How the NHS works

The System

Launched in 1948 to provide good healthcare for all – regardless of wealth, the NHS in England remains free at the point of use for all UK residents (with the exception of charges for some services). It serves 64.6 million people in the UK and 54.3 million people in England alone. The NHS in England deals with over 1 million patients every 36 hours covering everything from antenatal screening to end of life care. Find out the basics on the NHS website.

The King’s Fund offers a free 6-week online introductory course. The NHS Explained: How the Health System in England Really Works, gives a detailed understanding of the NHS – its inner workings, current and future challenges, and how everything fits together.

The NHS is constantly evolving and this King’s Fund video, How does the NHS in England work: An alternative guide, gives a 6-minute insight into its complexity. Produced in 2016, the video gives a good overview of the main bodies and what they do, but inevitably some facts have been superseded since then.


The main players in England

NHS England: Sets the priorities and direction of the NHS in England as well as sharing out more than £100 billion in funds – mainly to groups of GPs called Clinical Commissioning Groups (CCGs). CCGs plan and pay for local services such as hospitals and ambulance services.

NHS Improvement is the regulatory body that supports NHS trusts to give safe, high quality care within local health systems that are financially sustainable.

NHS Improvement and NHS England are currently undergoing an organisational restructure.

NHS Digital supplies information and data to the health service and provides technological infrastructure. It collects, processes and publishes data and information from across the health and social care system in England.

The Care Quality Commission (CQC) is the independent regulator of health and adult social care services in England. Service providers including hospitals, GP practices and care homes, must register with the CQC. The CQC monitors, inspects and regulates services to make sure they meet fundamental standards of quality and safety. It also  publishes performance ratings to help people choose care. Inspection reports for providers are on the CQC website.

The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care. NICE provides guidance, advice, quality standards and information services for health, public health and social care.

The Medicines and Healthcare products Regulatory Agency (MHRA) regulates medicines and medical devices including software applications (apps).

Find the full list of  15 arms-length agencies and partners that work with the Department of Health and Social Care.


Outside England

The NHS operates differently in the devolved nations: Northern Ireland, Scotland and Wales where different structures and funding mechanisms apply.


How providers are regulated and commissioned (and how the money flows)

This King’s Fund graphic shows how NHS providers are regulated and commissioned. It also shows how the money flows.


Opportunities for innovators

Policy drivers

In 2014, NHS England published The NHS Five Year Forward View which set out a new shared vision for the future of the NHS based around the new models of care. In 2016, the NHS and local councils formed sustainability and transformation partnerships (STPs) to support implementation of the Five Year Forward View.

In return for further NHS funds, the government challenged NHS England to come up with a 10-year plan to include efficiency savings to reinvest back into patient care. Following consultation with the public and NHS organisations The NHS Long Term Plan (published January 2019) responds to increasing pressures for funding, staffing, and increasing inequalities and pressures from a growing and ageing population. Chapter 5 describes how digitally enable care will go mainstream across the NHS.

Matt Hancock, The Secretary of State for Health and Social Care, published a policy document The future of healthcare: our vision for digital, data and technology in health and care.

This is part of a wider government industrial strategy to build a Britain ‘fit for the future’ and meet some of the ‘grand challenges’ such as positioning Britain at the forefront of science and technology and using innovation to help meet the needs of an ageing society.

The NHS recognises that innovation is critical if it is to realise the ambitions set out in the NHS outcomes framework: the framework that sets out the national outcome goals the Secretary of State uses to monitor the progress of NHS England.


Innovator opportunities

The NHS is a major investor and wealth creator in the UK for science, technology and engineering. To ensure the NHS is pivotal in driving research and translating scientific developments into benefits for patients (and contributing to economic growth), NHS England supports an innovation programme.

The Accelerated Access Review aims to speed up access to innovative drugs, devices, diagnostics and digital products for NHS patients. Annex C describes the accelerated access pathway for digital products, including apps and wearables, from the perspective of products.

NHS apps library – 100 digital health and care tools evaluated against key standards for the apps library.


Real world validation

New Care Models (Vanguards) arose out of the Five Year Forward View to support the  improvement and integration of services. A number of vanguards are focused on implementing digital solutions as an approach to care. NHS providers describes how five vanguards are harnessing technology.

The Test Bed Programme, brings together NHS organisations and industry partners to test combinations of digital technologies with pathway redesign in real world settings. Care City London is an example.


Innovation and Technology Payment (ITP)

The Innovation and Technology Payment (ITP) is a payment mechanism that supports the NHS to adopt innovative market-ready medical devices, diagnostics, digital platforms and technologies which have demonstrated improvement to the quality and efficiency of patient care, by removing financial or procurement barriers to uptake.


Academic Health Science Networks

The Academic Health Science Networks (AHSNs) have a clear objective to encourage uptake of ITP products.



Money, performance and reform are NHS priorities outlined in this King’s Fund blog.

NHS Improvement is driving the use of digital technology to address demand, particularly in relation to flow in acute settings (outpatients, theatres and accident and emergency). The NHS Improvement Hub indicates some of the areas of focus for the regulator across the sector.

The GP Forward View gives a snapshot of the pressures in general practice and the initiatives in motion around investment, workforce, workload, infrastructure and care redesign – including online services.


How decisions are made at a local level

Commissioning in the NHS

NHS England gives an overview of commissioning in England – what it is who does it and how it’s changing.

Clinical commissioning groups (CCGs) are groups of general practices (GPs) which come together in each area to commission the best services for their patients and population.

CCGs buy services for their local community from any service provider that meets NHS standards and costs – these could be NHS hospital trusts, social enterprises, voluntary organisations or private sector providers. Theoretically, this means better care for patients, designed with knowledge of local services and commissioned in response to their needs.

NHS England holds a list of 195 CCGs in England and The Office for National Statistics maps show the  boundaries of CCGs. NHS England has a statutory duty to conduct an annual assessment of each CCG.


Population based models of care

In 2017, NHS England published Next Steps on the Five Year Forward View. This described how its focus was evolving from Sustainability Transformation Partnerships, to ICSs (Integrated Care Systems) formerly known as ACSs (Accountable Care Systems) and ACOs (Accountable Care Organisations), now referred to as ICPs (Integrated Care Providers). These population-based models of care integrate primary, secondary, community and other health and care services.

The NHS Long Term Plan (2019) states that local NHS organisations will increasingly focus on population health – moving to Integrated Care Systems (ICSs) which will cover the whole country by April 2021.

Find out what the BMA (the doctor’s union) thinks about Accountable Care Organisations (ACOs) and Integrated Care Providers (ICPs).


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