Analysis of activity by service area

 

Key points

  • Growth has varied hugely across NHS services.
  • Demographic factors (population size, composition by age and gender and proximity to death) explain only around a quarter of the overall growth seen – around 1% a year.
  • Generally, care in hospital has seen greater growth than other settings. For example, elective procedures have grown by 9.6% each year; consultations in general practice by only 0.7%.
  • In part, this is because funding, capacity increases and high-profile targets were focussed on hospital services.
  • However, the amount of time patients spend in a bed in a care facility declined for all services. This is linked to technological change and treatment norms.

Introduction

In this chapter we look at trends and patterns in levels of health care activity in England by service. We analyse how these have been shaped by changes in supply, demand and policy over the past two decades.

Our approach to analysing activity

NHS care covers a broad mix of services. We look at services in five major areas of care: unplanned care, planned care, maternity admissions, primary and community care, and mental health care.

For each service, we estimate the change in activity that is explained by basic demographic factors which are relatively simple to model, and are often used to predict future service use. This recognises there are other important drivers of services use.

For all services we modelled the size of the population. Where possible, we have modelled the proportion of any change that can be explained by a combination of population size, age, gender, and proximity to death (full model). These estimates are based on ONS population and mortality data and the assumption that the amount of care needed by those at different ages, genders and proximities to death is unchanged. For example, that the average number of unplanned hospital admissions by women aged 75, who are not within 2 years of death, is constant over time.

The difference between observed activity growth and that explained by demographics, is unexplained growth. This means it is due to other factors. These are a combination of demand and supply side factors including changes in the age-specific prevalence of morbidity (demand) and changes in the availability of treatment (supply). Although it is difficult to model and quantify these factors, we attempt to identify which are most important for each service and the influence of policy on them.

Overall

Growth over the past two decades has differed widely by type of activity (Figure 12). The number of mental health admissions in acute hospitals has fallen 4.4% per year; there has been small growth in maternity admissions, consultations in general practice and community services; while elective procedures increased 9.6% per year.

Our analysis shows that demographic changes explain only a small part of the growth for most services. It explains a relatively high proportion of activity growth in a few services (major A&E attendances, consultations in general practice and community health services). This is not because these factors have a larger absolute impact in these areas, but because growth as a result of the other factors in our framework is much lower.

Figure 12: Annual growth (%) by service: projected by demographics, explained by other factors and observed

Source: Various, see Annex, *full model

Unplanned care

What is unplanned care?

Unplanned care is a necessary, highly visible and sometimes expensive point of health care provision. It includes:

  • Emergency care for life threatening illnesses or accidents that require immediate, intensive and time sensitive treatment. Services include the 999 service and ambulances, and emergency departments at major hospitals.
  • Urgent care for illnesses or injuries that require urgent attention but are not life threatening. Services include a phone consultation through NHS111, pharmacy advice, out-of-hours GP appointments, and urgent treatment centres (UTCs).

Table 3 shows the scale of these services in 2017/18 delivered by NHS Trusts and Foundation Trusts. This does not include care funded by the NHS but delivered by non-NHS providers.

Table 3: Unplanned care services in 2017/18

Service 

Activity 

Estimated unit cost 

Estimated total cost

Triage services and ambulance 

NHS 111 calls handled

14.6m 

£12**

£179m 

Calls to 999 

10.2m 

£7 

£73m 

Hear and treat or refer (help by phone)

806k

£37 

£30m 

Ambulance dispatches (treat on scene) 

2.4m 

£181 

£443m 

Ambulance conveyances to A&E

5.3m 

£247 

£1,306m 

A&E attendances 

Attendances at major A&Es 

15.4m 

£188 

£2,892m 

Attendance at minor A&Es

4.5m 

£67 

£306m 

Emergency admissions 

Emergency admissions to hospitals (non-electives)

9.0m

£1,698 

£15,282m 

Source: National schedule of NHS costs, NHS Trusts and Foundation Trusts

In 2017/18 the three largest areas of unplanned care spend (by NHS Trusts and Foundation Trusts) were emergency admissions to hospital (£15.3bn), attendances at major A&Es (£2.9bn) and ambulance transfers to hospital (£1.3bn). Together these accounted for 95% of total unplanned care spend.

Growth in unplanned care services

The chart below shows the annual growth by service, and the contribution of demographic factors from our model (Figure 13). There has been a rapid increase in activity for lower cost activities, mainly NHS 111 and calls to 999, with little explained by changes in population size. There has been lower growth in some of the services that have a higher cost, with a fall in unplanned bed days.

Figure 13: Annual growth for unplanned care services: projected by demographics, explained by other factors and observed

Source: Various, see Annex, *full model

What explains the growth?

All types of activity (with the exception of bed days) have grown more quickly than would be expected from changes in demographic factors alone. The reduction in bed days has been driven by a reduction in the number of unplanned admissions that lead to long stays in hospital.

NHS 111 (and its predecessor NHS Direct) and minor A&E departments, including UTCs, experienced high rates of growth. This is unsurprising as both NHS 111 and UTCs were set up during this period in an attempt to divert unnecessary attendances away from major A&E departments. Evidence suggests their success in doing so is mixed. An evaluation of a pilot NHS 111 identified the potential for supplier-induced demand, but there is stronger evidence that UTCs can reduce demand on A&E attendances.

Ambulance calls also increased rapidly, but the proportion of calls resulting in an ambulance transporting a patient to A&E fell from 89% in 2000/01 to 42% in 2018/19, leading to much slower growth in ambulance transports. Treatment at the scene was promoted by policy and planning as an alternative to transports. In part, this reflects the changing profile of patients – traditionally, ambulance services were designed to respond to life-threatening conditions, but by the early 2000s this accounted for only around 10% of cases, with increases in those seeking help with social care needs or long-term conditions. Changes in the skill mix and composition of staff were important in supporting more patients to be treated at the scene.

Attendances at major A&Es increased by 1.4% a year, 0.4pps above the growth expected from demographic factors alone. This is a smaller rate than many other acute services, with the lower growth driven in part by a reduction in attendances per head by younger males (Figure 14). This reflects sizeable declines in traffic and workplace accidents. By contrast, admissions increased significantly for those older than 75 (Figure 15). In 2014/15, 8.6% of A&E attendances were by people in their last 2 years of life, up from 7.2% in 2010/11.

Figure 14: Attendances at major A&E departments by age and gender, rate per 1,000 (2017/18)

Source: HES

Figure 15: Annual growth in rate of attendances at major A&E departments by age and gender (2007/08 to 2017/18)

Source: HES

Emergency admissions to hospital have grown by around 1.1pps a year more than expected from demographic factors alone. The growth in the rate of attendances per head was higher for women than men (Figure 16). Males aged 5–17 have seen very low rates of growth, as have men and women aged 65–74. Growth was higher among the very young (aged 0–4) and the elderly (85+) (Figure 17). The rate of emergency admissions for those within a year of death is 1,400 per 1,000 population, compared to 69.5 for those who survive beyond 2 years. 

Figure 16: Emergency hospital admissions by age and gender, rate per 1,000 (2017/18)

Source: HES

Figure 17: Annual growth in rate of emergency hospital admissions by age and gender (2000/01 to 2017/18)

Source: HES

One reason unplanned admissions may have grown faster than our modelling predicted based on demographic factors would be if admissions thresholds had reduced. However, research shows the opposite: admissions thresholds have actually increased. Instead, the increase seems to be the result of a greater severity of need, with a greater proportion of those attending therefore requiring an admission.

This may have been driven by changes in population health and the increase in the proportion of patients with multiple long-term conditions. By 2015/16, one in three emergency patients admitted for an overnight stay had five or more health conditions, up from one in ten in 2006/07. Research has shown that an unintended consequence of rising survival rates is a larger population of patients who are frail and at high risk of further hospital admissions. However, the pattern of emergency admission growth across age groups (eg the growth in admissions for 0–4 year olds) suggests other factors are at play too.

There have been various initiatives to reduce growth in emergency admissions. For example, attempts to make care more integrated – the Integrated Care Pilots, Pioneers and New Models of Care – were partly aimed at improving efficiency, often with a focus on reducing emergency admissions. Despite this, emergency admission growth in the second decade was 1.5% a year – 0.4 percentage points a year above that expected from population growth and ageing – compared to 2.2% a year in the first decade. 

While the policy aims for unplanned care have remained fairly consistent, policy aims in other parts of the system have limited their success. For example, the decision to reduce bed capacity has resulted in high occupancy rates, which have limited the ability of A&E departments to meet the 4 hour waiting time target intended to improve patient satisfaction and outcomes. Difficulties in discharging patients to appropriate care in the community have compounded this. Without a whole system approach, these trends will likely continue.

Planned care

What is planned care?

Planned care – largely hospital care that is not due to an accident or emergency – is arranged in advance and generally follows a referral from a GP. After a referral for treatment a patient has an outpatient appointment (here this excludes appointments for procedures, diagnostics and mental health). There the care team decide what course of treatment to follow and whether the patient requires a follow up appointment, a diagnostic test or an elective procedure. If it is a procedure, this can take the form of:

  • an outpatient procedure (only at the hospital for the duration of the consultation) 
  • a day case (given a hospital bed but not staying overnight), or
  • an inpatient procedure (an overnight hospital stay).  

Table 4 shows the scale of these services in 2017/18 delivered by NHS Trusts and Foundation Trusts. This does not include care funded by the NHS but delivered by non-NHS providers.

Table 4: Costs of planned care, 2017/18 

Service 

Activity 

Estimated unit cost 

Estimated total cost 

Outpatient appointments§§

74.5m 

£125

£9,305m 

Diagnostics 

Diagnostic imaging 

10.5m 

£90 

£941m 

Elective procedures

Outpatient procedures 

13.2m 

£140 

£1,841m 

Regular attendance

0.3m 

£327 

£93m 

Day cases 

5.9m 

£742 

£4,404m 

Electives¶¶

1.3m 

£4,023

£5,323m

Source: National schedule of NHS costs, NHS Trusts and Foundation Trusts

In 2017/18 the three largest areas of planned care spend (by NHS Trusts and Foundation Trusts) were outpatient appointments (£9.3bn), elective procedures (£5.3bn) and day cases (£4.4bn). Outpatient appointments were by far the largest area of activity.

Growth in planned care services

The chart below shows the annual growth by service, and the contribution of demographic factors from our model. This shows that there has been a rapid increase in all planned activities (with the exception of bed days). Growth has been most pronounced in elective procedures, followed by diagnostic tests, and outpatient appointments. 

Figure 18: Annual growth for planned care services: projected by demographics, explained by other factors and observed

Source: Various, see Annex; *full model

What explains the growth?

Much of the growth is not explained by the demographic factors in our model. This implies that the growth in planned care was driven by other factors, including funding, supply and policy.

Outpatient appointments have grown by 2.8pps per year above what is explained by demographic factors. Outpatient appointments increase with age, with those aged 75 and older accounting for nearly one in five appointments in 2017/18 (Figure 19). The rate of appointments for those close to death rose more quickly than for the rest of the population.

Figure 19: Outpatient appointments by age and gender, rate per 1,000 (2017/18)

Source: HES

Figure 20: Annual growth in rate of outpatient appointments by age and gender (2003/04 to 2017/18)

Source: HES

Some patients require a follow up appointment, and many require several. Growth in first appointments (4.0% per year) was marginally higher than follow ups (3.8%) over the whole period, meaning the rate of follow ups to first appointments delivered each year has fallen from 2.39 in 2000/01 to 2.33 in 2017/18.

From 2010/11 onwards, however, follow ups grew faster than first appointments. This has led to efforts to limit the number of follow up appointments, particularly those not deemed clinically necessary or desired by patients. Another proposal is to make greater use of digital appointments, something that may gain traction following COVID-19.

One of the most significant service developments of the past two decades has been an increase in diagnostics tests, driven by technological advances and investment in capital. From 2008/09 to 2018/19, we see a 75% increase in tests (5.8% per year). Imaging tests, including CT and MRI scans, account for most diagnostics. Our ability to diagnose increasing numbers of conditions has contributed to the rise in other areas of planned care.

Elective procedures (including outpatient, inpatient and day cases) have increased by 8.7pps each year above what is expected by demographic factors. This growth is larger than any other service area in our analysis. The proportion of elective procedures for those within 2 years of death has fallen steadily, from 14.0% of procedures in 2000/01, to 9.6% in 2014/15. A greater share of care, therefore, would seem to be for those with less acute needs.

Figure 21: Elective procedures by age and gender, rate per 1,000 (2017/18)

Source: HES

Figure 22: Annual growth in rate of elective procedures by age and gender (2000/01 to 2017/18)

Source: HES

Growth has been driven by outpatient procedures and, to a lesser extent, day cases. Day cases grew 6.5% per year between 2000/01 and 2017/18, while outpatient procedures grew 21.5% between 2003/04 (the first year of data) and 2017/18. Inpatient admissions declined 1.5% per year. As such, the proportion of elective procedures delivered in an outpatient setting increased from 15% in 2003/04 to 62% in 2017/18 (Figure 23).

Figure 23: Share (%) of elective procedures, by type

Source: NHS Digital, HES

This has been facilitated, in part, by technological changes that mean more patients can be treated without an overnight stay and discharged more quickly. An example is cataract surgery. Technological advances have allowed a shift from invasive surgery with a high complication rate and long recovery time, to a much quicker and safer surgery with shorter recovery. As the surgery was refined and became established, the threshold for procedures declined, leading to an increase in the number of surgeries performed. This and other similar changes meant that the proportion of cataract surgeries as inpatients fell from 15% in 2000 to 1% in 2017.

Overall, there has been a marked increase in the amount of planned care delivered. This has been supported and driven by increases in the supply of inputs, particularly an increase in the number of specialist doctors (8.2% growth per year across the period).

Over time, the health system has come under pressure not just to reduce mortality rates of diseases like cancer and heart disease, but also to improve quality of life through treatments such as hip or knee replacements. Increasing numbers of patients are eligible for these procedures, which are cost-effective and are being offered at lower levels of severity than in the past. This in turn changes societal expectations of the ‘right’ level of care. 

However, the amount of care provided is ultimately limited by capacity, underpinned by value judgements over what is feasible and desirable. This may be less obvious when funding and activity are growing, but recent slowdowns in funding growth have resulted in difficult decisions over care thresholds, with some local planners reducing access to procedures such as hip replacements.

Maternity admissions

What is maternity care?

One of the most common reasons for a hospital admission in England is having a baby. Table 5 sets out the elective and non-elective costs of maternity activity in 2017/18.

Table 5: Cost of maternity inpatient care, 2017/18 

Service 

Activity

Estimated unit cost

Estimated total cost

Elective – Maternity

12,500

£3,157

£39.5m

Non-elective (long stay) – Maternity

411,000

£3,686

£1,586m

Non-elective (short stay) – Maternity

818,000

£944

£771.9m

Source: National schedule of NHS costs, NHS Trusts and Foundation Trusts.

Growth in maternity admissions

Maternity admissions are recorded distinctly from elective (planned) or emergency (unplanned) admissions. This category includes admissions of a pregnant or recently pregnant woman to a maternity ward, except when the intention is to terminate the pregnancy.

The chart below shows the annual growth in maternity admissions by number of admissions and bed days. Here, the contribution of demographics is accounted for differently from other service areas: we use births instead. This shows that there has been an increase in maternity admissions (0.5% per year), but less than expected based on the number of births. Bed days fell 1.1% per year.

Figure 24: Annual growth for maternity admissions: projected by demographics, explained by other factors and observed

Source: Various, see Annex.

What explains the growth?

Maternity admissions were 9.3% higher in 2017/18 than in 2000/01 (0.5% growth per year). Admissions grew 2.2% per year between 2000/01 and 2010/11, but fell 1.8% per year thereafter. This reflects the fertility rate, which increased in the in the 2000s before falling again (see chapter 3 on demand).

Our model shows a substantial reduction in the number of maternity bed days. This has been driven by: 

  • a reduction in the ratio of admissions to births, from 1.76 admissions per birth in 2001/02 to 1.68 admissions per birth in 2017/18, and
  • a reduction in the number of bed days per admission, from 3.40 bed days per birth in 2001/02 to 2.56 in 2017/18.

There has been a rise in zero day admissions (those not lasting a day), with the proportion increasing from 34% in 2000/01 to 38% in 2017/18. This reflects trends in other countries and may be driven by a combination of patient choice, greater flexibility and safety, or a drive to improve efficiency.

There has also been a substantial reduction in maternity admissions for women younger than 27 and growth in admissions for women aged older than 27, mirroring the changing age profile of women giving birth. The older age profile of mothers may contribute to more complicated and challenging births.

Primary care and community services

What are primary care and community services?

Primary care and community services are provided outside of hospital. Primary care is the most used part of the health care service and has a relatively low cost per consultation (Table 6). While a broader definition includes areas such as dentistry and community pharmacy, here we use primary care to mean general practice. General practice is where most health needs are identified, monitored, treated. A patient may be prescribed medication or, where necessary, referred to specialist services. General practice plays a crucial role in keeping people well, and in keeping them out of hospital.

Community services cover a range of teams, from district nurses and therapists to palliative care. They are delivered close to home, including in people’s homes. Teams also provide preventative interventions, such as smoking cessation services, often in partnership with local government or the third sector.

The table shows the estimated scale of primary care and community care services in 2017/18.

Table 6: Primary care activity and costs, 2017/18

Service

Activity

Estimated unit Cost

Estimated total cost

Consultations in general practice††† (2018)

307m

£27

£8,182m

Community prescribing

1,106m

£8.20

£9,083m

Community services

88.3m

£62

£5,480m

Source: NHS England, Appointments in General Practice; CHE analysis of PSSRU, Unit Costs of Health and Social Care; Prescription Cost Analysis - England, 2017 and 2018; NHS reference costs.

Growth in primary care and community services

Figure 25 shows the annual growth by service, adjusted for changes in the size of the population. This shows that there has been a rapid increase in community prescribing (prescribing outside of the hospital) but almost no growth per person in primary care or community health services. This is despite a strong primary care system being crucial to preventing illness and supporting people to manage their own conditions, and despite policy ambitions to move care from hospitals to the community.

Figure 25 Annual growth for primary care and community services: projected by demographics, explained by other factors and observed

Source: various, see Annex; *full model

What explains the growth?

Unlike other service areas, demographic changes do explain the majority of observed growth in consultations in general practice and community services. Contacts with community services in 2017/18, up from 75.7 million in 2004/05 (Figure 25), increased by 11% between 2004/05 and 2017/18 or 0.9% per year. Considering population growth, contacts per person grew just 1%, 0.1% per year. Therefore, nearly all the growth in community contacts can be explained by population growth.

The rate of consultations in general practice in 2018/19 (5.0 consultations per person) was the same as in 2000/01, though this hides small fluctuations over time. The lack of growth has in part been explained by a lack of growth in the workforce. Indeed, the number of full-time equivalent GPs per head of population has fallen since 2010. This has led to a shift in who delivers care. The proportion of consultations delivered by other staff, including nurses, increased from 28% in 2000/01 to 41% in 2018/19, with an associated fall in the proportion delivered by GPs.

The rate of consultations in general practice generally increases with age (Figure 26) and is higher for women than men. The rate of consultations among younger people (up to the age of 35) has fallen (Figure 27). By contrast, the rate of use among older people, especially those aged 75 and older, has increased significantly. This is likely explained by the rising number of patients with long-term conditions, many of whom have complex needs and require longer consultations.

Figure 26: Consultations in general practice by age and gender, rate per 1,000 (2017/18)

Source: CPRD

Figure 27: Annual growth in rate of consultations in general practice by age and gender (2000/01 to 2017/18)

Source: CPRD

In contrast to consultations in general practice and community services, little of the growth in community prescribing can be explained by population growth. The number of community prescriptions increased by 96% from 2000/01 to 2018/19, or 3.8% per year (Figure 25).

One notable factor in explaining the growth is cost. Figure 28 looks at the change in the number of prescriptions and also the change in total spend for the top ten drugs by volume as defined by the British National Formulary (BNF). This shows the increase in cardiovascular drugs and drugs for the central nervous system has come with lower spending, reflecting a fall in the cost per drug as items come off patent and are replaced by cheaper generic alternatives.

Figure 28: Change in number of prescriptions and total spend, 2008–2018

Source: NHS Digital, Prescription Cost Analysis; Costs adjusted using GDP deflator

Policies, such as Transforming Community Services, emphasised the need to shift care outside of hospital, both by bolstering primary care and community services.87 Specific initiatives aimed to improve the management of long-term conditions (eg the Quality Outcome Framework), access to care (eg situating GP surgeries in A&E departments) and workforce capacity (eg task shifting to practice nurses). However, these have not been backed sufficiently by funding increases or, in general, with enough political attention. Community services in particular lack the clear metrics (eg waiting time targets) that other services have, making it more difficult to monitor progress and understand where there may be gaps.

Mental health services

What are mental health services?

Mental health services support people with a range of mental health conditions, from anxiety and depression to severe psychoses. Mental health is both a diagnosis and a specialty. Initially, most mental health conditions are discussed with a GP, and those with a high level of need are referred onto specialist services. Alternatively, a patient may present at hospital and from there be treated and/or signposted to a mental health service. At hospital, those who require intensive care may be admitted; those with less intensive needs may be seen as an outpatient. Consequently, care can take place as a hospital inpatient, outpatient, or by specialist services in the community.

Table 7 shows the scale of mental health services in 2017/18 delivered by NHS Trusts and Foundation Trusts. Note, significantly more outpatient attendances are recorded by Hospital Episode Statistics (HES) data, which includes care funded by the NHS but delivered by non-NHS providers.

Table 7: Mental health activity and costs, 2017/18

Service

Activity

Estimated unit cost

Estimated total cost

Hospital mental health

MH elective and non elective finished consultant episodes (FCEs)****

135,000

£1,886

£254m

MH outpatient appointments††††

67,000

£167

£11.3m

Community mental health

Specialist MH care (initial assessment)

874,000

£307

£268m

Specialist MH care

236m

£18

£4,227m

Adult IAPT (initial assessment)

781,000

£121

£95m

Adult IAPT

849,000

£353

£300m

MH care in secure facilities (initial assessment)

35,000

£870

£30m

MH care in secure facilities

1.4m

£521

£726m

Other specialist MH services

6.6m

£232

£1,535m

Source: NHS reference costs

As shown in Table 7, the majority of mental health spend (more than 90%) is delivered by specialist mental health services (community mental health). Community mental health covers a range of services, including specialist services for adults and older people, the Improving Access to Psychological Therapies (IAPT) programme and services such as drug and alcohol rehabilitation and Child and Adolescent Mental Health Services (CAMHS).

Growth in mental health services

The chart below shows the annual growth by service. This shows that there has been a rapid decrease in admissions and bed days, but strong growth in outpatient appointments. However, it is worth noting that outpatient growth stalled after 2010/11.

Figure 29: Annual growth for mental health services: projected by demographics, explained by other factors and observed

Source: Various, see Annex.

What explains the growth?

In community mental health, the biggest component of care, we are limited in our ability to explore and explain the growth in activity as a reclassification means data prior to 2011/12 are not comparable. Community mental health is also defined in relation to a mix of contacts and care clusters – here we present an aggregated index.

The amount of care increased in 2012/13, with 16% growth that year, but has since fallen (Figure 30). Activity was 9% higher in 2017/18 than in 2011/12, or 1.5% per year. The increase in population size explains much of this growth.

Figure 30: Community mental health services; activity and activity per person (index, 2011/12 = 100); annual growth in activity

Source: NHS Reference costs

There have been elements of growth in provision. Considering IAPT, a programme of talking therapies for people with low-moderate level depression and anxiety, the trend is very different. The number of people entering treatment per year grew 152% over this period, or 17% per year. Just 5% of this growth can be explained by changes in the size of the population, with the remaining 95% unexplained. This rapid growth is unsurprising as this programme was set up as a result of a major policy drive to increase the availability of psychological therapies. Decreased stigma around mental health and increased willingness to seek treatment have likely further contributed to the growth.

Considering care in acute hospitals, mental health admissions and bed days have both seen a decline. The number of mental health admissions declined 53% between 2000/01 and 2017/18, a steady 4.4% per year. By contrast, our model estimated that appointments would increase 0.4% per year. This is due to a drive to treat patients in the community or outpatient settings, which led to a marked reduction in mental health beds. This is reflected by weak growth in FTE hospital doctors and a reduction in mental health nurses over the period. However, there is some evidence the shift away from inpatient care may have gone too far.

Mental health outpatient treatments have increased by 116% between 2003/04 and 2017/18 or 6% per year. Notably, growth was rapid in the first decade, increasing 12% per year between 2003/04 and 2010/11, but was flat thereafter. Unlike mental health admissions, then, the other factors in our framework beyond demographic factors contributed to an increase in appointments and amounted to 4.7% of growth per year. The rate of outpatient appointments has increased most for young females (aged 5–17). This may reflect a rise in eating disorders among this group.


** There is significant uncertainty over this estimate.

†† Non-elective short and long stays, excludes mental health and maternity (covered below); activity is a count of finished consultant episodes; costs include cost of excess bed days.

‡‡ NHS Direct was set up in 2000. The service was replaced by NHS 111 in 2010, although the transition to NHS 111 was not completed until 2014.  

§§ Outpatient appointments excludes mental health (covered below)

¶¶ Electives excludes mental health and maternity (covered below), activity is a count of finished consultant episodes, costs include cost of excess bed days

*** Currency code starting NZ in NHS reference costs, includes ante-natal, delivery and post-natal care; activity is finished consultant episodes (FCEs); costs include cost of excess bed days.

††† Includes consultations delivered by other health care practitioners; cost is calculated by applying unit costs by health professional and mode to the estimated volume of consultations.

‡‡‡ For primary care consultation data, we use CPRD, a primary care dataset in England. As this is one of several datasets used in primary care, and does not therefore contain the whole population, we present the main results as rates of consultation.

§§§ Note, community mental health is defined in relation to a mix of contacts and care clusters, which help determine payment.

¶¶¶ See Annex for more detail.

**** Elective and non-electives with a currency code starting ‘WD’ or ‘PX09’

†††† Outpatient appointments with service code starting ‘71’ or ‘72’.

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