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The Structure of the NHS (Simplified!)

The Structure of the NHS (Simplified!)

Updated on: December 3, 2023
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Written By Dr Ollie

Every article is fact-checked by a medical professional. However, inaccuracies may still persist.

The structure of the NHS is a massive topic that takes a lot of getting your head round.

Importantly, it’s not one to be missed as medical school interviewers love to check that candidates have at least a basic understanding of how the National Health Service operates.

Formed in 1948, the NHS is actually an umbrella term for three different systems- NHS England, NHS Scotland and NHS Wales.

Each of these systems provides a comprehensive range of health services, free at the point of use, to its respective residents.

In this article, we’re going to unpick the structure of the NHS in England by looking at how money flows from the taxpayer right the way through to patients receiving care.

Who’s In Charge Of The NHS?

To understand the structure of the NHS we need to know who’s in charge.

Being a publicly funded healthcare system, the NHS is ultimately controlled by the government.

From the governing party, a senior minister will be appointed the Secretary of State for Health and Social Care.

This position is the head of the Department of Health and Social Care- a major government department.

The health secretary is responsible for the oversight of the NHS, as well as England’s social care policy, national public health and international health partnerships.

The government decides how much money the NHS receives and do top-level priority setting.

However, the vast majority of decision making is devolved to those who are actually a part of the system as we’ll see later…

Where Does Money For The NHS Come From?

Let’s now look at how money flows through the NHS.

To begin that journey we have to look at where the money comes from in the first place!

Although healthcare is free at the point of delivery in England, that money has to come from somewhere.

In short, the NHS is funded by taxpayer’s money.

Healthcare spending in England is roughly equivalent to £3000 per person, per year.

The NHS has three main sources of funding:

  1. General taxation: taxes can be raised by both central and local government. Taxes raised by local governments are usually earmarked for spending on healthcare in a specific region or area.
  2. National insurance: this is essentially another tax that the government uses to provide benefits to people who meet certain criteria e.g. the state pension or maternity allowance.
  3. Patient charges: these are things like prescription charges or the cost of parking at hospitals. Money can also be raised in other ways such as offering private treatments or selling land.

The Department of Health and Social Care

Funding for health services comes from the total budget of the Department of Health and Social Care.

In 2020/21 this was £212.1 billion, up from £150.4 billion in 2019/20.

The majority of the Department of Health and Social Care’s budget is passed on to NHS England.

St Thomas’ Hospital Emergency Department

The money that isn’t passed on to NHS England is spent on things such as public health, training and development of NHS staff, and regulating the quality of care.

These functions are in turn directed by organisations such as Public Health England, Health Education England and local authorities across the country.

Right, so now let’s follow the money down to NHS England…

NHS England

Every year the Secretary of State publishes a document known as the NHS mandate.

This document lays out the aims and objectives NHS England should seek to achieve over the year.

It’s then NHS England’s job to go out and commission the appropriate services to achieve these aims.

NHS England commissions some of these services itself, but the majority it leaves to Clinical Commissioning Groups or CCGs.

NHS England is an independent body, which means that the Department of Health and Social Care cannot interfere directly with its decisions.

Directly Commissioned Services

The majority of services NHS England commissions directly are delivered on a national level.

These are things like:

  • Specialised services such as rare cancer treatments. In these cases there aren’t enough patients to warrant local provisions
  • Military and offender medical care services
  • Primary care services including dentistry, pharmacy and optometry

Delegated Commissioning of General Practice

NHS England used to commission general practice services along with the other primary care services.

However, as of 1 April 2021 all CCGs have delegated commissioning arrangements for general practice.

The delegated commissioning of primary medical services is part of a wider strategy to achieve more integrated care.

It’s hoped with the delegation of primary medical services patients may enjoy improved access to primary care, a higher quality of care and improved health outcomes.

NHS Clinical Commissioning Groups

Clinical Commissioning Groups are who commission the vast majority of services for the NHS.

CCGs are groups of general practices that work together to commission the best services for their patients in a certain area.

As part of their governing body, in addition to GPs, each CCG has at least one registered nurse and one hospital doctor from outside the area.

A local clinical commissioning group meeting

They were introduced by the Health and Social Care Act 2012 with the aim of giving GPs and other clinicians the power to influence which services are chosen for their patients.

Services CCGs commission include:

  • Hospital care
  • Rehabilitative care
  • Urgent and emergency care
  • Community health services
  • Mental health services
  • Learning disability services

These services can be bought from any provider that meet NHS standards and costs.

That could be an NHS hospital, a social enterprise, voluntary organisation or a private company.

Not only does this mean CCGs can respond to their community’s requirements more accurately, by commissioning exactly what’s needed, but due to the competition between organisations the overall quality of care patients receive should be higher.

The amount of money each CCG receives depends not only on the size of the population it’s looking after but also on factors such as the average age and level of deprivation in the area.

Having assessed their population’s needs the CCGs then use this money to buy as many services as their budgets allow.

NHS Service Providers

Service providers are who actually deliver the care to patients on the front line.

They can be hospitals, GP practices, ambulance services or walk-in centres to name a few.

They’re regulated by a number of different bodies including the Care Quality Commission or CQC.

The CQC is sort of like an OFSTED for healthcare providers, inspecting facilities, outcomes and patient experience.

It reports directly to the Department of Health and Social Care if providers aren’t meeting its standard.

Other Key Organisations In The NHS

Having taken a linear view of the funding flow through the NHS we’ve missed out countless organisations that mesh together to support the NHS.

Some of the important bodies that don’t quite fit into this funding chain are as follows:

National Institute for Health and Care Excellence

The National Institute for Health and Care Excellence (abbreviated as NICE) aims to improve outcomes for people using the NHS and other public health and social care services.

It does this by:

  • Producing evidence-based guidelines for health professionals
  • Developing quality standards and targets for healthcare delivery
  • Providing information services across the health and social care industry

NICE is a non-departmental public body which means it carries out its work largely independently from ministers and is accountable to the public through parliament.

Health Education England

Health Education England recruit, educate and train the NHS workforce.

They’re essentially in charge of making sure the NHS has employees with the right skills, training and attitude to deliver top quality healthcare.

NHS staff conferring at the nurses’ station

Their mission statement is “to deliver and reform education to produce the best possible future workforce; to transform the current workforce to meet tomorrow’s health and care needs; and ensure the quality of our education and training system.”

NHS Improvement

NHS Improvement… well as the name suggests are all about improving the NHS!

They’re responsible for overseeing NHS trusts as well as independent providers in delivering safe, high quality and compassionate care to patients.

From 1 April 2019, NHS England and NHS Improvement were merged into a single organisation- but you may still see them referenced individually.

The Structure Of The NHS In The Future

The NHS is an ever-changing beast, with constant reforms and reorganisations.

These take place on both the micro and macro level, with the latest major shake-up having been announced on the 7th January 2019.

This was the publication of the NHS Long Term Plan.

This document laid out key ambitions for the NHS over the next ten years, as well as the reforms to help achieve them.

Integrated Care Systems

A big push for the future of the NHS is to provide more integrated care.

What this means is organisations working closer together to provide a more coordinated experience for patients.

This is because with so many different groups delivering care to patients it’s easy for things to become very disjointed.

This might occur when a patient moves from:

  • General practice to a hospital setting
  • Physical care to mental health services
  • NHS to council services

The Long Term Plan confirmed the introduction of integrated care systems to help with this goal.

Integrated care systems (ICSs) are partnerships that bring together providers and commissioners of NHS services across a geographical area with local authorities and other local partners to collectively plan health and care services to meet the needs of their population. 

The King’s Fund

It’s hoped that within an integrated care system there’ll be closer collaboration regarding both resource management and patient care.

All parts of England are now covered by one of forty-two integrated care systems.

Primary Care Networks

Improving care outside of hospitals is one of the key objectives from the Long Term Plan.

One of the ways the NHS plans to do this is to join small groups of general practices together into primary care networks.

Practices will enter network contracts, alongside their individual GP contracts.

Primary care networks are incentivised to proactively manage their population’s health through a ‘shared savings’ scheme.

This scheme will lead to financial benefits to networks that reduce accident and emergency attendances and hospital admissions.

A Digital Focus

Some of the plan’s most ambitious targets focus on the use of digital technology for healthcare provision.

This ranges from further development of the NHS app, to a new ‘right’ for patients to access their GP via an online consultation, to remote monitoring (via wearable devices) of patients.

The NHS app

NHS England is even supporting primary care providers to move to a digital first approach.

What this means in practical terms is that online tools need to be available to access all of a GP’s services- be that making an appointment or receiving a prescription.

This fits in with the wider plan for ‘fully digitised’ secondary care by 2024.

Final Thoughts

The NHS is a vast organisation made up of countless departments, bodies, providers and regulators.

However, hopefully by taking a simplified, linear view of funding flow you’ll have gained a workable understanding of the basic structure.

And in reality, that’s just what you need for your medical school interview.

They’re not expecting you to be an expert in the structure of the NHS, only to have a reasonable knowledge about the organisation you want to work for.

And once you’ve digested this article that’s exactly what you’ll have!

About the author
After studying medicine at the University of Leicester, Dr Ollie now works as a junior doctor in London. His interests include medical education and expedition medicine, as well as having a strong belief in the importance of widening access to medicine.