Whoever is in government after the next general election will inherit a health and care system in crisis. The NHS is under extreme strain and many people are going without the care they need. In July 2023, the waiting list for routine hospital treatment in England had grown to nearly 7.7 million – an all-time high – with almost 390,000 people waiting more than a year.¹ Grim data on access to hospital care reflect pressures right across the system – in general practice, community services, mental health, social care: everywhere. These pressures are causing unnecessary pain and suffering for people and their families, as well as severe strain on staff. Public satisfaction with the health service is at an all-time low.²  

But the NHS was not set up to go it alone. Good health depends on a broader set of factors beyond health care, like income, employment, housing, and the range of public services on offer. Yet too many of these building blocks of health have deteriorated after a decade of austerity and the COVID-19 pandemic – particularly for people living in the most deprived areas. Improvements in life expectancy in the UK have stalled,³ unfair differences in health between richer and poorer areas are wide⁴ and many people are out of work with ill health.⁵ 

The next UK government will face difficult choices on health and social care. Short-term pressures on the NHS require urgent attention, but so do longer term challenges facing the nation’s health, which – in turn – will shape future demands on the health service and the resources available to meet them. Understanding the range of challenges facing health and care in the future is essential to identify the action needed by policymakers to address them.  

We highlight nine trends that represent some of the major challenges facing any new government on health and care – focusing primarily on the NHS, social care and public health services in England. We then draw together some of the implications for policymakers. We produced this work for Nesta’s UK 2040 Options project, which is looking at the defining issues facing the country ahead of the next general election.⁶ Other briefings are being produced on related policy challenges – for instance, by the Institute for Fiscal Studies on tax and public finances. The next stage of work will set out policy options to address these challenges, including our priorities for a new government on health and care.

After a century of increases, the decade prior to the COVID-19 pandemic saw improvements in life expectancy among the UK population stall.⁸ For some, these improvements went into reverse: between 2010–12 and 2016–18, life expectancy among women living in the most deprived 10% of areas of England fell, with the largest decreases in the North East.⁹ 

Many countries experienced a similar trend, but the scale of the UK’s slowdown marks it out from other comparable countries.¹⁰ In 2000, the UK ranked 21st of 38 countries for female life expectancy at birth. By 2019, it had fallen to 26th place. Healthy life expectancy – the number of years that someone can expect to live in good health (not just how long they live) – has stagnated too. Recent analysis suggests that if trends in the decade leading up to the COVID-19 pandemic continue, it would take nearly two centuries (192 years) to reach the current government’s target to improve healthy life expectancy by 5 years (for men).¹¹ 

There are substantial inequalities in life expectancy. People living in more deprived areas of the UK tend to die earlier than people living in the least deprived areas, and spend a greater proportion of their lives in poor health.^12,13 There is currently a gap of almost 20 years in how long a woman can expect to live in good health depending on whether she lives in the most or least deprived areas of England (Figure 1 and Section 2).¹⁴ These inequalities have persisted and increased over time (Figure 2).^15,16 COVID-19 led to a sharp fall in life expectancy across the population – the biggest fall in England since World War II – but the impact of the pandemic was unequal and exacerbated existing inequalities further.^16,17

Figure 1

Smoking, poor diet, physical inactivity and harmful alcohol use are the leading risk factors of preventable ill health and mortality in the UK.²⁷ All of these risk factors are socially patterned and have multiple causes, including structural social and economic conditions.²⁸ For example, people’s ability to adopt healthy behaviours is strongly shaped by the resources they have to buy food, the kind of work they do, the shops in their local communities and whether there are safe and accessible spaces to play and exercise.²⁹ Commercial influences matter too – for instance, in shaping the expense and availability of unhealthy food, alcohol, and tobacco, and how they are advertised and promoted.³⁰ Exposure to these risk factors can be influenced through national policy, like changes in prices and regulation. And the costs of this preventable burden of ill-health are substantial to individuals and society: the annual cost of obesity in the UK, for instance, has been estimated to be as much as £58bn, with major impacts on workforce productivity as well as demands on NHS and other public services.³¹ 

Trends for some of these risk factors are going in the wrong direction.³² Rates of childhood obesity in England have risen sharply in recent years (though have fallen back slightly in latest figures), smoking rates remain high among people working in routine and manual jobs and people with poor mental health, alcohol-related deaths are increasing, and physical activity levels are lower than in the past.³³  

There are also significant – and in some cases widening – inequalities in exposure to these risk factors. This is particularly apparent for childhood obesity rates, which are highest and growing fastest in children from the most deprived areas (Figure 3). More than twice as many children from the poorest areas in England were obese in 2021/22 compared with those in more affluent areas. The prevalence of obesity in children in Year 6 increased from 24.6% to 31.3% among those living in the most deprived areas between 2013/14 and 2021/22, compared with an increase from 11.7% to 13.5% in the least deprived.³⁴  

Figure 3

A mix of factors affect the number of people living in poor health, including changes in the prevalence of leading risk factors for ill health, social and economic conditions, the size and age of the population and more. In England, the decade before the pandemic saw a more than 25% increase in the number of people living with major illness – conditions such as cancer and dementia or combinations of other illnesses.⁴² There has been a significant rise in the number of people living with multiple health conditions since the early 2000s.⁴³  

The burden of illness is not spread evenly. People living in more deprived areas are at greater risk of having multiple conditions and are more likely to develop them younger.⁴⁴ On average, a 60-year-old woman living in one of the poorest areas of England has diagnosed illness – such as chronic pain, diabetes, cardiovascular disease, or depression – equivalent to that of a 76-year-old woman living in one of the wealthiest parts of the country.⁴⁵ 

Recent analysis suggests these trends are likely to continue. By 2040, almost 1 in 5 of the adult population in England are projected to be living with major illness, an increase of 2.5 million people (37%) since 2019.⁴² Life expectancy is projected to rise by 1.4 years on average between 2019 and 2040, while the age at which people are expected to be living with major illness is projected to remain unchanged at 70 years old. Levels of multimorbidity are projected to rise for all age groups.

The growth in major illness will have substantial implications for the NHS and wider public services. Caring for more people with major illness will place additional demands on services across the NHS, but many of the conditions with the largest projected growth in absolute numbers, such as diabetes and chronic pain, tend to be managed in primary and community settings (Figure 4). Yet over the past 20 years, there has been a large shift in NHS activity and spending away from primary and community care and towards acute hospitals (Section 6). Changes in the population will also have implications for our ability to pay for growth in services. Our projections suggest that the ratio of the working-age population to the older population with major illness in England may reduce by nearly a third between 2019 to 2040.

Figure 4

While health needs are set to increase, the NHS and social care are already struggling to deliver care and support to people who need it. COVID-19 caused widespread disruption to services, but access to care had already been worsening for a decade before the pandemic. 

In July 2023, the waiting list for routine hospital treatment in England stood at 7.68 million – the highest since records began (Figure 5). Nearly 390,000 people had been waiting more than a year.⁴⁶ NHS waiting lists grew substantially in the decade prior to the pandemic, from 2.32 million in January 2010 to 4.57 million in January 2020. Targets for patient care are routinely being missed. The NHS constitutional standard that at least 92% of patients should wait no more than 18 weeks from referral to starting treatment has not been met nationally since 2016.⁴⁷ In cancer care, the 62-day waiting time target – that at least 85% of patients should start treatment within 62 days of an urgent GP referral – was last met in 2015.⁴⁸ 

Figure 5

A decade of underfunding going into the pandemic has constrained what health and care services can provide. Total government spending on health in England grew by only 2% a year in real terms over the decade before the pandemic – well below the long-run average of 3.8% (Figure 7).⁵⁹ Spending jumped up sharply during the pandemic (with annual growth of 5.7% between 2019/20 and 2022/23), when the NHS had to deal with the biggest shock in its history, with much of the extra funding going towards additional staff (see Section 7). Health spending is planned to increase by 0.1% in real terms between 2023/24 and 2024/25 – and future spending plans for the NHS are uncertain. There is strong public support for additional NHS spending (80% of the public in our latest polling), including most people intending to vote Conservative (60%) and the vast majority of Labour voters (93%).⁶⁰

Figure 7

Weak investment has contributed to constrained capacity across the health system – holding back what services can deliver, but also leaving them vulnerable to shocks. Going into the pandemic, the NHS in England had lower numbers of hospital beds per person than most comparable countries (2 beds per 1,000 people) – similar levels to Canada and Sweden, but lower than countries like France (3 beds per 1,000) and Germany (6 beds per 1,000) – as well as lower levels of diagnostic equipment, like CT and MRI scanners (Figure 9).⁷⁴ The NHS also had much shorter lengths of stay in hospital and higher bed occupancy – running the system ‘hot’ (Figure 10).

Figure 9

Staff shortages are widespread across the NHS and social care. Going into the pandemic, the NHS had fewer doctors and nurses per person than most comparable countries.^84,85 Staff numbers have grown over recent years and there are more people working in the NHS now than in 2019. But this growth has not been even⁸⁶ and gaps remain. Staff vacancies in NHS trusts in England currently stand at around 125,000, an estimated vacancy rate of around 9%.⁸⁷ The NHS is short of around 4,200 GPs.⁸⁸ The number of appointments in general practice in England are near record levels, but the number of full-time equivalent, fully qualified permanent GPs has decreased since 2015.⁸⁹ In social care, staff vacancies are estimated at 152,000 – a rate of 10.6% and up substantially over the past decade.⁹⁰ Staffing levels affect quality and access to care.^91,92

How far staff gaps grow over the next decade depends on policy action to address them. In summer 2023, national NHS bodies published a plan for meeting future staffing needs – including by training more doctors, nurses and other staff. Government committed £2.4bn funding for expanding training. But delivering the plan depends on sustained policy action and investment over many years – including in the buildings, equipment and IT needed for staff to work effectively (Section 6), as well as measures to help relieve pressure on staff and keep them working in the NHS. Substantial investment is needed to boost staff numbers to the levels set out in the plan,⁹³ and there are questions about capacity to boost training.⁹⁴ No similar plan exists for adult social care, where staff turnover is high, terms and conditions are poor and care workers experience shocking levels of poverty and deprivation (Figure 12).^95,96 

Figure 12

Public satisfaction with the NHS is at a 40-year low. The British Social Attitudes survey¹⁰¹ – a representative survey of adults in Britain conducted annually since 1983 – found that in 2022, only 29% of the public was ‘very’ or ‘quite satisfied’ with the NHS (Figure 14). Satisfaction has fallen sharply since the pandemic, with 60% of the public very or quite satisfied in 2019 – though satisfaction in 2019 was still well below its peak in 2010. The main reasons people gave for their dissatisfaction were waiting times for GP and hospital care (69%), staff shortages (55%) and a lack of public spending on the NHS (50%). Satisfaction fell across all ages, income groups and supporters of different political parties.

Figure 14

The NHS in England has been regularly reorganised. In its first 30 years, the structure of the NHS was relatively stable. But over the past 30 years, the NHS has been on a treadmill of top-down reform and reorganisation. NHS commissioners, for instance – responsible for planning and purchasing local services – have existed in almost constant organisational flux since the NHS internal market was introduced in 1991.¹⁰⁷ The latest round of reforms led to the establishment of 42 integrated care systems in England¹⁰⁸ – area-based agencies responsible for managing NHS services and spending. Evidence suggests that top-down restructuring in the NHS has delivered little measurable benefit – and can cause harm.¹⁰⁹ 

Meantime, social care has been neglected by national policymakers. The adult social care system in England is a threadbare safety net, with state-funded support only available to people with the highest needs and lowest means. Many people go without the care they need – and some face catastrophic costs. The absence of state protection against care costs is a glaring gap in our welfare state.^110,111 Successive governments have promised to reform the broken system. In 1997, Tony Blair told the nation that he did not want children to grow up ‘in a country where the only way pensioners can get long-term care is by selling their home’. Boris Johnson promised to ‘fix the crisis in social care once and for all’ when he became Prime Minister in 2019. And a long line of white papers, independent commissions and even legislation on social care reform came in between. But reform has been repeatedly ditched or delayed – and people and their families continue to suffer unnecessarily. 
 

The rollcall of health and care challenges facing the next government is long and daunting. Health systems around the world are still reeling from the effects of COVID-19 – and will be for years to come. But the underlying causes of the current crisis are much longer term – including a decade of underinvestment in the NHS and wider public services, weak capacity, staff shortages, political neglect of adult social care and more. Growing numbers of people are struggling to get the care they need today and pressures on services are only set to increase as more people live longer with major illness over the coming decades. The health of the population is stalling and inequalities between rich and poor are widening.

Responding to these challenges is not just about greater investment, but it will not happen without it. Services across the public sector are creaking after a decade of austerity¹¹² and the outlook for economic growth that drives investment is weak.^113,114 Policymakers face a choice: unless health spending grows over the long term in a way that reflects changing health needs, services will deteriorate, long waiting lists will be here to stay and the social contract underpinning the NHS may fray. But increasing spending on the NHS and other public services would likely require tax rises¹¹⁵ – and, even then, additional spending will take time and policy change to translate into better services. Government must also choose where to focus: for instance, how will it balance short-term objectives to increase access to NHS services with the longer term investment needed to improve social conditions shaping health?

Changes to how the health and care system works will be needed. Population ageing and the growing burden of disease mean longstanding policy objectives to strengthen disease prevention and deliver more coordinated services outside hospitals must become a reality. Past evidence shows this is easier said than done.^116,117 But there are obvious places to start. For instance, successive governments have promised and then failed to reform England’s broken system of social care and support – leaving a gap in our welfare state. Stronger policy action is also needed to tackle the leading risk factors of preventable ill health and mortality, such as obesity. Population-level interventions – policies that impact everyone and do not rely on high levels of individual agency, such as a sugar and salt reformulation tax and expanding eligibility for free school meals – are most likely to be effective and equitable.^119,120,121 Yet national policies implemented in England over the past decade have largely focused on individual behaviour instead.¹²² The next phase of Nesta’s 2040 Options project will look at these and other policy options to address the major challenges facing the nation’s health.

Debate about the future of NHS reform often focuses on the structure of the system. The NHS has been on an almost constant cycle of top-down reorganisations since the 1990s. And some media commentators and backbench MPs often point to the NHS’s funding model as a potential target for ‘radical’ reform – for instance, by introducing new user charges or switching to a different model for raising revenue. Evidence suggests these are the wrong places to look.^123,124,125 The public have little appetite for them either. Instead, policymakers should focus on how they can best support the NHS to test and expand new ways of delivering care to meet the changing health needs of the population – including harnessing developments in data and technology and strengthening primary and community services, as well as learning from the rapid service changes implemented during the pandemic.¹²⁶  

The trends we outline paint a gloomy picture. But how they play out in future is not inevitable. The NHS faced long waiting lists in the 1990s but brought them down through concerted policy action and investment over more than a decade.^127,128 Long-run falls in UK smoking rates since the 1970s illustrate the impact of population-level interventions to reduce major health risks.¹²⁹ And evidence on the impact of England’s health inequalities strategy in the 2000s shows progress on reducing inequalities is possible with sustained investment in public services and a mix of social programmes.^130,131 For better or worse, policy choices made by the next government will shape the future of the nation’s health.