What’s happened to NHS spending and staffing in the past 25 years?

Twenty five years ago, in the financial year 1998-99, the Department of Health in England spent £36.6bn in total, equivalent to £59bn in 2021-22 prices. The bulk of this covered the NHS but also included public health, arm’s length health bodies, and other health services. Today, in 2022-23, the department’s planned spending (excluding special covid spending) is likely to be around £165bn in 2021-22 prices, a real terms increase of 180%.

On average, this has meant health spending growing at a rate of around 4.4% each year since 1998-99. Not bad, and the sort of growth that should cover things such as population growth and demographic change, technological change, and improvements in care quality.

But growth in spending has not been an even 4.4% a year (fig 1).1 Even when adjusted for changes in the population and its demographic structure, it’s clear that the bulk of the increase in spending happened between 1998 and 2009 (by 6% a year). Between 2009-10 and 2019-20 average annual growth was just 0.4%.

Fig 1

Change in total health department spending since 1998-99 (excluding covid-19 measures), England, at 2021-22 prices

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Unsurprisingly, trends in health staff numbers more or less match spending trends. Between 1998 and 2022 the number of full time equivalent NHS and general practice staff grew by 62%, from 853 641 to 1 381 439. But this growth has been uneven: an increase of 29% between 1998 and 2005 was followed by a 1% decrease between 2005 and 2013, and then an increase again of 26% to 2022 (fig 2).2345

Fig 2

Change in total number of NHS and general practice staff since 1998-99, England

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Two key trends

Relative to the population of England over these three periods, total NHS plus general practice staff per head rose by 25%, fell by 7%, then rose again by 19%. If the figures are adjusted, as with spending, to take account of the change in England’s demography over the past 25 years, then the current rate in 2022 has more or less recovered to that in 2005, from a low in 2013 (fig 2).

Understanding trends in different staff groups is hampered by the fact that there have been many changes in definition and data collection systems over the years. Fig 3 shows the main trends in NHS and general practice staffing numbers, together with some of the more significant breaks in the data.2345

Fig 3

Trends in NHS staff numbers by professional group, England, since 1998-99

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Two trends worth noting are the large and consistent growth in the number of consultants—a rise of 163% over the past 25 years—and the rise and fall in qualified GPs. Since 2015 the number of qualified GPs (partners and salaried) has fallen by 7%, equivalent to 1900 GPs.

One lesson from these historical trends might be that healthcare could be in a better position now if spending had grown more consistently over time and across staff groups, allowing the workforce to grow in line with population change and to be able to deliver a better quality service.