How NHS works

December 17, 2025 Uk Living Guide

When most people think of the NHS, they think of the local GP surgery or the blue-lit ambulance racing toward an A&E entrance. But behind those front-line images is one of the most complex, massive, and—let’s be honest—confusing machines in the world.

If you’ve ever wondered why it takes six weeks to see a specialist, or how a single tax-funded pot manages to treat 67 million people, you’re in the right place. This isn’t a textbook definition; it’s a “real-world” look at how the National Health Service actually functions in 2026.

The Founding Heart: Free at the Point of Use

Before we get into the gears and cogs, we have to talk about the “why.” Founded in 1948, the NHS operates on three core principles:

It meets the needs of everyone.
It is free at the point of delivery.
It is based on clinical need, not the ability to pay.

In 2026, these principles are still the bedrock. While you might pay for a prescription or a dental check-up, you will never receive a bill for a life-saving operation or a stay in a hospital ward. It is funded almost entirely through general taxation and National Insurance.

The Hierarchy: Who is Pulling the Strings?

The NHS isn’t just one giant company with a single CEO. It’s a massive network of different organizations working (and sometimes clashing) together.

1. The Government (DHSC)

At the very top is the Department of Health and Social Care. They don’t run the hospitals; they set the budget and the big-picture goals—like “cut waiting lists for heart surgery” or “increase mental health support for teens.”

2. NHS England

Think of NHS England as the “manager” of the whole system. They take the government’s money and decide how to distribute it across the country.

3. Integrated Care Systems (ICSs) – The “New” Middlemen

This is where the real work happens in 2026. The UK is divided into 42 Integrated Care Systems. Their job is to make sure that the hospital, the GP, the local council, and social care are all talking to each other.

Why this matters: In the past, you might be ready to leave the hospital but couldn’t because there was no one to look after you at home. ICSs are designed to bridge that gap so that “health” and “care” work as one unit.

The Three Levels of Care

To navigate the NHS, you have to understand the “tiers.” You don’t just walk into a heart surgeon’s office; you move through a gateway.

Primary Care: The Front Door

This is your first port of call. It includes:

GPs (General Practitioners): Your local doctor who manages 90% of health issues.
Pharmacies: In 2026, pharmacists do much more than hand out pills; they can now prescribe for minor ailments like earaches or shingles.
Dentists and Opticians: High-street services that keep the basics in check.

Secondary Care: The Specialists

If your GP can’t fix the problem, they “refer” you to secondary care. This is almost always hospital-based. It includes:

Elective care (planned operations like hip replacements).
Specialist clinics (cardiology, oncology, etc.).
A&E (Accident & Emergency): The place for life-threatening crises.

Tertiary Care: The High-Tech Hubs

This is for very rare or complex conditions. Think of children’s heart transplants or specialized cancer trials. These services are often concentrated in “Centres of Excellence” in major cities like London, Manchester, or Edinburgh.

The “Shift” of 2026: Community Over Hospitals

If you’ve noticed your local GP surgery looks a bit different lately, it’s likely because of the “Neighborhood Health” movement.

The NHS is currently trying to move away from “Hospital-centric” care. Why? Because hospitals are expensive and, frankly, most people would rather be treated near home. We are seeing a huge rise in Neighborhood Health Centres—one-stop shops where you can get a blood test, see a physio, and meet a mental health counselor all in one building, usually open 12 hours a day.

The Digital Front Door: The NHS App

In 2026, the NHS App isn’t just an extra; it’s the primary way the system functions.

Self-Referral: For things like physiotherapy or podiatry, you often don’t even need to see a GP anymore; you can refer yourself through the app.
AI Triage: Before you book an appointment, the app might ask you a series of questions. This isn’t to “block” you, but to make sure you see the right person (sometimes a nurse or pharmacist is better than a doctor).
Digital Records: Your “Single Patient Record” means that if you go to a hospital in Cornwall, the doctors there can see the notes your GP made in Newcastle.

The Reality Check: Challenges in the System

It would be dishonest to write a blog about the NHS without mentioning the “waiting list” elephant in the room.

The system is under immense pressure. We have an aging population with more complex needs (like diabetes and dementia) than ever before. This creates a bottleneck in secondary care. While the 2026 targets aim for 70% of patients starting treatment within 18 weeks, the reality on the ground often involves longer waits for non-urgent care.

How to get the best out of it:

Use 111 First: Unless it’s a life-threatening emergency, call 111 or use the website. They can often book you a direct slot in an Urgent Treatment Centre, saving you six hours in an A&E waiting room.
Pharmacy First: For things like UTIs or sore throats, go straight to the chemist. It’s faster and frees up the GP for more complex cases.
Keep your “NHS Login” updated: Ensure your phone number and email are correct in the app so you don’t miss appointment notifications.

Funding: Where Does the Money Go?

The NHS budget for 2025/26 is over £200 billion. That sounds like a lot (and it is), but here is where it actually goes:

Staffing: Over 1.5 million people work for the NHS. Paying the doctors, nurses, cleaners, and porters takes up the biggest slice of the pie.
Drugs and Tech: Specialized cancer drugs and the new AI-diagnostic tools are incredibly expensive.
Buildings: Maintaining thousands of clinics and hospitals, some of which are over 100 years old.