Who runs the NHS?

No one. That’s the problem.

Well, no one individual or organisation runs it [“thanks CKDEx, that’s clear” Ed].

Actually it’s not clear Ed. And it is not an easy question to start answering [“great” Ed].

But here goes. Responsibility for the NHS is devolved in the 4 nations of the NHS. Therefore there are really 4 NHSs – i.e. England, Scotland, Wales and Northern Ireland. There is alot to be responsible for. The NHS employs over 1.6 million people and is the biggest employer in Europe. And on a typical day:

More than 1.6 million people go to a pharmacist
More than 1 million people attend a GP appointment
More than 250,000 people attend a hospital outpatient appointment
Nearly 45,000 people are assessed in A&E majors (and about 25 per cent of those patients are admitted into hospital).

So.

It is easier to ask who runs the NHS in England

The Department of Health and Social Care (DHSC; also known as ‘DH’) – led by the Secretary of State – is theoretically ‘in charge’ in England. They give the lion’s share of their budget (currently over £150 billion per year) to NHS England – led by doctors, nurses and managers.

This has been the case since the passing of the Health and Social Care Act 2012, enacted in 2013. These were also called the ‘Lansley reforms’ as he was the Secretary of State at the time.

Attempting to separate DH from running of NHS

The idea was that the day-to-day running of the NHS would pass from politicians ( i.e. political interference) to health professionals (who might run it ‘better’); and thereby “limit the ability of the secretary of state to micromanage and intervene”.

It did this through establishing NHS England as a separate entity from the DH, which would have the power to spend most of the NHS budget (in England) and commission a significant quantity of healthcare services. It would be controlled through a yearly mandate set by the Secretary of State and be left to get on with the job.

History shows that this is not the first time that this has been tried. Margaret Thatcher’s government created the NHS Management Board in April 1985. They even moved it to Leeds in another attempt to distance the running of the health service from politics. It returned to London within a year.

This separation of power strategy ended in failure as the NHS Management Executive (which the Board had morphed into, in 1995) was eventually abolished in 2002 – and power was taken back into DH. The same fate may be ahead for NHS England.

Other power bases

To make it more complicated, there were (and are) other sources of power within the system, partly due to the dispersal of power away from ministers to NHS England and its linked quangos – and also because of the personalities and backgrounds of those in charge of all these groups. These are the principle ones:

UK Health Security Agency, UK-HSA (previously Public Health England, PHE)
Care Quality Commission, CQC
NHS Improvement (that has recently been incorporated into NHS England)
Health Education England, HEE
NHS Digital (both HEE and NHS Digital are now being incorporated into NHS England)
NHS Business Services Authority (NHSBSA)
General Medical Council, GMC
National Institute of Health and Social Care Excellence, NICE
Medicine and Healthcare Products Regulatory Authority, MHRA.

The NHS in prisons (NHS Health and Justice, NHS H&J) and the Armed Services are also run semi-independently.

Variable regional substructures

Most of these organisations have a regional substructure. Unfortunately they are different in number and not geographically co-terminous. For example there are 7 NHS England regions, HEE has 12 regional LETBs (or ‘deaneries’), UK-HSA has 8 regions, and NHS H&J has 4 regions. None are linked up and have little connection to the 10 English Ambulance Trusts.

Views of some doctors

Also, many doctors do not feel that any of these organisations are really in charge – they are! And they exert considerable power through the British Medical Association (BMA, their main union; especially GPs) and Royal Colleges (hospital consultants and registrars).

Some of the colleges are very ancient. For example the Royal College of Physicians (London) was founded in 1518. Hence some doctors feel that DH (especially NHS England) are the ‘new kids on the block’, and should not be trusted or followed.

There is an even more cynical view held by some doctors. They think that the idea that ‘Government-DHSC-NHS England-management’ is in any way in charge, is a myth. In other words, could it be an enormous bureaucratic gravy train of people who just count what is actually happening anyway?

They would say people get ill, go to GP or a hospital and need care. If enough of them do this, there is a clinical need and we build a service for that; and someone (who thinks they are in charge) has to pay for it. To make management think they are in some way proactive, not reactive, they invent the idea they have ‘commissioned’ (i.e. planned and bought) the service. This view is not that far fetched, and not without merit.

Pros and cons of complexity

The complexity of the system, and the vast number of people involved, has the advantage of being pro-democratic – i.e. no one is really in charge. But it has the disadvantage of it being very hard to change the system, and ‘drive’ the NHS any harder than it (especially the doctors) wants it to go.

So, who is in charge?

Like we say, it is not clear. For all of these reasons, DH itself has become less able to assert its authority in the running of the NHS, partly as there aren’t as many civil servants working there now. NHS England and the CQC between them now have over four and a half times as many senior civil servants as the DH.

The Secretary of State is able, to an extent, to use his powers of patronage to ensure that those running all these NHS quangos are in line with the Government’s thinking.

Summary

So, to sum up ‘who runs the NHS?’ .. there was and is confusion about who runs the NHS. And the current division of roles and responsibilities is unlikely to remain stable for very long.

Last Reviewed on 10 March 2024