How the NHS Is Structured

Ask most NHS staff who their employer is and they'll say "the NHS." It's an understandable shorthand, but it isn't quite accurate — and the difference matters more than it might seem when you're trying to understand your contract, raise a grievance, move jobs, or work out what happens to your continuous service. "The NHS" is really a system of many separate organisations working to a shared national framework, not one single employer. This guide maps out how that system actually fits together, from national government down to your own workplace, based on the structure introduced by the Health and Care Act 2022 and now well established as of 2026.

The national level: DHSC and NHS England

At the top of the structure sits the Department of Health and Social Care (DHSC) — a UK government department, headed by the Secretary of State for Health and Social Care, that sets overall health policy, decides how much funding the NHS gets each year, and answers to Parliament for how the system performs. DHSC doesn't run hospitals or employ clinical staff directly; its role is setting direction and controlling the purse strings.

Below DHSC sits NHS England, the body responsible for the day-to-day operational leadership of the NHS in England — allocating funding to regions, setting national standards and priorities, and overseeing the performance of ICBs and Trusts. Since 2023, NHS England has taken on a considerably wider remit than it had a few years earlier: it absorbed the functions of NHS Digital (health data and technology) and Health Education England (HEE) (NHS workforce planning and training), following government decisions to consolidate several arm's-length bodies into a single organisation. The practical effect for staff is that workforce planning, technology and operational oversight now sit under one national umbrella rather than being split across separate bodies, though exactly how these functions are organised internally has continued to evolve, so treat this as the general shape rather than a precise organisational chart.

The regional level: Integrated Care Boards (ICBs)

Beneath NHS England, England is divided into a number of Integrated Care Boards (ICBs) — roughly 40 of them, though the exact count and boundaries can change as boards occasionally merge or realign, so treat any specific figure as approximate rather than fixed. Each ICB is a statutory NHS organisation responsible for planning and buying ("commissioning") health services for its local population, working alongside a linked Integrated Care Partnership that brings in local authorities and social care to plan more broadly for health and wellbeing across the area.

ICBs replaced Clinical Commissioning Groups (CCGs) — the GP-led bodies that had commissioned most local NHS services since 2013 — when the Health and Care Act 2022 came into force on 1 July 2022. The change moved commissioning from smaller, more numerous, GP-led CCGs to larger, more regionally consolidated ICBs intended to work more closely with social care and other partners under a single local plan.

Most frontline NHS staff don't work directly for an ICB — only a relatively small number of roles, mostly in commissioning, planning and public health, are ICB employees. But ICBs still matter to your working life indirectly: they influence which services get funded and prioritised in your area, and they oversee the Trusts and other providers that deliver care locally.

The employer level: Trusts, Foundation Trusts, GP practices and PCNs

This is the level that matters most directly for almost everyone reading this. The organisations that actually employ NHS staff — issue contracts, run payroll, manage HR processes, and appear as the name on your payslip — are:

• NHS Trusts — including acute (hospital) trusts, ambulance trusts, mental health trusts and community trusts.
• NHS Foundation Trusts — the same range of services, but with a different legal and governance status (explained below).
• GP practices — independent contractor businesses that hold a contract with the NHS, rather than being NHS bodies themselves, but that employ practice staff directly.
• Primary Care Networks (PCNs) — groups of neighbouring GP practices, usually covering a combined population of roughly 30,000–50,000 patients, that work together and increasingly employ shared staff directly. The Additional Roles Reimbursement Scheme (ARRS) funds PCNs to employ roles such as clinical pharmacists, paramedics, physiotherapists, social prescribing link workers and others, growing the range of staff employed at PCN level rather than by a Trust or an individual practice.

Whichever of these applies to you, this is your real, legal employer — not "the NHS," and, for most staff, not the ICB either.

Trust vs Foundation Trust: what's actually different

The difference between an ordinary NHS Trust and an NHS Foundation Trust is mostly about governance and financial autonomy, not day-to-day working life. Foundation Trusts have a greater degree of operational and financial independence — they can, for example, retain surpluses and borrow within limits in ways ordinary Trusts generally cannot — and they're accountable to a board of governors that includes elected members from staff and the local public, alongside NHS regulatory oversight. Ordinary Trusts are more directly accountable to NHS England.

For staff, the practical difference is usually small: the same national Agenda for Change pay framework applies whether you work for a Trust or a Foundation Trust. You won't be paid on a different scale purely because of Foundation status. Where you might notice a difference is in some local policies, service structures, or how quickly local decisions get made — Foundation Trusts have somewhat more freedom to set their own operational priorities.

Why pay can still vary slightly despite being "national"

Agenda for Change is a national pay framework across England, Wales and Northern Ireland — the same bands, the same pay points, and the same headline percentage pay award apply regardless of which Trust employs you. But because each Trust is a separate legal employer rather than a branch of one single national organisation, small practical differences can still show up: how quickly a confirmed pay award is actually applied to payroll, exactly how some local or non-consolidated allowances are administered, and how individual local policies (on things like flexible working requests or some enhanced contractual terms that go beyond the national minimum) are written and applied. These are exceptions at the margins rather than the norm — the core pay structure is genuinely national — but they're a direct consequence of "the NHS" being many employers rather than one.

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How Scotland, Wales and Northern Ireland differ

Everything described above — DHSC, NHS England, ICBs — applies specifically to NHS England. Health is a devolved policy area in the UK, which means Scotland, Wales and Northern Ireland each run their own health service structures independently, with their own governments and health bodies rather than sitting under NHS England or DHSC.

• NHS Scotland is overseen by the Scottish Government and organised around regional Health Boards rather than Trusts and ICBs. Scotland also negotiates its own separate Agenda for Change pay deal and pay spine, distinct from England, Wales and Northern Ireland.
• NHS Wales is overseen by the Welsh Government and is also organised around regional Health Boards, though Wales shares the same Agenda for Change pay spine as England and Northern Ireland.
• Health and Social Care Northern Ireland (HSC) is overseen by the Northern Ireland Executive's Department of Health, and delivers services through regional Health and Social Care Trusts, which integrate health and social care more closely than in the other UK nations. Northern Ireland shares the England/Wales Agenda for Change pay spine.

If you're comparing pay or structure across UK nations, Scotland is the one to pay closest attention to, since its pay spine and negotiation timetable genuinely diverge from the rest of the UK — see our Agenda for Change pay scales guide for exactly how the current Scottish rates compare to England, Wales and Northern Ireland.

Putting it together

It's worth holding onto one central point from all of this: the NHS is best understood as a system of separate, related organisations working to shared national standards and pay frameworks, not one single employer with a simple org chart. Policy and funding flow down from DHSC through NHS England and your regional ICB, but your actual employment relationship — your contract, your payslip, your HR processes, your line management — sits with one specific Trust, Foundation Trust, GP practice or PCN. Knowing which one that is, and understanding roughly how it fits into the wider system, makes it much easier to know where to go when something in your working life needs sorting out.

Who regulates the NHS — and why that's a different question from who runs it

Everything above describes who commissions and who employs — the ICBs that plan and fund services, and the Trusts, Foundation Trusts, GP practices and PCNs that actually deliver them. A separate layer of national bodies exists purely to regulate that system, and it's worth being clear these are different organisations doing different jobs, not just other names for the same thing:

• • The Care Quality Commission (CQC) — the independent regulator that inspects and rates the quality and safety of individual providers (hospitals, GP practices, care homes) against national standards. It has no role in commissioning or funding decisions — its job is entirely about whether a provider is safe and well-led, not where its budget comes from.
• • Professional regulators — bodies like the NMC, GMC and HCPC regulate individual registered professionals, not organisations. A Trust can pass a CQC inspection while an individual clinician within it is separately under investigation by their own professional regulator, and vice versa; the two processes run on entirely separate tracks. See our fitness to practise explainer for how that individual-level process actually works.
• • NHS Resolution — the national body that handles clinical negligence and related legal claims against NHS organisations, sitting outside the regional ICB/Trust structure as a specialist national function rather than a local one.
• • Special Health Authorities — a small number of national bodies with a specific, England-wide function (blood and transplant services and national data/business services functions among them) that sit outside the regional ICB/Trust structure entirely, reporting more directly to the national level described earlier on this page.

The practical takeaway: if something goes wrong, who you actually need to contact depends on whether the problem is with funding and planning (your ICB), day-to-day delivery (your Trust or practice), an individual professional's conduct (their regulator), or the overall safety and quality of a provider (the CQC) — four genuinely different questions that "who runs the NHS here" can quietly bundle together if you're not used to the structure.

This layered separation between funding, delivery and regulation also explains why a Trust can look financially or operationally troubled in the news while individual services within it still carry a good CQC rating, or vice versa — the two things are assessed by entirely different bodies, on entirely different criteria, and don't automatically move together. It's also worth knowing as a jobseeker: a CQC rating tells you something genuine about the quality of a specific service you might be applying to join, in a way that a Trust's size, reputation or funding headlines don't necessarily capture on their own.

Related reading

Agenda for Change explained The national pay framework that applies across almost every one of these employers. NHS redundancy pay explained How continuous service actually works when you move between separate NHS employers. NHS unions and royal colleges explained Who represents you, separately from your employer and any regulator. NHS whistleblowing and your legal rights Where a safety concern actually goes, and what protection you have for raising it. How to join the NHS Applying to the Trusts, practices and PCNs described on this page. NHS Trust profiles Individual profiles of major Trusts and Health Boards across the UK.

Frequently asked questions

What's an ICB? +

An Integrated Care Board (ICB) is a regional NHS body that plans and buys ('commissions') health services for a specific area of England — roughly 40 of them cover the whole country, though boundaries and the exact number can shift over time as they merge or realign. ICBs replaced Clinical Commissioning Groups (CCGs) when the Health and Care Act 2022 came into force. Most frontline staff don't work directly for an ICB — you're far more likely to be employed by a Trust, a Foundation Trust, or a GP practice/PCN — but the ICB in your area still influences funding, service priorities and which providers get contracts.

Is my Trust the same as my employer? +

For most NHS staff, yes — your NHS Trust or NHS Foundation Trust is your actual legal employer, the organisation that issues your contract, runs your payroll, and is named on your payslip. 'The NHS' isn't a single employer in a legal sense; it's a system of separate organisations (Trusts, Foundation Trusts, GP practices, PCNs, and a smaller number of roles employed directly by ICBs or arm's-length bodies) that all work within the same national framework, including Agenda for Change pay. If you're not sure who your legal employer is, check the organisation name on your payslip or contract of employment rather than assuming.

What happened to CCGs? +

Clinical Commissioning Groups (CCGs) — the GP-led bodies that commissioned most local NHS services in England from 2013 — were abolished on 1 July 2022 under the Health and Care Act 2022. Their commissioning functions transferred to the new Integrated Care Boards (ICBs), which operate at a larger, more regional scale and work alongside a linked Integrated Care Partnership covering health, social care and local government.

How is NHS Scotland different from NHS England? +

Health is a devolved matter in the UK, so NHS Scotland is run entirely separately from NHS England — it has its own governing structure (Scottish Government and NHS Scotland's national bodies), its own regional Health Boards instead of Trusts and ICBs, and, importantly for pay, its own separate Agenda for Change pay negotiations and pay spine. NHS Wales and Health and Social Care Northern Ireland are likewise separately run, with Health Boards and Health and Social Care Trusts respectively. See our <a href="/pay/agenda-for-change-pay-scales-2026-27/">Agenda for Change pay scales guide</a> for exactly how Scotland's pay rates differ from the rest of the UK.

Does it matter which Trust I work for if the pay scale is national? +

It can, in a few practical ways even though the headline Agenda for Change bands are national. Because your Trust (not 'the NHS' as a whole) is your legal employer, moving from one Trust to another is technically a change of employer — which is why continuous service rules matter for things like redundancy pay and some contractual entitlements, even though the NHS generally recognises continuous service across most NHS employers for these purposes. Individual Trusts can also set slightly different local policies on things like flexible working, some non-consolidated allowances, or how quickly a pay award is applied to payroll.

What's a Primary Care Network (PCN)? +

A Primary Care Network is a group of neighbouring GP practices — typically covering a population of around 30,000 to 50,000 patients — that work together and share staff and resources. PCNs have become an increasingly significant employer in their own right, particularly through the Additional Roles Reimbursement Scheme (ARRS), which funds PCNs to directly employ roles like clinical pharmacists, paramedics, physiotherapists and social prescribing link workers alongside traditional GP practice staff.

What's the difference between my ICB and the Care Quality Commission (CQC)? +

They do genuinely different jobs. Your ICB is a commissioner — it plans local services and decides where funding goes, working with the providers (mostly Trusts and GP practices) that actually deliver care in its area. The CQC is an independent regulator — it inspects and rates the quality and safety of individual providers (a hospital, a GP practice, a care home) against national standards, entirely separately from who funds or commissions that provider. An ICB can fund a service; only the CQC rates whether it's safe and well-led.

If I have a concern about patient safety, does that go to my Trust, the CQC, or somewhere else? +

It depends what kind of concern it is. Day-to-day safety issues on a ward or in a service are generally raised internally first — with your manager, through your Trust's incident reporting system, or via your Trust's Freedom to Speak Up Guardian. The CQC is more the right destination for a pattern of serious concern about a provider's overall safety or quality, and it also accepts information from staff and the public directly. See our <a href="/explainers/nhs-whistleblowing-rights/">NHS whistleblowing rights guide</a> for how legal protection and the Freedom to Speak Up route actually work if you're raising something formally.

What is NHS Resolution and when would it be involved? +

NHS Resolution is the national body that handles clinical negligence and some other legal claims against NHS organisations in England, largely through the Clinical Negligence Scheme for Trusts. It sits outside the ICB/Trust structure described on this page, as a specialist national body rather than a regional or local one, and it's generally only relevant if a formal claim is being made — it isn't part of everyday service commissioning or delivery.

Are GP practices legally part of the NHS if they're independent contractors? +

Yes, in the sense that matters practically — a GP practice holds a contract with the NHS (commissioned via its ICB) to deliver NHS primary care services, and staff working there are working within the NHS system even though the practice itself is typically an independent business rather than an NHS body in the same legal sense as a Trust. This is exactly why 'the NHS' isn't one single employer: a GP practice, a PCN and an NHS Trust can all deliver NHS-funded care in the same town under three different employment and legal structures.