, “for the most challenged organisations that require the most support to improve.” It said these organisations would be considered for entry into the ‘provider improvement programme’ (subsequently referred to as the National provider improvement programme (NPIP)), which replaced the ‘recovery support programme.’

All NHS foundation trusts and NHS trusts must hold an NHS provider licence, a regulatory tool that sets conditions for the delivery of NHS services that providers must comply with. It provides the legal basis for NHS England to provide mandated support to challenged providers.

As a measure of last resort, the trust special administration (TSA) regime can be used to address urgent issues affecting the ability of a trust to deliver patient care. This is a time-limited measure where a Trust Special Administrator takes over the trust and makes recommendations for its future.

NHS intensive recovery programme

In March 2026, the government announced an ‘NHS intensive recovery programme’ (IRP) to support “challenged” trusts. The selected trusts ranked lowest in NHS league tables and faced long care waits, persistent financial difficulties and high leadership turnover.

Under the IRP, the selected trusts receive tailored support, including:

• changes of leadership, where necessary
• high-performing teams brought into underperforming areas
• merging or separating trusts so that resources can be reallocated according to need
• improving access to capital for improving NHS estates

The first five trusts to face these measures are:

• North Cumbria Integrated Care NHS Foundation Trust
• Mid and South Essex NHS Foundation Trust
• Hull University Teaching Hospitals NHS Trust
• Northern Lincolnshire and Goole NHS Foundation Trust
• East Kent Hospitals NHS Trust

A parliamentary question on Mid and South Essex NHS Foundation Trust provides more detail on how the programme works and how it fits with the existing oversight framework:

This programme marks a clear shift in approach, namely moving away from a one size fits all approach, with individual trust boards taking ownership of a clear plan to make their organisation sustainable going forward. Each organisation will be engaged with a tailored and time-limited improvement approach, designed jointly between local leadership and NHS England regional and national teams.

NHS England is currently working with Mid and South Essex to pinpoint the key constraints and barriers to sustainable change and improvement, and to develop a plan to improve performance. As part of the Intensive Recovery Programme, NHS England national and regional teams have met with the new Chief Executive of Mid and South Essex, to begin developing a recovery compact that focuses on stabilising performance in-year across quality, finance and operational performance, and to develop a turnaround plan that addresses longstanding issues.

The East of England NHS regional team continue to lead day-to-day oversight of provider and integrated care board delivery, with escalation to the Regional Executive Team and Regional Support Group where required. The region takes a holistic view of how well the organisation is delivering its statutory duties and agreed priorities, and this determines the level of scrutiny and how NHS England directs incentives, resources, support and interventions. Mid and South Essex is currently in Segment 4 of the NHS Oversight Framework, meaning the organisation is subject to the most intensive level of scrutiny until its delivery and/or capability improves and it can demonstrate that this improvement can be sustained.

PQ 8795 [on Mid and South Essex NHS Foundation Trust: Standards], 19 June 2026

In relation to the difference between the National provider improvement programme (NPIP) and the IRP, in April 2026 the government said that the IRP would not replace the NPIP. However, it said it was “reviewing the approach to ensure organisations receive the right level of support.” 

Changes to oversight under the Health Bill 2026-27

The Health Bill is currently passing through Parliament, with second reading in the House of Lords scheduled for 13 October 2026. The main purpose of the bill would be to abolish NHS England. It is expected that NHS England will be formally abolished in April 2027, and that most of its functions will be transferred to ICBs and the Department of Health and Social Care (DHSC).

The DHSC has published a fact sheet on how the bill would change oversight of the health system. It explains that the Secretary of State for Health and Social Care would take on responsibility for NHS England’s provider regulation functions.  This would include taking on oversight of the provider licence and would add a new purpose for setting or modifying licence conditions. The aim of this would be to strengthen the use of the provider licence as a regulatory tool for compliance with legal obligations.

The bill would also create a new power for the Secretary of State to convert (or “de-authorise”) foundation trusts to trusts. Currently, NHS England is not able to convert a foundation trust to a trust. The new power would be used to respond to performance issues in the most serious circumstances. The government has said this would maintain foundation trust status as a mark of good performance and incentivise challenged foundation trusts to improve.

The bill would also remove the requirement for NHS foundation trusts to have a council of governors and transfer most of the existing governance functions of the council to the Secretary of State.

Currently the power to place trusts into the TSA regime is split between NHS England (for NHS foundation trusts) and the Secretary of State for Health and Social Care (for NHS trusts). The Health Bill would provide a process for the Secretary of State to make an order appointing a TSA to an NHS trust or NHS foundation trust, and make some other changes to the TSA process.

For more information on the Health Bill, see the Commons Library briefings on:

• Health Bill 2026-27, 27 May 2026
• Health bill 2026-27: Progress of the bill, 1 September 2026

Commentary and further reading

• The NHS Alliance, The NHS Alliance responds to the publication of the National Oversight Framework, 11 June 2026
• The NHS Alliance, NHS Providers and NHS Confederation respond to Intensive Recovery programme, 25 March 2026
• Nuffield Trust, Time to clear the tables: why NHS league rankings don’t work, 3 July 2026
• DHSC, Leading the NHS: proposals to regulate NHS managers: consultation document, 26 November 2024
• DHSC, Leading the NHS: proposals to regulate NHS managers consultation response, 21 July 2025