NHS Structure & Function

Question 1

The NHS

Answer 1

• Created in 1948
• Accessed by approximately 1.5 million people each day
• Interestingly the life expectancy of men and women has increased by an average of 10 years since the creation of the NHS

Question 2

NHS and the hierarchy within it.

Answer 2

Primary care is the first point of contact for most people and is delivered by a wide range of independent contractors, including GPs, dentists, pharmacists and
optometrists

Within secondary care Clinical Commissioning Groups (CCGs) commission most of the hospital and community NHS services in the local areas for which they are
responsible

Question 3

different bodies involved with the NHS

Answer 3

At the heart of the NHS are the people and communities. The inner ring covers local health and care services available to patients and is composed of primary (e.g. GP surgeries and dentists) secondary (hospitals) and tertiary (home or care home) care.
The next two rings cover local and national organisations that form part of the different areas of the NHS, including commissioning and regulation.
The fourth ring covers regulators and organisations involved in safeguarding patients, and the outer ring covers Government departments.
The key shows the functions that the different bodies
have in the NHS, this can range from front line care such as in Pharmacies or Hospitals to safeguarding patients such as the work done by NHS Improvement or the
MHRA.

Question 4

NHS Outcomes Framework

Answer 4

1. preventing people from dying prematurely
2. enhancing quality of life for people with long term conditions
3. helping people to recover from episodes of ill health or following injury
4. ensuring that people have a positive experience of care
5. treating and caring for people in a safe environment and protecting them from avoidable harm

Question 5

Roles in the NHS

Answer 5

• Secretary of State for Health
– Ultimate responsibility for provision of a comprehensive health service
• Department of Health
– Strategic leadership for health and social care

Question 6

NHS • Main aim is to improve health outcomes and deliver high-quality care for people in
England by:

Answer 6

• Providing national leadership for improving outcomes and driving up the quality of care;
• Overseeing the operation of clinical commissioning groups (CCGs);
• Allocating resources to clinical commissioning groups;
• Commissioning primary care and directly commissioned services

Question 7

NHS ENGLAND

Answer 7

• NHS England is a clinically led organisation.
• It has a budget of just over £95 billion.
• Within this overall funding, it allocates over £65 billion to CCGs and local authorities, which commission services locally for patients.
• The remainder is allocated to direct commissioning activities and to operational costs.
• NHS England’s responsibilities are discharged through four regional teams (North, Midlands & East, London and South) and 27 Local Area Teams

Question 8

NHS England

• Responsibility for commissioning:

Answer 8

– Primary care
– Specialised healthcare services
– Health services for armed forces
– Health services for prison and secure accommodation

Question 9

Clinical Commissioning Groups

CCG

Answer 9

• All GP practices belong to a CCG
• Commission services for their local population
– Planned hospital care
– Rehabilitative care
– Urgent and emergency care
– Most community health services
– Mental health and learning disability services

• England’s 211 clinical commissioning groups (CCGs) replaced the 150 primary care trusts and responsible for £65bn of the NHS commissioning budget.
• They plan and commission healthcare services for local populations- including hospital care and community and mental health services.
• Each serves a median population size of around 250,000 people (range 61,000 to 860,000).
• All GP practices have to be members of a CCG, and every CCG board will include at least one hospital doctor, nurse and member of the public.

• Can commission any service provider that
meets NHS standards and costs (not just NHS)
• Must meet quality standards e.g. NICE and CQC
• Must involve patients, carers and public in decisions
CCGs are clinically led local organisations that know the area in which they are working, and so are able to commission services that are specifically required by the
population that they serve.

Question 10

CCGs are responsible for commissioning the following services in their ‘patch’:

Answer 10

• Urgent and emergency care (for example, A&E);
• Elective hospital care (for example, outpatient services and elective surgery);
• Community health services (services that go beyond GP); This includes pharmacy
• Maternity and newborn;
• Mental health and learning disabilities.

Clinical commissioning groups can commission services from a range of providers, including from the voluntary and private sectors- competition in the NHS.

Question 11

Health & Wellbeing Boards

Answer 11

• Forum for local commissioners across the NHS,
social care, public health and other services
• Role:
– Strengthen links between health and social care
– Encourage integrated commissioning of health and
social care services
– Improve the health and wellbeing of their local
population & reduce health inequalities

-The Health and Social care Act 2012 establishes health and wellbeing boards as a forum where key leaders from the health and care system work together to improve the health and wellbeing of their local population and reduce health inequalities.
-The boards will help give communities a greater say in understanding and addressing their local health and social care needs.
-Health and wellbeing boards will have strategic influence over commissioning decisions across health, public health and social care.
-Boards will bring together clinical commissioning groups and councils to develop a shared understanding of the health and wellbeing needs of the community. They will undertake the Joint Strategic Needs Assessment (JSNA) and develop a joint strategy for how these needs can be best addressed. This will include recommendations for
joint commissioning and integrating services across health and care.

Question 12

Public Health England

Answer 12

• PHE’s mission is “to protect and improve the nation’s health and to address inequalities”
• Supports public health and responds to emergencies

• It has taken over the roles of organisations including the Health Protection Agency, National Treatment Agency, public health observatories and cancer registries.
• It has 15 centres across England, each of which provides leadership and support across all three domains of public health - health protection, health improvement and healthcare public health.
• This includes:
-supporting local government in its leadership of the local public health system
-supporting directors of public health
-working with the NHS England on commissioning key specialist services and national public health programmes
-providing leadership in responding to emergencies.

Question 13

Public Health England

• Role

Answer 13

– Coordinate a national public health service (and deliver some of it)
– Build an evidence base to support local public health services
– Support the public to make healthier choices
– Support development of public health workforce

Question 14

Local Authorities

Answer 14

• Each LA has a fully operational Health &
Wellbeing board
• In partnership with CCGs responsible for
commissioning majority of NHS services in area
• New duties to protect and improve public health
– Commissioning and providing health and social care
services

• Local government has a new set of duties to protect and improve public health. These include commissioning and providing public health services including:
-Sexual health services
-Drug and alcohol misuse services
-Stop smoking services
-NHS Health Checks
-Children’s vaccinations
• LA also commission social care for their local populations based local criteria and national minimum standards.
• Sorts of things community pharmacy might be commissioned to provide are supervision of methadone consumption, needle exchange, EHC, smoking cessation
• Again competition exists, community pharmacies do not necessarily have right to these services. They maybe provided by other providers e.g. nurses, charities etc.

Question 15

Special Health Authorities

Answer 15

• SHAs are NHS Trusts working on a national level
• They include bodies such as:
– NHS Business Services Authority (NHSBSA)
– National Institute for Health and Clinical Excellence (NICE)
– National Patient Safety Agency

They have been set up to provide a national service to the NHS or the public under section 9 of the NHS Act 1977. They are independent, but can be subject to
ministerial direction in the same way as other NHS bodies

Question 16

NICE

Answer 16

• Provide national guidance on promoting good health and preventing and treating ill health
• Undertake activities relating to:
– Public health
– Health technologies
– Clinical treatment
• Supports the commission or provision of healthcare

Question 17

MHRA

Answer 17

Medicines & Healthcare products Regulatory
Agency
• Executive agency
• Ensures safety of medicines and devices
• Licensing body in the UK

Government agency responsible for ensuring that medicines and medical devices work, and are acceptably safe.

Question 18

MHRA

• Aims

Answer 18

– To protect public health through regulation, with
acceptable risk, by developing benefit profiles for medicines and devices
– To promote public health by helping people to understand the risks and benefits of the products they use
– To improve public health by promoting and facilitating developments in products that will benefit people

Question 19

Care Quality Commission (CQC)

Answer 19

• NHS independent regulator
• Responsible for quality of health and social care in England
• Functions include:
– Undertaking assessment of services
– Making recommendations for improvement
– Investigates serious problems
– Monitors specific treatments

Assessment covers acute trusts, mental health trusts, ambulance services, primary care trusts and those providing specialist services for people with learning disabilities.
CQC also inspect private hospitals and clinics, beauty salons providing non-surgical cosmetic treatments e.g. botox, care homes.
Assessments look at factors such as waiting times, cleanliness, dignity in care and also financial management
Scores may be excellent, good fair or poor Monitoring of treatments such as: Controlled drugs, Ionising radiation

Question 20

NHS Trusts

Answer 20

• Acute trusts & Foundation trusts
• Ambulance trusts
• Mental health trusts
• NHS acute or foundation trusts provide the hospital, out-patient and other services commissioned by CCGs to meet local population needs
• Ambulance trusts provide services responding to 999 calls, transporting patients, and providing out-of-hours care in some areas
• Mental health trusts provide specialist care for people with complex and severe mental health problems

There are almost 250 hospital, mental health and ambulance trusts in England

Question 21

NHS Hospitals – Acute Trusts

Answer 21

• Acute
• Specialist – paediatric, renal, spinal injuries, burns
• Long term care – care of the elderly, spinal injuries
• Mental health – acute and long term

-Hospitals in England are managed by acute trusts – some of which already have gained foundation trust status. Acute trusts ensure hospitals provide high-quality
healthcare and check that they spend their money efficiently. They also decide how a hospital will develop, so that services improve.
-Some acute trusts are regional or national centres for more specialised care, while others are attached to universities and help to train health professionals.
-Acute trusts can also provide services in the community – for example, through health centres, clinics or in people’s homes.

Question 22

Private Hospitals (UK)

Answer 22

• Run by private companies
• All services are paid for including drug treatments
• Referred for treatment by GP (NHS services usually)
• Consultants provide the majority of medical care

Many private hospitals may have their own pharmacy service
Some buy services from local NHS
Specialist services may be contracted from elsewhere

Question 23

Foundation Trusts

Answer 23

• Created under Health & Social Care Act 2003
• Run by local members, staff and the public
• Have greater financial and operational freedom
• Not under direct government control but overseen by independent regulator (NHS Improvement)

Board of governors is elected by local members – includes representatives of local members, and other stakeholders such as PCT, Local Authorities, staff and the local University where relevant.
Residents and patients in the areas served by Foundation Trust can become members, as can other patients and their carers if the Trust allows. Financial freedoms:
Retain financial surplus
Borrow money from pubic and private sources
Overseen by independent regulator “NHS Improvement” (formerly Monitor) – ensures they comply with their terms of authorisation
Currently 129 in England
Ensures a relationship with both patients and members of the public
Increases providers awareness of the needs of service users
More responsive to local needs

Question 24

Social Care

Includes:

Answer 24

• Residential homes
• Nursing homes
• Hospices

Care homes for older people may provide personal care or nursing care. A care home which is registered to provide personal care will offer support, ensuring that basic personal needs, such as meals, bathing, going to the toilet and medication, are taken care of. In some homes more able residents have greater independence and take care of many of their own needs.
Some residents may need medical care and some care homes are registered to provide this. These are often referred to as nursing homes. Some homes specialise in certain types of disability, for example, dementia.
NHS continuing care (i.e. medical care) is commissioned by CCGs. This is not means tested and is dependant on a clinical assessment.
Social care (i.e. personal care) is commissioned by LA. Open to all (no medical needed) however it is means tested.
Someone in a nursing home may get their NHS continuing care paid for by CCGs and their social care paid for by LAs.

Question 25

Residential homes

Answer 25

• Short or long term
• In addition to accommodation, they provide help and assistance with:
– Personal hygiene
– Continence management
– Food and diet
– Counselling and support
– Simple treatments
– Personal assistance

These homes are residential, which means people live in them either short or long term.
In addition to the accommodation, they provide help and assistance with:
Personal Hygiene, including help with washing, bathing, shaving, oral hygiene and nail care.
Continence management, including assistance with toileting, skin care, incontinence laundry and bed changing.
Food and Diet, including preparation of food and fulfilment of dietary requirements and assistance eating.
Counselling and support, including behaviour management, psychological support and reminding devices.
Simple treatments, including assistance with medication (including eye drops), applications of simple dressings, lotions and creams and oxygen therapy.
Personal assistance, including help with dressing, surgical appliances, mechanical or manual aids, assistance getting up or going to bed.

Question 26

Nursing homes

Answer 26

• For those very frail or unable to care for themselves
• Provides same help and assistance as residential homes
• Professional registered nurses and care assistants in constant attendance
• Provides 24 hour nursing care services for more complex health needs

These homes provide the same help and assistance with personal care as those without nursing care but they also have professional registered nurses and experienced care assistants in constant attendance who can provide 24-hour nursing care services for more complex health needs as prescribed by physicians.
In addition to being registered to provide general nursing care, many homes also offer rehabilitaion services; different therapies, including physical, speech and pain
therapies; and specialist health care including, dementia care, EMI nursing care, cancer care, services for younger people with physical disabilities (usually aged 18 - 64).
These homes are for people who are very frail or for people who are unable to care for themselves, who have numerous health care requirements.

Question 27

Hospices

Answer 27

• Hospice care aims to improve the lives of people whose illness is not curable
• It helps people to live as actively as possible after diagnosis to the end of their lives, however long that may be
• The highest value is put on respect, choice and empowerment

People may be referred for hospice care as soon as a diagnosis is made, not just at the very end of life.
Access is via GP and/or hospital referral
Once referred to the service people may arrange to access services directly with the hospice
Hospice care is commissioned by CCGs.

• Palliative care is the name for the type of care provided by hospices
• It aims to meet the needs of people from all cultures and communities, and extends beyond the patient, to supporting family and close friends

Question 28

Hospices

• The services offered will differ between hospices but are likely to include:

Answer 28

– Medical and nursing care
– Pain and symptom control
– Rehabilitation
– Therapies, including physiotherapy and complementary therapies
– Spiritual support
– Practical and financial advice
– Bereavement care

McMillan / Marie Curie Nurses provide round-the-clock nursing care for people with cancer at homes.

Care at home
Hospices often manage this by providing specialist advice and support, working alongside a person’s own doctor and district nurse.

Hospice at Home
Additional hands-on nursing support in a person’s home: this may be for end of life or respite care, or sometimes it may be during a time of crisis.

Community palliative care nurses offer specialist advice on managing symptoms of illness and can also offer practical, psychological and emotional support. Accessed through district nurses or GP.

Hospices and palliative care services will provide support for carers in the community too; this may be through a support and info group or by providing one-to-one advice.
Hospice or palliative care inpatient units
Day hospices