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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.
STILL no mention of Patient Participation which is supposed to shape service development.
Congratulations to the Kings Fund for ALMOST capturing the controlled chaos!!
• Who creates the wealth to fund it?
• Why do we reward misuse of the resources such as hip replacements for obese patients?
• What about the damage caused by doctors such as anti-biotics being handed out like sweets
• We should take politics out of the discussion and start with a blank sheet of paper and set out a contract with the public as to what the NHS will fund
I'm keen to see much more home monitoring and diagnostics for early indicators of health deterioration.
I would also like to see charities strengthening and collaborating at the regional level to share costs. and streamline family support.
A fantastic piece of communication that anyone can understand and relate to. Great production, too!
Absolutely excellent in every way. Clear, succinct, does not use jargon. It's so helpful to have the structure of the NHS explained and the acronyms that are used. Also the changes. I am especially pleased that it does not go off on a tangent and attempt to provide a critique of the NHS and the changes. When critiques are embedded within the factual description about the structure and function of anything it just makes it more difficult to understand. Critiques should be kept separate and this is what the Kings Fund has done here. As a lay person who finds it very difficult to understand and keep up with the changing structure of our health care system I am enormously grateful to the Kings Fund for this video. There's even a transcript. Also the video is accessible having subtitles and the means to slow down the speech. This is the best thing I've seen in a long time. Thank you Kings Fund.
Thank you, this is excellent.
I think the fact it takes 6 minutes to explain how the NHS works says it all really! The organisation is a bureaucratic behemoth. Also the line 'the NHS never stays the same for long. Why? We all presume change is for the benefit of the service, but often it is not. How about keeping things the same for 10 years or so? Actually give it a chance to work?
This is a very good summary of what is going on, but unfortunately whatever the 'plans' are, finance decides whether they are implemented or not?
I cannot help but conclude that the King's Fund is fully on board with the privatisation and cuts agenda.
so you think the problems of the NHS are basically about fat people getting hip replacements? You don;t think that the massive privatisation and cuts are the problem then? Are you even aware of them? Take your nose out of the Daily Mail for a few hours and do some real research perhaps.
Hi Simon, you can see our work on NHS funding and privatisation here: https://www.kingsfund.org.uk/publications/articles/nhs-funding-privatis…
Great video. For service integration to work, its critical that non-NHS services understand what's going on in the NHS and this video is a great starting point. However, its also critical that the NHS understands non-NHS services, such as social care. Can you do one of these videos for social care please?
Hi Brad, glad you liked the animation. We've recently produced a series of short videos to help explain social care in England. You can see them here: https://www.kingsfund.org.uk/projects/what-is-social-care
Brilliant. It's impossible to keep a hold on the acronyms and shifting organisations and quangos simply by reading about them, and that visual approach really works.
The healthcare systems lumber along with a huge amount of wheel-inventing and ego-driven change, with successive ministers determined to make their mark (whilst ridding government of the stigma they have had to contend with of at times of poor management and underfunding).
I still can't keep all of it in my head, and in some ways with the continual change of terms that would never be possible. This is a good snapshot though, and I'll refer to it.
An excellent visual presentation as usual. I cannot help thinking about how much of our money goes to pay the salaries of all these organisations.
An excellent presentation. Very easy to relate to though the narrator could have slowed down a bit and spent 10 and not 6 minutes rushing through her explanation. Well done King's Fund!
Why doesn't the NHS advertise it's excellent website on TV channels to stop bad 'googling' for help and information - the public needs daily health info - how tomanage colds and flu at home, on breakfast TV and advice for new mums (nuclear family syndrome), discussion groups on childcare on morning TV instead of buying 2nd homes? We managed in the 40's and 50's because the radio told us how to help ourselves, and A & E's were just for serious ailments. Can't you influence the public broadcasters? It's not enough to put notices in GP practices ad many patients can't read or read English now. Discuss the pressures put on the NHS by over 3 million migrants and stop blaming 'the elderly'. Educate non-academic schoolgirls to take up caring professions with health education and diet classes and get fewer single mums who take babies to A & E by ambulance with colds as on Victoria Derbyshire this week!
An informative and well produced animation. ... however , for someone taking a new look at NHS 'organisation' it truly is a dystopian nightmare. ( and no, I do not believe that making something more complicated and fulfilling an accountant's world vision makes it more credible with the public).
Good presentation but the Health and Social Care Act removed the responsibility of the Secretary of State to provide a universal health service, which in turn allowed the formation of this over complicated and expensive structure. Money is being spent on the management of these extra organisations, so less is going to patient care.
Privatisation of the NHS is ongoing and I have little doubt, given the present structure (ACOs etc.), that we are heading for a US style health system. We will soon be asked to buy expensive health insurance. This is very worrying!
This is an almost deceptively clear account of some of the recent changes in the NHS. It is deceptive because what is actually going on is not what it seems. And this is NOT clear. Even apparent facts are loaded. Katie Mantell hardly touches upon the fact that with ACSs/ACOs the budget will be fixed - with no mention as to whether it will be adequate. And she doesn't mention the growing involvement of private companies (many of them the usual suspects - SERCO, Care UK, Capita etc) at all. These omissions are significant. Christina (above) makes the point that facts should be separated from what she calls 'critiques', but when discussing the NHS this is impossible and even undesirable to do. The NHS was political and remains political. Which 'facts' you choose to emphasise and which you choose to ignore are part of that almost necessary politicisation. Because discussing the future of the NHS (if it is to have one) is about how we want to live, and in what kind of society. So let's have a proper debate about this in the context of where we want to go, and how we want to resource it. And let's not blame 'migrants' or 'non-academic schoolgirls' for underfunding, Celia Hart!