Quick guide to the healthcare system (England)

On 1 April 2013 the Health and Social Care Act 2012 officially came into effect and introduced radical changes to the way that health services in England are organised. This webpage is intended to provide an overview to help RCPCH members navigate and understand the implications of the new system. 

What did the Act do?
What does this mean?
  - Commissioning health services
  - Commissioning public health services
  - Local accountability
  - Support for commissioners
  - Regulation
  - Standards and data
  - Training and education
  - Five Year Forward View
How to influence the new system?
 

There is more detailed information available online, including a diagram of the system by NHS England and an animated guide by the Kings Fund.

What did the Act do?

In July 2010 Andrew Lansley MP, the then Secretary of State for Health, published plans for NHS reform in the White Paper, Equity and Excellence: liberating the NHS. The Health and Social Care Bill met with considerable opposition but was introduced in July 2011, completing its passage through the Houses of Parliament to be granted Royal Assent and become the Health and Social Care Act in April 2012. The Act came into force on the 1 April 2013.

The Act was the most extensive reorganisation of health services in England to date. The Act:

  • abolished the responsibility of the Secretary of State for Health to ‘provide or secure’ health services for all UK people (in place since the inception of the NHS in 1948)
  • abolished Primary Care Trusts and Strategic Health Authorities
  • created a number of new statutory bodies including the NHS Commissioning Board (later renamed ‘NHS England’ on 1 April 2013), Clinical Commissioning Groups, and Health and Wellbeing Boards
  • restructured public health services, granting local authorities responsibilities for improving the health of the people in their area and stipulating that they must employ a Director of Public Health
  • extended the role of Monitor to be the system regulator for all NHS funded services
  • removed the Care Quality Commission's responsibility for assessing the performance of NHS commissioners, which has been taken on by the NHS Commissioning Board (now NHS England).

What does this mean?

The Government now sets out its objectives for the health service in England each year through a mandate to NHS England (a new executive non-departmental public body of the Department of Health i.e. an arms-length body to the government). NHS England has a concurrent duty with the Secretary of State to promote a comprehensive health service.

NHS England and Clinical Commissioning Groups (CCG) are now responsible for commissioning the majority of NHS services, with local authorities responsible for commissioning public health services.

Commissioning health services

  1. NHS England and its four regional teams (North, Midlands & East, London, South) is responsible for directly commissioning specialised services, health services for people who are in prison or other secure accommodation, victims of sexual assault, and health services for serving personnel and families in the armed forces.
     
  2. Specialised services are split into six programmes of care, including one for women’s and children’s services. The programmes of care are steered by Clinical Reference Groups(CRG) which bring together clinicians, commissioners, public health experts, patients and carers and provide advice to NHS England, including the development ofservice specifications.
     
  3. The previous system of 152 primary care trust has been replaced with 209 CCG. CCG commission most hospital, community and mental health services and control the majority of the NHS budget (around £65billion).
     
  4. CCG are groups of general practices which come together in each local area to commission services for their population. They are led by clinicians, mainly GPs but including at least one hospital doctor, nurse and member of the public. NHS England is responsible for the authorisation, oversight and performance management of CCG.
     
  5. Primary care services were originally commissioned by NHS England but there has been a recent move to co-commissioning of primary care services between NHS England and CCG.

Commissioning public health services

  1. Public Health England, a new executive agency of the Department of Health, has been established to oversee the public health system and is accountable to the Secretary of State.
     
  2. The majority of the public health budget is now held by local authorities who are responsible for commissioning and providing public health services (including health visiting services and the healthy child programme). Each local authority (LA) has been required to appoint a director of public health.

Local accountability

  1. Local Healthwatch organisations have been established across England (supported by a national body, Healthwatch England) to gather people’s views on the health service and provide feedback to providers and commissioners.
     
  2.  A local Health and Wellbeing Board has been established in each LA with a duty to encourage integrated commissioning between health, social care and public health. Membership includes: a local elected representative, a representative of local HealthWatch, a representative of each local CCG, the LA director for adult social services, the LA director for children’s services and the LA director of public health.
     
  3. Health and Wellbeing Boards are required to produce a joint strategic needs assessment and a health and wellbeing strategy to feed into CCG planning.

Support for commissioners

  1. NHS England has divided England into 12 areas; each area maps onto CCG and LA boundaries.
     
  2. Each geographical area has a Clinical Senate, set up to help CCG and Health and Wellbeing Boards by providing a broader, strategic view on the totality of healthcare within that area. For example, on major service changes and reconfigurations.
     
  3. In each of the 12 regions there are also Strategic Clinical Networks (SCN) which focus on four areas of major healthcare challenge: cancer; cardiovascular; maternity, children and young people; and mental health, dementia and neurological conditions. The SCN aim to provide a whole system, integrated approach by working across the boundaries of commissioner, provider and voluntary organisations as a vehicle for improvement for patients.
     
  4. Fifteen Academic Health Sciences Networks (AHSN) have also been established to promote and encourage the adoption of innovation in health services by bringing together academia, commissioners, providers and industry.The Oxford AHSN and the UCL Partners AHSN currently include programmes of activity focused on children.
     
  5. Operational Delivery Networks (ODN) have been introduced within the geographical areas of the clinical senates to focus on coordinating patient pathways between providers over a wide area to ensure access to specialist support and expertise. They cover specific areas such as neonatal intensive care.

Regulation

  1. The Care Quality Commission (CQC) remains as the key inspectorate, responsible for ensuring that health and social care services meet safety and quality requirements.
     
  2. Monitor and the Trust Development Agency (TDA) have responsibility for national pricing and tariffs and financial regulation. They are currently merging into a new body called NHS Improvement which will focus on supporting providers to become more efficient as well as providing higher quality care (NHS England’s patient safety function will also move to the new body).

Standards and Data

  1. The National Institute for Health and Care Excellence (NICE) continues to provide advice and guidance to the NHS, and now has an extended role into social care.
     
  2. The Health and Social Care Information Centre (HSCIC) has been established to provide a central source of health and social care information and data.

Training and Education

  1. Health Education England (HEE) has been established to lead workforce planning, education and training. HEE has 13 Local Education and Training Boards (LETB) who are responsible for the training and education of NHS staff within their local area (and taking over the functions previously carried out by the Deaneries).

Five Year Forward View

  1. The NHS Five Year Forward View was published in October 2014, setting out a vision for the future of the NHS. It describes various models of care which could be provided in the future including prevention, new local models of service delivery, integration and leadership.
     
  2. To support the Five Year Forward View, NHS England has selected 50 ‘vanguards’ under its New Care Models Programme to test new ideas and care models. The vanguards fall under five topics: integrated primary and acute care systems; enhanced health in care homes; multispecialty community providers; urgent and emergency care; and acute care collaborations.

How to influence the new system?

There are a number of ways to influence the new system, for example, by applying to be a secondary care representative on a CCG (normally one outside your area) or by getting involved in the work of your local children’s SCN

With responsibility for commissioning health services now split across CCG, NHS England and local authorities, it’s often difficult to know who to contact if you have a concern about the commissioning of your service. But as a broad guide:

  • If you are a specialist tertiary service, the Chair of the relevant CRG should be able to provide advice and put you in touch with the accountable commissioner
  • If you are a secondary care service, contact the lead for children at your local CCG (some trusts may provide services to more than one CCG population)
  • If you are a public health service, contact the Director of Public Health in your local authority

Nearly three years on, we are now starting to see the real implications of the Act. The RCPCH continues to monitor developments closely; please share with us examples of what is happening on the ground so we can advocate effectively by emailing health.policy@rcpch.ac.uk