How does the NHS in England work? An alternative guide

This content relates to the following topics:

Part of Alternative guides to health care

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

Notes

  • 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.

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.

Comments

Irene Short

Position
PPG member,
Comment date
19 October 2017
Amazing animation of our painfully fragmented and underfunded NHS.
STILL no mention of Patient Participation which is supposed to shape service development.
Congratulations to the Kings Fund for ALMOST capturing the controlled chaos!!

Stephen Lorrimer

Position
Head of Analysis & Insight for Finance,
Organisation
NHS England
Comment date
19 October 2017
Thank you; another fantastic resource.

Ebony Rose

Position
Artist Teacher,
Organisation
Self
Comment date
19 October 2017
Currently working on a body of work initially generated within homerton hospital, challenging mental health and the way it's approached - please contact me directly for a detailed outline and if you could provide dimensions of space to fill that would be helpful - my practice is based on Stoke Newington. I have years of experience working with minority's groups - as well as the body of work as a series of portraits it is also possible to arrange some on site workshops either within schools in terms of theory and hands on as an art therapy based practice within a mental health setting -
shereenaliisalways@gmail.com
07496728597

Irene

Comment date
19 October 2017
Great snapshot of recent history and organisational changes of the NHS in England. Very clear and easy to watch. What next - I immediately thought about the implications of Brexit. Something similar covering the 70 years of the NHS would be interesting ...

Tom Sheeran

Position
Rheumatologist,
Organisation
Royal Wolverhampton trust
Comment date
19 October 2017
Excellent, easy to follow explanation of our expanding NHS. I will be using this as part of our explanation of the NHS to patients, colleagues and staff. Well done to everyone involved.

Judith Joy

Position
Retired.,
Comment date
19 October 2017
Where is the elephant in the room hiding? Pity it could not be tackled too.Next time look at finance, management costs and privatisation .

Holly

Position
Business Manager,
Organisation
Oxford University Hospitals
Comment date
19 October 2017
Another brilliant unique way to help Me when I'm try & explain the NHS.

Holly

Position
Business Manager,
Organisation
Oxford University Hospitals
Comment date
19 October 2017
Another brilliant unique tool, thank you

ratan das

Position
GP,
Organisation
Beds & Herts CCG
Comment date
20 October 2017
An useful snapshot of NHS reform from Kings fund.

julie

Position
Engagement lead,
Organisation
NHSD
Comment date
20 October 2017
Love this - great induction for those new into the NHS

David

Position
Programme Manager,
Organisation
NHS Digital
Comment date
20 October 2017
Really great straightford overview of the system. Well done all.

Valerie knight

Position
Teacher,
Comment date
20 October 2017
What a dishonest explanation of the changes to our health service. Just describing it as the NHS is misleading. The commonwealth Trust-an independent assessor of world health services has already announced that we do not have and NHS any more! This whole description was achieved without mentioning that we are well down the road towards a US style private health service. Hunt and Let win have both written books on how to achieve that end and what the King's Fund describe is the process towards this. Read 10 ways to dismantle the NHS by Yuseff el Gingihy. THEN you will understand the "NHS"!

David Yare

Position
Retired,
Comment date
20 October 2017
The key issues that are constantly ignored whenever the NHS is discussed are:
• 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

Mike Leaf

Position
Independent consultant,
Organisation
Innovation Agency/ NW Leadership Academy
Comment date
21 October 2017
Excellent; Succinct; easily understood; informative; up to date. Well done

Anthony Dooley

Position
Campaigner,
Organisation
Suffolk Unite Community
Comment date
22 October 2017
Valerie Knight is spot on. The Battle lines are clear: capitulation to the inevitable full privatisation of the health service or fight for the reinstatement of the NHS based on it being publicly funded, publicly provided and free at the point of need. And the money to fund it properly, start with scrapping the replacement of Trident.

Laurie Reynolds

Position
Concerned and interested early 60s patient,
Organisation
AquamatiX Ltd.
Comment date
22 October 2017
Very helpful roadmap explaining a very complex set of dynamic relationships.
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.

Michelle

Comment date
22 October 2017
Thank you. This is the best explanation I have seen for people new to the system. Congratulations!

Janet whaley

Position
Retired,
Organisation
PPG member
Comment date
23 October 2017
I heard a lot of "you might" in the presentation. Every change has brought more complication to the already over complicated system.

David Million

Position
Director,
Organisation
David Million Associates Limited
Comment date
24 October 2017

A fantastic piece of communication that anyone can understand and relate to. Great production, too!

Christina

Position
Lay person. Activist.,
Comment date
25 October 2017

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.

Ben Rusholme

Position
Doctor,
Organisation
NHS
Comment date
29 October 2017

Thank you, this is excellent.

Andrew

Position
NHS Administrator,
Comment date
31 October 2017

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?

Simon O' Connor

Position
NHS,
Organisation
NHS
Comment date
31 October 2017

I cannot help but conclude that the King's Fund is fully on board with the privatisation and cuts agenda.

Simon O' Connor

Position
NHS,
Organisation
NHS
Comment date
31 October 2017

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.

Brad

Position
Health Informatician,
Organisation
iCareHealth
Comment date
02 November 2017

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?

Jkerridge

Position
Consultant,
Organisation
NHS
Comment date
06 November 2017

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.

Add your comment