Structure and organisation of the NHS

Question 1

Types of Healthcare

Answer 1

Primary care
• Generally first point of contact
• Includes GPs, pharmacists, dentists, optometrists, NHS-walk-in centres, NHS 111, nurse practitioners, can include other HCP

Secondary care
• Care received after referral by primary care provider
• Includes planned hospital care, acute care and emergency care (A&E), community care, rehabilitative services, mental health services, ambulances

Tertiary care
• Specialist services provided by relatively few specialist centres e.g.
burns, renal services, mental healthcare in secure units, transplant surgery

Social care
• Help and support provided to enable people to as independent a life as
possible and to improve quality of life
• Provided in own home, residential homes, day centres
• Includes social work, support services, personal care, protection, support for carers

Question 2

NHS Next Stage Review: High Quality Care for All

Answer 2

Why was it important?
• Set out 10 year plan to provide highest quality of care and service for patients in England
• Led to publication of various documents e.g. NHS Constitution that have shaped monitoring and development in the NHS

Question 3

High Quality Care for All – summary (8 key areas)

Answer 3

1. Change – locally led, patient centred and clinically driven
2. Changes in healthcare and society
3. High quality care for patients and the public
4. Quality at the heart of everything we do
5. Freedom to focus on quality
6. High quality work in the NHS
7. The first NHS Constitution
8. Implementation

Question 4

NHS Next Stage Review: A High Quality Workforce

Answer 4

Why was it important?

• Describes a system for workforce planning, education and training

Question 5

Health and Social Care Act (2008)

Answer 5

Why was it important?
• Aimed to modernize and integrate Health and Social Care

Contained 4 key policy areas:
• Care Quality Commission
• Professional Regulation
• Public Health Protection Measures
• Health in Pregnancy Grant

Question 6

NHS Constitution

Answer 6

Why is it important?
• From January 2010 all providers and commissioners of NHS care are under legal obligation to have regard to NHS Constitution in all their decisions
• Government has legal duty to review the Constitution every 10 years

Acts as a guide to:
• The rights to which patients, public and staff are entitled
• Pledges which the NHS is committed to achieve
• Responsibilities which patients, public and staff owe to one another
- Also sets down the 7 key principles that guide the NHS

Question 7

7 Key Principles of the NHS

Answer 7

1. NHS provides a comprehensive service, available to all
2. Access to services is based on clinical need, not ability to pay
3. NHS aspires to highest standards of excellence and professionalism
4. The patient will be at the heart of everything the NHS does
5. NHS works across organisational boundaries and in partnership with other organisations in the interests of patients, local communities and the wider population
6. NHS is committed to providing best value for taxpayer’s money and the most effective, fair and sustainable use of finite resources
7. NHS is accountable to public, communities and patients that it serves

Question 8

NHS Values

Answer 8

‘Patients, public and staff have helped develop this expression of values that inspire passion in the NHS and that should underpin everything it does.

Individual organisations will develop and build upon these values, tailoring them to their local needs.

The NHS values provide common ground for co-operation to achieve shared aspirations, at all levels of the NHS’.

Working together for patients
Respect and dignity
Commitment to quality of care
Compassion
Improving lives
Everyone counts

Question 9

NHS 6 C’s

Answer 9

1. Care
2. Compassion
3. Competence
4. Communication
5. Courage
6. Commitment

Question 10

Background

Answer 10

 Funded centrally from national taxation
 Overall NHS budget for staff, drugs/supplies, buildings, equipment, training costs, medical equipment, catering, cleaning
 Budget increased significantly due to Covid-19
 In 2019/20: £150.4 billion
 In 2020/21: £148.7 billion plus £63.4 billion extra
for Covid-19
 In 2021/22: £159 billion plus 22.4 billion extra for
Covid-19

Question 11

Challenges identified in 2010

Answer 11

 Rising demand and treatment costs
 Need for improvement to maintain/improve standards in NHS
 State of public finances (beginning of austerity measures)

Question 12

Equity and Excellence: Liberating the NHS

Answer 12

Why was it important?
• Coalition Government strategy for NHS July 2010 (also the basis for the changes taking place today)

Promises made:

1. Putting patients and public first
2. Improving healthcare outcomes
3. Autonomy, accountability and democratic legitimacy
4. Cutting bureaucracy and improving efficiency

Question 13

1. Putting patients and public first

Answer 13

Patients would have:
• Shared decision making – ‘no decision about me without me’
• Access to information needed in order to make decisions about their care
• Choice of any provider, choice of consultant led-team, choice of GP practice, choice of treatment
• Ability to rate hospitals and departments on quality of care received
• Personalised care and support for carers
• New consumer champion ‘Health Watch England’ (within Care Quality Commission)
• Everyone to benefit, whatever their need or background

Question 14

2. Improving healthcare outcomes

Answer 14

Government’s objectives –↓mortality, ↓morbidity, ↑ safety, improve patient
experience and outcomes
• NHS judged against clinically relevant, evidence-based outcome measures, not process targets
• Culture of open information, active responsibility NICE (National Institute for Health and Care Excellence) quality standards to inform commissioning of NHS care
• Money to follow the patient
• Providers to be paid according to performance

Question 15

3. Autonomy, accountability and democratic legitimacy

Answer 15

• Devolution of power and responsibility to GPs working in consortia (commissioning groups)

• Establishment of independent, accountable NHS Commissioning Board (NHS England) to lead on achievement of health outcomes, allocate and
account for NHS resources, lead on quality improvement and promoting patient involvement and choice. The Board would have an explicit duty
to promote equality and tackle inequalities in access to healthcare

• Increase the freedoms of foundation trusts, NHS staff to have a greater say in the future of their organisations, including as employee-led social enterprises

• All NHS trusts to become or be part of a foundation trust
• Monitor to become the economic regulator for healthcare
• Increased role of CQC as inspectorate of health and social care

Question 16

4. Cutting bureaucracy and improving efficiency

Answer 16

Need to achieve unprecedented efficiency gains (NHS not immune to the financial climate)
• With the proposed changes the NHS would release up to £20 billion of efficiency savings by 2015 (reinvest to support ↑ quality)
• ↓NHS management costs by more than 45% over a four year period (↑resources for frontline care)
• de-layer and simplify the number of NHS bodies, and radically ↓ DoH’s NHS functions

Question 17

What this meant for NHS Structure

Answer 17

 ↓ role of DoH
 Primary Care Trusts to go (but CCGs arrived)
 SHA’s abolished (but NHS Trust Development Authority arrived)
 All NHS Trusts to become Foundation Trusts (or part of one)
 Every GP practice had to join a Clinical Commissioning Group (CCG) CCGs replaced PCTs on 1st April 2013
 £60 – 80 billion of the healthcare funds were transferred from PCTs to CCGs
 New executive agency of the DoH was established = Public Health England
 Health and Social Care Act 2012 – important because it provided
legislation for this extensive reorganisation of the NHS

Question 18

Organisation within NHS

Answer 18

 Secretary of State for Health and Social Care
 Department of Health and Social Care
 NHS England (operating name of NHS Commissioning Board)
 Public Health England
 Clinical Commissioning Groups
 Health and Wellbeing Boards
 Providers
 Provides national leadership for improving health outcomes and driving
up quality of care
 Oversees the operation of CCGs
 Allocates resources to CCGs (CCGs are responsible for approx. 2/3rds of the total NHS England budget)
 Commissions primary care and specialist services

Question 19

Delivering NHS Services

Answer 19

CCGs can commission any service provider that meets NHS standards
and costs
Provider organisations are predominantly NHS Foundation Trusts or NHS Trusts but can include private providers

Question 20

Regulation and Safeguards

Answer 20

 Care Quality Commission
 NHS Improvement (brings together Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change team and the Intensive Support Teams)
 Individual professional regulatory bodies
 Healthwatch

Question 21

Reasoning behind all the changes

Answer 21

Proposed benefits:
 Patients would be more involved in decisions about their care
 GPs best placed to know what services are needed (clinical
commissioning)
 ↓ bureaucracy (?)
 Acknowledged some of the work of the previous Government (including
Darzi report)
 NHS England would be be free from day-to-day political interference

Question 22

Concerns about the changes

Answer 22

 Speed of the reforms
 GP consortia have to manage financial risks
 GPs involved in managing commissioning have less time to spend with patients
 May need more GPs
 GPs may not have the skills required (PCTs developed skills over many
years)
 Some GPs may not want this role
 Would need to change the GP speciality training
 CCGs may need to make difficult decisions re-allocation of funds – need authority to do so
 Reforms were far-reaching –careful management and transition to new
structure would be needed
 NHS had to find savings of £20billion over next 5 years (reforms would only save £1 billion)
 May change the relationship between patients and their GP (patient advocate vs holder of the purse strings) – loss of trust
 Patient choice, although good, may damage provision of some services e.g. loss of smaller or rural practices, thus disadvantaging less mobile or vulnerable patients
 Plans were too ambitious
 NHS England to be funded by (? and responsible to) DoH
 Reorganisation always costs money
 Need co-operation not competition between providers
 Not sure what the ‘knock-on’ effects of reforms would be

Question 23

What happened in 2015?

Answer 23

 Election – change of Government (Conservative Government)

The policies remained basically the same

Question 24

NHS post 2015

Answer 24

 Restructuring went ahead and is on-going
 Challenges for the NHS remain, including:
• 7 day working
• Junior doctor’s contracts (disputes over
reduction in pay)
• Ageing population
• Lifestyle related conditions
• And since 2020, Covid-19

 Government policies include:
• 5 Year Forward View (2014) and Next Steps on the 5 Year Forward View (2017)
• NHS- Long Term Plan (2018)
• The NHS Mandate 2021-2022

Question 25

NHS Long Term Plan

Answer 25

The NHS Long Term Plan:

 Released nationally in early 2019
 Covers the plan to 2029, with a review in 2024
 Important because we can now plan services and working partnerships without worrying if the idea will be cancelled in 12 months
 Previously NHS plans & funding was released in small chunks to cover the next 12 or maybe 24 months
- This makes it impossible to plan as you cannot rely on how you are going to pay staff or what you will be required to do
 Stressful for staff, managers, and results in poor care for
patients
 How the NHS will move to a new service model in which patients get more options, better support, and properly joined-up care at the right time in the optimal care setting (e.g. all patients access to digital GP appointments)
 New, funded, action the NHS will take to strengthen its contribution to prevention and health inequalities (e.g. funding
for new evidence based program to prevent smoking)
 NHS’s priorities for care quality and outcomes improvement
for the decade ahead
 Sets out how current workforce pressures will be tackled, and
staff supported.
 A wide-ranging and funded programme to upgrade technology and digitally enabled care across the NHS.
 How the 3.4% five year NHS funding settlement will help put the NHS back onto a sustainable financial path.

Question 26

Organisation within NHS

Answer 26

 Vanguards were introduced in 2015 as part of the NHS Five Year Forward View.
 The 50 chosen vanguards are tasked to develop new care models and potentially redesign the health and care system
 It is envisaged that this could lead to better patient care, service access and a more simplified system
 Sustainability and Transformation Plans (STPs)
Also a result of the NHS Five Year Forward View.
The purpose of STPs is to help ensure health and social care services in
England are built around the needs of local populations
They are five-year plans covering all aspects of NHS spending in England
 Sustainability and Transformation
Plans (STPs)
- Improving quality and developing new models of care
- Improving health and wellbeing
- Improving efficiency of services

Question 27

The NHS Mandate

Answer 27

 Sets out the Government’s direction and objectives for NHS England, as well as the budget
 NHS England is legally required to seek to achieve the objectives and comply with the requirements of the NHS Mandate
 Produced annually, it sets out the objectives for the NHS in order to
achieve the long-term objectives and goals the Government has for the NHS
 For 2021-22 there are 5 key objectives
 Objective 1: Continue to lead the NHS response to Covid-19
 Objective 2: Continue to implement the NHS Long Term Plan, focusing on transformation of services, to support NHS resilience, and continue to inspire public confidence
 Objective 3: With support from Government, deliver the manifesto priorities that will enhance delivery of the NHS Long Term Plan
 Objective 4: Improving prevention of ill health and delivery of NHS public health services
 Objective 5: Maintain and improve information

Question 28

Primary Care Network (PCN)

Answer 28

Primary healthcare providers working together to manage and improve health for populations of between 30,000-50,000 patients.
 Designed so that the patients served by each PCN share similar health demographics
 Easier to share staff and provide good services
 The GP surgeries in this designated area hold the contract for the services that they coordinate
 This contract is called the “PCN Directed Enhanced Service (DES)”
- Clinical Pharmacists in GP
- Pharmacy Technicians in GP
- First Contact Physiotherapists
- Physician Associates in GP

Question 29

Integrated Care Partnership/Provider

Answer 29

 The term for an organised group of primary care providers, including PCNs, Pharmacies, social care, etc working together to support the health of a “Place” under a single contract
 Multi-speciality Community Provider (MSCP) or Integrated Primary and
acute care systems (PACS) models

Question 30

Integrated Care Systems

Answer 30

Integrated Care Systems are the Regional Strategic bodies which support the Integrated Care Partnerships to deliver healthcare effectively.
 ICSs will formally merge with/take over CCGs by April
2022.
 This means services will be commissioned more regionally.