How does the NHS in England work? What organisations make it up? And how is it changing over time?
Since the NHS is largely funded by our taxes, let’s start with the government: they decide how much money the NHS receives, and do top-level priority setting. The Secretary of State for Health is in charge of the Department of Health, which is actually quite slimmed down compared to what it used to be, and it passes most of its money on to a range of other organisations.
The lion’s share goes to an organisation called NHS England. It was created in 2013 as part of sweeping reforms aimed at improving services by increasing competition, cutting red tape and keeping the government out of the day-to-day running of the NHS. But this is all actually quite far from what’s really happening – as we’ll see.
NHS England is responsible for overseeing the commissioning, the planning and the buying, of NHS services. In practice it also sets quite a lot of NHS strategy and behaves like an NHS headquarters. NHS England commissions some services itself, but passes most of its money onto 200 or so clinical commissioning groups across England, also known as CCGs, which identify local health needs and then plan and buy care for people in their area – people like you and me.
CCGs buy services from organisations of different shapes and sizes – from NHS trusts that run hospitals and community services, to GPs and others that provide NHS care, including organisations run by charities and the private sector.
Jostling for position alongside NHS England is NHS Improvement. It oversees NHS trusts and right now its focus is very much on managing the money. So, for example, it tries to ensure that trusts keep a lid on costs, operate efficiently and you know… improve.
Also in the mix is the Care Quality Commission, which inspects the quality of care provided. There are also a whole load of other bodies with their own remits and acronyms.
This is quite a crowded landscape and the upshot is that these different organisations can at times issue seemingly contradictory messages. There are also unclear boundaries about exactly which organisation is responsible for what, prompting questions about who’s really in charge.
But the NHS never stays the same for long and the way these organisations work together is changing. The most recent changes started in 2014 when NHS England published a vision for the future of health care called the NHS five year forward view. This called for more of a focus on preventing people getting ill in the first place, and giving patients more control of their own care.
It also set out a range of so-called “new models of care” that aimed to get services working together to provide “joined-up care” for patients. There’s not been much progress on the prevention bit, but lots of energy’s been put behind the “new models.” These set out to do things like provide care traditionally delivered in hospitals, like chemotherapy, in people’s homes and get people to work differently, for instance, dementia specialists carrying out clinics in GP surgeries.
This new way of working is particularly designed to help meet the needs of increasing numbers of people who need support to help manage a range of long term health conditions, particularly older people. 50 areas across England, known as vanguard sites, have been trialing these different ways of delivering more joined-up care over the past couple of years.
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 marketplace. The NHS has invented or adopted a whole array of acronyms to describe this new and evolving approach.
Firstly there are STPs or Sustainability and Transformation Partnerships, which aren’t things or organisations in themselves but – as the name suggests – more 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 in their patch.
There are 44 STPs in England, all focused on progressing the ideas set out in the Five Year Forward View, but they haven’t exactly had an easy birth, with accusations of plans being cooked up behind closed doors, and driven by financial cuts.
Some STP areas are on track to develop into another three letter acronym – ACSs – or accountable care systems. These 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 particular area.
In part, these changes are all about managing the limited resources available to the NHS. But they’re 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.
Some areas are taking this regional based approach even further. So, for example, in Greater Manchester, devolution is giving local NHS and council leaders more control over how health and care services should work there. And across England, we’re also starting to see CCGs merging, hospitals working together in chains and GPs forming large groups of practices.
So where does this leave us and what next?
Well, there’s a lot of change going on, and it throws up loads of unanswered questions, not least: what does this all mean for patients like you and me?
Well, in some ways, nothing much changes – you’ll still see a GP when you’re ill, and there’ll still be hospital care. But if these changes are successful, you may well get more support and treatment at home rather than having to go to hospital, more help to stay healthy and you might also get to see your GP quicker. You might see more controversial changes too – for example, you may need to travel further from home to access better hospital services.
All of these changes take time, and won’t be easy, especially when the NHS budget is failing to keep up with the growing cost of caring for an ageing population with increasingly complex health care needs, and when NHS staff are feeling stretched and under pressure.
70 years after its creation, the NHS continues to be highly valued by the public, with many seeing it as a national treasure. Looking at the bigger picture, change in the NHS is nothing new, and this is just a snapshot of where we are now. The story will, inevitably, continue.