How does the NHS in England work? An alternative guide

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  • Posted:Friday 06 October 2017

This animation is a whistle-stop tour of how the NHS works in 2017 and how it is changing. 

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.


  • The final image is available for download here.
  • You can buy a poster of the final image in A0 (841 x 1189 mm), A1 (594 x 841 mm), or A2 (420 x 594 mm).
  • The animation was produced by CreativeConnection.
  • This is an update of our 2013 animation on the structure of the NHS.

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Celia Hart

retired information officer,
Various in Milton Keynes
Comment date
14 December 2017

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!


Social Carer,
Comment date
19 December 2017

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).

Malcolm Law

Defend Our NHS York
Comment date
22 December 2017

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!

Mike Hope

Brain Injury Case Manager,
Comment date
08 January 2018

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!

David Peach

member of the public
Comment date
21 January 2018

I thought it might give details of the role of private healthcare providers such as Virgin and their associates, one example virgin demanding to run to child care which I found disturbing also who controls the quality of these carers and nurses they use and who regulates them also my concerns are about patient confidentiality. Because when I wanted an opt/out form I could not obtain one, And the main concern all decisions have been with no public or NHS staff consultation.

Regina Holley

University of West London
Comment date
08 February 2018

Thank you Kings Fund for a clear description of the NHS. A great resource for those training to work in this complex organisation.


oral health Improver,
Comment date
19 June 2018

Totally agree with this!! We never give anything we change a chance to embed itself, and so we never really know what owrks, before we change it all again!!

Bassey Okon Ekpe

Medical Social worker and counsellor,
University of Calabar Teaching Hospital (UCTH) Calabar.
Comment date
18 September 2018

that's a good one. Great job done.

Suzanne Battle

Senior Travel Trainer (TITAN),
Norfolk County Council
Comment date
15 January 2021

Excellent resources, just shows that much more joined up thinking needs to take place.

Mary Ridgway

ATTCARE charity [Attleborough Health, Care & Wellbeing Trust]
Comment date
13 March 2021

This very straightforward explanation of the structure of NHS England helps our charity to design its policy for the provision of ALL health and social care provision required within the Attleborough Neoghbourhood plan [2017]

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