The NHS is one of the largest organisations in the UK, and its structure can be hard to get navigate. We outline how the NHS is structured, how this has changed over time – and how it could change in the future, with more devolved healthcare.

What Was the Initial Structure of the NHS?

For the first few decades of its existence, the structure of the NHS had a ‘tripartite system’ which was made up of the following services:

  • Hospital services, organised into regional hospital boards in charge of administration.
  • Primary care, including GPs, dentists and opticians who worked as independent contractors rather than salaried employees of the government.
  • Community services, including maternity, child welfare, vaccination and ambulance services.

Medical professionals soon called for this system to be unified, and in 1962 Enoch Powell (Minister of Health) responded with a 10-year plan to build a new district general hospital to serve each population area of at least 125,000.


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How Did the NHS Structure Change?

In 1980, The Black Report concluded that despite the foundation of the NHS, poorer people had higher infant mortality rates and lower life expectancies.

In addition to this, advances in medical science meant that costs were, and are, always being pushed up. Which means that the NHS almost always has a problem with money.

The Thatcher government’s response was to introduce the concept of an ‘internal market’ which still governs the NHS today.

The NHS and Community Care Act 1990 gave regional health authorities budgets with which to buy health provisions from hospitals and other health organisations, putting hospitals in competition with each other to sell their services.

In 2003, the Labour government introduced Payment by Results, where NHS bodies are allocated money based on how many patients they see. Whilst this can be cost-efficient, it can also risk services being too target-driven and compromising on the quality of care.

What Does the Structure of the NHS look like now?

The next big overhaul came with the Health and Social Care Act 2012, which introduced huge structural reforms to the NHS.

The NHS is now divided into a series of organisations that work at a local and national level. The structure of NHS England is as follows:

  • The Department for Health is the government department responsible for funding and coming up with policies to do with healthcare in the UK.
  • Sustainability and Transformation Partnerships (STPs) were introduced in 2016. They bring together NHS providers, commissioners, local authorities and other partners to plan services based on the long-term needs of the local populations. STPs cover areas with populations of 1-3 million people. Integrated care systems (ICSs) are evolving from STPs in some areas, and the NHS Long Term Plan confirmed that every part of England would be covered by an ICS by April 2021. ICSs are a closer collaboration, where organisations take on more responsibility for resources and care of the local population.
  • Clinical Commissioning Groups (CCGs) are a group of hospitals and services that cover a geographical area of the UK. They’re responsible for commissioning most NHS services. In 2020, there were 135 CCGs, following a series of mergers. Each group decides which services and treatments are available in their hospitals and chooses how secondary care is provided.
  • NHS England is the umbrella body that oversees healthcare. It is an independent body, which means that the Department for Health cannot interfere directly with its decisions. It’s responsible for ensuring that there is an effective system of CCGs and must provide support for commissioning. In 2019, NHS England and NHS Improvement were merged, but maintain separate boards.
  • NHS Foundation Trusts provide the care that the CCGs commission. They include hospital, ambulance, mental health, social care and primary care services.
  • Primary Care is delivered by general practitioners who often work holistically, thinking of a patient in their entirety. Since July 2019, almost all GP practices in England have come together to form about 1,300 primary care networks (PCNs). These cover a population of 30,000-50,000 people and bring general practices together, along with local providers to provide a wide range of professional skills and community services.
  • Secondary Care is provided to patients by specialists and healthcare professionals to whom patients are often referred through a GP. It includes both emergency and non-emergency hospital contacts such as A&E, outpatient routine clinics, and mental and maternity health access.
  • Tertiary care is provided to patients by specialised doctors and nurses in specialised hospitals, such as a plastic surgery unit. Patients can only access tertiary care if they are referred by a health professional working in secondary care.
  • The National Institute for Health and Care Excellence is known as NICE. It regularly evaluates the most up-to-date evidence behind treatments and details what the best approaches are, putting prospective treatments through rigorous analysis and evaluation. CCGs are legally obligated to make funding available for treatments recommended by NICE following publication.
  • The Care Quality Commission is an independent monitoring agency, like OFSTED is for schools, which inspects the safety and quality of care in hospitals, general practices, care homes, ambulance services and walk-in centres, then delivers a publicly available evaluation. The CQC reports to the DHSC and aims to improve the quality of healthcare provision across the UK. It publishes ratings of each trust and its services – if services do not meet certain standards, the CQC can issue warnings, restrict services or even prosecute the provider.
  • Health Education England is the overseeing body for the lifelong training and education of the NHS workforce, committed to “ensuring that the workforce of today and tomorrow has the right numbers, skills, values and behaviours at the right time and in the right place.”
  • In January 2019, the NHS set out its Long Term Plan, which sets out the key ambitions for the service over the next 10 years. Its aims include giving people more control over their own health and the care they receive, as well as encouraging Integrated Care Systems and preventing/tackling health inequalities. STPs and ICSs then had to set out how they planned to take on the ambitions set out in the Long Term Plan and turn them into local action.

The structure of the NHS was then subject to another major overhaul following the approval of the Health and Care Act 2022. It has restructured the NHS in England, solidified the role of ICSs by giving them a legal basis, established Integrated Care Boards (ICBs) and abolished CCGs.

The powers of the Secretary of State for Health and Social Care have been strengthened as well. They have a range of powers over national NHS bodies and local systems and trusts.

They also have a new statutory responsibility to report on the system for assessing and meeting the needs of the NHS workforce in England.

The Health Services Safety Investigations Body has become a statutory body, too. It is responsible for investigating serious patient safety risks across the healthcare system. It has its own independence and develops recommendations for lessons to be learned and improvements to be made.

How Does Devolution Affect This?

The four countries of the UK have their own NHS services. This means that responsibility for running the NHS in these areas has been transferred from central government — MPs in Westminster —  to powers in Scotland, Wales, Northern Ireland and England since 1999.

The UK Parliament allocates block funding to each national government, but it is up to them to decide how much to spend on their NHS.

Some people think that even more regional devolution would be beneficial to the NHS.

This was tested with DevoManc – a trial which gave Manchester control of their health and care spending and decisions in 2016. Some key results include:

  • Investment in, and access to, Children’s Mental Health services has improved
  • Physical inactivity is being tackled three times faster than the national average
  • 6,000 people who were primarily out of work due to poor health have been helped back to work
  • The number of people sleeping rough on the streets has dropped by 37% thanks to the ground-breaking A Bed Every Night scheme – funded in part by the Greater Manchester NHS
  • Care homes continue to see an increase in good and outstanding ratings – from 54% in April 2016 to 81% currently. For home care, there has been a similar increase from 62% to 90%.

Find out more here.


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