Medicine Interview Hot Topics: NHS Structure: Primary, Secondary & Tertiary Care
The care that the NHS provides can be divided into Primary, Secondary and Tertiary care. Above these sits the Department of Health, which is accountable to the Secretary of State for Health, who in turn is accountable to Parliament. The Secretary of State decides, in line with other ministers and senior figures in the NHS and Department of Health, where the NHS budget will be directed. The Department of Health is responsible for running the NHS, and provides strategic direction, investment, and sets standards.
Clinical Commissioning Groups(CCGs)
Clinical Commissioning Groups(CCGs) are responsible for providing primary care at a local level. Their leadership is made up of senior consultants, nurses, and GPs, ensuring a fair representation of the different professionals who should be consulted when making funding decisions. They receive around 60% of the total funding of the NHS. They use this for funding hospitals as well as primary care, often according to how a surgery or hospital might perform against preordained targets. Essentially that means that the CCGs are responsible for funding the whole spectrum of care - primary, secondary and tertiary - for their allotted area.
The Role of Trusts
There are further, semi-independent, NHS trusts that cover secondary care provision. You will encounter Acute Trusts - these manage a hospital or group of hospitals, and are responsible for the medical and surgical care of the local population. These employ the majority of NHS staff. Foundation Trusts are more independent than an Acute Trust, and have more separation from the NHS’s central oversight, and local CCGs. They are also able to focus on the teaching of newly qualified doctors. Mental Health Trusts are responsible for providing for the mental health requirements of an area. There are 60 in the UK. There are then a further 12 Ambulance Trusts that cover England, and Care Trusts, designed as a link between community social care and community healthcare.
Understanding Primary, Secondary, and Tertiary
Primary care is the first point of contact for people that need healthcare. It is your GP, dentist, local GUM clinic, pharmacy, or drop-in centre. Think about any health provider in your community who acts as a gatekeeper, or first access point, to the healthcare service. This service - free care at the point of use - is the central pillar of the NHS.
Secondary care is sometimes referred to as ‘hospital and community care,’ and may be planned or involve urgent or emergency care. For example, think about planning an operation for a varicose vein procedure, and having an operation at a set time after a four month wait, versus being suddenly admitted to hospital after visiting your local A&E department with a broken leg. Both are secondary care, albeit accessed in very different ways.
Tertiary care refers to highly specialised treatment beyond the remit of traditional secondary care. It would usually be provided over an extended period of time by specialists, involve advanced procedures, and likely involve special or state-of-the-art facilities. Services that might come under this umbrella include neurosurgery, transplant operations, and secure forensic mental health services.
Potential questions which may be asked in the interview
- What is the structure of the NHS now?
- What does the structure of the NHS tell us about the way that healthcare is provided in this country?
- What do you think are the problems with the way that the NHS is structured?
- If you were the Secretary of State for Health, how might you consider changing the structure of the NHS?
- Do you think that the way the NHS currently divides its budget, or how it directs its budget to different areas, is done efficiently?
- Should doctors be given more power to make decisions on the NHS? I.e should managers have less power, or there be fewer managers present?
- Do you think it’s important for medical students and doctors to understand the structure of the NHS, or do you think that their time might be better spent focusing on clinical work?
- Do you think it’s important for the wider public (i.e. laypeople) to understand the structure of the NHS? Do you think that the government makes enough effort to make the structure intelligible by the public?
How to answer questions on the structure of the NHS
Make sure that you’re confident on the concept of primary, secondary and tertiary, and that you understand that both CCGs and a variety of Trusts exist within this framework. Try to think about a change that you might make, and why.