Executive summary


An understanding of the past helps us to prepare for the future. In this, the REAL Centre's first report, we look back at the care and treatment provided by the NHS in England over the past two decades – as measured by health care activity. Measures of activity – what the NHS does – form the basis of much NHS planning. Together with measures of quality, these are used as proxies for understanding the contribution the NHS makes to population health. Understanding the drivers of this activity is therefore crucial to service and resource planning.

In this report, we provide a framework for understanding the drivers of health care activity. We describe how supply and demand side factors interact, and how policy can influence the care the NHS provides. We look at the overall trends in activity and how specific services have changed. Where possible, we estimate the proportion of any change that can be explained by four demographic factors: population size, age, gender, and proximity to death. We then explore what drives the remaining change, unexplained by demography.

Although we focus on England, many of the lessons may be relevant to the other countries of the UK. We take an in-depth look at emergency and planned hospital care, mental health, community and primary care, but do not look in detail at areas such as high cost drugs or highly specialised services. Social care, too, is beyond the scope of this initial report but will be the focus of subsequent analysis by the REAL Centre.

NHS activity since 2000

Between 2000/01 and 2017/18, the amount of NHS-funded care in England, either delivered by NHS hospitals or other providers, more than doubled – increasing by 114%, an annual average of 4.6% a year. We estimate that hospital activity increased 4.7% per year, with planned care (6.1%) growing by almost 2.5 times the rate of emergency care (2.6%).

Overall, our analysis suggests that the amount of care provided by the NHS since 2000/01 would have needed to grow by less than 1% a year to meet the demand pressures arising from demographic changes. This means that more than three-quarters of the growth in NHS care since 2000/01 is the result of other factors relating to demand, supply, political priorities and health care policies.

While overall health care activity has grown substantially, this growth has not been shared equally between services. Consultations in general practice have grown just 0.7% per year, while planned procedures increased 9.6%. The different growth rates seen between services, combined with changes to the cost of different activities, have produced a major shift in the composition of spend towards hospital-based care and away from other areas.

The expansion in activity means the population receives significantly more health care today, which has contributed to lower mortality rates for a range of conditions and, up until 2010, increasing life expectancy. However, improvements and increases in care have not been uniform over the past two decades. Between 2000/01 and 2010/11 activity rose by 5.3% a year, quality of care improved, and life expectancy grew by nearly 3 months a year for women and almost 4 months a year for men. As funding slowed after 2010 so too did activity. Between 2010/11 and 2017/18 activity grew by 3.6% a year, quality gains slowed and life expectancy has stalled overall and for some groups declined (notably for women younger than 50 in deprived areas). But it is not just life expectancy that has changed. Over the past two decades the amount of life spent living with long-term health conditions has increased and more people are living for prolonged periods with multiple long-term health problems.

New technologies, changes in prices, and the increasing availability of information about treatments have increased clinician and public expectations about what the NHS can and should provide. Medical advances have meant more treatments can be provided without the need for patients to stay overnight in hospital and more can be done in outpatient departments or as day cases. This means that while the number of people being treated in NHS hospitals has increased, the number of bed days for unplanned admissions fell 1.1% per year.

New services have been established. For example, NHS 111 and Urgent Treatment Centres (UTCs) were introduced with the aim of moderating demand in other areas of emergency care. Both have seen substantial growth. Changes to the workforce have also determined service use. Slow growth in consultations in general practice, for example, is reflected in slow growth in the number of GPs. Meanwhile, an expansion in hospital consultants has supported the rapid increase in outpatient appointments and elective procedures.

Underpinning many of these drivers, particularly around the supply of health care, are political and policy choices. The level of funding the NHS receives is a political choice. Unsurprisingly funding growth is related to activity growth. In the first decade of the century, health spending in England grew by 6.0% a year; in the second it grew by 1.3%.

Government’s shifting priorities for the NHS over the past two decades have also shaped the pattern of growth. In the early 2000s there was a focus on reducing waiting times and improving outcomes particularly for the ‘big killers’ of cancer, stroke and cardiovascular disease. A mix of additional NHS funding and a range of policies from financial incentives, to the maximum 18-week wait from referral-to-treatment target help explain the rapid growth in elective procedures. In the 2010s, in the face of lower funding growth the focus shifted to efficiency gains, contributing to the slowdown in activity growth.

Across the past two decades, much of the policy narrative was about shifting the focus of care away from acute services towards community and primary care to prevent avoidable admissions and manage care more proactively. There is little sign of this policy goal being achieved.

Lessons for the future

Looking at the overall changes in the volume and pattern of care provided over the past two decades, there has been remarkable success in some areas in expanding treatment to benefit the health of the population. Because these changes happen gradually, they are not always recognised, and the NHS can instead be portrayed as rigid or slow at adopting innovation. In fact, changes have been substantial.

However, it is also clear that some changes have been despite – rather than because of – the stated policy goals of successive governments and system leaders. Policy intent has not always been matched by a coherent programme of policy and investment decisions needed to translate rhetoric into reality – the misalignment of workforce plans and service delivery plans is an obvious and stark example.

Our analysis leads us to suggest six lessons for the future.

  1. In the long term, what the health care system does is largely determined by choices. Clear population health goals are needed to help steer these choices. The contribution of demographic factors to growth is relatively small. Other drivers of changes are not well understood, but are within the influence of policymakers if we consider the full range of policy instruments available, especially over a longer time horizon. We need clearly stated population health goals against which to judge the decisions taken.
  2. A better understanding of the contribution of different services to population health goals, and what this means for the future composition of NHS services, is required. Activity growth has not been spread equally across services. For example, we have seen a rapid growth in hospital services compared to community-based services. We need to better understand the contribution of different services to improving healthy life expectancy and reducing inequalities in health across the country and between population subgroups.
  3. Systematic national projections of future trends in morbidity are needed to inform national and local NHS planning. If changes to the composition of NHS services are to meet the future health needs of the population, we need good projections of those needs. As the types of services needed by different groups of patients differ – from cancer to mental health – projections need to cover different forms of morbidity, and, increasingly, multi-morbidity.
  4. There is a need for more sophisticated models of future activity and health outcomes, incorporating other important drivers of growth, including policy choices, as well as demographic factors. The debates about future pressures on the NHS often pay too little attention to supply-side factors, such as workforce or new technologies, in shaping the care provided. We do not have a good enough understanding of the role that drivers beyond demography play in activity growth, such as the changing composition of the workforce. Consequently, they are rarely included in future projections of activity.
  5. Technology plays a major role in shaping both demand (a new treatment makes it possible to address an unmet need) and supply (drug therapies replacing complex surgery). The UK is a world leader in research and the NHS makes a vital contribution to supporting clinical trials. Innovation is inherently unpredictable and complex, but there are also several choices in what gets developed and adopted. It is vital that we better understand the forces shaping those decisions and the impacts this has on the health system.
  6. Shifts in activity take time and there is a need to be realistic about what can be achieved. For example, reducing avoidable emergency admissions has been a long-standing policy goal and, since 2010, has been an aim of the various national integrated care programmes. However, although there has been some evidence of modest success, the ambitions for these programmes exceeded what has been achieved. We need a better understanding of the wider drivers of activity in order to set realistic ambitions and timeframes.

Trends over the past 20 years show how widely investment and growth in services has varied, with hospital care winning out over primary and community care. Numerous factors have driven these changes, but the changing size and age structure of the population plays a relatively minor role. New technologies and drugs, as well as political, policy and planning choices, are among the most potent influences shaping investment. There has been no systematic analysis of how these factors have shaped care over the past two decades. Nor any serious overarching attempt to match the substantial investment we as a society make in the NHS with the health needs of the population.

We cannot know the future and no amount of research and modelling can eliminate this inherent uncertainty – coronavirus (COVID-19) has vividly shown this. But managing uncertainty and anticipating change is the job of policymakers and planners. Health systems are built over many years: hospitals take time to build, staff need years of training, and knowledge and relationships are developed over time. To make the best decisions and to sustain the NHS, what is needed is a strategy for investment based on evidence, analysis and modelling. This needs to be adaptable regionally to allow for differences in population health and health care systems. Above all, this needs to be guided by a ruthless focus on the founding principle of the NHS – to improve health and wellbeing and ensure that care is based on need, not the ability to pay.

* This is cost-weighted. See section 3 for further detail.

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