Since its founding in 1948, the National Health Service (NHS) has been a cornerstone of British society — free at the point of use, publicly funded, and based on need rather than ability to pay. Yet behind the enduring principles lies a system that has undergone near-constant reformation. These reforms have reshaped the organisation, funding, and commissioning of health services across the decades.
The National Health Service (NHS) was officially launched on 5 July 1948, under the post-war Labour government led by Prime Minister Clement Attlee. It was the brainchild of Health Minister Aneurin Bevan, who envisioned a system that would provide comprehensive health care to all citizens, regardless of wealth or social status.
At its core, the NHS was built upon three enduring principles that remain central to its mission today:
It meets the needs of everyone – ensuring universal access to health services.
It is free at the point of delivery – removing financial barriers to care.
It is based on clinical need, not the ability to pay – ensuring treatment is provided fairly and equitably.
These ideals marked a profound shift in the nation’s approach to health care, establishing the NHS as one of the first fully publicly funded healthcare systems in the world.
Despite its visionary intent, the original design of the NHS was inherently fragmented, consisting of three distinct branches:
Hospital Services: Managed by newly established Regional Hospital Boards, which were accountable to the Ministry of Health. These boards oversaw hospital infrastructure, specialist services, and staffing.
Primary Care: Delivered largely by independent contractors, including GPs, dentists, opticians, and pharmacists. Unlike hospital doctors, these professionals retained autonomy and operated under individual contracts with the NHS.
Community Services: Such as health visitors, district nurses, school nurses, and midwives, were the responsibility of local authorities. This meant they were administered separately from both hospitals and primary care.
While the tripartite system enabled the NHS to be established quickly by leveraging existing institutions, it also entrenched organisational silos. Coordination between hospitals, GPs, and community services was poor, leading to duplication, inefficiencies, and gaps in patient care.
Bevan himself acknowledged this compromise, famously stating he had “stuffed their mouths with gold” to secure the cooperation of the British Medical Association and other vested interests. While politically necessary, it laid the groundwork for decades of structural reform aimed at achieving true integration.
In 1974, a significant restructuring of the National Health Service (NHS) took place under the Conservative government, marking a pivotal moment in the organisation and delivery of healthcare services across the UK. This restructuring led to the abolition of the Regional Hospital Boards, which had previously overseen hospital services within specific regions.
In their place, the government introduced two key new bodies: the Area Health Authorities (AHAs) and the Regional Health Authorities (RHAs). The creation of these authorities was designed to streamline the NHS’s organisational framework and improve coordination and efficiency across healthcare services.
The AHAs and RHAs had a far-reaching impact, as they consolidated responsibility for a wide range of healthcare services, including hospital care, community health services, and some public health functions. By bringing together these various elements under one umbrella, the new authorities aimed to ensure that healthcare delivery was more integrated, enabling better communication and coordination between hospitals, community care providers, and public health organisations.
This restructuring marked a critical shift in how healthcare services were managed and delivered, laying the foundation for the modern NHS system that continues to evolve and adapt to the needs of the population today.
In 1983, the Griffiths Report made a significant recommendation for the National Health Service (NHS), calling for the introduction of general management practices to enhance accountability and efficiency within the healthcare system. The report highlighted the need for a more structured approach to management, with a focus on clearer roles, responsibilities, and performance measurement. This marked a shift toward a more business-like approach to managing healthcare, seeking to address inefficiencies and improve outcomes for patients.
The idea of introducing general management was just the beginning of a broader transformation. By 1990, under the leadership of Prime Minister Margaret Thatcher, the NHS underwent a major reform with the passage of the NHS and Community Care Act. This legislation brought the concept of the “internal market” into the NHS, fundamentally changing the way healthcare services were purchased and provided.
The internal market created a clear distinction between two key roles: purchasers and providers. Health authorities, and later GP fundholders, were designated as the “purchasers” of healthcare services. These entities were responsible for commissioning services on behalf of local populations, essentially acting as buyers of care. On the other side, hospitals, community health services, and other healthcare providers became the “providers” in the system, competing against one another for contracts to deliver services.
This market-based approach led to a competitive environment where providers had to meet certain standards and prove their value to secure contracts, while purchasers sought the best quality and value for money in the services they commissioned. The introduction of the internal market effectively separated the functions of commissioning and provision, a distinction that would go on to shape the structure of the NHS for decades to come.
The legacy of this division between commissioning and provision is still evident in the current NHS structure, where Clinical Commissioning Groups (CCGs) and other commissioning bodies are responsible for procuring services, while hospitals and other healthcare providers focus on delivering care. While the internal market has undergone various modifications and reforms over the years, the fundamental separation of commissioning and provision remains a defining feature of the NHS.
When the Labour government, led by Tony Blair, came to power in 1997, it sought to strike a balance between maintaining the concept of commissioning while reasserting public accountability within the NHS. Blair’s government aimed to ensure that the NHS remained publicly accountable and was focused on improving patient care, but without abandoning the principles of commissioning that had been introduced in the previous decade.
In 1999, a key step in this direction was the establishment of Primary Care Groups (PCGs). These new entities, led by General Practitioners (GPs), were designed to take on the responsibility of commissioning local health services. The PCGs were intended to bring more locally driven, clinically led decision-making into the commissioning process, with GPs directly involved in shaping the health services available in their communities. This was seen as a move towards decentralising decision-making and allowing for more tailored, responsive healthcare provision.
In 2002, the role of PCGs was further expanded and formalised with the creation of Primary Care Trusts (PCTs). This transition granted PCTs greater autonomy and control over a much larger portion of the NHS budget, estimated at around 75%. The shift from PCGs to PCTs marked a significant expansion in the scope of their responsibilities. Whereas PCGs had been limited primarily to commissioning primary care services, PCTs were given a broader mandate to commission a full range of healthcare services, including primary care, community health services, and even secondary care, such as hospital services.
This increase in responsibility allowed PCTs to have a more comprehensive view of the local health needs and to plan and purchase services accordingly. It also meant that they had greater control over how resources were allocated, enabling them to take a more strategic approach to healthcare delivery in their regions. At their peak, there were 303 PCTs across England, each with its own local health priorities and commissioning strategies.
The PCTs played a crucial role in the functioning of the NHS during this period, driving local health policy, managing budgets, and ensuring that health services were delivered in accordance with local needs. However, over time, PCTs faced criticism for inefficiencies and for being overly bureaucratic. In 2013, as part of a wider reorganisation of the NHS under the Health and Social Care Act, PCTs were dissolved and their responsibilities transferred to new bodies, including Clinical Commissioning Groups (CCGs), marking the end of the PCT era. Despite this, the legacy of the PCTs remains in the ongoing emphasis on local commissioning and public accountability within the NHS.
In 2006, as part of ongoing efforts to streamline the National Health Service (NHS) and reduce administrative complexity, the Labour government introduced significant reforms that reshaped the structure of Primary Care Trusts (PCTs) and created new oversight bodies known as Strategic Health Authorities (SHAs). The goal was to make the system more efficient, reduce bureaucratic overhead, and improve the delivery of healthcare services.
Under this restructuring, the number of Primary Care Trusts was significantly reduced from the previous high of 303 to just 152. This reduction was part of a broader effort to consolidate resources, eliminate duplication, and foster greater collaboration across local health services. The intention was to create more manageable and effective regional bodies that could focus on their core responsibilities of commissioning and delivering healthcare services, while reducing the fragmentation that had arisen due to the large number of PCTs.
Alongside this reduction in the number of PCTs, the creation of Strategic Health Authorities (SHAs) was a pivotal part of the reform. A total of 10 SHAs were established across England to oversee and coordinate the work of the PCTs. SHAs were given a broader strategic role, ensuring that healthcare provision across entire regions was aligned with national priorities and policies, while also supporting the PCTs in achieving their objectives. Each SHA acted as an intermediary body between the Department of Health and the individual PCTs, providing guidance, monitoring performance, and ensuring that resources were being used effectively.
The creation of SHAs was aimed at reducing the administrative burden at the local level, allowing the PCTs to focus more on direct healthcare delivery and commissioning. By centralising certain strategic functions and oversight at the SHA level, the government hoped to create a more streamlined and coherent structure, capable of making faster decisions and responding to the evolving needs of local populations.
This restructuring was seen as a necessary step towards improving the NHS’s efficiency and ensuring that health services were managed in a way that would deliver better outcomes for patients, while also reducing unnecessary overhead costs. However, as with many reforms in the NHS, the impact of these changes was debated, with some critics arguing that the administrative simplification may have led to a loss of local accountability and decision-making power. Nonetheless, this restructuring marked a significant moment in the ongoing evolution of the NHS and its approach to managing healthcare delivery across the country.
Arguably, the most significant post-war reorganisation of the National Health Service (NHS) occurred with the passage of the Health and Social Care Act 2012, a landmark piece of legislation spearheaded by Andrew Lansley, then Secretary of State for Health. This reform fundamentally reshaped the structure of the NHS, aiming to increase efficiency, introduce greater competition, and shift the focus toward clinically led decision-making.
A central feature of the Health and Social Care Act was the abolition of Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs), two key bodies that had been responsible for commissioning and overseeing healthcare services. In their place, a new system was created in which Clinical Commissioning Groups (CCGs), largely led by General Practitioners (GPs) and other clinicians, would take on the responsibility of commissioning the majority of healthcare services. This shift was designed to put healthcare decision-making directly in the hands of professionals with clinical expertise, who could make more informed choices about the services their local populations needed.
Alongside the introduction of CCGs, NHS England was established as a new non-departmental public body. NHS England took on the critical role of overseeing the commissioning process, ensuring that health services were delivered effectively, and maintaining overall accountability for NHS performance. This central body was tasked with monitoring CCGs, setting national standards, and ensuring that the delivery of services was aligned with the broader objectives of the NHS.
To further integrate health and social care services, Health and Wellbeing Boards were created within local authorities. These boards brought together local leaders from health and social care sectors to collaborate on planning, ensuring that health and social care services were more closely aligned to meet the needs of local communities. The goal was to break down traditional silos between health and social care, creating a more holistic approach to service delivery that took into account the full spectrum of individual and community needs.
One of the most controversial elements of the reform was the encouragement of the private sector to compete for NHS contracts. Under the “Any Qualified Provider” (AQP) model, healthcare providers, including private companies, could enter into competition to deliver services, provided they met a set of minimum quality standards. This model aimed to introduce competition and market forces into the NHS, with the belief that this would drive efficiency and improve service quality. However, it also led to concerns about privatisation and the potential for undermining the public nature of the NHS.
At the time of their inception, there were 211 Clinical Commissioning Groups (CCGs) across England, each tasked with commissioning healthcare services for their local populations. Together, these CCGs held control over approximately £65 billion of NHS funding, marking a significant decentralisation of financial responsibility and decision-making. The goal was to create a more locally focused approach to healthcare provision, where decisions were made closer to the communities they served.
While the Health and Social Care Act 2012 was intended to modernise the NHS, increase efficiency, and improve the quality of care, it sparked considerable debate and controversy. Supporters argued that the reforms would lead to more responsive and innovative healthcare delivery, while critics feared that the increased role of the private sector and the shift toward competition might undermine the principles of universal access and equity that the NHS was founded on. Nonetheless, the Act represents one of the most transformative and contentious reorganisations of the NHS in its history.
The most recent significant shift in the structure of the NHS occurred with the Health and Care Act 2022, which marked a dramatic return to collaboration and integration, moving away from the competitive model that had been introduced by the Health and Social Care Act 2012. This reform aimed to address longstanding challenges within the NHS, such as health inequalities, fragmented care, and a lack of coordination between health and social services. The Act sought to create a more unified, patient-centered approach to service delivery.
A key feature of the Health and Care Act was the abolition of Clinical Commissioning Groups (CCGs), which had been responsible for commissioning healthcare services at the local level. The shift away from CCGs reflected a desire to move towards a more integrated and collaborative system that placed greater emphasis on the collective delivery of care, rather than individual commissioning bodies operating in silos.
In their place, the Act placed Integrated Care Systems (ICSs) on a statutory footing. ICSs are partnerships that bring together NHS organisations, local authorities, and other key stakeholders to work collectively in the planning and delivery of health and care services. These systems are designed to foster collaboration across sectors, enabling the delivery of more coordinated care that is tailored to local needs.
Within each ICS, two key entities were created to oversee and manage the delivery of services:
Integrated Care Boards (ICBs): These bodies are responsible for the oversight of NHS budgets and the planning of healthcare services within the ICS. ICBs are accountable for ensuring that the resources allocated to the NHS are spent effectively and that health services are planned in a way that meets the needs of local populations. They work to align priorities across the NHS and other local organizations to deliver high-quality, integrated care.
Integrated Care Partnerships (ICPs): These partnerships bring together a range of stakeholders, including local authorities, NHS bodies, and other service providers, such as social care, public health, and voluntary organizations. ICPs are designed to promote joint working and collaboration between these diverse groups, ensuring that care is delivered in a holistic, person-centered way. By bringing together various sectors, ICPs aim to break down barriers between health and social care, making services more integrated and accessible to communities.
The new model established by the Health and Care Act is focused on addressing health inequalities, integrating care, and ensuring that services are delivered in a way that is responsive to local needs. By placing greater emphasis on collaboration and partnership, the government aims to reduce disparities in health outcomes, improve service coordination, and ensure that care is delivered closer to communities. This integrated approach is intended to help prevent illness, support people to live healthier lives, and provide more effective care when it is needed.
As of 2025, 42 ICSs are operational across England, each working to improve the health and wellbeing of their local populations through more coordinated, collaborative approaches. These systems represent a shift away from the fragmented, competitive structures of the past and are designed to bring together different parts of the healthcare system to deliver more holistic, seamless care for individuals and communities.
The NHS has never stood still. From PCTs to CCGs to ICSs, every reform has attempted to solve challenges of efficiency, integration, and sustainability — yet often brought new complexities. General practice and primary care have remained at the heart of commissioning and delivery, despite increasing centralisation and shifting responsibilities.
Understanding this history helps us make sense of today’s NHS. It reminds us that while organisational charts may change, the values underpinning the NHS — universality, equity, and free access — must remain constant.