Health & SafetyHealth & Safety
National Health Service (1993-2014)
Author: Mark Bobe


The National Health Service was established by Act of Parliament in 1948 on the principle that it provides comprehensive health care for all citizens of the United Kingdom and that care is provided on the basis of clinical need, not on the ability to pay. In 1993, the NHS has a budget in excess of £41 billion and employs almost one million people making it the largest employer in Europe. In 2014, the budget is nearly £100 billion.

Provision of services by the NHS falls into three main categories:

  • Primary care (family doctors, opticians, dentists, and other health professionals;
  • Secondary care (hospitals and ambulance services) and;
  • Tertiary care (specialist hospitals).

Alongside these services the NHS works in partnership with locally based social service departments to provide community care. Services are, for the most part, provided free of charge at the point of service delivery.

Primary Care

The cornerstone of the NHS is the General Practitioner (GP), a local community doctor who provides, in most cases, the first point of contact for patients. In 1993 there were 26 000 GPs in the United Kingdom, who on average maintain a list of 1 900 patients, providing primary healthcare in local communities and referral facilities to hospitals or other specialist treatments.

Most GPs operate from within group practices which generally consists of several doctors, nursing staff and support staff. The recent introduction of performance related GP contracts has served to encourage many practices to operate health promotion clinics, conduct minor surgical procedures and improve the rates of immunisation to disease, especially amongst children.

In an effort to improve primary healthcare and expedite access to hospitals and other facilities GPs have been given the opportunity to become financially responsible for purchasing some or all of their patients healthcare needs. Approximately 2 000 practices have taken up the opportunity to become "fundholders" and run their own budgets. Such practices can purchase health care that they consider to most beneficial to their patients such as routine surgery, outpatient treatment and specialist nursing services.

Primary health care is also provided by 15 000 dentists who can provide treatment under contract to the NHS, although following legislative and financial reforms dental treatment is increasingly being split into public (i.e. NHS) treatment and private treatment. Opticians services are provided almost exclusively though the private sector although eye tests and glasses are available to low income groups through the NHS. Other services are provided by pharmacists, health visitors, midwives, community nurses, physiotherapists, occupational and speech therapists.

Secondary Care

Within England there are approximately 280 major district hospitals in 1993, who provide a broad range of care to patients. Such hospitals vary in size from very large specialist institutions to smaller community hospitals.

Hospital numbers and status have been modified in 1997 and 2003 by Tony Blair's government. In 2014 they are divided into hospital groups (209), hospital Trusts (155 including 101 foundations) and psychiatric Trusts (56).

Tertiary Care

Additional to the district hospitals are what the NHS describes as centres of excellence; these are located throughout England, usually in major metropolitan areas. Such hospitals tend to be centres of excellence for treatment of certain diseases such as cancer or for treating specialised groups of patients such as children.

Community Care

The care of those with physical or mental disabilities or who are vulnerable has increasingly been placed within the community, particularly following the closure of large, generally Victorian, institutions. Such community care is provided by the NHS in cooperation with locally based social services departments via drop in centres, sheltered housing and health visitors.

Organisation of the NHS

Responsibility for the NHS in England lies with the Secretary of State for Health who is supported by the Department of Health based in London. The Secretary of State provides strategic direction to the NHS and reports directly to Parliament. Management of policy and the day to day operation of the NHS lies with the NHS Executive, which is headquartered in Leeds and supported by a network of eight regional offices. The NHS Executive is responsible for the implementation of policy as laid down by the Secretary of State, managing NHS funding, organising the running of the NHS and agreeing corporate contracts with local healthcare professionals.

Recent changes in the organisation of the NHS (The Internal Market) has resulted in a split between purchasers and providers of care and treatment. The primary purchasers are local health authorities and those GPs who have elected to become fundholders. Primary providers are hospitals, ambulance services, and community services. Purchasers are charged with the responsibility of assessing the needs of local patients and for purchasing the best possible care for them.

Since 2013, NHS is divided into four structures corresponding to the four nations of the United Kingdom. Each regional NSH is divided into five parts: the Commissioning including Clinical Commissioning Group (all practitioners); local authorities and local health observatory; Health Services including secondary and tertiary services of care; management and reglation authorities; resource statistics and information centres and teaching structures.


Two types of local health authority currently exist; the Family Health Service Authority and the District Health Authority. Family Health Service Authorities are responsible for purchasing primary health care and District Health Authorities are responsible for hospitals, mental health services and community care. The size of health authorities varies from 125 000 to 960 000 people; averaging around 500 000 people. Each and every health authority is responsible to its regional health authority which is chaired by an appointee of the Secretary of State.

In order to effectively assess and hence purchase health care appropriate to local communities the health authorities have to publish an annual health strategy based upon local consultation, surveys, meetings with local groups and GPs. Once such consultation has been completed annual contracts are agreed with providers specifying thequantity and quality of services expected.


Hospitals, community services and ambulance services are currently almost all run as self-governing NHS Trusts which allows them to decide staff numbers and locally determine rates of pay. These Trusts have limited powers to invest and indeed borrow capital to finance services and future investment. The management of the Trusts is undertaken by a chairperson and board of directors who are drawn from many walks of life who, it is hoped, will bring expertise and insights form the commercial and voluntary sectors to the running of the Trusts. Whilst the Trusts are now independent of local health authorities they remain an integral part of the NHS and are accountable directly to the Secretary of State.