How the NHS in England is organised

There is no single employer called “the NHS” in England. The Department of Health and Social Care sets policy and funding, NHS England has run the service nationally, 42 integrated care boards plan and pay for care in their areas, and the care itself is delivered mostly by NHS trusts, foundation trusts and GP practices. An NHS job puts your contract with one of those organisations, usually a trust.

The national level

The Department of Health and Social Care (DHSC) is the government department. The Secretary of State answers to Parliament for the health service, and DHSC agrees the overall budget with the Treasury, sets the mandate and accepts or rejects pay review body recommendations. The 3.3 per cent Agenda for Change award for 2026/27 was a government decision announced in February 2026.

NHS England has been the arm’s length body that oversees the service day to day, allocates money to ICBs and sets national priorities. The government has announced that NHS England would be brought into DHSC and its functions merged, a process involving large job reductions in both organisations. If you are looking at jobs in national bodies, check what stage the merger has reached, because posts are being restructured.

Other national bodies you may come across include the Care Quality Commission (the regulator), the NHS Business Services Authority (which runs the NHS Pension Scheme and NHS Jobs) and NHS Blood and Transplant.

Integrated care boards

England is divided into 42 integrated care systems, each with an integrated care board. The ICB holds the NHS budget for its population and commissions hospital, community, mental health and GP services. ICBs also employ staff, mostly in commissioning, finance, data and clinical quality roles. ICBs have been told to cut running costs and several are merging, so the number of boards is set to fall.

Trusts and foundation trusts

Most NHS staff work for a trust. Acute trusts run hospitals, mental health, community and combined trusts run services outside hospital, and ambulance trusts cover 999 and NHS 111 services across a region. Many trusts are foundation trusts, which have a membership and council of governors and somewhat more financial freedom. NHS trusts and foundation trusts explains the differences and why they matter less to staff than they sound.

Trusts use NHS Jobs or Trac to advertise and almost all pay on Agenda for Change. Band 5, the usual entry band for newly qualified nurses and allied health professionals, starts at £32,073 in England from 1 April 2026.

Primary care

GP practices, dental practices, community pharmacies and optometrists deliver NHS services under contract but are mostly independent businesses. A GP practice is usually a partnership, and the partners employ the receptionists, practice nurses, salaried GPs and managers. They are not bound by Agenda for Change and set their own pay, though many use it as a guide. Access to the NHS Pension Scheme depends on the employer’s arrangements, so ask.

Practices increasingly work together in primary care networks (PCNs), which employ some staff directly through a lead practice or a federation, such as social prescribing link workers, care coordinators and clinical pharmacists. These roles are funded through national schemes and their pay varies.

How pay is set nationally

Trusts are separate employers, but pay for most NHS staff in England is negotiated nationally. The NHS Pay Review Body recommends an award for Agenda for Change staff each year, the government decides whether to accept it, and the NHS Staff Council (employers and unions together) maintains the terms and conditions handbook that every trust uses. Doctors and dentists have their own review body, the DDRB, which recommended 3.5 per cent for 2026/27. NHS Employers, part of the NHS Confederation, represents employers in those talks and publishes the pay scales.

That national framework is the reason a band 6 physiotherapist earns the same basic pay in Cumbria as in Cornwall, with only London and the surrounding fringe getting a high cost area supplement. See NHS Agenda for Change pay bands for every band.

Who employs whom

Organisation	Typical jobs	Pay framework
NHS trust or foundation trust	Nurses, doctors, AHPs, HCAs, porters, admin	Agenda for Change; doctors on national contracts
Integrated care board	Commissioning, finance, analysts, CHC nurses	Agenda for Change
GP practice or PCN	Receptionists, practice nurses, salaried GPs	Set by the practice
National bodies (DHSC, NHSBSA, CQC)	Policy, digital, finance, inspectors	Civil Service or body’s own scale

Independent and voluntary providers also deliver NHS-funded care, for example in community services or mental health. Staff there are employed by the provider, which may or may not use NHS terms.

Why the structure matters to you

Your employer sets your contract and policies and decides whether your service continues. Moving between NHS trusts, or from a trust to an ICB, usually keeps your continuous NHS service for annual leave, sick pay and redundancy under Agenda for Change. Moving to a GP practice or private provider usually does not, even though the work is NHS-funded. Moving between NHS trusts covers what carries over.

The structure in Scotland, Wales and Northern Ireland is different again, with health boards rather than trusts and separate pay deals. See health services in Scotland, Wales and Northern Ireland.