Structure of the NHS & NHS Politics
Who runs the NHS, who pays for it, and why the whole map keeps being redrawn. A trainee's survival guide to the machinery behind the consulting room door.
π₯ Downloads
Useful downloads for learning, teaching, or last-minute rescue revision β all in one place.
π Web Resources
A hand-picked mix of official guidance and real-world GP training resources. Because sometimes the best pearls are not hiding in the official documents.
ποΈ Core Official Guidance
π GP Contract & Primary Care
π Trainee-Friendly Explainers
π₯ Profession & Representation
π History & Big Picture
β‘ Quick Summary β One-Minute Recall
If you only read one section before your next tutorial, AKT, or polite dinner-party argument β read this.
1Three founding principles
Since 1948: comprehensive, universal, free at the point of delivery, based on clinical need not ability to pay. Funded mostly from general taxation, not insurance.
2Four UK systems
England, Scotland, Wales and Northern Ireland each run their own NHS. They share the name and the ideals, but the structure, pay and guidance can differ.
3Everything is being rewired
NHS England is being abolished and merged back into the DHSC, with legal abolition targeted for April 2027. ICBs are being halved in running cost and many are merging. The 10 Year Health Plan is pulling care into the community.
4The three big shifts
Hospital β Community. Analogue β Digital. Sickness β Prevention. These are the headlines driving every reform you'll see for the next decade.
5GPs are independent contractors
Most GPs are not NHS employees. Practices hold contracts (GMS, PMS, or APMS) with NHS commissioners to deliver services.
6PCNs bring practices together
Primary Care Networks are groups of practices covering ~30,000β50,000 patients. They unlock extra staff through the ARRS and form the building block of "neighbourhood health".
7Know your three acronyms
LMC = local representative body for GPs. BMA/GPC = the trade union. RCGP = the professional college (standards, training, exams). Different jobs. Don't mix them up.
8GP services are free to almost everyone
Anyone in England can register and consult a GP without charge β regardless of immigration status. Secondary care charging rules are completely different.
π€ Why This Matters in GP
You might be tempted to think NHS structure is dry bureaucracy. But it shapes almost everything in your working day:
In the consulting room
Patients ask you why they can't get a hospital appointment, why their drug isn't funded, why they have to pay for a private scan, or why the surgery closed down the road. Knowing the structure lets you answer without blagging.
In the exam room
About 10% of AKT marks (~16 questions) come from the "Organisational" domain. Candidates consistently under-prepare for this and lose easy marks on a finite, learnable topic.
In your career
Partner? Salaried? PCN clinical director? Portfolio GP? LMC rep? The structure decides how you are paid, what you can claim, who you answer to, and where your voice is heard.
In your professional safety
Know who to ring when things go wrong β CQC, GMC, MDU/MPS, LMC, ICB, NHS Resolution. Each has a different job. Getting the wrong one wastes weeks.
π‘ The honest truth
The NHS has been reorganised so many times that GPs joke they've stopped learning the names. But each reorganisation changes something real β your contract, your referral pathways, your funding, your ability to complain. Learn the current map. Ignore the dead acronyms (PCTs, CCGs, SHAs). Keep an eye on the new ones.
π NHS History & Founding Principles
Where it all came from β and why the founding ideas still shape every GP consultation.
The three founding principles (1948)
Launched by Aneurin Bevan on 5 July 1948 at Park Hospital, Manchester (now Trafford General), the NHS was built on three simple ideas that still quietly shape your clinic today:
π‘ Why this still matters
Every time you see a patient who hasn't paid anything, who isn't asked for insurance, who isn't turned away β you are practising the Bevan principles. These are not just history. They explain why UK general practice feels different from almost every other country in the world.
An NHS timeline every GP trainee should know
ποΈ The Current Structure of the NHS in England
From Parliament down to your consulting room. One map, six layers.
The NHS in England is a layered system. Money and instructions flow downwards; data and accountability flow upwards. Here is the simplified map as it stands in 2026 β and note that it is changing fast. The top two levels are being merged.
Know the key acronyms
π΄σ §σ ’σ ³σ £σ ΄σ Ώ The Four UK Systems
One NHS, four systems. The MRCGP is a UK-wide exam β so know the differences.
Since devolution, health is run separately in each of the four UK nations. They share the ideals but differ in structure, contracts, and some clinical guidance.
| Nation | NHS body | Key structural features | Guidance body |
|---|---|---|---|
| England | NHS England (being abolished) β DHSC | ~26 ICBs, PCNs, GMS/PMS/APMS, QOF | NICE |
| Scotland | NHS Scotland | 14 regional Health Boards. No PCNs. 2018 GMS contract. QOF abolished 2016 (replaced by GP Clusters). | SIGN + NICE |
| Wales | NHS Wales / GIG Cymru | 7 Local Health Boards. QOF still in place but has been adjusted. | NICE + AWMSG |
| Northern Ireland | HSC Northern Ireland (Health & Social Care) | Integrated health and social care system β unique in the UK. 5 HSC Trusts. | NICE (adopted selectively) |
π AKT implication
The RCGP explicitly states that structural and administrative differences between the four nations are taken into account when writing AKT questions. Some questions will even test this. For example: QOF exists in England and Wales but not Scotland. ICBs exist only in England. HSC integrates health and social care only in Northern Ireland. SIGN guidelines originate in Scotland.
π¨ The Big 2025β2027 Shift β What Every Trainee Must Know
The most significant NHS reorganisation since 2012. It's already happening.
In March 2025 the government announced a major shake-up. On 3 July 2025 it published the 10 Year Health Plan for England β "Fit for the Future". Here is what has actually changed, and what is coming:
π¨ NHS England is being abolished
Its functions are being merged back into the Department of Health & Social Care. Legal abolition is targeted for April 2027 (subject to legislation), with the combined headcount set to fall by around 50%. This reverses a decade of arm's-length separation between politicians and the NHS.
π¨ ICBs are being cut and merged
ICB running costs must be cut by 50%. Most ICBs have formed "clusters". The first formal mergers take effect on 1 April 2026, reducing 42 ICBs down to around 26. Further mergers are planned for 1 April 2027. ICBs are being repositioned as strategic commissioners.
π¨ Integrated Care Partnerships are being wound down
The 10 Year Health Plan signalled the intent to abolish ICPs, with their population-health and partnership role moving primarily to health and wellbeing boards and local government. Formal abolition requires legislation; in the meantime ICPs remain a statutory requirement and new ICPs will still be established alongside new ICBs in April 2026 until the law changes.
β οΈ Other bodies being closed or reviewed
The reforms are also closing or restructuring a range of NHS-adjacent organisations β including Healthwatch England and local Healthwatch branches, Commissioning Support Units (CSUs), the Health Services Safety Investigations Body (HSSIB), and the National Guardian's Office β as part of a wider effort to reduce duplication across the health system.
The "Three Big Shifts"
All reform rhetoric for the next decade will be framed around these three shifts. Learn them β they are the skeleton key to understanding almost every policy announcement you will read:
What this means for general practice
- More work in the community. A greater share of outpatient appointments, diagnostics, rehab and post-operative care will move into local settings β and much of this lands in primary care.
- Neighbourhood health centres. New community hubs housing GPs, nurses, physios, social care, mental health, debt advice and lifestyle services under one roof. 43 pilot sites were announced in September 2025.
- Contract reform. A full renegotiation of the national GP contract is planned within this parliament. The Carr-Hill formula (which weights GP funding) is being reformed.
- Digital by default. The NHS App is being expanded so patients can self-book, self-refer, see their record, and rate their care by 2028.
- More GPs. The government reports 1,700 extra GPs recruited between October 2024 and April 2025, with plans to train thousands more.
π‘ A word of healthy scepticism
Every decade delivers a big NHS plan promising transformation. Some succeed in part; most partially run out of steam. As a trainee, learn the current language and structure β it's what the AKT and your ICB will test you on β but don't be surprised if the map changes again before you CCT.
π° Follow the Money β How NHS Funding Flows
Who gets the money, and who decides how it's spent.
The Department of Health & Social Care had a budget of around Β£192 billion in 2024β25, most of which was spent on the NHS in England. That's roughly 10% of UK GDP. Here's how that money actually reaches your patient:
Roughly how the pot is spent
π‘ The uncomfortable truth behind "shifting resources"
Everyone agrees care should move into the community. But hospitals absorb around half the NHS budget and have the strongest political voice. Shifting just 1% of hospital spend into primary care would transform general practice β and that's the unspoken battle behind the 10 Year Plan.
π GP Contracts β GMS vs PMS vs APMS
The three ways a practice can be contracted to deliver NHS primary care.
Unlike most NHS staff, GPs (and their practices) are independent contractors. They hold a contract with an NHS commissioner (currently the ICB) to deliver services. There are three main contract types:
| Feature | GMS | PMS | APMS |
|---|---|---|---|
| Full name | General Medical Services | Personal Medical Services | Alternative Provider Medical Services |
| Who can hold it? | GP partners, partnerships, limited companies of GPs | GPs, NHS employees, or limited companies of either | Almost any provider β GPs, private companies, social enterprises, voluntary sector |
| Negotiated where? | Nationally (NHS England + BMA GPC England, annually) | Locally with the ICB β based on GMS but flexible | Locally β highly flexible |
| Duration | Open-ended (indefinite) | Open-ended (indefinite) | Time-limited (usually 5β10 years) |
| Approx share of practices (England) | Around 70% | Around 25β29% | Around 3β4% |
| Typical use case | Standard practice | Historic local adjustments, special populations, enhanced services | Asylum seekers, homeless, specialist populations, practices taken over after closure |
- GGMS = GOLD standard. The national default. Most practices. Negotiated nationally.
- PPMS = PERSONAL tweak. Locally adjusted. Same core, but with local wrinkles.
- AAPMS = ALTERNATIVE provider. For anyone who isn't a traditional GP partnership. Time-limited.
The structure of GP income
A GP practice's income is usually built in layers:
- Global sum β a core payment per registered patient, weighted by the Carr-Hill formula (which takes account of age, sex, rurality, and workload).
- Quality and Outcomes Framework (QOF) β pay for achieving clinical and organisational indicators (e.g. blood pressure control, cancer screening).
- Directed Enhanced Services (DES) β national optional extras (e.g. seasonal flu, childhood immunisations, the Network Contract DES).
- Locally Enhanced Services (LES) β extras commissioned locally by the ICB or local authority.
- Network Contract DES payments β flowing via the PCN (core PCN funding, ARRS, Enhanced Access, Capacity & Access payments).
- PMS baseline (if PMS) β a locally-agreed supplement in place of some GMS elements.
- Item-of-service payments β per-item fees (e.g. maternity services, vaccinations).
π Key contract concepts you should recognise
Core hours: 8.00amβ6.30pm Monday to Friday (excluding bank holidays). Practices must provide essential services during these hours β and from 2025β26, keep online consultation tools open during them too. Clinically urgent requests must be dealt with on the same day.
Essential services: mandatory for all practices β managing illness, health advice, referral, and care of registered patients and temporary residents.
Out-of-hours (OOH): most practices opted out of OOH provision under the 2004 contract. Their list size is adjusted by an OOH deduction per weighted patient.
CNSGP: the Clinical Negligence Scheme for General Practice β a state-backed indemnity scheme introduced in April 2019 covering NHS clinical negligence liabilities for GP practices and their staff in England. It does not cover private or non-NHS work, GMC fitness to practise investigations, disciplinary or regulatory matters, coroner's inquests, or Good Samaritan acts β for those you still need an MDO (MDU / MPS / MDDUS).
π PCNs & ARRS β The Engine of Neighbourhood Care
Groups of practices working together β and how extra staff get funded.
Primary Care Networks (PCNs)
PCNs launched in July 2019 under the Network Contract DES. They are groups of GP practices β usually 5β15 practices β covering a combined population of typically 30,000 to 50,000 patients. Almost every GP practice in England is part of one.
Each PCN:
- has a Clinical Director (CD) β usually a GP β who leads and represents the network.
- signs a Mandatory Network Agreement setting out how member practices will work together.
- has a nominated payee β one member practice that receives and distributes PCN funding.
- receives funding linked to its adjusted population β including core PCN funding, Enhanced Access payments, Capacity & Access Support Payments, Care Home Premium, and the ARRS.
The Additional Roles Reimbursement Scheme (ARRS)
The ARRS is the scheme that lets PCNs recruit additional staff at no direct cost to the practices β the salary and on-costs are reimbursed up to a maximum amount per role. It was designed to expand the wider primary care workforce.
π― Key 2025β26 ARRS changes
- The separate "GPs in ARRS" pot has been merged into the main ARRS β one single pot for all roles.
- Practice nurses are now eligible under ARRS for the first time.
- No caps on numbers or types of staff within a PCN's total allocation.
- Maximum GP salary reimbursement rose from Β£73,113 (2024β25) to Β£82,418 (2025β26), rising again to Β£118,759 for 2026β27 (Β£120,921 in London).
- PCNs are now required to use risk-stratification tools to identify patients needing continuity of care.
Typical ARRS roles
β οΈ A live debate
The expansion of ARRS has been controversial. Supporters see it as essential to grow the wider primary care team. Critics argue it has led to practices employing physician associates or pharmacists in roles that really needed a GP, and that it has undercut substantive GP employment. A joint review of ARRS is underway through 2025β26 and may reshape the scheme for 2026β27 and beyond.
π₯ Who's Who in GP Politics β Untangling the Alphabet Soup
Trainees mix these up all the time. Here is the plain-English version.
People often confuse the LMC, the BMA, the RCGP, the CQC and the GMC. They do completely different jobs. Here's the map:
| Body | Role | When you'll meet them |
|---|---|---|
| LMC (Local Medical Committee) |
Local statutory representative body for GPs (partners, salaried, locums, trainees). Advises on local contract issues, supports GPs in difficulty, negotiates locally with the ICB. Recognised in law. | When there's a local dispute, you're worried about a patient complaint, or a partner wants to work out if a PCN decision is reasonable. |
| BMA (British Medical Association) |
The doctors' trade union. Its GPC England negotiates the national GP contract with government. Campaigns on pay and conditions. | Pay disputes, employment contract issues, industrial action, national contract negotiations. |
| RCGP (Royal College of GPs) |
The professional college. Sets the curriculum, runs MRCGP exams (AKT, SCA, WPBA), produces clinical guidance, awards Fellowship. | Throughout your training. Every exam you sit is RCGP-run. |
| GMC (General Medical Council) |
The regulator of doctors. Holds the medical register. Sets Good Medical Practice. Handles revalidation and fitness to practise investigations. | Registration, revalidation, and (hopefully never) concerns about a doctor's practice. |
| CQC (Care Quality Commission) |
The regulator of services β practices, hospitals, care homes. Inspects against Safe, Effective, Caring, Responsive, Well-led. | CQC inspection of your practice (usually every 3β5 years, sooner if concerns). |
| MDU / MPS / MDDUS | Medical defence organisations. Provide professional indemnity for non-NHS work, support during GMC investigations, coronial inquests, disciplinary matters. Give medico-legal advice. | Patient complaint, serious incident, GMC letter, SUI, coroner's inquest, media enquiry. |
| NHS Resolution | The body that handles clinical negligence claims for NHS work (including CNSGP for GPs). | If a clinical negligence claim is made against you for NHS work. |
| NICE | Produces national clinical guidance, guidelines, quality standards and technology appraisals. Technology appraisals carry a statutory funding requirement within 90 days; clinical guidelines are strongly expected to be followed but are not legally mandated. NICE CKS is the GP-friendly summary. | Daily. Every management decision you make is shaped by NICE. |
| ICB | Your local NHS commissioner. Holds your contract (if GMS), allocates funding, commissions local services, performance-manages primary care. | Contract variations, local enhanced services, complaints pathways, primary care development. |
- RRepresent me β LMC (locally), BMA (nationally, with teeth).
- TTrain me β RCGP (curriculum and exams).
- RRegulate me β GMC (the doctor) + CQC (the service).
- DDefend me β MDU / MPS / MDDUS + NHS Resolution (for CNSGP).
- CCommission me β ICB (gives me the contract and the money).
π‘ LMC and BMA: not the same thing
A very common confusion. The LMC is a statutory local representative body that represents all NHS GPs in an area β whether they are BMA members or not. The BMA is the national trade union, with individual membership. The two work closely together: LMCs feed into the BMA's GPC England via the annual Conference of LMCs. But they are separate organisations with different funding and different roles.
π Trainees and the LMC
Your LMC welcomes GP trainee representation. Many LMCs have a specific "GP trainee representative" role β often by co-option rather than election β so you can attend meetings, bring back intelligence to your VTS, and learn how GP politics actually works. If you want to understand general practice beyond the consulting room, this is the single best thing you can do as a trainee.
π Overseas Visitors & NHS Entitlement
Who gets what for free β and where the boundaries actually sit.
This comes up on the AKT, in exam-style organisational questions, and β more importantly β in real clinic. Here's the rule that catches most trainees out:
π© The single most important rule
GP services are not included in the overseas visitor charging regulations. Anyone physically present in England may register with a GP and consult without charge β regardless of nationality, immigration status, or length of stay. This includes asylum seekers, refugees, undocumented migrants, and short-term visitors.
The charging rules apply only to secondary (hospital) care and some community services. Do not confuse the two.
Registering someone as a GP patient
- You don't need proof of address, ID, or immigration status to register. NHS England has been clear about this.
- A practice can only decline registration if the list is closed, the person lives outside the practice boundary, or there are other reasonable grounds β and the refusal must be given in writing within 14 days with the reason recorded.
- If someone will be in the area for 24 hours to 3 months, they can be a temporary resident. Longer than 3 months β permanent registration.
- Registration with a GP does not automatically entitle someone to free hospital care.
Secondary care β the "ordinary residence" test
Services always free β regardless of immigration status
- GP and other primary medical services (including consultations and referrals).
- Treatment in an A&E department β free up to the point of admission as an inpatient or referral to an outpatient appointment. Care given after admission (including via Same Day Emergency Care) may then be chargeable if the person is not entitled to free care.
- Family planning and contraception services.
- Diagnosis and treatment of specified infectious diseases (e.g. TB, HIV β the full list is in the charging regulations).
- Diagnosis and treatment of sexually transmitted infections.
- Treatment for physical or mental illness caused by torture, FGM, or domestic/sexual violence.
- Compulsory treatment under mental health legislation.
- Maternity care β must never be delayed or denied even if chargeable; payment is pursued separately.
- Palliative care provided by a registered palliative care charity or community interest company.
Groups always entitled to free secondary care
- People "ordinarily resident" in the UK (the main route).
- Refugees and asylum seekers whose applications are being considered (and failed asylum seekers in some circumstances).
- Victims of modern slavery identified by the National Referral Mechanism.
- Looked-after children, prisoners, immigration detainees, UK armed forces members.
- Those covered by a reciprocal healthcare agreement (e.g. EU visitors with a valid EHIC for emergency care).
- Those who have paid the Immigration Health Surcharge (IHS) as part of a visa.
β οΈ Important nuance: the GP's role
When you refer a patient for secondary care, you refer on clinical grounds alone. It is not your job to assess eligibility β the receiving hospital's Overseas Visitor Manager (OVM) does that. But do note it on the referral, because the hospital may ask the patient about their status.
π³οΈ NHS Politics in Plain English
The big tensions every GP will encounter β and why they never fully resolve.
NHS politics is not just about political parties. It's about the unresolvable tensions built into the system itself. Most NHS debates boil down to a small number of recurring tugs-of-war:
π’ Centralisation vs devolution
Should the NHS be run from Whitehall with tight targets, or devolved to local systems that know their populations? The pendulum has swung back and forth for 40 years. The 2025 reforms pull both ways β abolishing NHS England (centralising) but handing ICBs stronger strategic commissioning (devolving).
π΅ Hospital vs community
Hospitals soak up the money. Community care needs it. Every plan for 30 years has promised to shift resources β and every plan has been partly defeated by political pressure to keep hospitals afloat. The 10 Year Plan is the latest attempt.
π State vs independent contractor
GPs are still independent contractors β a 1948 compromise with the BMA. Every few years, governments consider moving GPs to salaried status. Every few years, the profession resists. The current direction is to keep partnership but offer alternative at-scale models.
π£ Rationing β openly or silently?
The NHS cannot fund everything for everyone. Rationing happens constantly β waiting lists, NICE thresholds, prescribing formularies, referral criteria, IFRs (Individual Funding Requests). The political question is whether to admit this openly or keep the pretence of unlimited access.
The private sector and the NHS
Private healthcare has always existed alongside the NHS β about 8% of the UK population has private cover, usually as an add-on. The 10 Year Health Plan explicitly signals a "plurality of provision": more blurring of boundaries, including more use of the private sector for waiting list reduction and potentially more mixed NHS/private pathways.
π© The rule to remember: no subsidising private care with NHS money
NHS bodies cannot subsidise private healthcare, directly or indirectly. Patients can choose to go private at any time β but must fund the private part entirely themselves. Care should be "clearly separate". This comes up in AKT organisational questions surprisingly often.
The "Red Tape Challenge" and GP workload
The 2025 reforms promise to reduce bureaucratic workload in general practice β through cloud-based telephony, AI "scribe" voice technology rolling out in 2026β27, single sign-on, the Single Patient Record, and a reworked approach to hospitalβGP communication. None of it is magic. But collectively it aims to liberate roughly 10% of clinician time.
π₯ AKT High-Yield Points β Organisational & NHS Structure
Around 10% of AKT marks (~16 questions) come from the organisational domain. This is a small, finite, high-yield area. If you memorise the facts in this section you are likely to collect several marks most trainees lose.
π― Why this section matters for the AKT
Clinical questions feel endless. Organisational questions are from a contained pool β there are only so many facts about NHS structure, contracts, commissioning, regulation and medico-legal frameworks. Trainees consistently under-prepare for this domain and lose easy marks. RCGP examiner feedback highlights this repeatedly. Spend targeted time here β it is one of the most efficient places to pick up marks in the exam.
π Commonly tested facts β learn these cold
1. The founding principles (1948)
- Three principles: comprehensive, universal, free at the point of delivery based on clinical need not ability to pay.
- Funded primarily from general taxation β not from an insurance scheme.
- Launched 5 July 1948 by Aneurin Bevan at Park Hospital, Manchester.
- GPs remained independent contractors, not salaried employees.
2. Key organisations and their jobs (the "who does what" staple)
- DHSC β government department. Led by Secretary of State for Health & Social Care.
- NHS England β arm's-length body (being merged back into DHSC by 2027).
- NICE β produces national clinical guidelines and technology appraisals. Technology appraisals carry a legal funding requirement for the NHS (within 90 days); clinical guidelines are strongly expected but not legally binding.
- CQC β regulator of services (practices, hospitals, care homes). Five Key Questions: Safe, Effective, Caring, Responsive, Well-led.
- GMC β regulator of doctors. Medical register, revalidation, fitness to practise.
- MHRA β Medicines and Healthcare products Regulatory Agency (drug and device safety; Yellow Card scheme).
- NHS Resolution β handles NHS clinical negligence claims, including CNSGP for GPs.
- HSSIB (being closed) β national investigations of patient safety incidents.
- Healthwatch (being closed) β patient and public voice.
3. Current structure β the 2026 picture
- NHS England is being abolished, merging into DHSC β legal abolition targeted for April 2027 (subject to legislation).
- 7 NHS regions oversee ICBs and providers.
- 42 ICBs from 1 July 2022; reducing towards ~26 from April 2026.
- ICBs replaced CCGs (Clinical Commissioning Groups) in 2022.
- Before CCGs there were Primary Care Trusts (PCTs) (abolished in 2013).
- Each ICS = ICB + ICP (+ wider partners). ICPs remain a statutory requirement but are being wound down under the 10 Year Health Plan, with final abolition subject to future legislation.
- Primary care commissioning has been delegated to ICBs since April 2023.
4. The 10 Year Health Plan β "Fit for the Future"
- Published 3 July 2025.
- Three shifts: Hospital β Community Β· Analogue β Digital Β· Sickness β Prevention.
- Flagship: Neighbourhood health centres.
- Expanded NHS App as the "front door" to the NHS by 2028.
- Single Patient Record accessible to patients from 2028.
- Commitment to train thousands more GPs.
- Review of the Carr-Hill formula.
5. GP contract types
- GMS β national standard, ~70% of practices, negotiated yearly between NHS England and BMA GPC England.
- PMS β locally negotiated with ICB, ~25β29% of practices.
- APMS β flexible framework (any provider, including private/voluntary sector), ~3β4% of practices, time-limited.
- Core hours: 8.00amβ6.30pm MonβFri, excluding bank holidays.
- From 2025β26: clinically urgent requests must be dealt with same day; practices cannot cap online consultation volumes or tell patients to call back another day.
- CNSGP introduced 2019 β state-backed indemnity for NHS clinical negligence only.
6. Funding mechanics you should recognise
- Global sum β core per-patient payment, weighted by the Carr-Hill formula.
- QOF β Quality and Outcomes Framework (pay for performance).
- DES β Directed Enhanced Services (national optional extras).
- LES β Locally Enhanced Services (commissioned by ICB or local authority).
- Network Contract DES β funds the PCN (including ARRS).
- ARRS β Additional Roles Reimbursement Scheme, funds additional PCN staff.
- IIF β Investment and Impact Fund (PCN quality payments).
- GMS contract uplift 2025β26 = 8.9% (following the DDRB pay uplift).
7. Primary Care Networks (PCNs)
- Introduced July 2019.
- Typically cover 30,000β50,000 patients.
- Led by a Clinical Director (CD).
- Funded by the Network Contract DES.
- ARRS 2025β26: single pot for all roles, no caps, GPs and practice nurses now eligible.
- PCNs must use risk-stratification tools to identify patients needing continuity of care (2026β27).
8. Overseas visitor entitlement
- GP services are free to everyone β regardless of nationality or immigration status.
- Registration does not automatically confer secondary care entitlement.
- Secondary care eligibility = "ordinarily resident" in the UK.
- A&E treatment is free to all up to the point of admission or outpatient referral; care given after admission may become chargeable.
- Always free: family planning, TB, STIs, FGM-related care, torture/domestic/sexual violence, compulsory mental health treatment.
- Maternity care: must never be delayed or refused even if chargeable.
- Chargeable rate = 150% of NHS national tariff.
- Non-EEA migrants typically pay the Immigration Health Surcharge (IHS) upfront with their visa.
9. Four UK systems β differences
- England: NHS England (being abolished) + ICBs + PCNs + QOF.
- Scotland: 14 Health Boards; QOF abolished 2016; SIGN guidelines.
- Wales: 7 Local Health Boards; QOF in modified form; AWMSG for medicines.
- Northern Ireland: HSC β integrated health and social care (unique).
10. Representation & regulation β know the difference
- LMC = local statutory representative body (not a trade union).
- BMA = national trade union (negotiates contracts via GPC England).
- RCGP = professional college (curriculum, exams, standards).
- GMC = regulates doctors.
- CQC = regulates services.
- Classic trap: assuming BMA and LMC are the same. They are not.
π© Classic AKT traps on this topic
- Confusing GMC with CQC. GMC regulates doctors; CQC regulates services.
- Confusing NICE with NHSE. NICE produces guidance; NHSE commissions and oversees services.
- Thinking all GPs are NHS employees. Most are independent contractors working under GMS/PMS/APMS.
- Confusing GMS with PMS. GMS is national and standard; PMS is locally negotiated.
- Thinking GP registration gives secondary care entitlement. It does not.
- Thinking A&E treatment can be charged. A&E attendance is exempt; admission is different.
- Confusing ICB with ICP. ICB = statutory NHS body holding the money; ICP = wider partnership forum (being abolished).
- Thinking CNSGP covers everything. It covers NHS clinical negligence only β not GMC, not disciplinary, not private work, not coronial.
- Confusing NHS Resolution with NHS England. Different bodies, different jobs.
- Applying England rules to Scotland / NI. Structures and contracts differ. Read the stem carefully.
π Related organisational topics tested alongside NHS structure
Organisational AKT questions often blend NHS structure with adjacent areas. Be familiar with:
- DVLA fitness-to-drive rules (group 1 vs group 2; common conditions).
- Capacity, consent, and Gillick competence.
- Confidentiality and permissible disclosures (GMC guidance).
- GMC Good Medical Practice duties.
- Notifiable diseases and public health duties.
- Fit notes (Statement of Fitness for Work / Med 3).
- Screening programmes (what's national and when).
- Safeguarding (children and adults).
- Clinical governance & significant event analysis.
- Duty of Candour (statutory and professional).
- Revalidation β every 5 years. Based on annual appraisal with a Responsible Officer making the recommendation. Doctors in training revalidate through the ARCP process; their Responsible Officer is the Postgraduate Dean.
π Insider pearls from trainees who scored high
- Read RCGP AKT feedback reports from the last 2β3 exam sittings. Examiners routinely flag areas trainees got wrong β those areas tend to reappear.
- The organisational domain has only ~16 questions β but because the topic is finite, a focused weekend of revision can meaningfully lift your total score.
- Use the first few chapters of the Oxford Handbook of General Practice as a quick organisational refresher.
- Keep a one-page "organisational cheat sheet" β structures, contracts, regulators, overseas rules. Read it every day for the last week.
- Watch out for recency β the 2025 NHS England abolition and the 10 Year Health Plan are highly likely to feature in future AKT sittings.
π For Trainers & TPDs β Teaching NHS Structure
Ideas for tutorials, discussions, and trainee-led learning.
Common trainee blind spots
- They assume GPs are NHS employees β and are surprised to learn about the partnership model.
- They confuse the BMA and the LMC, the GMC and the CQC, and NHS England with the DHSC.
- They know the word "QOF" but can't explain how it actually changes behaviour in the consulting room.
- They don't realise GP services are free to overseas visitors.
- They don't know the difference between an ICB and an ICP β and with ICPs now being abolished, many will need updating.
- IMGs, in particular, may carry assumptions from other healthcare systems where primary care is structured completely differently.
Tutorial ideas
π‘ "Draw the map"
Ask the trainee to draw the NHS structure from memory on a whiteboard. Most will stumble after DHSC β NHSE β ICB. Use their stumbles as teaching points. Then redraw it together.
π‘ "Follow the complaint"
Present a scenario (e.g. a patient unhappy with your prescribing). Ask the trainee to trace every body that might become involved: PALS β ICB β ombudsman β CQC β GMC β MDO. This builds real-world understanding of what each does.
π‘ Visit the LMC
Arrange for the trainee to attend an LMC meeting. Most LMCs welcome trainee observers. It transforms understanding of GP politics in a single afternoon.
π‘ "Rewrite the 10 Year Plan for this practice"
Ask the trainee: if the three shifts (hospital β community, analogue β digital, sickness β prevention) are real, what would we actually change in this practice? Great for learning how national policy lands locally.
Reflective questions for trainees
- What kind of GP career model do you want β partner, salaried, locum, portfolio? How does the structure shape each?
- Who would you ring if you received a GMC letter? Why not the BMA first?
- What would you do if the ICB refused funding for a treatment recommended in a NICE technology appraisal?
- How would you explain "why the NHS is free but dentistry isn't" to a patient?
- If ICPs are being abolished, where does population health leadership go next?
- What do you think will be different about being a GP in 10 years β and what will still be the same?
Linking to the RCGP curriculum
This topic sits squarely within the Professional Topic Guides, particularly The GP Consultation in Practice, Improving Quality, Safety and Prescribing, and the overarching Knowing Yourself and Relating to Others and Being a GP in the Wider Professional Environment themes. Excellent evidence for capabilities such as Organisational Management and Leadership, Making a Diagnosis/Making Decisions (particularly around referrals and resource allocation), and Community Orientation.
β Frequently Asked Questions
The questions trainees actually ask when the tutorial ends.
Is NHS England really being abolished?
Yes. The government announced in March 2025 that NHS England would be merged back into the Department of Health & Social Care. Legal abolition is targeted for April 2027 (subject to legislation), with the combined headcount reducing by around 50%. Many NHS England functions will transfer directly to DHSC; others will devolve to the seven NHS regions or to ICBs.
What's the difference between an ICB and an ICP?
An ICB (Integrated Care Board) is the NHS statutory body within an Integrated Care System β it holds the money and commissions services. An ICP (Integrated Care Partnership) is the wider partnership forum that brings together the NHS, local authorities and other partners to produce an integrated care strategy. Under the 10 Year Health Plan, the government intends to abolish ICPs and move their population health role to health and wellbeing boards β but this requires legislation, and for now ICPs remain a statutory requirement.
Why are GPs not NHS employees?
Because that was the deal cut in 1948. Bevan originally wanted GPs to be salaried. GPs, backed by the BMA, refused. The compromise β independent contractor status, paid per registered patient, working from practice-owned premises β has shaped British general practice ever since. The 10 Year Health Plan confirms the partnership model will be retained where it's working, but will sit alongside newer at-scale "neighbourhood" models.
Can a GP practice refuse to register someone?
Only on limited grounds: the practice list is closed to new patients, the person lives outside the practice boundary, or there are other reasonable grounds. Immigration status, lack of ID, or lack of proof of address are not valid reasons. Any refusal must be recorded and explained in writing to the patient within 14 days.
If a patient doesn't have ID, must I register them?
Yes. NHS England has been very clear that proof of address or identity is not required to register. Asylum seekers, refugees, undocumented migrants, people who are homeless, and overseas visitors can all register without charge. Any practice policy that says otherwise is not in line with national guidance.
What is ARRS and why is it controversial?
The Additional Roles Reimbursement Scheme funds PCNs to recruit additional staff β pharmacists, paramedics, mental health practitioners, physician associates and, since 2025β26, GPs and practice nurses. It has significantly expanded the primary care workforce but has been criticised for potentially undercutting substantive GP employment and for inconsistent deployment of roles. A national review of ARRS is running through 2025β26.
What's the difference between the BMA and the LMC?
The BMA is the national doctors' trade union (membership-based). Its GPC England arm negotiates the national GP contract. The LMC is the local statutory representative body for all NHS GPs in an area β regardless of BMA membership. LMCs are funded by a levy on practices. They work closely with the BMA but are separate organisations. A common AKT trap.
Who do I call if something goes wrong?
It depends on what has gone wrong.
- Clinical error or complaint? Call your MDO (MDU / MPS / MDDUS) first. They will guide you.
- Patient complaint escalating? LMC can advise, PALS can help the patient, ICB handles formal complaint processes.
- GMC letter? MDO immediately. Do not respond first and then tell them.
- Coronial matter? MDO again β for support at inquest.
- Clinical negligence claim for NHS work? Goes through NHS Resolution (under CNSGP). Your MDO still supports you.
- CQC concern? The practice management team and the CQC's practice contact. MDO if there's a medico-legal dimension.
What will the NHS look like in 5 years?
Nobody knows for certain. But several directions are clear: fewer, bigger ICBs; neighbourhood health centres in every community; a much more powerful NHS App; AI scribes and ambient voice technology in clinics; a Single Patient Record; and a renegotiated GP contract. Expect a stronger central grip on performance (from DHSC) alongside more local delivery flexibility. Expect the hospital-to-community shift to be partial, contested, and slower than promised.
I'm an IMG β anything I specifically need to know?
Three things that often surprise IMGs:
- GPs are independent businesses, not government employees. Partnership is optional, salaried and portfolio work are common.
- GP services are free to everyone, regardless of status β this is very different from many health systems.
- Gatekeeping is real. UK GPs are the mandatory first point of contact for almost all NHS care (except emergencies, sexual health, and a few others). Patients cannot usually self-refer to specialists on the NHS.
For the AKT, give the organisational domain dedicated time. Many IMGs find this the most unfamiliar territory because the concepts (ICB, QOF, PCN, Carr-Hill, CNSGP) simply don't exist in other countries.
Is the NHS really in crisis?
"Crisis" is a loaded word. What is not in dispute: the NHS is facing record demand, record waiting lists, workforce shortages, an ageing population, and a widening gap between funding and need. General practice is under particular pressure, with GP numbers per patient having fallen over the past decade. The 10 Year Health Plan is the government's response. Whether it succeeds will depend on funding, workforce, and political will β and the AKT will not expect you to predict outcomes, only to understand the landscape.
β Final Take-Home Points
The bits to remember tomorrow morning.
- Three founding principles. Comprehensive. Universal. Free at the point of delivery, based on clinical need not ability to pay. Funded from general taxation. Since 5 July 1948.
- GPs are independent contractors. Not NHS employees. Most practices hold GMS (national), some hold PMS (local), a few hold APMS (flexible, time-limited).
- Know the current map. DHSC β (NHS England, being abolished) β 7 NHS Regions β ICBs (42 β ~26) β PCNs β practices. ICPs are going; health and wellbeing boards are rising.
- The three shifts shape the decade ahead. Hospital β Community. Analogue β Digital. Sickness β Prevention.
- PCNs power the wider team. 30,000β50,000 patients each. Funded via the Network Contract DES. The ARRS now covers GPs and practice nurses too.
- Don't confuse your acronyms. LMC represents. BMA negotiates. RCGP trains. GMC regulates doctors. CQC regulates services. MDO defends. NICE guides. ICB commissions.
- GP services are free to everyone. Regardless of immigration status. Secondary care charging is a completely separate system based on "ordinarily resident".
- Four UK systems, one name. Structure, contracts and some guidance differ between England, Scotland, Wales and Northern Ireland. The AKT tests these differences.
- Organisational AKT questions are low-hanging fruit. A finite topic worth ~10% of marks. Target it deliberately β don't leave it to the last week.
- NHS change never stops. Learn the current structure. Don't waste energy mourning the dead acronyms (PCTs, SHAs, CCGs). Watch for the next ones quietly forming.
How does the NHS in England work?
The NHS is a complexΒ system, which can sometimes make it difficult to understand β especially working out who is responsible for what. Itβs made up of a wide range of different organisations with different roles, responsibilities and specialities. These organisations provide a variety of services and support to patients and carers.