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Introduction to the Health System

The Health and Social Care Act 2012  changed the structure of the NHS and the way it operates, with most of the changes having taken effect from 1st April 2013.

In theory, the structure saw a change from directly centralised control from the Department of Health to control at one remove, with a slightly more independent NHS England (originally called the ‘NHS Commissioning Board’).  Under the old system the DH controlled the NHS through 10 Strategic Health Authorities (SHAs) and 152 Primary Care Trusts (PCTs).  Under the new system the Secretary of State provides the overall policy guidance for NHS England which commissions primary care and a number of specialised services, while local Clinical Commissioning Groups (CCGs) commission secondary care.  CCGs are now (2014) being given the opportunity to co-commission primary care alongside NHS England.

NHS England (originally called the NHS Commissioning Board) oversees the NHS’s budget (£95.6bn in 2013-14) of which £64.7bn goes to the CCGs.  The body directly commissions £25.4bn of mainly primary care plus some other specialised services.

Geographically, NHS England is organised into 4 regions and 27 local area teams.

There are now 209 Clinical Commissioning Groups (CCGs) (originally 211) responsible for commissioning secondary care.  All 8,000 or so GP practices are members of a CCG.  The CCG boards also have to have at least one hospital doctor, a nurse and a member of the public.

There is a new Health and Wellbeing Board in each of the 152 county and single tier council areas.  This has representatives from the council the CCG(s) and Healthwatch.  Its role is to promote integration between health and social care, to produce the Joint Strategic Needs Analysis (JSNA) and the Joint Health and Wellbeing Strategy (JHWS).  Both the Council and CCG(s) have to take account of the JHWS when commissioning services.

Commissioning Support Units (CSU’s), as the name suggests, provide support on commissioning to CCGs, but also to NHS England and others.  They were spun out of PCTs and it is up to CCGs whether and how much they use them.  From 2016, they will be independent, having to operate in a competitive market.  There are 18 CSUs in England, and although they are each based in a different area, they do not have to provide services only to that area.

For more information see: http://www.england.nhs.uk/ourwork/commissioning/comm-supp/csu/

There are 12 clinical senates in England, each with a clinical senate council and an assembly.  The assembly includes professionals from both health and social care, experts, voluntary groups and the public.  Their role is to provide independent, strategic advice and guidance to commissioners.  The senate council is a small multi-professional steering group that manages the business of the senate.

There is no minimum or maximum size of the assembly.  Membership is locally determined but based on national principles and is overseen by the Area Team Medical Director.

They generally don’t meet in public (http://www.publications.parliament.uk/pa/ld201314/ldhansrd/text/140224w0002.htm#wa_st_232 (via www.theyworkforyou.com).

For more details on clinical senates see: http://www.england.nhs.uk/ourwork/part-rel/cs/

There are 12 strategic clinical networks, covering the same geographical areas as the clinical senates.  Strategic clinical networks bring together experts, including patients, to provide advice for commissioners relating to particular conditions.

The strategic clinical networks cover four specialist areas:

  • Cardiovascular
  • Maternity, children and young people
  • Mental health, dementia and neurological conditions
  • Cancer

There may also be other networks within each region dependent on local need.  They are not statutory bodies and do not have operational powers.

For more, see: http://www.england.nhs.uk/ourwork/part-rel/scn/

Other sources of information on the restructured NHS

A very clear and informative introductory guide on the NHS, designed for those working and training in the NHS but useful for others as well, was published by NHS England in June 2014.
http://www.england.nhs.uk/2014/06/26/understanding-nhs/

There is a very good summary of the changes to the health system, with helpful diagrams, from the BBC here: http://www.bbc.co.uk/news/health-19674838.  (From 1st March 2013).

There is a good presentation (11 slides) from the Nuffield Trust, from 1st April 2013, here: http://www.nuffieldtrust.org.uk/talks/slideshows/new-structure-nhs-england

Also from the Nuffield Trust, a fascinating timeline of NHS reforms:
http://nhstimeline.nuffieldtrust.org.uk/

I personally find the Department of Health’s diagram (from September 2012) less helpful, though it might be useful to be aware of it: http://healthandcare.dh.gov.uk/system-overview-diagram/

There is a briefing on the new system relevant for voluntary organisations published in March 2013: http://www.regionalvoices.org/changes

There is a summary of the new system from the House of Commons Library here (8pp), published in November 2013.
http://www.parliament.uk/briefing-papers/SN06749/the-reformed-health-service-and-commissioning-arrnagements-in-england

Page last updated 18th December 2014.

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