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The NHS in England

The NHS structure explained

The NHS is undergoing major changes in its core structure. Most of the changes took effect on April 1 2013, though some were in place before then. It will be some time before all the changes are fully implemented. All vital NHS services will continue as usual during the transition period and beyond.

View large version of the new NHS structure graphic

These changes have an effect on who makes decisions about NHS services, how these services are commissioned and the way money is spent.

Some organisations such as primary care trusts (PCTs) and strategic health authorities (SHAs) have been abolished, and other new organisations, such as clinical commissioning groups (CCGs), ave taken their place.

NHS services will be opened up to competition from providers that meet NHS standards on price, quality and safety, with a new regulator (Monitor) and an expectation that the vast majority of hospitals and other NHS trusts will become foundation trusts by 2014. 

In addition, local authorities have taken on a bigger role, assuming responsibility for budgets for public health. Health and wellbeing boards now have duties to encourage integrated working between commissioners of services across health, social care, public health and children’s services, involving democratically elected representatives of local people. Local authorities are expected to work more closely with other health and care providers, community groups and agencies, using their knowledge of local communities to tackle challenges such as smoking, alcohol and drug misuse and obesity.

However, none of these changes will affect how you access NHS services in England. The way you book your GP appointment, get a prescription, or are referred to a specialist will not change. Healthcare will remain free at the point of use, funded from taxation, and based on need and not the ability to pay.

The section below will give you a brief introduction to the new organisations and their roles.

Overview of organisations and their role

The Secretary of State for Health

The Secretary of State for Health has ultimate responsibility for the provision of a comprehensive health service in England, and ensuring the whole system works together to respond to the priorities of communities and meet the needs of patients.

The Department of Health

The Department of Health (DH) is now responsible for strategic leadership of both the health and social care systems, but is no longer the headquarters of the NHS, nor will it directly manage any NHS organisations. For detailed information about the department's new priorities and roles, visit the DH website.

NHS England

Formerly established as the NHS Commissioning Board in October 2012, NHS England is an independent body, at arm’s length to the government. It's main role is to improve health outcomes for people in England. It:

  • provides national leadership for improving outcomes and driving up the quality of care
  • oversees the operation of clinical commissioning groups
  • allocates resources to clinical commissioning groups
  • commissions primary care and specialist services

For more information, visit NHS England.

Clinical commissioning groups (CCGs)

Primary care trusts (PCTs) used to commission most NHS services and controlled 80% of the NHS budget. On April 1 2013, PCTs were abolished and replaced with clinical commissioning groups (CCGs). CCGs have taken on many of the functions of PCTs and in addition some functions previously undertaken by the DH.

All GP practices belong now to a CCG and the groups also include other health professionals, such as nurses. CCGs commission most services, including:

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

CCGs can commission any service provider that meets NHS standards and costs. These can be NHS hospitals, social enterprises, charities, or private sector providers.

However, they must be assured of the quality of services they commission, taking into account both National Institute for Health and Care Excellence (NICE) guidelines and the Care Quality Commission's (CQC) data about service providers.

Both NHS England and CCGs have a duty to involve their patients, carers and the public in decisions about the services they commission.

Find your local CCG.

Health and wellbeing boards

Every "upper tier" local authority is establishing a health and wellbeing board to act as a forum for local commissioners across the NHS, social care, public health and other services. The boards are intended to:

  • increase democratic input into strategic decisions about health and wellbeing services
  • strengthen working relationships between health and social care
  • encourage integrated commissioning of health and social care services

For more information, read the DH’s guide on the Health and wellbeing boards.

Public Health England

A new organisation has been created: Public Health England (PHE), which provides national leadership and expert services to support public health, and also works with local government and the NHS to respond to emergencies. PHE: 

  • coordinates a national public health service and deliver some elements of this
  • builds an evidence base to support local public health services
  • supports the public to make healthier choices
  • provides leadership to the public health delivery system
  • supports the development of the public health workforce 

Regulation - safeguarding people’s interests

Since April 2013, some elements of the regulation system have changed. Responsibility for regulating particular aspects of care is now shared across a number of different bodies, such as:

For more information about individual regulators, see our Health watchdogs and authorities section. 

The Care Quality Commission (CQC)

The CQC continues to regulate all health and adult social care services in England, including those provided by the NHS, local authorities, private companies and voluntary organisations.

Read more about the CQC.

Monitor

Monitor expanded its role to regulate all providers of health and adult social care services. Monitor aims to promote competition, regulate prices and ensure the continuity of services for NHS foundation trusts.

Under the new system, most NHS providers will need to be registered with both the CQC and Monitor to be able to legally provide services.

Note: all service providers are required to hold a licence issued jointly by the CQC and Monitor. To get a licence, providers will need to meet essential standards of quality and safety. They’ll also have to follow certain behaviours relating to price setting, integrated care and competition. More importantly, providers will have to ensure services don't stop in the event of financial difficulties. If a provider does not fulfil the terms and conditions of the licence, both Monitor and CQC can take independent action, such as issuing warning notices or financial penalties.

Find out more about Monitor

Healthwatch

Healthwatch is a new organisation and functions as an independent consumer champion, gathering and representing the views of the public about health and social care services in England.

It operates both at a national and local level and ensures the views of the public and people who use services are taken into account.

Locally, Healthwatch will give patients and communities a voice in decisions that affect them, reporting their views, experiences and concerns to Healthwatch England. Healthwatch England will work as part of the CQC.

Read more about Healthwatch England.

Other changes to the regulation system

Following the abolition of strategic health authorities (SHAs), the NHS Trust Development Authority (NHS TDA) is now responsible for overseeing the performance, management and governance of NHS Trusts, including clinical quality, and also managing their progress towards foundation trust status. The TDA has a range of powers, from appointing chairs and non-executive directors, to requiring a trust to seek external advice.

For more information visit the TDA website

Other parts of the UK

For information on the health service in other parts of the UK, please visit:

The Isle of Man and the Channel Islands have their own independent health service structures. For more information, please visit:

Page last reviewed: 28/01/2013

Next review due: 28/01/2015

Get the new NHS graphic

Download the large graphic of the new NHS structure (PDF, 2.12Mb).

About Monitor

Monitor is the sector regulator for health services in England. Find out about it's responsibilities and powers that help to protect and promote the interests of patients.

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