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The NHS in England

NHS authorities and trusts

In 2013 the NHS underwent a fundamental restructure. Under the old NHS system there was a wide range of NHS trusts – such as acute trusts, ambulance trusts, and mental health trusts – that managed NHS hospital care in England, including community care and mental health services.

Today most of these services are provided through NHS foundation trusts and NHS trusts providing ambulance services, emergency care services, or mental health services – see below for more information.

Founded in 2016, NHS Improvement is an umbrella organisation bringing together Monitor, the NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change Team, and the Intensive Support Teams.

It oversees and supports NHS foundation trusts, NHS trusts and independent providers delivering NHS-funded care. If necessary, it holds them to account – for example, putting trusts on special measures

Read more about NHS Improvement.

NHS England took on full statutory responsibilities in April 2013. Prior to this, all NHS planning and delivery was done by the Department of Health (DH), strategic health authorities and primary care trusts.

Visit the NHS England website for more information.

If you want to learn more about how commissioning in England works, download the leaflet Commissioning: what's the big deal? (PDF, 297kb). Note: some of the statistics in this document are now out of date.

What is primary care?

Primary care is the first point of contact for most people and is delivered by a wide range of independent contractors, including GPs, dentists, pharmacists and optometrists, as well as NHS walk-in centres and the NHS 111 telephone service.

See NHS services explained for more details.

NHS England is responsible for purchasing primary care services and some specialised services, including military health care.

There are four regional teams responsible for the commissioning of services in their areas, as well as providing professional leadership on finance, nursing, medicine, specialised commissioning, patients and information, human resources, organisational development, assurance and delivery. 

The regional teams also commission public health programmes, such as immunisation and screening. 

Find out more about regional teams on the NHS England website. 

What is secondary care?

Clinical commissioning groups (CCGs) commission most of the hospital and community NHS services in the local areas they are responsible for. They also co-commission GP services with NHS England as a result of the NHS Five Year Forward View objectives.

Services that CCGs commission include:

Use the Services near you facility to find your local CCG or find out how CCGs perform to compare them.

NHS trusts explained

What is a foundation trust?

Most hospitals in England are now managed by NHS foundation trusts. First introduced in April 2004, they differ from other existing NHS trusts. They are independent legal entities and have unique governance arrangements. They are also accountable to local people, who can become members and governors.

Each NHS foundation trust has a duty to consult and involve a board of governors – including patients, staff, members of the public, and partner organisations – in the strategic planning of the organisation.

They are set free from central government control and are no longer performance-managed by health authorities. As self-standing, self-governing organisations, NHS foundation trusts are free to determine their own future.

They have financial freedom and can raise capital from both the public and private sectors within borrowing limits, determined by projected cash flows, and are therefore based on affordability. They can retain financial surpluses to invest in the delivery of new NHS services.

Foundation trusts are overseen by NHS Improvement.

Find your local NHS foundation trust.

What is an acute trust?

Some hospitals in England are managed by acute trusts, some of which have also gained foundation trust status. You may come across both terms for the same trust.

Acute trusts ensure that hospitals provide high-quality healthcare and check they spend their money efficiently. They also decide how a hospital will develop so services improve.

Acute trusts employ a large part of the NHS workforce, including nurses, doctors, pharmacists, midwives, and health visitors. They also employ people doing jobs related to medicine, such as physiotherapists, radiographers, podiatrists, speech and language therapists, counsellors, occupational therapists, psychologists, and healthcare scientists.

There are many other non-medical staff employed by acute trusts, including receptionists, porters, cleaners, specialists in information technology, managers, engineers, caterers, and domestic and security staff.

Some acute trusts are regional or national centres for more specialised care, while others are attached to universities and help train health professionals.

Acute trusts can also provide services in the community – for example, through health centres, clinics, or in people's homes.

Find your local NHS trust.

What is an ambulance trust?

Ambulance services in England help many people with serious or life-threatening conditions. They also provide a range of other urgent and planned healthcare and transport services. Ambulance services are managed by either an ambulance trust or a foundation trust.

 If you call for an emergency ambulance, the calls are prioritised into:

  • category A – immediately life threatening 
  • category B or C – not life threatening

The emergency control room decides what kind of response is needed and whether an ambulance is required. For all three types of emergency, they may send a rapid-response vehicle, crewed by a paramedic and equipped to provide treatment at the scene of an incident. 

Learn more about ambulance services.

Figures from the Health and Social Care Information Centre (HSCIC) show that in 2014-15, ambulance trusts dealt with 9 million 999 calls – on average, this works out as 17.1 emergency calls per minute. You can find the full report about ambulance services in England on the HSCIC website. You can also see our guidance on when to dial 999: responding to emergencies.

The NHS is also responsible for providing transport to get many patients to hospital for treatment. In many areas the ambulance trust provides this service.

Find your local NHS trust.  

What is a mental health trust?

Mental health trusts provide health and social care services for people with mental health problems. Many NHS trusts have merged over the past couple of years and may now be governed by a foundation trust, which provides a mental health service. Again, you may hear both terms mentioned for the same trust.

Mental health services are provided through primary care, such as GP services, or through more specialist care. This might include counselling and other psychological therapies, community and family support, or general health screening.

For example, people experiencing bereavement, depression, stress or anxiety can get help from their GP or informal community support. If they need more involved support, they can be referred to a specialist mental health service.

Find out how to access mental health services in England.

More specialist care is normally provided through NHS trusts or local authorities. Services range from psychological therapy to very specialist medical and training services for people with severe mental health problems.

For local support and information services, use our Services near you search. Try the following directories:

Alternatively, you can use one of the directories below:

What are clinical senates and strategic clinical networks?

A number of other organisations support and advise NHS England and clinical commissioning groups (CCGs). Two of these are clinical senates and strategic clinical networks.

Clinical senates

Clinical senates are advisory groups of experts from across health and social care. There are 12 senates covering areas across England. Senates are formed by clinical leaders from across the healthcare system, as well as those from social care and public health. Patients and members of the public will also be involved.

Find out more about clinical senates on the NHS England website.

Strategic clinical networks

Strategic clinical networks are advisory groups of clinical experts covering a particular disease group, patient group, or professional group. Again, there are 12 across England.

Strategic clinical networks offer advice to CCGs and NHS England. Their particular focus is on helping to improve care pathways. They:

  • reduce unwarranted variation in health and wellbeing services
  • encourage innovation in how services are provided now and in the future
  • provide clinical advice and leadership to support their decision making and strategic planning

Find out more about strategic clinical networks on the NHS England website.

What are special health authorities?

Special health authorities provide a health service to the whole of England, not just to a local community. Examples are:

They have been set up to provide a national service to the NHS and the public under section 9 of the NHS Act 1977. They are independent, but can be subject to ministerial direction in the same way as other NHS bodies.

Get a full list of special health authorities.

Page last reviewed: 13/04/2016

Next review due: 13/04/2019

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