The NHS Structure

Understanding the structure of NHS leadership and governance is important for appreciating how healthcare policy, funding, workforce planning, and service delivery are coordinated.

Department of Health and Social Care (DHSC)

The Department of Health and Social Care (DHSC) is a government department responsible for setting national health and social care policy in England.

Its responsibilities include:

Developing government health and social care strategy.
Setting national priorities and legislation.
Allocating overall funding for health and social care.
Providing oversight of the organisations responsible for delivering services.

The DHSC is ultimately accountable to government for the overall direction and performance of the health and social care system.

NHS England

NHS England is a central arm’s-length body of the government. Arm’s-length bodies are publicly funded organisations that operate with a degree of independence from government while delivering specific functions.

NHS England has historically been responsible for:

Planning and commissioning NHS services.
Supporting delivery of NHS priorities.
Allocating funding to NHS organisations, including NHS trusts and Integrated Care Boards (ICBs).
Improving quality, outcomes, and efficiency across the NHS.

As part of NHS reforms of 2025, NHS England is being brought closer into the DHSC structure. The intention is to reduce duplication, streamline decision-making, and improve efficiency by removing overlap between organisations.

NHS England’s functions are expected to be absorbed into the DHSC by 2027, with the organisation being wound down as a separate entity.

Health Education England (HEE)

Health Education England (HEE) was responsible for:

Workforce planning.
Medical and healthcare education.
Training and development of healthcare professionals.

In 2023, HEE merged with NHS England, creating a single organisation responsible for both NHS service delivery support and workforce development.

As NHS England is restructured, workforce and education functions are expected to transition into the DHSC.

Integrated Care Systems, Integrated Care Board and Integrated Care Partnerships

At a glance...

ICS ICP ICB explained structure of the NHS

ICS = the whole partnership ("the system")
ICP = the strategy group ("what should we achieve together?")
ICB = the NHS delivery organisation ("how will the NHS deliver its part?")

The ICP develops the long-term strategy for improving health and reducing inequalities across the system, while the ICB uses NHS resources to plan and commission services that help deliver that strategy. Both operate within the wider ICS, alongside NHS providers, local authorities and other partners.

Example

Suppose an ICS identifies that diabetes rates are increasing:

ICP: Develops a strategy to reduce diabetes through prevention, early diagnosis, and better integrated care.
ICB: Commissions diabetes clinics, community services, GP support, and digital monitoring programmes to implement the NHS elements of that strategy.
ICS: Brings together the NHS, councils, public health teams, schools, and voluntary organisations to coordinate all these efforts and improve outcomes for the local population.

Integrated Care Systems (ICSs) are local partnerships that bring together NHS organisations, local authorities, social care providers, voluntary organisations, and other community partners to improve the health and wellbeing of their populations.

Established as statutory bodies on 1 July 2022, the 42 ICSs across England aim to create more joined-up services by developing shared plans, improving collaboration, and ensuring healthcare is designed around the needs of local communities.

An ICS is the whole health and care system for a local population, usually covering around 1–3 million people.

It is not a single organisation but a partnership of:

NHS providers (hospital, community and mental health trusts)
Primary care (GPs, dentists, pharmacists, optometrists)
The Integrated Care Board
Local authorities
Voluntary, community and social enterprise (VCSE) organisations
Other partners such as housing or public health

The four national aims of an ICS are to:

Improve population health and healthcare outcomes.
Reduce health inequalities.
Enhance productivity and value for money.
Support broader social and economic development.

Its primary responsibility is to produce an Integrated Care Strategy, which sets out how organisations across the ICS should work together to improve health and wellbeing and tackle inequalities.

In detail...

Integrated Care Partnership (ICP)

The ICP is a joint committee formed by:

the ICB, and
local authority representatives.

It also includes wider partners such as:

NHS trusts
Primary care
Public health
VCSE organisations
Social care representatives

Its primary responsibility is to produce an Integrated Care Strategy, which sets out how organisations across the ICS should work together to improve health and wellbeing and tackle inequalities.

Think of the ICP as setting the shared strategic direction.

Integrated Care Board (ICB)

The ICB is the statutory NHS body responsible for running NHS services across the ICS area.

Its responsibilities include:

Receiving NHS funding from NHS England.
Planning and commissioning most NHS services.
Developing operational plans.
Improving quality and performance.
Working with providers and local authorities to deliver the ICP's strategy.

The ICB replaced Clinical Commissioning Groups (CCGs) in July 2022.

On 1 April 2026, NHS England restructured ICBs, abolishing 12 existing ICBs and establishing six new, larger ICBs, thereby reducing the total number of ICB's from 42 to 36. These changes were designed to reduce running costs, build on the efficiencies achieved through ICB clustering in 2025, and streamline the planning and delivery of NHS services.

Think of the ICB as the organisation responsible for delivering NHS services and spending the NHS budget.

NHS Trusts vs NHS Foundation Trusts

If you're applying for consultant posts, you'll notice that some vacancies sit within an "NHS Trust" and others within an "NHS Foundation Trust." The distinction rarely changes your day-to-day clinical work, but it's worth understanding — both for interview preparation and for making sense of how the organisation you might join is actually run.

At a glance...

Both are NHS organisations providing free-at-the-point-of-use care under the same core NHS principles. The difference is one of governance and autonomy, not of clinical standards or employment terms.

NHS Trusts are directly part of the NHS hierarchy, established by the Secretary of State for Health and Social Care, with chairs and non-executive directors appointed by NHS England.

NHS Foundation Trusts (FTs) are legally independent public benefit corporations, established under the National Health Service Act 2006, with greater freedom from central government control and a formal structure of local accountability.

In detail...

Origins

Foundation Trusts were introduced from 2004 as a way of giving the best-performing NHS Trusts more autonomy and flexibility to shape services around their local population, on the logic that organisations with a strong track record could be trusted to manage more of their own affairs. Not every Trust has made — or sought — this transition, so both types continue to exist side by side.

Governance: the key practical difference

This is where the two models genuinely diverge.

NHS Trusts are run by a board of directors, with non-executive appointments made centrally. They are accountable upward, through NHS England, to the Department of Health and Social Care.

NHS Foundation Trusts have an additional layer: a Council of Governors, made up of elected representatives of the public, patients, and staff, alongside appointed representatives from partner organisations. Local people can register as members of the Trust and vote in governor elections. The council holds the non-executive directors to account and has a say in major strategic decisions. Foundation Trusts remain accountable to Parliament, but day-to-day, they answer more directly to their local community than a standard Trust does.

Regulation and oversight

Historically, Foundation Trusts were overseen by an independent regulator (Monitor, later merged into NHS Improvement), separate from the oversight of standard Trusts. That regulatory landscape has consolidated significantly in recent years, and today both Foundation Trusts and NHS Trusts sit under a single oversight framework from NHS England, with both types of provider inspected by the Care Quality Commission (CQC) against the same national standards for quality and safety. In other words, the regulatory gap between the two models has narrowed considerably compared to a decade ago.

Finance

Foundation Trusts have historically had more freedom over how they raise and retain capital, including borrowing and retaining surpluses, compared with the more centrally controlled financial arrangements of standard Trusts. In practice, since the introduction of Integrated Care Systems (ICSs), financial planning for both types of Trust is now heavily coordinated at system level, which has reduced some of this practical distinction too.