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This page outlines the basic structure of the NHS and the way it has changed over the years. It answers the following questions:

  • What was the initial structure of the NHS?
  • What happened in later years?
  • What does the NHS look like now?
  • What is devolution and how does it affect patients and doctors?
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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.

What Happened in Later Years to the Structure of the NHS?

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 provision from hospital 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 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. It 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.
  • 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.
  • Clinical Commissioning Groups (CCGs) are responsible for commissioning healthcare for their local area. They are run by GPs, nurses and consultants who assess local health needs and commission the services to meet them. They are in charge of around 60% of the NHS budget.
  • NHS Foundation Trusts provide the care that the CCGs commission. They include hospital, ambulance, mental health, social care and primary care services.

What is Devolution and How Does it Affect Patients and Doctors?

The four countries of the UK now 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.

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 will be beneficial to the NHS. ‘Devo Manc’ is a project initiated by the coalition government to devolve health and social care to Manchester authorities. It’s very early to tell, but the experiment could have several implications:

  • If it goes well, devolution could mean that services are more aligned with the needs of the specific region, which may have benefits to local population health.
  • But some worry that devolution at a time of austerity will complicate an already complex system, which could distract from basic care provision.
  • With any reorganisation there is a risk of redundancies, and it will be up to the Manchester authorities to decide whether they want to increase or decrease the amount of private sector services they commission. In the past, NHS workers have found themselves transferred to the private sector which has implications for pay, benefits and job security.

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