1. How the NHS works

Secretary of state for health
This is the government minister responsible for the NHS in England and is answerable to Parliament for its work.

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.

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’.

• Primary care covers everyday health services such as GP’s surgeries, dentists and opticians and these are delivered by ‘primary care trusts.’
• 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, all accountable to the strategic health authorities

2. The different types of trusts

Primary care trusts
There are about 300 primary care trusts in England. They decide what health services their area needs and make 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 are responsible for secondary planning: they 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’.

NHS trusts
NHS Trusts run most hospitals and are responsible for specialised patient care and services such as mental health care. The trusts make sure that hospitals provide high quality health care and spend their money efficiently. They employ most of the NHS workforce from hospital doctors and radiographers to security staff.

• Acute trusts: These look after hospitals that provide short-term care, such as Accidents and Emergencies, maternity, surgery, x-ray etc
• Care trusts: These work in both health and social care and they can carry out a variety of services such as mental health services and primary care provision. 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. Specialist care that a mental health trust might provide includes 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 and these provide access to emergency healthcare. Ambulance trusts are responsible for providing transport to get patients to hospital for treatment

Foundation trusts
From April 2004 certain NHS trusts will be allowed to receive foundation status, paving the way for a new kind of hospital. Although they remain part of the NHS and people will continue to receive free healthcare, foundation trusts will have much more freedom and financial flexibility and less central control and monitoring.

Foundation trusts won’t be run by central government. They will be owned by their community, local residents, employees and patients and they will have the power to manage their own budgets and shape their healthcare provision according to local needs and priorities, for example by having the freedom to address long waits for certain treatments. The trusts will also have more access to funds for investment and this can come from the public or the private sector.

They will be held accountable by an elected board of governors and an independent regulator will monitor their performance. Like all healthcare organisations, they will be inspected by the Healthcare Commission (currently called the Commission for Healthcare Audit and Inspection).

The government hopes that by 2008 all NHS trusts will be able to become foundation trusts. You can read the Foundation hospitals: an iCan briefing for more information on the issue.

3. How the private sector and the NHS work together

The government is keen to encourage the use of private healthcare within the NHS. They argue that as it is free at the point of need and the service is good, it is not important who provides the service to patients but that it is. The private sector now works with the NHS in a number of ways.

Outsourcing treatments: Parts of the NHS use private healthcare companies to help them provide more treatment to more people and to help reduce waiting lists:

• Many primary care trusts outsource work to private companies. Out-of-hours healthcare is often provided by private companies
• Some NHS hospitals pay for private treatment to clear backlogs and waiting lists
• Treatment centres, which offer pre-booked short-term surgery and diagnosis in areas with long waiting lists such as ophthalmology have been set up across the UK. Some of these are NHS run and others are managed by private companies although they deliver a free NHS service

Private finance initiatives (PFI): The government is building more hospitals using private money. PFI is a way of funding major public building projects and involves private companies contracted for about 30 years to design, build and manage these large new projects. The building is leased by a health trust from the private company for this period while the government pays back the building cost with interest. The developer maintains the building during this period. Because the payment can be spread over time the government has been able to start an extensive building programme.

4. The private healthcare sector

There are a number of ways that people access private healthcare.

Private health insurance: Membership of health insurance schemes such as BUPA accounts for a large proportion of private health treatment and more employers are offering membership of such schemes.

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 especially 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
• Treatment for addiction or rehabilitation

Private hospitals:There are over 300 private hospitals in the UK. Private hospitals are provided by six organisations: the NHS, which runs a number of private patient units within its hospitals and five private hospital groups: BMI Healthcare, BUPA, Nuffield Hospitals, Capio Healthcare UK and HCA International.

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, only for its paying clients. Private hospitals are licensed by the local healthcare authority and they conduct two inspection visits a year. Private hospitals are not regulated by the national inspection bodies that inspect NHS organisations.

5.The regulation and inspection of healthcare

A number of bodies have been set up to check that people are getting good healthcare services. These ‘special healthcare authorities’ primarily 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 on 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 are issued as ‘best practice’ guides.

Monitoring healthcare standards
The Healthcare Commission (currently known as the Commission for Healthcare Audit and Inspection) is responsible for monitoring healthcare standards and efficiency in the UK.

It is also responsible for publishing the NHS performance ratings and indicators. Star rating affects how much independence trusts have and the ability to become a foundation trust. NHS organisations in England are allocated 0-3 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 will work in parallel to the Healthcare Commission (currently known as the Commission for Healthcare Audit and Inspection). Its commissioners will be 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
• Publishing the star ratings for social services authorities