It is an organisation which is ever-changing and one the British public hold close to their hearts. And as the NHS looks set for another unpredictable few years, health correspondent Geraldine Scott explores the various non-NHS organisations which make up Norfolk and Waveney's heath service.
A debate has been sparked about the privatisation in the health service as the number of non-NHS organisations providing care and services in Norfolk was revealed.
Concern was raised in February when board papers from the region's mental health trust suggested Richard Branson's Virgin Care could be interested in running children's mental health services in Norfolk.
And although commissioners were quick to rubbish the 'unfortunate speculation' it shone a spotlight on the non-NHS firms providing health services in Norfolk.
Non-NHS providers can include charities, such as Change, Grow, Live (CGL) - a new charity which took over drug and alcohol treatment services from April.
Or the term can refer to social enterprises, such as East Coast Community Healthcare (ECCH), which provides services in Great Yarmouth and Waveney. Another social enterprise is IC24, the provider of the NHS 111 telephone service.
Alternatively, it can mean private, profit-making companies in the traditional sense, such as ERS Medical, a private firm which provides non-emergency ambulances.
Or the use of private firms by NHS providers when they do not have the capacity to look after patients.
One example is the use of the Priory Group by the region's mental health trust for inpatient services, if there are no NHS beds available. Another is at the ambulance trust where £1.7m was spent on bringing in private resources in the first five months of 2017/18.
In a survey carried out by the NHS Norfolk Action Group (NHS NAG) last year, out of 295 people asked 277 said they would prefer to be treated by the NHS than a private firm.
And the majority of people also said they were concerned to learn about non-NHS companies operating health services in the county.
But the non-NHS providers hit back, with the majority pointing out any surplus was reinvested to improve the care patients received.
A spokesman for Norfolk and Waveney's clinical commissioning groups said: 'It is commonplace for non-NHS organisations to provide some NHS services. Indeed, some of the organisations listed by this newspaper employ local GPs, nurses and hospital doctors to provide those services to patients, at NHS rates.
'Care and nursing homes, pharmacies, and social enterprises such as IC24 and ECCH are contracted to provide services and are regarded as crucial and cherished members of the wider NHS family. Private hospitals bring additional expertise and are used to add valuable capacity when required, relieving pressure on a busy NHS.
'Spend on non-NHS organisations represents a small fraction of the NHS budget.'
But Jan McLachlan, Sue Vaughan and Jan Ainsley - from the NHS NAG - said: 'The creeping privatisation agenda has been operating very stealthily [...] this is because if the public really knew how far down the line NHS privatisation really was there would be a massive outcry.'
They cited the controversial Naylor Review into the sale of surplus NHS land as an example. And said as STPs progress it will mean 'a mixture of public and private health and care providers and will have multinational businesses as partners'.
All the organisations contacted by this newspaper said patient care and safety was their top priority.
Vicki Markiewicz, director of CGL, said their services typically outperformed the national average by 30pc. She added: 'We work hard to make sure that our partners, supporters and service users have complete confidence in what we do and how we operate.'
Chief executive of IC24, Yvonne Taylor, said they were 'very different from a private company' and would welcome the opportunity to meet with NAG.
While ECCH chief executive Jonathan Williams added: 'ECCH is different because it is owned by its employees who have a real say in how the organisation is run.'
East of England Ambulance Trust said they had hired hundreds of new staff in recent years to meet growing demand, but admitted they still used private ambulance services 'as a flexible resource to meet spikes in demand'.
But a spokesman said they continued to increase their own frontline staffing which helped them 'significantly reduce the use of private ambulance services this financial year'.
ERS Medical did not respond to a request for comment.
More than £20m spent with non-NHS companies in three months
More than £20m was spent on non-NHS companies by Norfolk's NHS in the space of three months.
Providers and commissioners - those who buy the care - must, by law, publish data on any spending over £25,000.
And analysis by this newspaper found between December last year and February this year, the county's five commissioners, the ambulance trust, the mental health trust, and the community health trust spent at least £20,677,266.40 on health and social care services provided by non-NHS organisations.
Organisations which appeared in the data regularly included Integrated Care 24, ERS Medical, and Bourn Hall fertility clinic.
But hundreds of thousands of pounds were also spent with Global Diagnostics Ltd - which provides radiology services.
Some payments went to private care home groups, or staffing agencies.
While others went to charities such as Voluntary Norfolk and Age UK.
Hundreds of thousands of pounds was also spent with Spire Healthcare, which runs private hospitals.
Chief says PFI helped deliver world-class hospital
Perhaps the starkest example of private involvement in Norfolk's NHS is the private finance deal used to build the county's busiest hospital, the Norfolk and Norwich.
Around £20m a year is paid to consortium Octagon Healthcare for building the hospital - and accounts show there is still £194m to pay off.
But the financial pressure this places on the hospital has been cited as one of the reasons the trust is running a deficit.
In the NAG survey, 281 people said they did not think future building should be funded out of PFI.
But Richard Parker, NNUH chief operating officer, said: 'The PFI arrangement has helped us to deliver a world-class hospital, providing a fantastic environment for our staff to deliver care and for the people of Norfolk to receive care. Since moving to our current site we have been able to expand dedicated services, develop a teaching hospital and become an internationally renowned centre for research working with partners in the Norwich Research Park and UEA.'
New care system bid for Norfolk
Councillors and representatives from health and social care organisations in Norfolk have been working through a bid to create an integrated care system (ICS) in Norfolk.
It comes as the next stage of the region's healthcare overhaul, known as the sustainability and transformation partnership (STP). And the idea is the Norfolk-wide system will take more control of funding with less involvement from national bodies.
Some, including Professor Stephen Hawking, launched legal action over the introduction of accountable care organisations (ACOs) - a different version of integrated care being introduced elsewhere in the country. They believe the partnership bodies are a step towards privatisation. But a spokesman for the STP said the Norfolk system would 'bear no relation to American models of care'.
The Department for Health and Social Care have previously strongly rejected such claims. It said it was 'misleading' and 'irresponsible scaremongering' to suggest ACOs were being used to support privatisation of the NHS.
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