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How the NHS works

A close up of a doctor wearing an NHS lanyard - view from the back of her neck. 

The National Health Service (NHS) was launched in 1948 and since then it has grown exponentially to become the world's largest publicly funded health service. The NHS deals with over 1 million patients every 36 hours.

The NHS was born out of a long-held ideal that good healthcare should be available to all, regardless of wealth - a principle that remains at its core. With the exception of some charges, such as prescriptions and optical and dental services, the NHS remains free at the point of use for anyone who is a UK resident. That is currently more than 63.2 million people.


What does the NHS cover?

NHS services cover everything from antenatal screening and routine treatments for long-term conditions, to transplants, emergency treatment and end-of-life care.

Responsibility for healthcare policy was devolved to Scotland Wales and Northern Ireland in 1999, and since this time, healthcare policy has increasingly diverged across the four nations. 

There is variation in the level of legislative responsibility devolved to the national assemblies and parliament, however each government is responsible and accountable for decision making around the delivery of health services in each nation.

The NHS in England is the biggest part of the system by far, catering to a population of 53 million and employing more than 1.35 million people.

The NHS in Scotland, Wales and Northern Ireland employs 153,427 - 84,817 and 78,000 people respectively.


  • How the NHS works in England

    What does it look like?

    The new structure of the NHS in England can be baffling to anyone on the outside.

    There is a split between the purchaser and the provider.

    There are commissioners (purchasers) who are responsible for an areas strategic healthcare planning and who purchase healthcare for a defined population from providers of healthcare services.

    Within secondary care the commissioners or purchasers of care are currently known as Clinical Commissioning Groups (CCGs) and the providers of care (hospitals) are run by NHS trusts or Foundation trusts.

    This set-up is commonly known as the internal market, it was designed to allow competition between providers for commissioner's money.

    Primary care is commissioned mostly by NHS England (although some primary care can now be commissioned by CCGs as well) and provided by General Practitioners.


    NHS organisations

    The NHS in England is divided into a series of organisations:

    NHS England

    Monitors the performance of the NHS nationally and supports commissioning locally. It also commissions GP services and undertakes specialist commissioning which includes buying the services for conditions which affect a relatively small number of people but can include major services such as cancer services.

    Clinical commissioning groups (CCGs)

    There are about 200 CCGs. They are run by GPs and other local healthcare professionals, who assess local health needs and then commission the services to meet them. They are responsible for about 60% of the NHS budget.

    NHS acute or foundation trusts

    These provide the hospital, out-patient and other services commissioned by CCGs to meet local population needs

    Ambulance trusts

    These provide services responding to emergency calls, transporting patients, and providing out-of-hours care in some areas

    Mental health trusts

    These provide specialist care for people with complex and severe mental health problems

    Care trusts

    They co-ordinate health and social care services for individual users, there are currently very few of these organisations.

    Other local primary care services

    These are provided through GP practices, NHS Walk-in Centres, dental practices, pharmacists and opticians.


    How big is the NHS?

    Almost 1.3 million people are employed by NHS England. There are almost 250 hospital, mental health and ambulance trusts in England and over 160 CCGs.

    NHS hospitals employ the largest number of people in the NHS, both as clinical staff in hospitals and across a wide range of support functions. The local hospital may well be one of the most important employers in a town or city.


    How do all the pieces fit together?

    Primary care is provided in the local community via a local GP, NHS walk-in centre, dentist, pharmacist and optician. The NHS 111 phone service is also responsible for providing healthcare advice and information 24 hours a day via the internet and over the telephone.

    Hospital and mental health trusts are dependent on CCGs buying services such as elective surgery, outpatient visits and other treatments from them. They may also be commissioned to run community services such as district nursing and health promotion. Alternatively, CCGs may commission other providers, such as social enterprises or local charities, to run these services.


    Changing times

    The NHS is currently going through a period of rapid change.

    The NHS has had to respond to numerous challenges, such as problems associated with the aging population, increased demand, not enough money and changing patient expectations.

    The NHS has developed policy initiatives to tackle these issues, and these initiatives are dramatically changing the way in which the NHS is run.


    How is the NHS different now?

    There is an increased emphasis on the integration of care, which involves greater coordinated working between healthcare providers, and particularly between health and social care providers and commissions.

    Initiatives such as the 'Five year forward view' and the 'better care fund' have been developed to enable more integrated services to be developed. Another major change is the proposed introduction of 7 day services, this will enable a broad range of healthcare to be available on the NHS 7 days a week.

    There is also a considerable focus on quality improvement and increasing the efficiency of the NHS and there are numerous ongoing programmes to ensure that the NHS is fit for purpose in the modern world.

  • How the NHS works in Northern Ireland

    The NHS in Northern Ireland employs around 62,603 staff who work across 6 health and social care trusts.

    There are also around 22,500 social workers and social care workers registered in Northern Ireland. Staff costs account for approximately 70% of the overall spending on healthcare.

    In addition there is a land border with the Republic of Ireland and co-operation exists across a number of areas, most recently, the provision of paediatric congenital cardiac services on an all-Ireland basis.


    Who uses the service?

    The NHS in Northern Ireland provides health and social care to a population of approximately 1.8 million people.

    Northern Ireland like the rest of the UK is experiencing similar demographic shifts in terms of ageing and life expectancy. Figures from the 2011 census show that those aged 65 and over represent 15% of the population in NI and the percentage increase in those over 85 since 2001 is 35%. 

    In addition, public expectations and attitudes towards their care are changing but support for a universal NHS remains high on the agenda in NI at 73%.



    Northern Ireland has been distinct from England, Scotland and Wales in that health and social care have been, at least in theory, integrated since 1973.

    The Minister of the Department of Health, Social Services and Public Safety (DHSSPS) is ultimately responsible for the delivery of health and social care in Northern Ireland. A cross-party health committee in the Northern Ireland Assembly performs a scrutiny role of decisions made by the Minister, the operation of the department and other health and social care bodies and functions.



    Health and social care is commissioned by a regional single health and social care board (HSCB) supported by 5 Local Commissioning Groups established in 2007 which cover the same geographical areas as the health and social care trusts.

    We have also retained the purchaser or provider split in the commissioning of health and social care. A review of commissioning is currently underway. The HSCB commission general practitioner services for the population of Northern Ireland via the General Medical Services contract.


    Heath and Social Care Trusts

    There are six health and social care trusts in Northern Ireland. Five health and social care trusts (HSCT) are geographically based and are responsible for providing health and social services in Northern Ireland.

    The five health and social care trusts are:

    • Belfast HSCT
    • Southern HSCT
    • South Eastern HSCT
    • Northern HSCT
    • Western HSCT

    The sixth Trust is the Northern Ireland Ambulance Service, which operates a single Northern Ireland wide service.


    The Regulation and Quality Improvement Authority

    The Regulation and Quality Improvement Authority (RQIA), monitors and inspects providers of health and social care.


    Public Health

    The Public Health Agency (PHA) is responsible for health improvement and health protection. The Northern Ireland Executive's key strategy for tackling public health inequalities is 'Making Life Better'.

    The PHA is jointly responsible with the HSCB for the development of a fully integrated commissioning plan for health and social care in Northern Ireland.



    Like Scotland and Wales, Northern Ireland receives a block grant from HM Treasury based on the Barnett Formula and the Northern Ireland Assembly determines its own priorities.

    Department of Health, Social Services and Public Safety (DHSSPS) receives 46% of the total budget for Northern Ireland.

    The integration in the delivery of services in Northern Ireland is mainly achieved through the division of health and social care into Programmes of Care (PoCs).  

    There are nine PoCs:

    • Acute services
    • Maternity and child health
    • Family and child care; elderly care
    • Learning disability
    • Physical and sensory disability
    • Health promotion and disease prevention
    • Primary health and adult community.

    Acute services and elderly care accounts for about two-thirds of the total expenditure.

  • How the NHS works in Scotland

    NHS Scotland employs around 140,000 staff who work across 14 territorial NHS Boards and seven Special NHS Boards.



    At a macro level, the framework for NHS funding is set by the Westminster Government.

    The Treasury agrees the overall NHS settlement for England. Thereafter amounts for the other three countries (Scotland, Wales and Northern Ireland) are determined according to the 'Barnett formula'. It is then for the Scottish Government to determine how much they allocate to health as part of their overall budget considerations.  

    Levels of funding to NHS Boards are determined by the cabinet secretary and ministers, and approved by the Scottish Parliament. Allocations between the NHS Boards are determined by the Government using the National Resource Allocation Committee (NRAC) formula. 

    This is a weighted capitation formula which means that funding is allocated based on the population of the area and takes into account factors such as morbidity and deprivation in order to adjust for relative health need.



    Each NHS Board is accountable to Scottish Ministers, supported by the Scottish Government Health and Social Care directorates.

    Territorial NHS Boards are responsible for the protection and the improvement of their population’s health and for the delivery of frontline healthcare services. 

    Special NHS Boards support the regional NHS Boards by providing a range of important specialist and national services e.g. Scottish Ambulance Service, NHS24 and the Scottish Blood Transfusion Service.

    Unlike in England, there is no internal market in NHS Scotland. Instead the 14 NHS boards are responsible for both planning and delivering services.

    The 32 Local Authorities provide social care services. Boards have an operating division that runs their acute hospital services, whilst community health partnerships (up until April 2015) were responsible for overseeing community and primary care services.

    In Scotland as in the rest of the UK, primary care services are provided in the local community via a local GP, dentist, pharmacist and optician as well as services provided by the allied health professions such as self referral to physiotherapy services. 

    NHS 24 offers a phone and internet advice and information service as well as providing an out of hour telephone triage service.


    Changing times

    The NHS in Scotland is undergoing significant transition at the moment. 

    An agenda of integrating adult health and social care is underway and new health and social care partnerships will be responsible for planning and delivering health and social care within agreed single budgets.


    Regulation and inspection

    NHS Healthcare Improvement Scotland (HIS) has a key role in setting standards for care and treatment and then inspecting Boards' performance against them.

    HIS is also responsible for the regulation of independent healthcare, a role which previously belonged to the Care Commission.

    HIS also incorporates the Healthcare Environment Inspectorate (HEI) which is responsible for inspecting hospital compliance with Healthcare Associated Infection Standards.

    Find out more about HIS

  • How the NHS works in Wales

    The health service is Wales' largest employer - directly employing more than 70,000 people.

    Health and social services spending accounts for 40 per cent (£6bn a year) of the Welsh Governments overall budget. The majority of this is directly allocated to the Local Health Boards and Trusts.

    NHS Wales provides healthcare to a population of some 3 million people. Patients in Wales come into contact with the NHS Wales more than 20 million times each year, with 80% of contacts taking place outside of hospital, such as in a GP practice or through a community health service.

    Every year, NHS Wales also undertakes more than 700,000 first out-patient appointments, more than 600,000 inpatient and day-cases, and more than 1m people are seen in Accident & Emergency departments.



    In 2009 the NHS in Wales underwent major change. NHS Wales now delivers services through seven Health Boards that are responsible for delivering all healthcare services within a geographical area, and three all-Wales Trusts.

    There is no purchaser provider split in NHS Wales and very little use of the private sector. Social Services remains the responsibility of local authorities, of which there are 22 in Wales.


    Health Boards

    The seven Local Health Boards (LHBs) in Wales plan, secure and deliver healthcare services in their areas:

    • Aneurin Bevan Health Board
    • Abertawe Bro Morgannwg University Health Board
    • Cardiff & Vale University Health Board
    • Hywel Dda Health Board
    • Cwm Taf Health Board
    • Betsi Cadwaladr University Health Board
    • Powys Teaching Health Board


    NHS Trusts

    There are 3 NHS Trusts in Wales with an all-Wales remit:

    • Welsh Ambulance Services Trust - for emergency services
    • Velindre NHS Trust - offering specialist services in cancer care and a range of national support services
    • Public Health Wales - this is the unified Public Health organisation in Wales, it now also exercises the functions previously held by the National Public Health Service, Wales Centre for Health, Welsh Cancer Intelligence & Surveillance Unit, Congenital Anomaly Register & Information Service for Wales, and Screening Services Wales.


    Primary care

    Primary care services are provided by general practitioners (GPs) and other health care professionals in health centres and surgeries across Wales.

    Around 90 per cent of all patient interaction with the NHS is with primary care services. In addition to GP practices, primary care covers dental practices, community pharmacies and high street optometrists.

    The seven Health Boards commission General Practitioner services via the GMS (General Medical Services) contract so that services can be delivered locally.


    National Delivery Group

    The Chief Executive of NHS Wales is responsible for providing the Minister with policy advice and for exercising strategic leadership and management of the NHS.

    To support this role, the Chief Executive chairs a National Delivery Group, forming part of the Department for Health and Social Services (DHSS). This group is responsible for overseeing the development and delivery of NHS services across Wales.


    Community Health Councils

    The seven Community Health Councils in Wales are statutory lay bodies that represent the interests of the public in the health service in their district. They give people an independent voice in their local NHS and the services it provides.

    • The NHS Wales Shared Services Partnership
    • The NHS Wales Shared Services Partnership (NWSSP) is an independent organisation, owned and directed by NHS Wales. NWSSP supports NHS Wales through the provision of a comprehensive range of high quality, customer focused support functions and services.
    • National Institute for Social Care and Health Research (NISCHR)
    • NISCHR is responsible for the development and implementation of policy relating to health and social care research


    Regulation and Inspection

    Healthcare Inspectorate Wales (HIW) is the independent inspectorate and regulator of all health care in Wales.

    Through the Auditor General for Wales, the Wales Audit Office (WAO) is responsible for:

    • Auditing the financial accounts of public bodies
    • Reporting on how services are being delivered
    • Assessing whether value for money is being achieved
    • Checking how organisations are planning and delivering improvements