How UK healthcare works
Structure of the NHS
The National Health Service in England is a chain of bodies, from the Secretary of State for Health and Social Care down to the general practice on the high street. This is the map: who sits where, what each body does, and how the organisational layers fit together.
Dr Seth Rankin
MBChB MRCGP. Founder of LoveMyLife. Former NHS Commissioner and Managing Partner of Wandsworth Medical Centre.
23 April 2026
11 min read
The National Health Service (NHS) is a chain of bodies. Parliament sets the budget, the Secretary of State for Health and Social Care holds political responsibility, the Department of Health and Social Care (DHSC) administers the policy settlement, NHS England translates that settlement into a national NHS plan, Integrated Care Boards (ICBs) commission local services, and NHS trusts, general practices, and contracted providers deliver the care.
This article sets out the organisational map of the NHS in England: who each body is, what each body does, and how the layers fit together. It is intended as a reference for anyone trying to work out which part of the NHS holds responsibility for what. Scotland, Wales, and Northern Ireland have their own structures, which are summarised briefly at the end. Sources are listed at the end.
Parliament and the political tier
At the top of the NHS chain of accountability is Parliament. Parliament legislates on the NHS, sets the NHS budget through the annual Budget and the multi-year Spending Review, and scrutinises NHS performance through Select Committees and statutory reporting.
The Secretary of State for Health and Social Care is the Cabinet minister with political responsibility for the NHS in England. They are a Member of Parliament, appointed by the Prime Minister, and supported by a team of junior health ministers covering specific portfolios (hospitals, social care, mental health, primary care, public health, and others from time to time).
The Secretary of State has statutory duties under the Health and Care Act 2022 and earlier legislation to promote a comprehensive health service, publish an annual mandate for NHS England, and lay accounts before Parliament.
The Department of Health and Social Care
The Department of Health and Social Care (DHSC) is the ministerial department that supports the Secretary of State and sets national policy for health and adult social care in England. DHSC has roughly 3,000 staff and is headquartered in London.
DHSC's role is strategic and policy-setting rather than operational. It does not run hospitals or GP practices. It sets the mandate for NHS England, commissions public-health functions through the UK Health Security Agency (UKHSA) and the Office for Health Improvement and Disparities (OHID), manages relationships with the regulators, and oversees a portfolio of arm's-length bodies that together deliver NHS functions in England.
NHS England
NHS England is an arm's-length national body that leads operational NHS commissioning in England. Created in its current form by the Health and Social Care Act 2012, and reshaped significantly by the Health and Care Act 2022, it receives the annual mandate from the Secretary of State, allocates NHS funding to the Integrated Care Boards, and sets national frameworks for NHS commissioning, workforce, and quality.
NHS England holds direct commissioning responsibility for several categories of care that are not devolved to ICBs.
Specialised commissioning for rare and complex conditions where concentration of expertise is needed.
Primary medical care contracts, although day-to-day management of primary care has substantially transferred to ICBs.
Public health services commissioned nationally, including the national screening and immunisation programmes.
Offender health and armed-forces health.
Since April 2023, NHS England has absorbed the former Health Education England (HEE) and NHS Digital, bringing workforce education and health-data functions into a single national body. HEE's functions on workforce, training, and education are now delivered by NHS England's Workforce, Training and Education directorate.
Integrated Care Systems and Integrated Care Boards
The Health and Care Act 2022 replaced the Clinical Commissioning Groups (CCGs) introduced in 2012 with Integrated Care Systems (ICSs) and Integrated Care Boards (ICBs). There are 42 Integrated Care Systems in England, each covering a defined geographic population ranging from around 500,000 to over 3 million people.
Each ICS comprises:
The Integrated Care Board (ICB). The statutory NHS body that holds the commissioning budget for its population. Forty-two ICBs in total. The ICB is answerable to NHS England nationally and is the closest thing to a local NHS "authority".
The Integrated Care Partnership (ICP). A broader statutory committee bringing together the ICB, local authorities, voluntary-sector partners, and other community stakeholders to plan integrated care across health and social care in the area.
Each ICB commissions most local NHS services including general practice, community health services, mental health services, most secondary care, and most pharmacy and dental services. ICBs cannot override national guidance from NICE or NHS England; they can and do make local decisions on service design, formularies, referral pathways, and investment priorities.
The move from 211 CCGs (2012) to 42 ICBs (2022) consolidated the commissioning layer substantially and brought NHS planning into a single geographic structure with local-authority partners for the first time since 1974.
NHS trusts and foundation trusts
The providers that actually deliver NHS care are organised as NHS trusts and NHS foundation trusts. There are around 215 trusts in England in total, of several types.
Acute trusts. General and specialist hospitals providing most inpatient, day-case, outpatient, and emergency services. Large acute trusts often include several hospital sites.
Mental health trusts. Inpatient and community mental-health services.
Community trusts. District nursing, community therapy, community hospitals, community palliative care, and other community-based clinical services.
Ambulance trusts. There are ten ambulance trusts in England providing 999 and NHS 111 operational services.
Specialist trusts. Teaching hospitals, children's hospitals, specialist cancer, cardiothoracic, orthopaedic, and neurology hospitals that serve regional or national catchments. Examples include Great Ormond Street Hospital, the Royal Marsden, the Royal Brompton and Harefield (now part of Guy's and St Thomas'), and the Christie.
Foundation trusts are a category introduced in 2003 for trusts that have met specific performance and governance criteria. They have greater operational autonomy, are able to retain financial surpluses, and are governed by a council of governors drawn from staff, patients, and the local population. Most acute trusts in England are now foundation trusts.
Every NHS trust is regulated by the Care Quality Commission (CQC) for quality and safety, and by NHS England for operational and financial performance.
Primary Care Networks
Primary Care Networks (PCNs) are a layer of organisation introduced in 2019. They are groups of neighbouring GP practices, typically serving populations of 30,000 to 50,000 people, working collaboratively to deliver extended services that would be too small for individual practices and too local for an ICB.
A PCN is not a legal entity that replaces the general practice contract. It is a collaborative structure funded through a specific Directed Enhanced Service (DES) contract on top of each member practice's core General Medical Services (GMS) contract.
PCNs typically employ additional clinical staff that individual practices could not support alone: clinical pharmacists, paramedics, social prescribers, mental-health practitioners, physiotherapists, and care co-ordinators. They deliver extended-hours access, structured medication reviews, enhanced health in care homes, early cancer diagnosis, and tackling inequalities in health.
General practices as independent contractors
Every NHS general practice in England is an independent contractor holding an NHS contract, as discussed in the Cluster B anchor article on how the NHS pays its doctors. There are roughly 6,500 general practices in England.
A general practice is a private small business that holds one of three types of NHS contract:
General Medical Services (GMS), the national standard contract.
Personal Medical Services (PMS), a locally negotiated variant.
Alternative Provider Medical Services (APMS), a time-limited contract used for specific commissioned work or in areas where GMS/PMS does not fit.
Practices can be traditional partnerships (the majority), limited companies, sole practitioners, or social enterprises. All are regulated by the CQC for quality and safety and by NHS England for contractual compliance. All are commissioned at the local level by the ICB.
Regulators and oversight
Several independent bodies regulate or oversee different aspects of the NHS.
[Care Quality Commission (CQC)](https://www.cqc.org.uk/) regulates the quality and safety of health and social care in England, including all NHS providers and all independent healthcare providers. Inspection ratings range from Outstanding to Inadequate.
[National Institute for Health and Care Excellence (NICE)](https://www.nice.org.uk/) issues clinical and cost-effectiveness guidance that the NHS is required to follow (see the dedicated article How NICE decides what the NHS adopts).
[General Medical Council (GMC)](https://www.gmc-uk.org/) regulates doctors, holds the Medical Register and Specialist Register, and oversees medical education.
[Nursing and Midwifery Council (NMC)](https://www.nmc.org.uk/) regulates nurses and midwives.
[General Pharmaceutical Council (GPhC)](https://www.pharmacyregulation.org/) regulates pharmacists and pharmacies.
[Health and Care Professions Council (HCPC)](https://www.hcpc-uk.org/) regulates a long list of allied health professions including physiotherapists, paramedics, occupational therapists, and radiographers.
[NHS Resolution](https://resolution.nhs.uk/) manages NHS clinical negligence claims and some employer liability claims.
[Healthwatch England](https://www.healthwatch.co.uk/) and local Healthwatch bodies represent the patient and public voice to NHS commissioners and providers.
[Medicines and Healthcare products Regulatory Agency (MHRA)](https://www.gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency) regulates medicines and medical devices.
These are independent of NHS England and of the DHSC, although all sit within the wider DHSC sponsorship or Ministry of Justice framework.
Other national NHS bodies
A number of national NHS bodies deliver specific functions rather than commissioning or regulating.
[NHS Business Services Authority (NHSBSA)](https://www.nhsbsa.nhs.uk/) manages prescriptions, dental charges, exemption certificates, and NHS-related payment administration.
[NHS Blood and Transplant (NHSBT)](https://www.nhsbt.nhs.uk/) runs the national blood donation, organ donation, and stem-cell donation services.
[UK Health Security Agency (UKHSA)](https://www.gov.uk/government/organisations/uk-health-security-agency) manages health protection, communicable disease surveillance, and emergency preparedness, created in 2021 from functions formerly held by Public Health England.
[Office for Health Improvement and Disparities (OHID)](https://www.gov.uk/government/organisations/office-for-health-improvement-and-disparities) sits within DHSC and leads on public health improvement and health inequalities, also created in 2021 from former Public Health England functions.
[National Institute for Health and Care Research (NIHR)](https://www.nihr.ac.uk/) is the NHS-linked national research infrastructure.
These bodies often interact directly with patients (through prescription exemption, organ donor registration, blood donation, and public-health campaigns) even though they are not providers of clinical care.
The NHS in Scotland, Wales, and Northern Ireland
Health is a devolved matter. The three devolved nations run their own health systems.
[NHS Scotland](https://www.scot.nhs.uk/) is answerable to the Scottish Government and the Cabinet Secretary for Health. It is organised into 14 regional Health Boards plus seven Special Health Boards. There are no CCGs, ICBs, or trusts in Scotland. Prescription charges were abolished in Scotland in 2011.
[NHS Wales](https://www.wales.nhs.uk/) is answerable to the Welsh Government and Cabinet Secretary for Health and Social Care. It is organised into seven Local Health Boards, three NHS Trusts, and a Shared Services Partnership. Prescription charges were abolished in Wales in 2007.
[Health and Social Care Northern Ireland (HSC)](https://www.health-ni.gov.uk/topics/health-and-social-care) is answerable to the Northern Ireland Department of Health. It is organised into five HSC Trusts plus a Public Health Agency and a Business Services Organisation. Unlike the other UK systems, health and social care are formally integrated in Northern Ireland. Prescription charges were abolished in Northern Ireland in 2010.
NICE technology appraisals apply directly in England. In Scotland, the Scottish Medicines Consortium (SMC) performs the equivalent assessment. In Wales, the All Wales Medicines Strategy Group (AWMSG) plays a similar role, often adopting NICE guidance directly.
How it fits together
A patient in England walks into a GP practice, which is an independent-contractor small business holding a GMS contract issued by the local ICB, working in a Primary Care Network with four to ten other practices, regulated by the CQC, with its clinical practice shaped by NICE and its doctors regulated by the GMC. If that patient is referred to a hospital specialist, they go to an NHS acute trust commissioned by the ICB, whose consultant is a salaried employee of the trust and on the GMC Specialist Register. If they are prescribed a new high-cost medicine, eligibility flows through a NICE technology appraisal funded under a statutory duty on the ICB. If they donate blood, it is managed by NHS Blood and Transplant. If they are exempt from prescription charges, the NHSBSA verifies the exemption. If they complain about their care, the process runs through the trust's complaints system, Healthwatch, the CQC, or the Parliamentary and Health Service Ombudsman depending on the issue.
Above the whole thing, NHS England sets the national plan, DHSC sets the policy, and the Secretary of State is accountable to Parliament.
That long chain of bodies is what sits behind every NHS consultation. It is also what makes the system recognisable as the same NHS from one corner of England to another.
The summary
The NHS in England runs through a chain of organisational layers: Parliament, the Secretary of State, DHSC, NHS England, Integrated Care Boards, NHS trusts, Primary Care Networks, general practices, plus a set of independent regulators and national bodies that cover specific functions. The Health and Care Act 2022 simplified the commissioning layer to 42 ICBs. The Health and Social Care Act 2012 introduced the NHS England arm's-length model. The 1948 settlement created the structural elements most of the rest has been built on.
Scotland, Wales, and Northern Ireland have their own structures, with their own regulators, formulary bodies, and charging rules.
Knowing where each part of the system sits makes the rest of UK healthcare navigation substantially easier.
Sources and further reading
gov.uk, Department of Health and Social Care. The ministerial department.
gov.uk, Secretary of State for Health and Social Care. The ministerial post.
NHS England, england.nhs.uk. The national NHS commissioning body.
NHS England, Integrated Care Boards. The 42 ICBs.
legislation.gov.uk, Health and Care Act 2022. The Act creating ICBs.
NHS England, General practice. NHS primary-care information.
NHS England, Primary Care Networks. The PCN programme.
Care Quality Commission, cqc.org.uk. Regulator of health and social care quality.
NICE, nice.org.uk. Clinical and cost-effectiveness guidance body.
General Medical Council, gmc-uk.org. Regulator of doctors.
Nursing and Midwifery Council, nmc.org.uk. Regulator of nurses and midwives.
General Pharmaceutical Council, pharmacyregulation.org. Regulator of pharmacists and pharmacies.
Health and Care Professions Council, hcpc-uk.org. Regulator of allied health professions.
NHS Resolution, resolution.nhs.uk. NHS clinical negligence claims management.
Healthwatch England, healthwatch.co.uk. Patient and public voice body.
MHRA, gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency. Medicines and devices regulator.
NHS Business Services Authority, nhsbsa.nhs.uk. Prescription, dental, and exemption administration.
NHS Blood and Transplant, nhsbt.nhs.uk. Blood, organ, and stem-cell donation services.
UK Health Security Agency, gov.uk/government/organisations/uk-health-security-agency. Health protection and disease surveillance.
Office for Health Improvement and Disparities, gov.uk/government/organisations/office-for-health-improvement-and-disparities. Public health improvement within DHSC.
NIHR, nihr.ac.uk. NHS-linked research infrastructure.
NHS Scotland, scot.nhs.uk. Scottish Government-run health service.
NHS Wales, wales.nhs.uk. Welsh Government-run health service.
Health and Social Care Northern Ireland, health-ni.gov.uk. Northern Ireland health and social care system.
Scottish Medicines Consortium, scottishmedicines.org.uk. Scottish equivalent of NICE for medicines.
All Wales Medicines Strategy Group, awmsg.nhs.wales. Welsh equivalent of NICE for medicines.
Clinically reviewed
Dr Seth Rankin · MBChB MRCGP - Founder and Medical Director, LoveMyLife
About the author
Dr Seth Rankin qualified in medicine at Auckland School of Medicine in New Zealand in 1990 and worked as a junior doctor across New Zealand, Australia, and the UK before qualifying as a Member of the Royal College of General Practitioners (MRCGP) through the London Deanery in 2004. He was Managing Partner of Wandsworth Medical Centre from 2006 to 2016 and served as a Board Member of Wandsworth Clinical Commissioning Group for nine years. He is the founder of London Travel Clinic, London Doctors Clinic, London Medical Laboratory, and LoveMyLife.
Ready to start?
If you would like a consultation with an MRCGP-registered GP, the next step is to book.
Begin your consultation at this link. Online or in person at Westfield London.