To build a sustainable future, hospices are increasingly working within and alongside their local health and care systems. But it can be difficult to start engaging and co-ordinating with statutory systems.
On this page you’ll find an overview of the statutory providers in the UK and an explanation of how health services are commissioned.
Hospitals are part of the National Health Service (NHS). They provide ‘secondary’ or ‘acute’ care that is often within specialties, using specialist skills and diagnostic equipment. They have inpatient and outpatient departments where appointments and admissions are categorised as ‘planned / routine / elective’, or ‘unplanned / urgent’.
Many hospitals have Emergency Departments (ED), also referred to as A&Es (Accident and Emergency), where patients can walk in or will be taken by an ambulance (if they have called 999).
Patients are mostly referred by GP practices for planned care but enter via A&E for urgent care.
Health and care systems work together to avoid patients needing to be admitted for urgent care, by providing community and GP services to stop health problems from escalating. Likewise, health and care systems work together to discharge patients from hospital beds when there is no further clinical need for care in the hospital setting, providing them with appropriate community care to meet their needs.
In England, hospitals are currently NHS Trusts or Foundation Trusts. In Northern Ireland, Scotland and Wales they are part of wider Boards.
Community services are provided outside hospital, often in people’s own homes. Originally focusing on public health and maternity services, including midwives and health visitors, care across a range of disciplines is now provided outside hospital. The NHS describes these services as ‘community care’.
Mental health services have a more complex delivery which is shared between inpatient units and community services.
Across the UK, there is significant variation in how these organisations are structured and integrated with the rest of the health system.
General Practitioners (GPs) are the clinical gatekeepers of the NHS, central to a health system that delivers free care on the basis of clinical need not financial ability. They provide ‘primary care’ services alongside dentists, pharmacists and opticians.
NHS patients need to be registered with a GP practice. Around 90% of patient care is delivered by GP practices (King’s Fund, 2011). Most non-emergency appointments in secondary care require patients to be referred from a GP.
GP practices across the UK remained as independent contractors when the NHS was formed and have been so ever since. They hold NHS contracts ‘in perpetuity’ which means GP partners who own their businesses and are named in the contracts must hand them over to new GP partners if they leave or retire.
Emergency response and patient transport is provided by separate ambulance services. As with other healthcare providers, their size and governance has changed over time.
There are currently:
10 ambulance NHS Trusts covering the English regions
the Welsh ambulance service NHS Trust
the Scottish ambulance service special NHS Board
the Northern Irish ambulance service Health and Social Care (HSC) Trust.
Most local authorities are responsible for adults’ and children’s social care services, except in Northern Ireland where they are integrated into HSC Trusts. Local authorities generally commission care, including care homes and domiciliary care, rather than providing it directly. This might be by:
awarding ‘block’ contracts for providers to deliver care services, or
allocating Personal Budgets to individuals to purchase their own care.
Social care in England and Wales is means tested (the thresholds are more generous in Wales than those in England). In Scotland, and even more so in Northern Ireland, much of the personal, nursing and domiciliary care is universally funded.
Local authorities have separate funding streams and are not NHS providers. However, as health and social care is interdependent, systems across the UK strive for coordination. Local Public Health services, most notably in England, sit within local authorities rather than the NHS.
How health services are commissioned
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Commissioning: the purchaser / provider split
The way statutory health providers are funded has changed over the years. Having a basic knowledge of this will help you understand how the commissioning system behaves and why.
In 1990, the Government introduced into UK legislation a split between the purchasers (commissioners) and providers of healthcare. This established the internal market and competition for service contracts.
Services were competitively tendered and awarded to NHS and private providers through formal contracting arrangements. Instead of block contracts, tariffs were devised to pay for units of activity. GP practices continued to be paid by ‘capitation’ (depending on the number of their registered patients).
In 1999, most healthcare was devolved from Westminster. Powers were given to the Northern Ireland Assembly, Scottish Parliament and Welsh Senedd. Since this time, healthcare structures have developed differently across the UK nations.
However, the structures and systems in all the UK nations are now moving back towards more integrated models of commissioning and providing health and social care.
The structure of health and care systems
Now that you understand how health and care services are commissioned and delivered, you need to know how the health and care system is structured in each UK nation. This will help you understand who you need to engage with.
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The structure of health and care systems
An overview of how the health and care system is structured in each UK nation, and where hospices and palliative and end of life care providers can gain influence.
