In The bigger picture, the REAL Centre's first report, we look back at what we can learn from changing NHS care over the past two decades in England. Here are 10 key charts from the analysis, followed by six lessons for the future.
Lessons for the future
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, 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. A systematic national projection of future trends in morbidity is 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 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 is one of the most powerful factors 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.