Source: NHS 70
The National Health Service was created in 1948 and celebrated 70 years on 5 July 2018.
Without getting too wrapped up into the history, the Health and Social Care Act of 2012 must be mentioned, as it introduced arguably the biggest reorganisation in the NHS’s history.
Much of the legislation took effect from 2013, when amongst many changes, NHS England and clinical commissioning groups (CCGs) took on responsibility for commissioning health services, and strategic health authorities and primary care trusts were abolished.
The Department of Health took a step back from the direct running of the NHS. However, the Health Secretary retains influence through the mandate, which sets out areas the service is expected to focus on and through which the NHS is accountable to Parliament.
The Department (also known as the Department of Health or DH) supports the Health Secretary and ministerial team in overseeing the health and social care system in England.
The DHSC is supported by 15 arm’s length bodies and several other agencies and public bodies. The Department employs over 2,000 staff who work in locations across the country.
This course will explore some of the more important organisations in further detail.
NHS England — oversees the NHS in England, commissions specialised healthcare services and primary care services and oversees clinical commissioning groups.
National Institute for Health and Care Excellence — provides advice on treatment procedures and assesses healthcare interventions for cost-effectiveness.
NHS Improvement — combines the roles of Monitor (which oversaw foundation trusts and applications from NHS trusts seeking foundation trust status) and the NHS Trust Development Authority (which had the function of helping NHS trusts achieve foundation trust status).
Medicines and Healthcare Products Regulatory Agency — assesses, licenses and regulates medicines and medical devices for use in the UK.
Public Health England — responsible for delivering public health improvement, through prevention and raising awareness, and protection and infection control.
Care Quality Commission — inspects providers of health and adult social care in England, ensuring that they meet essential standards of safety and quality.
NHS Digital — provides statistics and informatics support to the health and care system.
Health Education England — responsible for ensuring training is available to develop the healthcare workforce.
Human Tissue Authority — regulates the use of human tissue in research and therapeutic treatments.
Human Fertilisation and Embryology Authority — regulates and inspects in vitro fertilisation, artificial insemination and the storage of human eggs, sperm or embryos. It also regulates human embryo research.
Health Research Authority — protects and promotes the interests of patients and the public in health research.
NHS Blood and Transplant — responsible for the supply of blood, organs, tissues and stem cells; their donation, storage and transportation.
NHS Business Services Authority — provides business support services to NHS organisations, including the administration of the NHS pension scheme.
NHS Litigation Authority — handles negligence claims and helps the NHS learn lessons from claims to improve patient and staff safety.
NHS Counter Fraud Authority — tasked with leading the fight against NHS fraud and corruption.
NHS England allocates resources and provides commissioning (or buying) guidance for the commissioning system, which is directed by clinical commissioning groups. It is responsible for overseeing what taxpayers' money is spent on within the NHS and ensuring the provision of high quality services.
It has an important role in setting direction for the health and care system. The government’s mandate to NHS England sets its objectives and budget and helps to ensure that the NHS is accountable to Parliament and the public.
NHS England has responsibilities to:
While CCGs commission the majority of NHS services, including most hospital services, NHS England commissions directly certain services at a national or regional level such as primary care services (including GP services, where this has not been delegated) and specialist or specialised services.
The mandate is an annual set of objectives that the Health Secretary asks NHS England to deliver. Once the mandate is published, NHS England is under obligation to achieve the objectives and is held accountable to it.
The mandate also contains budget and resource allocations for NHS England.
Objectives in the mandate influence and are influenced by the NHS outcomes framework.
The framework sets the national goals that the Health Secretary uses to monitor the progress of NHS England. It does not set out how these outcomes should be delivered — NHS England has to determine how best to deliver improvements by working with clinical commissioning groups.
Indicators in the framework are grouped around five domains, which set national outcomes that the NHS should be aiming to improve. They focus on improving health and reducing health inequalities in the following areas:
Commissioning involves deciding what services are needed for local populations and ensuring that they are provided.
Essentially, commissioning is the purchase of health services from health providers. NHS commissioners are provided with a budget and are expected to make the best use of it on behalf of the patients in their area. This involves assessing the needs of the population; deciding what to prioritise; purchasing care; monitoring the organisations providing services; measuring impacts and planning next steps.
Around 200 clinical commissioning groups (CCGs) are responsible for commissioning the majority of NHS services for their local populations, including:
Every general practice must join the CCG for their area.
In assessing local needs and developing commissioning plans, CCGs must work with local authority health and wellbeing boards.
CCGs work alongside NHS England in specifying the treatments patients can receive. NHS England holds CCGs to account for their performance through the CCG outcomes indicator set.
The CCGOIS provides comparative information for CCGs about the quality of health services and the associated health outcomes.
The indicators measure outcomes at CCG level to help inform priority setting and drive local improvement. The areas covered by the indicators contribute to the five domains of the NHS outcomes framework. The CCGOIS does not set thresholds or levels of ambition.
In addition to public health duties, local authorities are responsible for health and wellbeing boards (HWBs), which oversee local commissioning, and the co-ordination of health and social care services.
The main responsibility of HWBs is to produce joint strategic needs assessments (JSNAs) to identify current and future health and social care needs of their local community. These feed into the joint health and wellbeing strategy (JHWS) which sets out joint priorities for local commissioning.
Local authority, CCG and NHS England commissioning plans are then informed by these documents. HWBs do not hold a budget – allocating funding for services remains the responsibility of CCGs and local authorities, in line with their commissioning plan.
An NHS hospital trust, also known as an acute trust, is a trust that provides secondary health services. Hospital trusts are commissioned to provide healthcare services by clinical commissioning groups.
A large number of hospital trusts have evolved to become foundation trusts. All hospital trusts were expected to be awarded foundation status by 2016, however, many have not reached the required standard.
The best performing (in finance and patient care) NHS trusts have been able to transition to NHS foundation trusts. Such trusts are self-governing bodies that have greater financial and operational freedom from government than standard NHS trusts. They provide over half of all NHS hospital and mental health services.
They are directly accountable to Parliament and NHS Improvement. FTs will have a board of governors and members and their greater financial freedoms include the ability to borrow commercially and generate surpluses to reinvest in services.
In 2016, NHS organisations and local councils got together to develop shared proposals to improve health and care.
These sustainability and transformation partnerships (STPs) are designed around the needs of whole areas – not just individual organisations.
Some of the STPs have evolved into integrated care systems, where NHS providers and commissioners choose to take on collective responsibility for resources and population health, often in partnership with local authorities.
The CQC is the independent regulator for quality in health and social care in England (including private providers).
It registers and inspects hospitals, care homes, GP surgeries, dental practices and other healthcare services. It provides a rating for each trust and its core services.
If services are not meeting fundamental standards of quality and safety, the CQC has various powers, from issuing warnings and fixed penalty notices, through to suspending or cancelling a provider’s registration, and prosecuting the provider.
All NHS providers, whether they are foundation trusts, NHS trusts or independent providers of NHS-funded care, are overseen by NHS Improvement.
It supports healthcare providers to ensure they deliver patients with safe and compassionate care, and that local health systems are financially sustainable. NHS Improvement has the power to intervene if it identifies concerns. For example, it will work alongside the Care Quality Commission to act when the CQC reports that a hospital is failing to provide quality care.
NHS Improvement is also responsible for:
Monitor and the NHS Trust Development Authority came together to form NHS Improvement in 2015.
The National Institute for Health and Care Excellence (NICE) produces national guidance, quality standards and information to help health and social care professionals deliver high quality care.
It also decides which drugs and treatments can be made available on the NHS in England and Wales.
NICE technology appraisals make recommendations on innovative and existing medicines and treatments, considering clinical and cost effectiveness.
The aim of NICE technology appraisals is to standardise access to healthcare across England and Wales to reduce variation in the availability and quality of NHS treatments (the so-called postcode lottery of healthcare).
NICE quality standards define what high quality health and social care should look like for a specific disease, condition or clinical area taking into account: clinical effectiveness; patient safety; and patient experience.
NICE also produces NICE pathways which are interrelated guidance and information on a topic.
Most health policy in Scotland, Wales and Northern Ireland is devolved to the Department of Health’s counterparts.
Several health issues are wholly or partly reserved to Westminster, such as human genetics.
The Isle of Man and the Channel Islands have their own independent health service structures.
The Scottish Government is responsible for the Health and Social Care Directorate.
NHS Scotland consists of:
The Welsh Government is responsible for the Department of Health and Social Services.
Seven local health boards are responsible for planning and delivering healthcare services, and aim to integrate specialist, secondary, community and primary care and health improvements.
There are three all-Wales NHS trusts:
As well as being accountable to Welsh Ministers, the NHS in Wales is also accountable to community health councils, which provide a link between patients and the organisations that plan and deliver services.
The Northern Ireland Executive is responsible for its own Department of Health.
The Health and Social Care Board holds overall responsibility for commissioning services through five local commissioning groups.
Five health and social care trusts are responsible for providing integrated health and social care in their areas.
The Northern Ireland Ambulance Service is designated as a sixth region-wide trust.
A separate Public Health Agency has responsibility for improving health and wellbeing and health protection.
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