The Health Care System in the UK

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The National Health Service (NHS) was set up in 1948 to provide free healthcare for all the residents of the UK, British Nationals, those on the Highly Skilled Migrants Programme, and those in Employment. For its founders, the most important feature was that it was free at the point of need. This means that every time you go to the doctor or receive treatment at hospital, it is provided free of charge. The NHS is funded through general taxation and is run by the Department of Health. There are also private healthcare providers in the UK. People pay for private healthcare either through insurance or when they use their services.

Over the last few years the structure of the NHS has undergone considerable change. The private sector now has a role in supplying and funding some buildings and services within the NHS. The power to make important decisions about local healthcare is also being devolved to local communities in some areas.

There are now significant differences in how the NHS works between the different countries of the UK. This guide deals with England. You can also read our guide to How the healthcare system works in Wales, How the healthcare system works in Northern Ireland and The healthcare system in Scotland.


How the NHS works

Key decisions about local healthcare are taken by local branches of the NHS but overall strategy is left to the Department of Health and other regional bodies. The list below sets out the structure of the NHS.

Secretary of state for health

This is the government minister responsible for the NHS in England, and he or she is answerable to Parliament for the work of the NHS.

Department of Health

The Department of Health is responsible for the overall planning, regulation and inspection of the health service. It develops policies and decides the general direction of healthcare.

Strategic health authorities

There are 28 strategic health authorities in England. They look after the healthcare of their region. They are the link between the Department of Health and the NHS. They make sure that national health priorities (such as cancer programmes) are integrated into local health plans. The NHS website has a list of strategic health authorities in England.

Primary and secondary health services

Health services in the UK are divided into “primary” and “secondary” and are provided by local NHS organisations called “trusts” and these are directly accountable to the strategic health authorities.

Primary care covers everyday health services such as GPs’ surgeries, dentists and opticians and these are delivered by “primary care trusts”. You can find your primary care trust through the NHS website.

Secondary care refers to specialised services such as hospitals, ambulances and mental health provision and these are delivered by a range of other NHS trusts.


The different types of trusts

Hospitals are managed by 'acute trusts'

Primary care trusts

There are about 300 primary care trusts in England. They decide what health services their area needs and have responsibility for making sure these are delivered efficiently - for example, they are responsible for making sure there are enough GPs. Primary care trusts are responsible for services you access directly such as:

  • GPs
  • Dentists
  • Pharmacists
  • Opticians
  • NHS Direct
  • NHS walk-in centres


Primary care trusts decide on the amount and quality of services provided by hospitals, dentists, patient transport and population screening. They are also responsible for generally improving local health and making sure that NHS organisations work effectively with councils.

Primary care trusts are a crucial part of the NHS and they receive about 75% of the NHS budget. They also control funding for hospitals, which are managed by NHS trusts called "acute trusts".


Outsourcing treatment

Primary care trusts can also outsource work to private companies - for example, out-of-hours healthcare is often provided by private companies. Some of the treatment centres offering pre-booked short-term surgery and diagnosis in fields where there are long waiting lists, such as ophthalmology, are also privately run.


NHS trusts

NHS trusts run most hospitals and are responsible for specialised patient care and services, such as mental health care. The trusts' role is to make sure that hospitals provide high quality health care and spend their money efficiently and some pay for private treatment to clear backlogs and waiting lists. They employ most of the NHS workforce from hospital doctors and radiographers to security staff. The different types of trust include:

  • Acute trusts: These look after hospitals that provide short-term care, such as Accidents and Emergencies, maternity, surgery, x-ray
  • Care trusts: These work in both health and social care and they can carry out a variety of services, such as mental health services. They are generally set up when the NHS and a local authority decide to work closely together
  • Mental health trusts: There are a number of specialist mental health trusts in England, providing care, such as psychological therapy and specialist medical and training services for people with severe mental health problems
  • Ambulance trusts: There are over 30 ambulance services for England, each run by its own trust. Ambulance trusts are responsible for providing transport to get patients to hospital for treatment


Foundation trusts

High-achieving NHS trusts can opt out of NHS control and receive foundation status, which means that their hospitals can effectively run themselves. Foundation hospitals are a hotly-contested issue and you can read more about them in Foundation hospitals: an Action Network briefing.

Although they remain part of the NHS and people continue to receive free healthcare, foundation trusts have more freedom and financial flexibility and less central control and monitoring.

They are owned by their community, local residents, employees and patients and have the power to manage their own budgets and shape their healthcare provision according to local needs and priorities -for example, by having the option to address long waits for certain treatments. The trusts also have more access to funds for investment and this can come from the public or the private sector. They are held accountable by an elected board of governors and an independent regulator monitors their performance. Like all healthcare organisations, they are inspected by the Healthcare Commission. The government hopes that by 2008 all NHS trusts will be able to become foundation trusts.


Private healthcare

The private healthcare sector is much smaller than the NHS and does not have the same structures of accountability. It mirrors the NHS by providing GPs (many doctors in the NHS also have private practices), nursing homes, ambulances, hospitals and medical specialists, but it does not have to follow national treatment guidelines and health plans and it does not have responsibility for the health of the wider local community.

Private health insurance: Membership of health insurance schemes, such as BUPA, accounts for a large proportion of private health treatment. Many employers offer membership of such schemes or people pay for it themselves.

Secondary care in the private sector: Secondary care, which refers to more specialised health treatment such as hospitals, mental health provision and care for the elderly, is well served by the private sector. While people may be registered with an NHS GP, the private sector is often used for secondary care such as:

Diagnostic tests for certain conditions, one-off specialist treatment such as visiting a dermatologist, specific operations in a private hospital, non-essential treatment such as cosmetic surgery and treatment for addiction or rehabilitation

Private hospitals: There are over 300 private hospitals in the UK. Private hospitals are provided by private hospital groups and the NHS also provides a number of private patient units within its hospitals. Private hospitals are licensed by the local healthcare authority, which conducts two inspections a year. They are not regulated by the national inspection bodies that monitor NHS organisations.


The regulation and inspection of healthcare

A number of bodies check that people are getting good healthcare services. These “special healthcare authorities” mainly regulate and inspect important aspects of healthcare, such as clinical guidelines on medical conditions and patient safety.

Providing guidance on medical treatment

The National Institute for Clinical Excellence (NICE) publishes guidelines and advice for the public and for healthcare professionals in England and Wales. These cover specific diseases, drugs, medical devices and technologies and the management or treatment of certain conditions. The NHS is expected to take these guidelines into account. Private hospitals do not have to follow them, although they take them into account as “best practice” guides.

Monitoring healthcare standards

The Healthcare Commission is responsible for monitoring healthcare standards and efficiency. It is also responsible for publishing the NHS performance ratings and indicators. These ratings (popularly known as star ratings) affect how much independence trusts have and their ability to become a foundation trust. NHS organisations in England are allocated between zero and three stars based on their performance in areas such as:

  • Waiting times and waiting lists
  • The number of operations cancelled
  • Hospital cleanliness
  • Death rates
  • Financial position
  • Emergency re-admission rates


Monitoring social care standards

The Commission for Social Care Inspection is the body responsible for inspecting and regulating social care services and works in parallel with the Healthcare Commission. Its commissioners are appointed by an independent process and its role includes:

Carrying out inspections of all social care organisations, public, private and voluntary, carrying out inspections of local social service authorities, reporting to Parliament on the performance of social services and publishing the star ratings for social services authorities.


Monitoring patient safety

The National Patient Safety Agency was set up to improve standards of safety throughout the NHS by learning from adverse incidents involving patient care and safety. It encourages staff to report incidents and, by analysing reports, hopes to develop preventative measures in hospitals in England and Wales.

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