Ruth Robertson, Fellow at the King’s Fund, explores why it’s difficult to understand how the NHS works and what this means for sharing patient data.

If size is a sign of success, the NHS – which turns 70 this year - is top of the league table. It is one of the world’s biggest employers and costs around £2 billion a week to run.

The NHS is such a huge and complex system that people who have worked in it for decades can still find it difficult to navigate. It is therefore not surprising that the public struggles to understand how the system is structured and why different organisations within it want to access their patient data. In this blog I have focused on the NHS in England. In Scotland, Wales and Northern Ireland the health services are the responsibility of the devolved governments and run in slightly different ways.

There isn’t just one NHS

The first thing to explain is that the NHS is not a single organisation - it is a mosaic of thousands of organisations and its structure is always changing. This includes organisations that plan and pay for NHS services (commissioners), organisations that provide care (hospitals, general practices etc.) and those that oversee the system (national regulators and other bodies). While commissioners and regulators are public bodies, providers come from the public, private and charitable sectors.

All organisations that provide care collect information about the people that come through the door, and have a responsibility to keep that information safe and secure. They also have a responsibility to share this information where it benefits patient care, or helps to better plan the delivery of care.

Changes to NHS commissioning

Let’s look in more detail at commissioners. They assess the needs of local populations and plan services to meet them. Successive health secretaries have reorganised the commissioning sector, merging organisations and creating new ones, in an elusive quest to find the perfect structure. This constant change is part of the reason why the system can be difficult to get to grips with. The latest set of reforms was introduced by the Health and Social Care Act 2012 and created a commissioning structure in England that is largely still in place today. It consists of:

  • More than 200 clinical commissioning groups –  GP-led local organisations that plan and pay for the majority of NHS care in your area, including hospital care, community services and – in most cases – general practice.
  • Five NHS England regional teams – these are regional offices of NHS England (the headquarters of the NHS) that commission specialised hospital services for complex conditions and rare diseases. They also commission some primary care and public health services (which includes things like drug and alcohol services, and sexual health clinics).
  • 152 local authorities – since 2013 they have commissioned public health services for their local populations, and they have a long-standing responsibility to commission social care.

On top of this, commissioning support units (or CSUs) provide services for commissioners that include back office functions, business intelligence and strategic support. There are 152 health and wellbeing boards (they cover local authority areas) responsible for strategic planning and coordination across health and social care. More recently another layer has been added to the local planning infrastructure – sustainability and transformation partnerships or integrated care partnerships. These are groups of commissioners and providers who are working together to plan care across regions.

All of these organisations use information about people in their area to help them plan and improve services.

The quest to link up services and provide more coordinated care

What about health care providers? There are changes afoot on this side of the equation as well. NHS England has asked the NHS to develop ‘new care models’ in which different parts of the health system work together more closely, for example by putting GPs on the front door of A&E to ensure patients are seen by the right provider, or by linking hospitals with community services to improve care for patients as they move in and out of hospital. These models hinge on clinicians being able to see data about their patients from different health care providers. However, there are technical and legal challenges with sharing patient records. Different data systems need to be made to talk to each other, and patients need to be made aware that their information could be shared with other organisations that are involved in the delivery of their care.

Who oversees everything?

Overseeing the NHS are a group of national bodies that regulate and support local health and care systems to improve. These organisations include NHS England, which is responsible for overseeing NHS commissioning and sets a lot of NHS strategy; NHS Improvement, the financial regulator for NHS trusts; and the Care Quality Commission, the quality regulator that conducts inspections of health and care providers and publishes ratings. These organisations all review patient data as part of undertaking their roles. A range of other national bodies also play important oversight and support roles. One that is key to patient data is NHS Digital, which supplies data and technological infrastructure to the health service and is responsible for making sure patient data is protected and is used for the good of health and care.

Find out more

This just scratches the surface of a complex system. If you want to know more, watch The King’s Fund’s alternative guide to the NHS below and sign up to the Health and Care Explained conference in August – a day of presentations and discussion about how the health and care system works and how this is changing.

Video produced by The King's Fund.