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The NHS in England

NHS authorities and trusts

Under the old NHS system, there were a wide range of NHS health trusts managing NHS hospital care in England, including community care and mental health services. The NHS Trust Development Authority (TDA) is providing support, oversight and governance for all NHS trusts helping them to deliver the best patient care possible.

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.

If you want to learn more about how commissioning in England works, download the leaflet Commissioning - What's the big deal? (PDF, 297kb).

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, including NHS walk-in centres and the NHS 111 telephone service. Visit the NHS services explained section for more details.

NHS England is responsible for purchasing primary care services and some specialised services. Your local NHS England area team has direct commissioning responsibility for core services, but also functions as a regulator for individuals or performers who provide these services. The area team also commissions public health programmes such as immunisation and screening.

Secondary care

Clinical Commissioning Groups (CCGs) commission most of the hospital and community NHS services in the local areas for which they are responsible. Services CCGs commission include:

  • most planned hospital care
  • rehabilitative care
  • urgent and emergency care (including out-of-hours)
  • most community health services
  • mental health and learning disability services

Use the Services near you facility to find your local CCG or find out how CCGs perform and compare with each other.

What is an acute trust?

Hospitals in England are managed by acute trusts – some of which already have gained foundation trust status. Acute trusts ensure hospitals provide high-quality healthcare and check that they spend their money efficiently. They also decide how a hospital will develop, so that 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 to 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 nearest acute trust now.

What is a foundation trust?

NHS foundation trusts, first introduced in April 2004, differ from other existing NHS trusts. They are independent legal entities and have unique governance arrangements. They are 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 freedoms 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 Monitor.

What is the NHS Trust Development Authority (TDA)?

At the moment, the NHS Trust Development Authority (TDA) is preparing health trusts for the transition to foundation trust status.

Following the abolition of strategic health authorities (SHAs) in 2013, the TDA is now responsible for overseeing the performance management and governance of NHS trusts, including clinical quality, and managing their progress towards foundation trust status.

The TDA plays its part in safeguarding the core values of the NHS, ensuring a fair and comprehensive service across the country and promoting the NHS Constitution. It is accountable nationally for the outcomes achieved by NHS trusts and for financial stewardship within the NHS trust system, as it is winding down.

What is a mental health trust?

Mental health trusts provide health and social care services for people with mental health problems.

Mental health services can be provided through your GP, other primary care 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 primary care or informal community support. If they need more involved support, they can be referred for specialist care.

More specialist care is normally provided by mental health trusts or local council social services departments. Services range from psychological therapy to very specialist medical and training services for people with severe mental health problems. At least one in four people experiences a diagnosable mental health problem in any one year, and one in six experiences this at any one time. Find your nearest mental health trust.

What is an ambulance trust?

Ambulance services in England, provide emergency access to healthcare. If you call for an emergency ambulance, the calls are prioritised into:

  • Category A emergencies, which are immediately life-threatening
  • Category B or C emergencies, which are 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. Figures from the Health and Social Care Information Centre (HSCIC) that in 2013/14 ambulance trusts dealt with an average of 16.1 emergency calls per minute. You can find the full report about ambulance services in England on HSCIC's website.

The NHS is also responsible for providing transport to get many patients to hospital for treatment. In many areas, it is the ambulance trust that provides this service. For more information, read the following pages on: 

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 NHS England’s 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 more information about strategic clinical networks on NHS England’s website.

What are special health authorities?

Special health authorities are health authorities that 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.

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Page last reviewed: 07/01/2015

Next review due: 07/01/2017

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