Guide to the Healthcare System in England Including the Statement of NHS Accountability

for England May 2013

Contents | 1

Contents

Introduction: What is the NHS? 2

Providing care 4

Commissioning care 6

Safeguarding patients 12

Empowering patients and local communities 17

Education and training 20

Supporting providers of care 22

The Secretary of State for Health 25

Statement of NHS Accountability 28 2 | Guide to the Healthcare System in England

Introduction: What is the NHS?

“The NHS belongs to the people. It provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion or belief, gender reassignment, pregnancy and maternity, or marital or civil partnership status”. NHS Constitution

The NHS began in 1948 out of a Others, such as charities providing NHS principle that good healthcare should funded services, play a key role in be available to all, with access based on making the NHS what it is, yet are not clinical need, not ability to pay. NHS organisations themselves. That principle, of putting patients first, remains at its core. NHS services are Collectively, all of these organisations free of charge to patients in England, make up the healthcare system. This except where permitted by Parliament. guide seeks to explain that system. The service’s original focus was the The main audience for this document is diagnosis and treatment of disease. people who are interested in gaining an Now it plays an increasing role in both understanding of how the whole preventing ill health and improving the healthcare system works. The term physical and mental health of the ‘stakeholder’ is used throughout this population. document to describe the people who have an interest in the NHS. If you have The rights to which patients, families, any comments on or questions about carers, the public and staff are entitled, this document, please email and the pledges that the NHS is [email protected]. committed to achieve, are now set The Department plans to update it out in the NHS Constitution. Visit annually, or following any significant http://www.nhs.uk/Constitution to developments to the health and view the NHS Constitution. It articulates care system. the shared values of the NHS, and the responsibilities towards the NHS that The guide concludes with a Statement patients, families, carers, the public and of NHS Accountability; keeping an up staff have as they experience or work in to date version of the Statement is a NHS services. commitment set out in principle seven of the NHS Constitution. A number of different organisations make up and support the set of Figure 1 shows the main organisations common set of principles and values that make up the healthcare system in which are the NHS. Some of these are England. Visit https://www.gov.uk/ NHS organisations as set out in law, government/organisations#department- such as clinical commissioning groups. of-health for definitions and web addresses for all the organisations. Introduction: What is the NHS? | 3

Fig. 1 The healthcare system in England from April 2013

MENT OF

RT H

A E

P A

E LT

The health & care system Care

Quality

Commission

from April 2013

Human

Healthwatch

Fertilisation

NHS

England

& Embryology

Litigation

Human Authority

Authority

Tissue

Authority Local

Healthwatch

NHS Blood

& Transplant

Health

Research

Online/phone

Community Authority

NHS National

services

groups

Institute for O

England

Clinical Health Research

Commissioning

H NIHR Clinical

surgeries

Groups

Research Networks

Ambulances

C M

U G

O I

Monitor

Care homes

Hospitals N

NHS Trust

Development

Health & Social

Authority

M Care Information

A Centre

L Personal

Health D

R helpers

centres E A

NHS Business

Services

Authority

Home

Pharmacies Local Education

& Training E

S N KEY

Boards

E Health

C T I

V Education

Dentists R S

Public Health E

S England

Providing care Local Opticians E S

England R

A D R

Government C & A LTH O LOCAL HEA B

NG Commissioning care

EI LB WEL HEALTH &

Improving public health Professional

National Institute regulators

S for Health &

ION Empowering people and

SAT Care Excellence I LOCAL ORGAN

local communities

Medicines &

Healthcare Products

Regulatory Agency ON Supporting the health and

SATI NI

N L ORGA care system

ATIONA

Education and training

IN D

UAR

FEG & SA REGULATION Safeguarding patients’ E SECRETARY OF STAT interests 4 | Guide to the Healthcare System in England

Providing care

The NHS is made up of a wide range requires more specialised treatment, or of organisations specialising in different further investigation, patients may be types of services for patients. Together, referred to another healthcare provider. these services deal with over 1 million These could be based in a hospital, or patients every 36 hours. in the community. Patients are entitled (where possible) to choose between Providers of ‘primary care’ are the first different types of care and providers of point of contact for physical and their care. They should be supported to mental health and wellbeing concerns, make the choice that is best for them2. in non-urgent cases. These include general practitioners (GPs), but also Community based care is increasingly dentists, opticians, and pharmacists the preferred means of providing care (for medicines and medical advice). for the majority of longer term and There are over 36,000 GPs in England, mild to moderate conditions. This working in over 8,300 practices1. enables people to keep their normal For urgent cases, patients can visit a routine, staying close to family and provider of urgent care, such as an friends. Hospital services remain a key accident and emergency department. part of the NHS, such as for Healthcare information and advice can specialised, surgical or emergency care. also be accessed through NHS Choices (www.nhs.uk). Organisations that put patients first, by meeting NHS quality and financial Health care professionals within GP standards, are able to provide NHS practices aim to resolve problems funded services. Quality is the locally, including through services overriding priority for the healthcare provided by the practice. If a condition

2 For more detail on choice please see the 1 Source: www.indicators.ic.nhs.uk, GP Practice Handbook to the NHS Constitution or NHS Data, 2010 Choices on www.nhs.uk Providing care | 5

system; improving quality is the hospitals often belong to a single trust. responsibility of everyone working in In NHS foundation trusts, the board of the NHS. In healthcare, quality is a directors is directly accountable to their combination of good medical local population through their outcomes (supported by evidence), membership and council of governors. safe care and good patient experience. The public, patients, service users, their families and carers, and staff can join NHS funded services include both NHS their local foundation trust as provider organisations, and other members. Members elect governors providers of health services such as to represent them. In a foundation charities, private organisations, and trust, the council of governors oversees social enterprises. This document uses the organisation’s board, holding the the term ‘provider’ to refer to all types board to account for the performance of organisations that provide NHS of their organisation. funded care. All providers are led by a board of directors (or equivalent3), who have ultimate responsibility for the quality of care and for the ongoing financial stability of their organisation.

The majority of NHS services, such as hospitals, belong to either an NHS trust or NHS foundation trust. It is the Government’s ambition that all NHS trusts will ultimately become NHS foundation trusts. Each trust can have multiple sites, meaning one or more

What is an ‘outcome’? Rather than measure healthcare processes, for example – the number of hip replacements performed – it is better to ask patients whether their hip replacement was effective. This measures how good hip replacements are from a patient perspective. By using this measure, providers of hip replacements should focus on providing a good hip replacement service to patients, as opposed to focusing mainly on the number of operations completed.

3 Not all provider organisations will have a board as such, for example, GP practices are unlikely to have boards. Every organisation will have a person or people who are legally accountable for the service they are providing, and for simplicity, the term board will be used throughout this document. 6 | Guide to the Healthcare System in England

Commissioning care

Commissioning of NHS services that referral. This ‘secondary’ provider The NHS is funded by taxation with a is paid to treat the patient through the fixed budget available to spend on NHS payment system. What care the services for the whole population. GP can buy for their patient is The challenge faced by the NHS is how determined by the commissioning to spend that budget in a way that organisation. results in the best possible outcomes for individual patients and delivers Because of the complexity and scale value for money for the public. This of the healthcare system, it is more planning and purchasing of NHS efficient to plan and commission services is undertaken by organisations healthcare at a population level, such (or individuals) known as as a town and its surroundings or a commissioners. They are responsible metropolitan borough. All GP practices for assessing the reasonable needs of are required to be a member of a their populations and using their clinical commissioning group (CCG). buying power as purchasers to secure CCGs provide the organisational services that are affordable and of the infrastructure to enable GPs, working highest quality. They can buy services with other health professionals, to from any provider that meets NHS commission services for their local standards of care and prices. communities. CCGs’ governing bodies have GP, nurse and secondary care Commissioning happens on an representatives, as well as at least two individual level every day in a GP ‘lay’ members who are not NHS practice. For example, when a GP professionals. The services that CCGs refers a patient to a particular hospital commission include planned hospital for further investigation or treatment, care, rehabilitative care, urgent and the GP is effectively buying care for emergency care (including out-of-hours that patient from the hospital through and accident and emergency services), Commissioning care | 7

most community health services, some services for members of the maternity services, mental health and armed forces. NHS England is also learning disability services. responsible for commissioning primary care, including GP services. NHS In order to plan their commissioning England is a single organisation, with decisions, local authorities and CCGs 27 Area Teams across England. (coming together through health and wellbeing boards) use Joint Strategic In addition to commissioning services Needs Assessments (JSNAs), and Joint itself, NHS England also has Health and Wellbeing Strategies responsibility for ensuring the overall (JHWSs) to agree local priorities for system of commissioning NHS funded local health and care commissioning. services works well. This involves (see pages 9-10 for more information). working on plans to improve commissioning for specific conditions Once a CCG or other commissioning (e.g. dementia) or patient groups organisation has made a decision to (e.g. children’s services). NHS England buy a service from a provider of care, a provides information and resources for contract must be drawn up which CCGs, and holds them to account for clearly sets out the detailed how they carry out their specification of what the provider must commissioning activities and improve deliver. Commissioners must review the the health care outcomes that matter performance of providers through the locally. NHS England also looks at how contract and monitor the outcomes well CCGs operate within their achieved by the service, so they can budgets, engage with their local manage and check the quality of populations, and deliver the pledges, services and make an informed rights and values in the NHS decision when they plan services and Constitution. NHS England currently make decisions about which providers hosts (until they can become fully to choose in the future independent organisations) commissioning support units. These Although GPs and other local health units can support CCGs to fulfil their professionals commission most NHS commissioning duties, for example by services, some services are not helping with service redesign, giving appropriate to be commissioned advice when CCGs negotiate contract locally. NHS England (known in terms with providers or by assisting legislation as the NHS Commissioning with information analysis. Board)4 commissions services which are more appropriate to commission at a As part of their role, commissioners national level. These include specialised should work together with providers to services (such as those for rare determine the services needed for local diseases), offender healthcare and areas. NHS England is responsible for

4 http://www.england.nhs.uk 8 | Guide to the Healthcare System in England

working with CCGs to encourage them with the Secretary of State refreshing to collaborate, where appropriate, to it every year, yet not during the year plan the structure of services. For without the agreement of NHS services commissioned nationally, NHS England (except in exceptional England takes the lead role in circumstances or after a general coordinating key bodies in the local election). It is the main way in which areas. This can involve discussions over the Secretary of State holds NHS large changes to how services are England to account for the NHS organised, often called commissioning system. Ministers do reconfigurations. NHS England has not have a day-to-day role in the been set the objective of ensuring that running of the NHS. any proposals for major service change meet four tests: (i) strong public and At the heart of the Mandate is an patient engagement; (ii) consistency objective for NHS England to improve with current and prospective need for outcomes for people using the NHS, patient choice; (iii) a clear clinical in particular to improve against all evidence base; and (iv) support for indicators (or measures) in the NHS 6 proposals from clinical commissioners. Outcomes Framework . The NHS If the relevant local authority does not Outcomes Framework sets out the consider the proposed changes to be outcomes and corresponding indicators in the best interests of the local used to hold NHS England to account population, they can refer the matter for improvements in quality. It was to the Secretary of State for Health. developed in partnership between clinicians and stakeholders. Indicators NHS England is operationally from the NHS Outcomes Framework independent from the Department of are also used in the CCG Outcomes Health, with the Secretary of State Indicator Set7, which measures the setting out what the Government success of services commissioned by expects from NHS England in the CCGs. This allows the public, and CCGs Mandate5. The Mandate highlights the themselves, to compare performance areas of health and care where the of different CCGs. government expects to see improvements in the NHS and contains The Mandate, NHS Outcomes a number of objectives which NHS Framework and CCG Outcomes England must seek to achieve. Indicator Set cover the same five areas The Mandate is intended to provide (called ‘domains’) that are the over- the NHS with stability to plan ahead; arching priorities for the NHS in it is set for a number of years at a time, England:

6 https://www.gov.uk/government/publications/ nhs-outcomes-framework-2013-to-2014 7 http://www.england.nhs.uk/wp-content/ 5 http://mandate.dh.gov.uk/ uploads/2012/12/ois-ataglance.pdf Commissioning care | 9

Table 1: The five domains of the NHS Outcomes Framework.

Domain 1 Preventing people from dying prematurely;

Enhancing quality of life for people with Domain 2 long-term conditions;

Helping people to recover from episodes of Domain 3 ill health or following injury;

Domain 4 Ensuring that people have a positive experience of care; and Treating and caring for people in a safe Domain 5 environment; and protecting them from avoidable harm.

Local authorities and representatives of all CCGs in the Local authorities (or councils) have a health and wellbeing board’s area. wide range of duties and The local Healthwatch organisation responsibilities regarding the health of (see page 17 for more information) their populations, which extend also has a seat on the health and beyond the NHS into both public wellbeing board, as well as at least one health and social care. elected local authority member. In order to improve their work, CCGs Every upper tier or unitary local and local authorities have, for example, authority8 in England must have a the freedom to commission services health and wellbeing board. The health together. and wellbeing board encourages work to improve local health and wellbeing Health and wellbeing boards assess outcomes, including (where the current and future health and appropriate) more joined up working social care needs of the local across the NHS, public health, social community through Joint Strategic care, and other services. The core Needs Assessments (JSNAs). JSNAs are membership of the health and based on a principle of analysing the wellbeing board includes available evidence on the local commissioners from across the local community’s health and social care authority – the director of public needs. This includes engaging and health, director of adult social services working with a wide range of local and director of children’s services –

8 Visit https://www.gov.uk/understand-how- your-council-works for an explanation of the different tiers of local government. Upper tier local authorities are unitary authorities, county councils, London or metropolitan boroughs 10 | Guide to the Healthcare System in England

stakeholders such as patient groups, health effects through the planning of voluntary organisations and the public. other linked services, such as Using the JSNA, health and wellbeing education, housing, social care and boards will then jointly agreed strategic transport. Each local authority has a priorities for local health and social Director of Public Health, who is care services in Joint Health and responsible in law for exercising public Wellbeing Strategies (JHWSs). Taken health functions of the local authority together, JSNAs and JHWSs are and for publishing an annual report intended to form the basis of stating what progress has been made commissioning plans, across local towards improving the local health and care services, (including population’s public health. The main public health and children’s services) priorities for public health improvement for CCGs, NHS England and local including stopping smoking, reducing authorities. alcohol consumption, eating more fruit and vegetables, and increasing physical Upper tier and unitary local authorities activity levels. in England have, by law, powers to review and scrutinise any matter Public health relating to the planning, provision and Public Health England (PHE), an operation of the health service operationally independent executive (including public health) in its area. agency of the Department of Health, This enables scrutiny of the quality of supports local authorities in their duty services provided locally, and proposals to improve public health and has put forward for significant changes to national responsibility for protecting those services, such as re-organising the public against major health risks. stroke care in an area. NHS England also commissions some national public health services9.PHE Those local authorities also have the makes comparative data available to responsibility for improving the public help drive improvements and reports health of the people in their area. This annually on progress against the public includes the planning and provision of health outcomes set out in the Public public health services, such as smoking Health Outcomes Framework10. cessation, and considering the public

9 These include the national programmes for immunisation and screening, public health services for offenders in custody, sexual assault referral centres, and public health services for children aged 0-5 years (including health visiting, family nurse partnerships, and much of the healthy child programme). NHS England has responsibility for commissioning about half the public health budget. 10 https://www.gov.uk/government/news/ public-health-outcomes-framework-sets-out- desired-outcomes Commissioning care | 11

Social care Local authorities also commission social care for their local populations based on local criteria and national minimum standards. Social care or ‘care and support’ means the wide range of services and support designed to help people to maintain their independence and wellbeing, enabling them to play a fuller part in society and protecting vulnerable people. It encompasses support, both for people with care needs and people with caring responsibilities. Unlike NHS care, state‑funded social care is means tested.

The Department of Health has responsibility for national adult social care policy, and has committed to changing how care is paid for (subject to legislation) with the overall aim of a sustainable and fair partnership between the government and individual for care costs. The Adult Social Care Outcomes Framework11 defines national priorities for the social care sector, and includes indicators that enable the public and other stakeholders to assess the performance of services. The Department for Education has responsibility for national children’s social care policy.

11 https://www.gov.uk/government/publications/ the-adult-social-care-outcomes-framework- 2013-to-2014 12 | Guide to the Healthcare System in England

Safeguarding patients

Regulating services Providers of healthcare (including Organisations providing NHS services hospitals, care homes, care delivered in are ‘regulated’ to ensure they meet the home, dentists, GPs, mental health essential standards. The boards of and other specialist services – e.g. organisations providing NHS care have hospices) must register with CQC in the primary responsibility to ensure the order to be able to carry on regulated care they provide is safe and of high activities, which includes the provision quality. Regulators exist to ensure of NHS funded health services. At providers are fulfilling their obligations present, this involves meeting a set of to patients and the public. essential quality and safety standards known as registration requirements. The Care Quality Commission (CQC) is Following the Report of the Mid responsible for assessing and making Staffordshire NHS Foundation Trust judgments as to the level of safety and Public Inquiry, chaired by Robert Francis quality of care provided by providers of QC, and the subsequent Government health and social care. To make these response12, registration requirements these assessments, CQC can look at will be reviewed to include a set of information received from the provider fundamental standards. These will be itself, its patients, staff, information drawn up by the CQC working with other organisations, and also conducts NICE, patients, and the public. its own inspections. Information is published on the CQC website. CQC will appoint a Chief Inspector of Hospitals later in 2013. The Chief Inspector of Hospitals will lead the CQC’s assessment of quality in

12 www.gov.uk/government/publications/ government-initial-response-to-the-mid-staffs- report Safeguarding patients | 13

hospitals, and make a single certain additional functions which assessment about how hospitals are apply only to NHS foundation trusts. performing. A Chief Inspector for Social Care will also be appointed From April 2014, all providers of NHS to play a similar role for providers of funded care (except those exempt in social care. legislation) will need to hold a provider licence from Monitor in order to If a provider of NHS funded services is operate. This came into effect for NHS failing to meet required levels of foundation trusts from April 2013. quality, the primary responsibility for The licence specifies standards and resolving these failings sits with the behaviours that providers must follow, board of the provider, working with or face action from Monitor. Potential their local commissioners. At present, action could range from requiring a if this action is insufficient, further provider to take a certain course of action can be taken by interventions action, fining a provider or revoking from the Care Quality Commission, their licence altogether – temporarily and additionally by Monitor for NHS or permanently stopping the provider Foundation trusts, and by the NHS from providing NHS funded services. Trust Development Authority (NHS TDA) for NHS trusts. The Report of the One part of the licence will help ensure Mid Staffordshire NHS Foundation NHS funded services are priced fairly, Trust Public Inquiry identified a lack of with providers properly reimbursed for clarity about the roles of these their work. Monitor is working with organisations. In response, the NHS England to create a list of prices Government announced that, for NHS for NHS services, called the National Foundation trusts and NHS trusts, the Tariff. NHS England leads on which Care Quality Commission would focus services should be included, and on assessing the level of quality of Monitor leads on what the prices care, and Monitor and the NHS TDA should be. would focus on using their powers, Monitor also has a responsibility to where necessary, to intervene to investigate if commissioners or resolve quality failings. providers behave in ways that make Monitor has a main duty to protect competition between different and promote patients’ interests by providers unfair, where that could act ensuring that health care services are against patients’ interests. Other parts provided effectively, efficiently and of the licence discourage providers economically, while the quality of from doing things that could prevent services is maintained or improved. healthcare being more joined-up Monitor has functions which apply to around patients’ needs. all providers of NHS funded care, and 14 | Guide to the Healthcare System in England

If providers of NHS funded services Whilst organisations remain as NHS face serious difficulties, ensuring trusts, it is the role of the NHS Trust essential services for patients continue Development Authority (NHS TDA) to is ultimately the responsibility of support them to improve the quality commissioners. However, Monitor can and sustainability of their services for step in and help ensure that services patients. In some cases, securing these continue to be delivered if a provider improvements will mean helping Trusts gets into serious financial difficulty. to achieve foundation trust status in their current form. The provider licence also contains additional extra conditions for NHS In other cases, this will mean helping foundation trusts only. Monitor Trusts move to whatever other regulates foundation trusts to ensure organisational form is most likely to that they focus on good leadership and deliver the necessary improvements in stay financially strong, and holds their clinical and financial performance. The boards to account for the early NHS TDA has the power to direct NHS identification and effective resolution trusts over any aspect of their function of problems. of providing NHS services, and has a range of intervention powers including The Government intends that services appointing and removing chairs and and hospitals that are currently part of non-executive directors. NHS trusts will become part of NHS foundation trusts (or another type of Professional regulation organisation). As of May 2013, there Professional regulators are responsible are 145 foundation trusts and 102 NHS for ensuring that health and social care trusts. It is Monitor’s role to ‘authorise’ professionals are providing safe care. new foundation trusts. In order to They are focused on the individuals become a foundation trust, NHS trusts who give care, rather than must demonstrate to Monitor that they organisations that provide care. are well led and able to provide good quality services for patients on a In England, there are regulators for sustainable basis. Monitor takes advice different healthcare professions: from CQC regarding the trust’s •• doctors (the General Medical compliance with quality and safety Council) standards. Not all NHS trusts will be •• nurses and midwives (Nursing and able to achieve NHS foundation trust Midwifery Council) status in their current configuration. These trusts may become part of a •• dental teams (General Dental foundation trust, or a different type Council) of organisation. •• optical professionals (General Optical Council) Safeguarding patients | 15

•• pharmacists (General Pharmaceutical As well as assuring the quality of Council) training, professional regulators are responsible for safeguarding the •• chiropractors (General Chiropractic interests of patients by ensuring that Council) registered health professionals meet •• osteopaths (General Osteopathic the standards of competence, practice, Council) conduct and ethics. •• health, psychological and social All regulated health and social care work professionals (Health and Care professionals must meet the standards Professions Council). set by their professional regulator and are required to ensure that they stay How many registered up to date in terms of their professionals are there? professional skills. For doctors, there is •• General Dental Council – 101,901 a system of ‘revalidation’, whereby they •• General Medical Council – are subject to an ongoing evaluation of 252,431 their fitness to practise through an annual appraisal. •• Health and Care Professions Council – 310,942 The professional regulators are •• Nursing and Midwifery Council – overseen by the Professional Standards 675,148 Authority for Health and Social Care, which evaluates the regulators’ (Source: PSA, March 2013) performance.

These roles are collectively referred to Specialist safeguarding bodies as ‘professions’ because there are The interests of the patient and the specific rules, standards and ethics that public are further safeguarded through people must abide by in order to work. the role of four other bodies covering In order to practise legally, health specific areas of healthcare. professionals must be registered with the relevant professional regulator. If a The Medicines and Healthcare registered professional breaches any of Products Regulatory Agency (MHRA) the rules of their profession by harming is the government agency responsible or failing to treat a patient properly, for ensuring that medicines, medical patients may complain directly to the devices and blood components for relevant professional regulator. The transfusion meet applicable standards regulator takes a decision whether to of safety, quality, efficacy and investigate and if necessary, require effectiveness. They work to ensure that additional training is undertaken, that the supply chain for medicines, restrict or ban that professional from medical devices and blood components practising. is safer and more secure. 16 | Guide to the Healthcare System in England

The Human Tissue Authority is an diagnostic services to the NHS in independent watchdog that protects England. It matches, allocates and the public’s interest by licensing and commissions the retrieval of organs inspecting organisations that store and for transplant outcomes. It is also use human tissues and organs for responsible for raising awareness and purposes such as research, patient encouraging the public to donate treatment, transplantation, post- blood, stem cells, tissues and organs mortem examination, teaching and as the supply of these critical products public exhibitions. They also give and services depends entirely on the approval for organ and bone marrow altruism and loyalty of donors. As part donations from living people through of its national coordinating role it helps an independent assessment process. raise the quality of blood and transplant services in hospitals through The Human Fertilisation and research. Its primary role is to provide Embryology Authority is the UK’s services to hospitals, however it does independent regulator of treatment provide some specific specialist using eggs and sperm and of therapeutic services directly to patients. treatment and research involving human embryos. They set standards The Health Research Authority also and issue licences to fertility clinics. plays a key role. Its functions are considered alongside the research NHS Blood and Transplant collects, bodies in the ‘Supporting the tests, processes and supplies blood, healthcare system’ section. stem cells, tissues and related Empowering patients and local communities | 17

Empowering patients and local communities

NHS organisations have a legal duty to Healthwatch13 organisation to support make arrangements for the patient and public involvement involvement of patients in decisions activities in its area. The activities about the running of services. The NHS include promoting and supporting the Constitution sets out the responsibility involvement of local people in the the NHS has to individual patients commissioning, provision and scrutiny – that everybody has the right to be of local health and care services. Local informed about their healthcare and Healthwatch organisations are able to options, and to be involved in enter and view certain health and discussions and decisions. This means social care premises and produce that health care professionals should reports and make recommendations listen and respond to patients’ views that influence the way services are and any concerns they may have designed and delivered. Local during their care and treatment. Healthwatch organisations provide Providers of healthcare such as GP information and advice to the public practices and hospitals organise their about local services, and pass on own groups to engage with patients views to Healthwatch England. They and their local communities. For and can also make recommendations example, some GPs run patient to Healthwatch England and the Care advisory or participation groups which Quality Commission. If a local allow GP practices and their patients to Healthwatch organisation sends a work together to improve services. report or recommendation to a specified provider or commissioner of a Every upper tier and unitary local local health or social care service, the authority area in England has provider or commissioner is legally arrangements with a Local

13 Visit http://www.healthwatch.co.uk/ to find your local Healthwatch organisation. 18 | Guide to the Healthcare System in England

obliged to respond to the local organisation’s Chief Executive, or Healthwatch organisation in writing. equivalent, is an effective way to ensure any concerns reach senior Healthwatch England is a committee management. Alternatively, patients of the Care Quality Commission (CQC) can complain to the organisation that that acts with operational arranged and paid for their care, and independence in the interests of should expect a response from them. patients, social care service users and This is likely to be a local clinical the public. Healthwatch England commissioning group, local authority provides national leadership, support or NHS England. and advice to local Healthwatch organisations. It is a committee of the Many NHS providers have a Patient CQC in order to ensure that the Advice and Liaison Service (PALS) that collective voice of patients has a direct seeks to resolve patient concerns and route into the CQC’s decision-making help patients and carers in making a processes. However, it operates complaint. Local Authorities also independently from the CQC and it arrange advocacy services to support can escalate concerns about health people who wish to complain about and social care services raised by local the NHS. Local Healthwatch can Healthwatch, users of services and provide information on how to make a members of the public to the CQC. complaint, although, like the CQC, it Healthwatch England is able to provide does not handle individual complaints. advice and information (which could The CQC also provides information on include making recommendations and the quality and safety of local health reports) to the Secretary of State, NHS and care providers, which is available England, Monitor and English local on their website. authorities. The recipients of Healthwatch England’s advice are If a patient is unhappy with the way required in law to respond to their complaint has been handled, Healthwatch England in writing. they may contact the Parliamentary and Health Service Ombudsman. The Patients can feed in good or bad Ombudsman conducts independent experiences of health services in a investigations into complaints that the range of other ways. Every provider of NHS in England has not acted on NHS services must have clear properly or fairly, or has provided a procedures for receiving, and dealing poor service (the Ombudsman also with, patient feedback and complaints. covers other government departments Contacting the service provider, as the and a range of other public bodies in first port of call for patients, allows the UK). The Ombudsman can look staff in that organisation to put things at complaints about the actions of right promptly when things have gone providers of NHS care, as well as those wrong. Writing to a provider of NHS England and CCGs. The Empowering patients and local communities | 19

Ombudsman can also look at complaints about the Department of Health, the Care Quality Commission and Monitor. The Ombudsman is accountable to Parliament and is independent of government and the NHS. For local authority services and for services paid for by local authorities, patients can take their cases to the Local Government Ombudsman. The Department of Health has established an independent review to consider the handling of concerns and complaints that will report in summer 2013. 20 | Guide to the Healthcare System in England

Education and training

The relationship between patients and Higher education institutions in the UK staff is at the heart of the NHS and provide rigorous undergraduate and the people who work across NHS postgraduate training for those who services are in contact with more than become qualified healthcare 1.5 million patients and their families professionals such as dentists, doctors, every day. The NHS Constitution and nurses, midwives and paramedics. Handbook set out the rights and NHS Training to become a healthcare pledges to staff so that they are professional does not stop after treated with respect, have the training, qualification but continues throughout support and development they need to their career. Organisations that provide deliver high quality NHS services. In healthcare are responsible for return, all staff have responsibilities delivering the majority of training for relating to how they work with the all their staff, including those who are public, patients and colleagues to not a qualified healthcare professional. ensure the NHS Constitution’s values of The demands placed on the NHS are respect, dignity, care and compassion changing and medical technology is are upheld. constantly improving. In order to sustain improvements in health One of the NHS Constitution pledges services, the knowledge and skills of to staff commits the NHS to “provide the health and public health workforce all staff with personal development needs to be kept up to date and access to appropriate education and developed. training for their jobs and line management support to fulfil their potential”. Education and training | 21

A national, independent body called The Department of Health sets the Health Education England (HEE) is direction and its expectations for the responsible for promoting high quality whole education and training system training and education, undertaking through a document called the national planning and leadership, Education Outcomes Framework14 allocating financial resources, (EOF). Fulfilling the EOF requires a monitoring outcomes and securing the range of different national and local required supply of qualified staff. Long bodies that provide and plan care to term, national planning is needed, for work together effectively, including example, because a medical student HEE. The Department holds the graduating today will still be providing operationally independent HEE board care in 2050. of directors to account for HEE’s performance through a document At a local level, education and training specific to HEE called the ‘HEE is co-ordinated by local education and Mandate’. training boards (LETBs). The LETBs are statutory committees of HEE and act as the bodies for all providers and professionals to work collectively to improve the quality of education and training outcomes within their local area – in order to meet the needs of patients, the public and service providers. Each LETB covers a geographical area and develops comprehensive plans, considering existing workforce data, what healthcare services will be needed in the future and the demographic of the local population. HEE allocates funding for LETBs to spend on the education and training required in their local area and provides support to LETBs as they establish themselves.

14 http://www.hee.nhs.uk/work-programmes/ education-outcomes/ 22 | Guide to the Healthcare System in England

Supporting providers of care

Information, evidence and deliver national IT systems and services research to support health and care providers. Billions of pieces of information are HSCIC is responsible for assessing the generated in the NHS every day. quality of information it collects and The effective collection and use of making it readily available to those who information is critical to improving need it in safe, de‑identified formats, services for patients – from improving with safeguards in place to protect the speed at which patients can access confidential information. test results to improving the effectiveness of a surgical team’s Research is vital in providing the performance. Safeguards – such as knowledge needed to improve health laws around the sharing of data – outcomes and reduce inequalities. ensure information are used Every part of the health and care appropriately, and the NHS system has a role to play in research Constitution describes patients’ rights and the NHS Constitution confirms regarding their own information. the commitment of the NHS to “the promotion, conduct and use of Given the large number of organisations research to improve the current and involved in providing health and care future health and care of the and support there needs to be a focal population”. There is a legal duty to point for the collection, linking, storage promote research and the use of and publication of information to better research evidence, and powers to understand issues such as how support research, on the Secretary of treatments lead to healthcare State for Health, NHS England and outcomes. The Health and Social Care clinical commissioning groups. There is Information Centre (HSCIC) collects, a legal duty on Monitor to have regard analyses and publishes national data to the need to promote research by and statistical information and works to providers of NHS health research by Supporting providers of care | 23

providers of NHS services. All parts of health research by protecting them the system will require decisions about from unethical research, while enabling policy and practice to be based on them to benefit by simplifying research evidence. processes for ethical research, working closely with other bodies. The National Institute for Health Research (NIHR) provides a key means The National Institute for Health and through which the Secretary of State Care Excellence (NICE) is the main discharges his or her duty in respect of source of evidence-based guidance research. The NIHR commissions and and advice for health and social care funds research, provides the facilities practitioners, patients, service users and people needed for a thriving and the public on the most effective research environment and supports way to prevent, diagnose and treat the individuals carrying out and disease and ill health. NICE produces participating in research. It also quality standards15 – concise sets of promotes faster, easier clinical research statements that describe what high through unified, streamlined and quality care looks like for a particular simple systems for managing ethical condition or patient group – which are research and its outputs. Through a used to drive up the quality of health secure data service, the NIHR and the and care services. They are mainly Medicines and Healthcare Products based on NICE guidance that is Regulatory Agency will support health developed in partnership with research by providing life sciences professionals and patients, research data, with the support of independently of government. NICE the HSCIC. also helps the NHS by assessing whether drugs and other treatments In terms of individuals, the NHS represent value for money and the commits (in the NHS Constitution) to NHS is required to fund treatments inform patients of potential that NICE recommends. NICE guidance opportunities to participate in research also supports the adoption of efficient studies. Patients should be informed and cost effective medical devices, and supported to make choices about procedures and diagnostic tools more how they participate in research, rapidly, safely and consistently. recognising that research can be undertaken by bodies outside the NHS, Specialist NHS support such as medical research charities or The NHS is further supported through the pharmaceutical industry. The a number of bodies established to Health Research Authority’s core provide critical advice and specialist purpose is to protect and promote the expertise to the NHS in a variety of interests of patients and the public in different fields.

15 http://www.nice.org.uk/guidance/ qualitystandards/qualitystandards.jsp 24 | Guide to the Healthcare System in England

Organisations that are part of the NHS services includes those provided may face legal claims due to clinical directly to the public, for example, negligence, employers’ and public through the administration and issuing liability, or property damage or loss. of the European health insurance card In order to fairly resolve disputes and or the administration of the NHS Low protect public investments in the NHS, Income Scheme16, which provides the NHS Litigation Authority runs financial assistance for health related membership schemes that supports costs to those on low incomes. By the NHS in these areas. It also has a centralising these types of functions, role in improving the professional economies of scale can be realised in practice of clinicians, helping the NHS terms of calculation, payments, issuing and providers of NHS care to learn certificates and scanning paper forms. lessons from claims, and to better The NHS Business Services Authority manage risks and improve patient and delivers these large-scale transactional staff safety. Other responsibilities services on behalf of the Department include adjudicating in a range of of Health and NHS England to NHS primary care disputes and advising NHS bodies, NHS contractors, patients, staff colleagues on human rights, age and the public. The NHS Business discrimination and equal pay issues. Services Authority ensures that the delivery of these services is efficient, The NHS, through paper and electronic effective and offers value for money to forms, generates hundreds of millions the public. of transactions a year, between patients, providers and commissioners NHS Property Services Ltd develops of care. The range of transactional and manages more than 3,500 NHS buildings, estate and facilities, helping to improve the delivery of clinical services by providing safe, efficient and well-maintained estates buildings and facilities, including GP practices and community hospitals.

16 http://www.nhsbsa.nhs.uk/1125.aspx The Secretary of State for Health | 25

The Secretary of State for Health

The Secretary of State for Health has others, are fulfilled through responsibility to Parliament for the relationships with other bodies and the provision of the health service. The Secretary of State’s performance with Secretary of State works through the regard to his or her duties is covered in Department of Health to provide his or her annual report. The Secretary strategic direction for the NHS and of State, and all public bodies in the wider health and care system and holds healthcare system, must also comply all of the national bodies to account for with the public sector equality duty in their operational and financial the Equality Act 2010. performance, thereby ensuring that the different parts of the system work The Department of Health’s purpose is properly together. He or she takes to help people live better for longer. decisions on national health, public It leads, shapes and funds health and health and social care policy, advised by care in England, making sure people the civil servants who make up the have the support, care and treatment Department of Health. A team of junior they need, with the compassion and ministers, who each have responsibilities dignity they deserve. The Department, over specific policy areas, also support on behalf of the Secretary of State, the Secretary of State. acts as ‘system steward’ – it is the only body with oversight over the whole The Secretary of State has to fulfill a health and care system, and it works number of duties that are set out in to ensure the health and care system law, including: the promotion of a operates effectively to meet the needs comprehensive health service; to have of people and their communities. regard to the need to reduce health The Department’s stewardship role inequalities between the people of has the following main aspects: England; and to have regard to the NHS Constitution. These duties, and 26 | Guide to the Healthcare System in England

•• Setting national priorities which specifics of the relationships reflect what patients, service users between the Department and its and the public value. The sponsored bodies are set down in Department sets ambitions and ‘framework agreements’. priorities for the NHS and health •• Fostering relationships, collaborating care system, through the outcomes with patient organisations, and frameworks and the Mandate. ensuring the system works well The Department also supports the together. This involves ensuring all delivery of ministerial ambitions, of the health and care and other priorities and policies; and does this bodies work effectively together through obtaining information and and with common purpose, whilst intelligence, and appropriate recognising their own unique roles monitoring. and autonomy in deciding how to •• Securing and allocating resources to carry out their defined functions. meet priorities and deliver services. The Department also works with The Department secures and other government departments on distributes resources for the NHS health matters. and health and care system by •• Creating and updating the policy securing public funding for the NHS, and legislative frameworks within public health and social care from which the health and care system HM Treasury through the Spending operates. It oversees an effective Review process. The Department is regulatory framework that ensures an important stakeholder and all organisations and professionals shareholder in NHS provider meet essential standards of quality organisations, and is a key source and safety. of funding for capital investment. The Department can also secure •• Accounting to Parliament, and the additional sources of funding, for public, for the effectiveness of the example through existing health and care system. This prescription and dental charges, and includes supporting ministerial directly allocates resources to local accountability to Parliament and the authorities for public health. public for the effectiveness of the health and care systems, the •• Sponsoring national health and care effective use of resources voted by system bodies, by supporting them Parliament, and the discharge of and holding them to account for the Secretary of State’s legal duties. delivery of their role. ‘Sponsorship’ Ultimately, the Secretary of State means the Department ensuring has powers to remove the chairs of organisations are delivering their the major national health bodies functions, meeting their statutory from office and (in the case of duties, and using public money significant failure to exercise their efficiently and effectively. The functions properly) powers of The Secretary of State for Health | 27

direction which could force an organisation to undertake or cease a particular course of action. Failure to comply with such a direction could result in the function being carried out by another body. 28 | Guide to the Healthcare System in England

Statement of NHS Accountability

Principle seven of the NHS Constitution funded care must be provided within states: “The system of responsibility NHS quality and financial standards. and accountability for taking decisions Providers of NHS services are in the NHS should be transparent and accountable to their local populations clear to the public, patients and staff. in three main ways: The Government will ensure that there is always a clear and up-to-date Boards of directors (or equivalent) have statement of NHS accountability for responsibility for the quality of care this purpose.” This statement fulfils and for the ongoing financial stability this commitment. It is designed to of their organisation. In NHS complement the broader Guide to the foundation trusts, the board of Healthcare System, focusing on the directors is held to account by the key accountability relationships within council of governors – which is elected the NHS. by the foundation trust’s membership of the local public, patients, families, As set out in the NHS Constitution, carers and staff. NHS trusts are the NHS belongs to the people. accountable to the Secretary of State Organisations which make up the NHS for Health, assisted by the NHS Trust are accountable to the people they Development Authority. serve through a number of different mechanisms. Providers must support accountability to patients by having clear procedures Providing care for dealing with patient feedback and NHS funded care is provided by both complaints. Patients may escalate their NHS organisations (such as NHS complaint to the Parliamentary and foundation trusts) and non-NHS Health Service Ombudsman. In organisations (such as private and addition, all NHS organisations have a voluntary sector providers). NHS duty to make arrangements for the Statement of NHS Accountability | 29

involvement of patients in decisions commissioning services which impact about the running of services. on health and wellbeing (the NHS, adult social services, children’s services Performance information on providers and public health), with elected local is made readily available to all, and authority members and a providers are held to account by representative from the local commissioners, regulators and Healthwatch organisation. Health and democratically elected local authorities. wellbeing boards must prepare an assessment of the health and social Commissioning care care needs of their local population Accountability for the way that the (the JSNA), and a strategy for local majority of local NHS services are services to meet those needs planned and paid for rests with clinical (the JHWS). commissioning groups, supported by NHS England. The NHS is required to Improving public health fund the drugs and treatments that the Accountability for the planning and National Institute for Health and Care delivery of public health is different to Excellence recommends. Clinical that for NHS services. At a local level, commissioning groups (CCGs) hold local authorities are responsible for providers of NHS services to account promoting healthy lifestyles and through contracts, and CCGs are improving the health of the population accountable to NHS England for how in their area; and are accountable well they meet their population’s through local elections to their needs. population. Each local authority has a director of public health who is NHS England funds, oversees and responsible in law for exercising public supports the commissioning system at health functions of the local authority, a national level. It is accountable to the and publishes an annual report stating Secretary of State for Health for the what progress has been made towards performance of its functions and the improving the local population’s public delivery of the delivery of the Mandate, health. which sets out the government’s objectives for the NHS. Each year, NHS Local authorities are supported in this England must present a report to the work by Public Health England, an Secretary of State for Health which operationally independent national includes information about how well agency which is directly answerable to is has delivered on the objectives in the Secretary of State for Health. The the Mandate. main remit of Public Health England is to promote improvement in the health To enable local services to be planned of the general population and to carry in a coherent manner, health and national responsibility for protecting wellbeing boards bring together the the public against major health risks. people who are responsible for 30 | Guide to the Healthcare System in England

Empowering people and local Healthcare professionals are communities accountable as individuals to the Local Healthwatch organisations independent regulatory organisations support accountability by collecting (such as the General Medical Council) and feeding back the experiences of for the standard of care they provide. patients, and making the information These professionals are also available to the relevant organisations accountable to the organisations in in the system. Healthwatch England which they work. A national body, (an operationally independent Health Education England, is committee of the CQC) provides accountable to the Secretary of State national leadership, support and advice for Health for promoting high quality to local Healthwatch organisations. training and education of healthcare Specified recipients of local staff. Healthwatch’s reports and recommendations (certain providers Secretary of State for Health and commissioners of health and social The Secretary of State for Health has a care services) and Healthwatch duty to promote a comprehensive England’s advice (including the health service in England. He or she Secretary of State, NHS England, also has ministerial responsibility to Monitor and local authorities) are Parliament for the provision of the required in law to respond. health service. The Secretary of State has a number of further legal duties, Safeguarding patients particularly in relation to improving the All organisations that provide NHS quality of services and reducing health funded services (as well as privately inequalities. The Secretary of State funded health services, and social care) must also keep the performance of the are regulated for quality by the Care health service under review and lay Quality Commission. Monitor, the before Parliament annually a published health sector regulator, has a main report on this performance. It is the duty to protect and promote patients’ role of Parliament to hold the Secretary interests by ensuring that services are of State to account for the delivery of provided effectively, efficiently and his or her duties, and the role of the economically, while quality is Department of Health to support the maintained or improved. The NHS Trust Secretary of State in discharging them. Development Authority oversees the performance of NHS trusts. The Care Quality Commission, Monitor and the NHS Trust Development Authority are all accountable to the Secretary of State for Health for the performance of their functions.

© Crown copyright 2013 2900878 0p (0k) April 2013 (X&X) (000000) Produced by the Department of Health For further copies of this title visit www.orderline.dh.gov.uk and quote 2900013 The NHS Constitution. Tel: 0300 123 1002 Fax: 01623 724 524 Minicom: 0300 123 1003 (8am to 6pm, Monday to Friday)