Structure of the NHS

On 5th July 1948, the NHS was founded by Aeurin Bevan. Over recent years there have been changes to the way that the NHS is structured. The likelihood is that you may have not even noticed this, as it won’t have affected how you access your local doctor or hospital. But the changes have affected who makes decisions about health services and who holds the budget to pay for these services. This means that the NHS is now a very complex system, which can sometimes make it difficult to understand, especially when working out who is responsible for what. It’s made up of a wide range of different organisations with different roles, responsibilities and specialities. These organisations provide a variety of services and support to patients and carers.

It all starts with the government, who decide how much money the NHS receive, and do top level priority setting. The Secretary of State for Health is in charge of the Department of Health, which is smaller than it used to be, and it passes money, gained from taxes, on to a range of other organisations.

Some goes to NHS England, which started in 2013, as part of sweeping reforms aimed at improving services by increasing competition, cutting red tape (which Andrew Lansley said there was a lot of in the NHS – he wanted to give all money to GPs, but this was not agreed upon), and keeping the government out of the day to day running of the NHS. NHS England is in charge of the commissioning (planning and buying) of NHS services. In practice, it also sets a lot of NHS strategy, and behaves like an NHS headquarters. It commissions some services itself, but passes most of its money onto about 200 clinical commissioning groups (CCGs) across England, which are made up of GPs, nurses, hospital staff and members of the public.

Here is a diagram showing the funding flows in the NHS:

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CCGs identify local health needs, and plan and buy care for people in their area. They buy services from organisations of different shapes and sizes, from NHS trusts that run hospitals, to GPs and others the provide NHS care, including charities and other organisations in the private sector, all of whom have to be registered with the Care Quality Commission.

There are two main bodies that support CCGs. The first is commissioning support units, which provide technical support to CCGs. There are about 20 of these. They crunch data, do contract negotiations, and do some technical contract management. The second is clinical senates. When Lansley said that he wanted to give all money to GPs, there was outcry from many people, including hospital doctors who said that the complexity of some of their patients is far beyond the knowledge of GPs, so it is going to be difficult for them to commission services that they don’t fully understand. So, clinical senates bring together a whole range of medical professionals, working in a variety of fields, to give advice to CCGs on particular patient groups or conditions.

Alongside NHS England is NHS Improvement. This oversees NHS trusts, and at the moment it is mostly focused on managing the financial aspects of trusts, making sure that they don’t spend too much, that they operate efficiently, and overall, improve.

Public health, keeping the public healthy, has long been the territory of the NHS, with things such as healthy eating and smoking cessation campaigns. Recent health reforms have moved their budget to local government and Public Health England. Local governments also establish Health and Wellbeing boards, which bring together key players in the health and social care system, including local counselors, to improve health in a joined up way across health, social care, and other public services.

Healthwatch is another organisation which exists at a national and social level to represent the views of patients, and for people to engage in how services are planned. There are also a whole load of other bodies with their own remits and acronyms, including: NHS Digital, NICE, Health Education England (HEE), HSCIC (health and social care information centre), NHR, MHRA (medicines and healthcare products regulatory agency) and many more. The upshot is that these organisations can, at times, issue seemingly contradictory messages. There are also unclear boundaries as to exactly which organisation is responsible for what prompting questions about who is really in charge.

Here is a basic structure of the NHS diagram:

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Some definitions:

NHS England and NHS Improvement are responsible for providing national direction on service improvement and transformation, governance and accountability, standards of best practice, and quality of data and information. They came together in 2019 to act as a single organisation (maintaining separate boards). The aim of the merger is to work more effectively with commissioners and providers, making more efficient use of resources, and removing duplication.

The Care Quality Commission’s (CQC) role is to register care providers and monitor, inspect and rate their services in order to protect users. CQC publishes independent views on major quality issues in health and social care.

Regional NHS England and NHS Improvement teams are responsible for the quality, financial and operational performance of all NHS organisations in their region. Increasingly, they are working with local systems (ICSs/STPs) to oversee performance, support their development and make interventions when necessary.

Sustainability and transformation partnerships (STPs) bring together NHS providers and commissioners, local authorities and other local partners to plan services around the long-term needs of local communities. STPs cover populations of 1-3 million people.

In some areas, integrated care systems (ICSs) have evolved from STPs. ICSs are a closer collaboration in which organisations take on greater responsibility for managing local resources and improving health and care for their populations. According to the NHS long term plan, every part of England will be covered by an ICS by 2021.

Integrated care partnerships (ICPs) are alliances of providers that work together to deliver care by agreeing to collaborate rather than compete. These providers include hospitals, community services, mental health services and GPs. Social care, independent and third sector providers may also be involved. NHS England and NHS Improvement is developing an ‘integrated care provider contract’ as an option for formalising these partnerships.  ICPs cover populations of 250–500,000 people.

Primary care networks (PCNs) bring general practices together to work at scale with other local providers from community services, social care and the voluntary sector. Together they provide primary care by using a wide range of professional skills and community services. Since 1 July 2019, all except a handful of GP practices in England have come together in around 1,300 geographical networks. PCNs cover populations of 30–50,000 people.

But the NHS, and the way that these organisations work together is always changing. The most recent changes started in 2014, when NHS England published a vision on the future of healthcare, called the ‘NHS Five Year Forward View’. This called for more of a focus on preventing people from getting ill in the first place, and giving patients more control of their own care. It also set out a range of new models of care, which aimed to get services working together to provide joined up care for patients. There hasn’t been much progress on the prevention part, but lots of energy has been put behind the new models. Examples of what this aims to do include providing treatment traditionally administered in hospitals in people’s homes, such as chemotherapy, and get people to work differently, such as dementia specialists carrying out clinics in GP surgeries. This new way of working is particularly designed to meet the needs of increasing numbers of people who need support to manage long-term conditions, particularly older people.

Over the past couple of years, 50 areas across England, known as Vanguard sites have been trialing the delivery of more joined up care. This is all part of a broader shift towards organisations working together more closely to meet patients physical and mental health needs, and away from an NHS market place. The NHS has invented/adopted a whole range of acronyms to describe this approach.

Firstly, STPs (sustainability and transportation partnerships), which aren’t organisations in themselves, but describe a way of working together in partnership. These were created when NHS organisations were asked to come together with local authorities, charities, and others, to agree how to improve health, and modernise services. There are 44 STPs in England, all focused on progressing the ideas in the Five Year Forward View.

Some STP areas are on track to develop into another acronym, ACSs (accountable care systems), which take inspiration from parts of the US, where organisations work together under a set budget, to improve health and coordinate services for people who live in a certain area. In part, these changes are about managing the limited resources available to the NHS. But they are also about working together with services outside the NHS, like social care and public health, that have a really important impact on our health. This requires much closer working with local authorities.

So far, there are many aspects of the NHS which have come together, for example, CCGs have been merging, hospitals are forming chains, and GPs are forming federations. What’s more, in places like Manchester, many more choices are being made locally about health and care services should work there.

So, what next? There is a lot of change going on at the moment, which leaves a lot of unanswered questions, not least, what does this mean for patients? It should result in a better continuum of care at home, and a push to keep the population more healthy. But, with the NHS already over-spending, and being stretched more than ever with an ageing population, change is hard to implement, and may be very slow.

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