Poor understanding of what drives NHS growth has undermined national policy goals Health care per person has more than doubled since the millennium, with rapid growth in hospital care at the expense of other services

A comprehensive analysis published today by the Health Foundation’s REAL Centre looks back at how NHS care in England has changed over the last two decades. It finds a disconnect between the way services have developed and the changing health needs of the population.

The report, the first to be produced by the new REAL Centre, highlights that between 2000/01 and 2017/18, the amount of NHS-funded care in England more than doubled – increasing by 114%, or 4.6% a year on average.  But while the volume of health care delivered grew substantially, growth varied significantly across different services. For example, GP consultations grew by just 0.7% per year, while routine planned procedures, such as surgery for hip or knee replacements or cataracts, increased by 9.6% per year.

The big shift towards hospital-based care and away from primary and community services ran contrary to national policy aims to support the growing number of people with long term conditions to manage their condition better.

The reasons for the increase in hospital care are complex. Less than a tenth of the overall increase in hospital care provided could be explained by population growth and ageing. Workforce supply was also a factor – the much larger increase in the number of hospital specialists compared to the GP workforce has been an important barrier to shifting care outside hospitals. And government priorities such as reducing waiting times for hospital care have also shaped the way different services have grown.

The report concludes that if, over the next two decades, the NHS is to evolve in line with the needs of the population, there needs to be a much better understanding of future health needs, the services required to meet those needs, and the drivers shaping future patterns of growth.

Key findings by service area show:

• Planned procedures, including outpatient procedures, increased 9.6% per year between 2000/01 and 2017/18, an almost five-fold increase overall.
• Attendances at minor A&E units (eg urgent treatment centres) increased 6.5% per year between 2003/04 and 2017/18, while attendances at major A&E departments increased by 1.4% per year over the same period.
• Diagnostic tests, including scans and blood tests, increased 5.8% per year between 2008/09-2017/18.
• Consultations in general practice increased just 0.7% per year between 2000/01 and 2017/18. Most of this increase was accounted for by population growth, with the rate of GP appointments remaining at 5 consultations per person per year since 2000.
• Community services, which provide health visiting and district nursing, grew by only 0.9% per year. 

 
The report authors also note that the population of England grew by 13.7% between 2000 (when it was 49.2m) and 2019 (56.3m). Health care would only need to have grown by 1% per year to meet the pressures arising from demographic factors alone.

Anita Charlesworth, Director of Research and REAL Centre at the Health Foundation, said: 
  
‘NHS fortunes have waxed and waned over the last two decades, with insufficient attention given to the big picture - the aim of building a service that is resilient and meets the changing needs of the population. The shifts in the delivery of care have not always been in line with those needed to make the biggest contribution to population health. For example, the increasing share of people with multiple long-term conditions suggests there should have been a shift towards more prevention and primary care services. This has been recognised by policymakers, but not followed through with the right action.

‘The strength of the NHS depends on good long term decision-making. It takes more than a decade to train a doctor; and buildings, equipment and the IT infrastructure last for many years and shape the context in which care is provided. As COVID-19 has vividly shown, planning for the future is far from straightforward, but building resilience and sustainability into the NHS is more important than ever.’ 
 
The report highlights 6 key lessons for the future: 

1. There is a need for clearer population health goals to help steer future decision-making and choices. 
2. There is a need for a better understanding of the contribution different services make to population health goals, and what this means for the future composition of NHS services. 
3. Systematic national projections of future trends in illness and disease (‘morbidity’) are needed to inform national and local NHS planning.
4. There needs to be more sophisticated models of future activity and health outcomes, including drivers of growth, to aid future planning. 
5. Technology plays a major role in shaping both demand for care (eg a new treatment makes it possible to address an unmet need) and the way care is supplied (eg drug therapies replacing complex surgery) 
6. Shifts in activity take time and policymakers and health care leaders need to be realistic about what can be achieved.