The 75th anniversary of the NHS: How is it doing?

This article has been prepared in advance of the House of Lords debate scheduled for 30 November 2023:

Lord Hunt of Kings Heath (Labour) to move that this House takes note of the 75th anniversary of the National Health Service and its performance in waiting times.

Health is largely a devolved matter in the UK. Unless otherwise stated, this article focuses on NHS England and its services.

1. NHS: 75 years

1.1 Introduction and comparisons since 1949

The NHS marked its 75th anniversary on 5 July 2023, having been established in 1948 under the National Health Service Act 1946.

Issuing a statement on its anniversary, NHS England noted that it was the first “universal health system to be available to all, free at the point of delivery”.^[1] It said that public support for these principles remained strong today. These principles also form part of the seven principles set out in the current NHS constitution, namely:^[2]

• The NHS provides a comprehensive service, available to all.
• Access to NHS services is based on clinical need, not an individual’s ability to pay.
• The NHS aspires to the highest standards of excellence and professionalism.
• The patient will be at the heart of everything the NHS does.
• The NHS works across organisational boundaries.
• The NHS is committed to providing best value for taxpayers’ money.
• The NHS is accountable to the public, communities and patients that it serves.

According to NHS Digital, in 1949 the NHS had around 11,735 doctors, 68,013 nurses and 5,637 midwifery staff.^[3] In July 2023, this had risen to around 134,026 doctors, 336,164 nurses (including health visitors) and 22,122 midwifery staff.^[4] The health policy analyst Mehmet Bulut estimated in August 2023 that it may be the sixth largest employer in the world.^[5]

Government funding for the NHS has also grown considerably over time. In the first financial year after the NHS’s foundation, government expenditure on health services was £447mn.^[6] By 2022/23 this figure had reached £212bn.^[7]

As illustrated in the chart below (which draws on data from the House of Commons Library), public spending on health as a share of the economy has more than doubled since the NHS’s inception, from around 3.5% in 1949/50 to 8.4% in 2022/23.^[8] Health spending as a share of total public expenditure has likewise increased, from 9% in 1949/50 to 18% in 2022/23.

Figure 1. Government expenditure on public health services as a share of GDP from 1949/50 to 2022/23

Further information on NHS funding can be found in the House of Lords Library article ‘The NHS at 75: The past and future of its funding model’, 6 July 2023.

1.2 Timeline of the NHS: From 1944 to 2022

This section of the briefing provides a brief timeline of key events involving the NHS and its structure from 1944 to 2022.^[9] A more detailed history of the UK’s national health services, from inception to 2018, can be found in the House of Lords Library briefing ‘National Health Service: 70th anniversary’.

• 1944: Winston Churchill’s coalition government published a white paper recommending a national health service which was comprehensive and free.
• 1946: Labour’s Minister of Health Aneurin Bevan pushed ahead with a National Health Service Bill, which received royal assent that year. The legislation formed the basis for setting up the NHS.
• 1948: The NHS was inaugurated on 5 July 1948.
• 1949: The Nurses Act 1949 established a framework for the role of nursing within the NHS and made provision for the training of nurses.
• 1957–59: Following concerns about the treatment of people with mental illnesses, the Mental Health Act 1959 was passed. This brought the provision of mental health services within the NHS’s remit.
• 1962: The Conservative health minister, Enoch Powell, launched ‘A hospital plan for England and Wales’, which set out a 10-year plan to improve the NHS estate and develop a national network of district general hospitals throughout the UK.
• 1974: Following years of debates and reports on the structure of the NHS, major reorganisation took place in 1974 under the National Health Service Reorganisation Act 1973. This introduced a structure composing of regional, area and district health authorities.
• 1982: The Conservative government abolished area authorities, meaning that the regional health authorities had direct responsibility for the 192 district health authorities.
• 1983–84: The Griffiths report recommended that general managers be introduced throughout the service, reasoning that management by consensus had failed. These reforms were introduced in 1984.
• 1990: Following a number of papers published by Margaret Thatcher’s Conservative government in the preceding years, the GP contract was introduced (providing for performance-related payments) and an internal healthcare market separating ‘providers’ and ‘purchasers’ was facilitated by the National Health Service and Community Care Act 1990.
• 1991–92: The ‘Health of the nation’ white paper identified areas for improving health, including more focus on cancer, coronary heart disease, mental health and HIV/AIDS. A patient charter was also introduced setting out what standards of service should be expected.
• 1998: Healthcare responsibilities were largely devolved to Scotland, Wales and Northern Ireland following devolution settlements and legislation enacted under the Labour government. In addition, NHS Direct (the precursor to the 111 service) and the National Institute for Health and Clinical Excellence (NICE) were established. NICE was tasked with improving the consistency of healthcare across England and Wales by assessing the clinical costs and benefits of interventions and to make recommendations.
• 1999: Primary care groups were established, which allowed GPs, nurses and other workers to work together to commission care on behalf of local communities.
• 2000–01: The government published and implemented ‘The NHS plan: A plan for investment, a plan for reform’, which set out a ten-year modernisation programme of investment and reform. The plan sought to expand capacity and provide greater patient choice, including by utilising maximum waiting times for appointments and admissions, expanding education and training, and providing for greater use of the private sector by the NHS (including through private finance initiatives (PFIs)).
• 2002–06: Further measures to reorganise the structure of the NHS were implemented. This included the creation of NHS foundation trusts (intended to have greater independence from central government than traditional NHS trusts) and strategic health authorities (which undertook regional management for the NHS and oversaw a number of primary care trusts).
• 2009: The first NHS Constitution was published, setting out principles for how the NHS should act and make decisions, core values and pledges to patients and staff. The Care Quality Commission was established to regulate and inspect health and social care providers in England.
• 2011–13: The Coalition government passed and enacted the Health and Social Care Bill. The legislation abolished strategic health authorities and primary care trusts and gave NHS England and clinical commissioning groups statutory responsibility for commissioning health services.
• 2014–16: The NHS ‘Five year forward view’ was published, calling for better integration of GP, community health, mental health, care and hospital services. NHS organisations were tasked with progressing local plans to meet the paper’s objectives.
• 2017: NHS England published ‘Next steps on the five year forward view’ proposing national service improvement priorities for the next two years. This included improving accident and emergency (A&E) performance, cancer services and access to high quality GP services.
• 2019: A new ‘Long term plan’ was published by the NHS setting out a vision for the next 10 years. It included goals to reduce deaths from major conditions (including cancer and cardiovascular diseases) and the use of integrated care systems to bring together NHS organisations and local authorities for the planning of services and improving health outcomes across geographical areas.
• 2020: The Covid-19 pandemic hit the UK, resulting in the NHS’s rollout of a nationwide vaccination campaign. Public support was shown for the NHS during the pandemic, including a weekly ‘Clap for our carers’.
• 2022: The Health and Care Act 2022 restructured the NHS around integrated care systems. These formally replaced clinical commissioning groups.^[10]

Additional timelines of the NHS have been published by the Health Foundation; see ‘The history of the NHS’ and ‘NHS reform timeline’. NHS England also has a timeline which covers milestones for disease treatment (for example, it highlights the beginning of polio immunisation in 1956 and the evolution of heart transplants) at ‘NHS history’.

2. Key statistics on waiting times

The following charts show selected NHS England pledges and government targets for waiting times. Reducing waiting times was listed as one of the government’s five key priorities by Prime Minister Rishi Sunak in January 2023.^[11]

Figure 2. The NHS England waiting list for elective hospital treatment since 2007

Figure 2 shows that the waiting list for elective hospital care has increased significantly over the last three years, totalling almost 7.8mn in September 2023. In September 2020 it totalled 4.4mn. The NHS has stated that elective care waiting lists have been significantly impacted by the Covid-19 pandemic and that it is working to deal with the backlog.^[12] However, across the decade prior to the pandemic, the numbers on the waiting list had also grown, from 2.4mn in September 2009 to 4.4mn in September 2019.

Recent analysis by the Health Foundation has estimated that the waiting list could rise to over 8mn by the summer of 2024.^[13] It said this is regardless of whether there is further industrial action. It explained:

The analysis models four different future scenarios to look at the prospects for reducing the waiting list by the end of 2024. It shows that, on current trends, the waiting list could peak at 8mn by August 2024 if there is no further strike action, before starting to fall. If strike action were to continue the waiting list could be 180,000 higher.

The analysis finds that industrial action by consultants and junior doctors has so far lengthened the waiting list by around 210,000, just 3% of the overall size of the list, which totalled 7.75mn at the end of August 2023. The analysis also points out that strikes are also likely to have indirect impacts, by squeezing NHS finances and diverting management attention away from productivity improvement.

Another NHS performance measure is for patients to be dealt with within four hours when attending A&E. The following chart shows the percentage of patients waiting over four hours dating back to 2011.

Figure 3. Percentage of patients waiting over four hours in A&E

It shows that there has been a general rise in the numbers waiting over four hours, with 3.4% waiting longer than four hours in October 2011 and 29.8% waiting longer than four hours in October 2023. However, the October 2023 figure is an improvement on October 2022, when 30.5% waited longer than four hours, and it is less than the peak figure of 34.8% in December 2022. Further information on A&E waiting time targets can be found in the Nuffield Trust article ‘A&E waiting times’.

Figure 4. Average ambulance response times for category 1 (life-threatening) calls

NHS England has pledged that ambulance trusts will respond to category one calls (those for life-threatening illnesses or injuries) in seven minutes on average.^[14] Average response times for category 1 calls reached a peak in December 2022 when they were 10 minutes 58 seconds on average, almost four minutes above target. Response times have fallen since, averaging 8 minutes 40 seconds in October 2023, but they are still higher than the seven-minute target.

The NHS has a number of waiting time targets relating to cancer treatment.^[15] One of these is that 85% of patients should start receiving treatment for cancer within 62 days of an urgent suspected cancer referral. The below graph charts performance against this target since October 2009.

Figure 5. Percentage of patients waiting less than two months for cancer treatment after an urgent GP referral

The chart shows a general decline in the number of cases meeting the target since March 2018, when 84.7% started treatment within the 62 days. In September 2023 59.3% of cases hit the 62-day target, a fall of 1.5% from the previous September. The target was last achieved in December 2015. Further information and statistics for cancer waiting times can be found in the Nuffield Trust article ‘Cancer waiting times’.

Additional statistics on the NHS, including figures for performance, funding and staffing, can be found in:

• House of Commons Library, ‘NHS key statistics: England’, 15 November 2023
• NHS Confederation, ‘Key statistics on the NHS’, 18 August 2023
• Nuffield Trust, ‘QualityWatch: NHS performance tracker’, accessed 21 November 2023

3. Government policy on improving NHS performance

As noted above, reducing NHS waiting times was set out as one of the government’s five key priorities in January 2023.^[16]

Addressing a question about progress on this priority in October 2023, then Health Secretary Steve Barclay said that the NHS was working hard to “ensure those who have been waiting the longest receive treatment as soon as possible”.^[17] He said that waits over 78 weeks for elective procedures had been “virtually eliminated” and that focus was now on cutting waits over 65 weeks. He stated that the government had provided extra funding to try to tackle these waits:

The government has allocated an additional £8bn revenue funding and £5.9bn investment in NHS capital from 2022–25 to tackle the elective backlog and provide new beds, equipment, and technology.

Further information on efforts to reduce waiting lists is set out in the updated NHS mandate, published by the government in June 2023.^[18] The mandate sets out key priorities for NHS England to focus on, with progress monitored by the secretary of state. For example, on waiting times, the mandate stressed the importance of improving cancer outcomes, A&E times and access to GP services.

The mandate also contained priorities for NHS England to:

• Support the workforce through training, retention and modernising the way staff work. This includes NHS England leading on implementation of the ‘NHS long term workforce plan’ (30 June 2023).
• Deliver recovery through the use of data and technology. For example, developing the NHS app so that it can increasingly be used for managing appointments and accessing personal patient records, and rolling out electronic health records across most NHS trusts.^[19]

Commenting on the long term workforce plan published by the government in June 2023, Steve Barclay said it was “backed by significant government investment” and showed “our determination to support and grow the workforce”.^[20] The plan split objectives across three overarching areas: train, retain and reform. These were summarised as follows:

• Train. Significantly increasing education and training to record levels, as well as increasing apprenticeships and alternative routes into professional roles, to deliver more doctors and dentists, more nurses and midwives, and more of other professional groups, including new roles designed to better meet the changing needs of patients and support the ongoing transformation of care.
• Retain. Ensuring that we keep more of the staff we have within the health service by better supporting people throughout their careers, boosting the flexibilities we offer our staff to work in ways that suit them and work for patients, and continuing to improve the culture and leadership across NHS organisations.
• Reform. Improving productivity by working and training in different ways, building broader teams with flexible skills, changing education and training to deliver more staff in roles and services where they are needed most, and ensuring staff have the right skills to take advantage of new technology that frees up clinicians’ time to care, increases flexibility in deployment, and provides the care patients need more effectively and efficiently.^[21]

Further details on specific proposals under each of these areas can be found in the main document.^[22] For example, under training the plan pledged:

• doubling the number of medical school training places, taking the total number of places up to 15,000 a year by 2031/32
• increasing GP training places by 50% to 6,000 by 2031/32
• increasing adult nursing training places by 92%, so there are nearly 38,000 by 2031/32

In addition, the Department of Health and Social Care is developing a major conditions strategy. Providing an update on the strategy in August 2023, the department said it focuses on improving outcomes across six health conditions, which the department said drove over 60% of mortality and morbidity in England.^[23] These conditions are:

• cancers
• cardiovascular disease, including stroke and diabetes
• musculoskeletal disorders
• mental ill health
• dementia
• chronic respiratory disease

The government’s update also provided a strategic framework for how to approach these challenges over the course of patients’ lives; it covered primary and secondary prevention (for example, slowing the progression of conditions or addressing risk factors), diagnosis and prompt care, and long-term treatment and care. In particular, it highlighted five priority changes:

• rebalancing the health and care system towards proactive prevention by managing personalised risk factors
• embedding early diagnosis and treatment in the community
• managing multiple conditions effectively—including through aligning generalism and specialism
• better connection and integration between physical and mental health services
• shaping services and support around people, giving them more choice and control over their care^[24]

4. Commentary

Speaking at the Labour Party conference on 11 October 2023, Shadow Health Secretary Wes Streeting criticised the government’s record on the NHS and set out Labour’s commitments for the service.^[25] For example, he said that Labour would provide an extra £1.1bn of funding to tackle the backlog, including provision of evening and weekend clinics, an extra 2mn appointments a year and increased pay for NHS staff. He also said that the system itself required reform, stressing the need for more community-led prevention measures and a greater emphasis on primary care:

A neighbourhood health service as much as a National Health Service, pioneering cutting edge treatment and technology, preventing ill-health, not just treating it.

Primary care will be at the heart of Labour’s plan for the NHS—we’ll train thousands more GPs and cut the red tape that ties up their time. Labour will bring back the family doctor.^[26]

Labour has also published a mission plan for the NHS, setting out three key pledges:^[27]

• Change so that more people get care at home in their community. It listed improving GP access, expanding referral routes and the role of community pharmacies and increasing the number of district nurses, and also set out proposals to reform social care.
• Change so that we have the workforce we need, with the modern technology to deliver the best healthcare. This included proposals to train and retain staff, including increasing training places and providing more opportunities for staff development, and making better use of technology, including artificial intelligence (AI), across the service.
• Change so that we focus on prevention. This included commitments to policies to tackle smoking and vaping and improve health in childhood, such as breakfast clubs in all primary schools and a ‘Clean Air Act’, and focusing on reducing health inequalities (for example, by improving provision of midwives and health visitors to ensure better continuity of care).

The paper also proposed long-term goals focused on improving performance (for example, reducing wait times), reducing deaths from issues such as cancer, cardiovascular disease and suicide, and improving healthy life expectancy across all groups.^[28]

The Liberal Democrats have also criticised the government’s management of the NHS, citing poor performance against targets and an inability to meet demand for GP services. In addition, their health spokesperson, Daisy Cooper, claimed that around half of the nation’s health burden was “lifestyle induced” and this therefore required more focus on good physical health, mental health, and social health.^[29]

Ms Cooper set out 10 party commitments for improving health:

• Focus on prevention and people’s health. Make the improvement of the nation’s health a key priority for government, emphasising prevention, addressing inequalities, and adopting an ‘invest to save’ funding model.
• Empowering communities. Progressively restore the public health grant to 2015 levels, with a proportion of these funds set aside for local communities experiencing the worst health inequalities to co-produce plans on how the money should be spent in their area.
• Children’s health. Ban energy drink sales to under 16s, only allowing junk-food advertising after 9pm, and grant local authorities powers to restrict junk-food advertising and unhealthy food outlets near schools.
• Promoting movement. Launch a government-backed nationwide campaign to encourage exercise and healthier habits, dedicating an existing bank holiday for wellness events.
• Schools and hospitals. Implement higher food standards in schools and hospitals to ensure every child and patient receives a healthy, balanced diet.
• Tackle vaping and smoking among children with standardised packaging, advertising restrictions and banning disposable vapes. Reduce vaping among non-smokers, while recognising the important role vaping plays in helping adults quit smoking.
• Blood pressure checks. Widen access to blood pressure tests in community spaces like pharmacies and libraries to reach underserved populations.
• Social prescribing. Invest in community projects that counter loneliness and share best practice across local authorities, the NHS, GPs, and primary care services.
• Digital health. Introduce a new kite-mark for clinically proven health apps, enabling individuals to manage their own health.
• Critical health infrastructure. Consider a new national designation to safeguard local health facilities in times of crisis.^[30]

In July 2023, the chief executives of three health think tanks, the Health Foundation, Nuffield Trust and the King’s Fund, wrote a letter to party leaders Rishi Sunak, Keir Starmer and Ed Davey calling for an end to “short-termism in NHS policy making”.^[31] In its press release, the King’s Fund explained:

The think tanks state that recovering NHS services and reducing waiting times for treatment should rightly be a key priority for any current or future government. But they warn that promising unachievable, unrealistically fast improvements without a long-term plan to address the underlying causes of the current crisis is a strategy ‘doomed to failure’.

It outlined four key areas to focus on: investing in physical resources, reforming adult social care, committing to the long-term workforce plan, and cross-government working on the underlying economic and societal conditions impacting health. The letter explained further:

The NHS has endured a decade of under-investment compared to the historic average, and capital spending has been well below comparable countries. As a result, the health service has insufficient resources to do its job: fewer hospital beds than almost all similar countries, outdated equipment, dilapidated buildings and failing IT. Despite long-term objectives to reduce reliance on acute hospitals and move care closer to people’s homes, spending continues to flow in the opposite direction. Long-term thinking is essential to meet the challenges ahead—from responding to changing health needs to harnessing AI and new technology.

[…] the NHS long term workforce plan signals a welcome cross-party consensus on the need for a long-term approach to health service staffing. The plan now needs a sustained cross-party commitment to updating forecasts and providing the resources it needs to succeed. However, ambitious steps to increase the number of staff through training, apprenticeships and international recruitment risk being frittered away if trainees continue to drop out and poor morale and sickness continue to drive staff to leave the service and retire early. A failure to act to retain existing staff would be fatal to the NHS and the health of the nation—again, this needs sustained action over the long-term to make the NHS a better place to work.

Serious reform of adult social care has been shamefully neglected by successive governments. Changing this is critical for the people, families and carers who rely on social care services and would also make a major contribution to reducing pressures on the NHS. A long funding squeeze has led to chronic staff shortages, high levels of unmet need and providers struggling to deliver high quality care. To overcome these challenges, new funding should be carefully deployed as part of a reform package that improves access to high quality care, prioritises better pay and conditions for staff, and gives people far greater protection against social care costs […]

Long-term political action is also needed to address the fraying health of the UK population. The NHS was not set up to go it alone. Protecting and improving people’s health depends on a wider system of services and support that includes local government and social security. Yet people are falling between the cracks of public services and the NHS is often left to pick up the pieces.^[32]

In November 2023, Kate Duxbury, research director at the market research firm Ipsos, noted that public satisfaction with the running of the NHS was at its lowest level in 25 years and that over half (54%) thought the standard of care would get worse over the following year.^[33] In the article, which also featured an interview with Tim Gardner, assistant director of policy at the Health Foundation, she highlighted various issues the NHS was facing, including increasing numbers leaving the workforce after the pandemic and funding levels that didn’t keep pace with its needs. On funding, she referenced the growing and aging UK population, and the increased number of long-term health conditions that this presented. However, she noted that this population trend was also a sign of the NHS’s success.

Looking to its future, she reported strong public support (around 80%) for increased funding for the NHS and also for reform in how it provides its services:

76% think the NHS needs to make big changes to the way it runs and provides services in order to improve—including 60% who assert that it also needs more money, and 16% that it needs to make changes but does not need more money.

However, she said that the public did not want “fundamental reform” and still strongly backed the NHS model and its founding principles. Instead, reflecting on her interview with Tim Gardner, Kate Duxbury said that these changes should include reform to social care (she claimed that around a third of patients in hospital who didn’t need to be there were waiting for social care) and technological change, including greater use of AI and data.

Concluding her piece, she backed the Health Foundation’s call for longer-term thinking on NHS policy:

As Gardner notes at the end of our interview, there is reason for optimism: “We have got the fundamentals of what could be a very high performing health system”. But while the NHS is likely to be a key battleground in the run up to the general election, the improvements that are needed will take more than an electoral cycle to bear fruits. Actions that will future proof the NHS require long-term vision and patience, beyond an election campaign.

5. Read more

• House of Lords Library, ‘King’s Speech 2023: Health and social care’, 1 November 2023; ‘NHS in England: Current performance and innovation’, 8 June 2023; and ‘The NHS at 75: The past and future of its funding model’, 6 July 2023
• House of Commons Library, ‘NHS key statistics: England’, 15 November 2023; and ‘The structure of the NHS in England’, 10 July 2023
• NHS Assembly, ‘The NHS in England at 75: Priorities for the future’, June 2023
• Our Future Health website (a collaborative research programme, involving charities, life sciences groups and UK Research and Innovation, looking at long term health)
• King’s Fund, ‘Public satisfaction with the NHS and social care in 2022: Results from the British Social Attitudes survey’, 29 March 2023

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Cover image by Ian Taylor on Unsplash.