Key points

  • Between 2000/01 and 2017/18, the amount of NHS-funded care in England more than doubled – increasing by 114%, an annual average of 4.6% a year.
  • Our analysis suggests that the amount of care 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%. This has produced a major shift in the composition of spend towards hospital-based care and away from other areas.
  • 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.


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.

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.

With thanks to The Strategy Unit who provided the detailed analysis and modelling of activity in chapter 4 of the report, alongside guidance and comments.


Executive summary

  1. Introduction

  2. A framework for understanding health care activity

  3. Analysis of overall health care activity

  4. Analysis of activity by service area

  5. Discussion

  6. Lessons for the future

With thanks to The Strategy Unit who provided the detailed analysis and modelling of activity in chapter 4 of the report, alongside guidance and comments.


An earlier version of this report referred to health spending in England growing by 6.6% per year in the first decade and 1.2% in the second decade of the 20th century. This has been corrected to 6.0% and 1.3% in the current version of the report. In the executive summary (p.4), we incorrectly stated that activity growth had moderated from 4.8% per annum to 2.7%; this has been removed. On p.22, we stated that output per person grew by 4.1% per year, 4.9% between 2000/01 to 2009/10 and 2.7% thereafter; this has been corrected to 3.9% overall, 4.6% between 2000/01 and 2010/11 and 2.8% thereafter. On p.24, the number of FTEs in 2000 was 874,000, not 849,000; we have added a footnote to explain that the growth in workforce is based on an adjustment arising from a discontinuity in the series.

Cite this publication

Tallack C, Charlesworth A, Kelly E, McConkey R, Rocks S. The Bigger Picture. 2020. (

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