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This Evidence Review highlights the richness of the current agenda around health and care, particularly regarding public health and inequalities being a rising concern of the newest analyses and policy papers. Thinking around and collection of evidence on primary care, prevention, integrated models of care point toward the tensions of financing structure, the lack of financing of services, demographic changes, and future perspectives on public health outcomes.

The concern about the growing gap of inequalities regarding health outcomes makes the agenda of prevention and systemic approach to health particularly important. Chris Whitty’s lecture provides an overview of the key statistics highlighting the characteristics of the inequality gap regarding health and mortality. Most recent reports on mortality, death, or the fresh analysis of infant mortality plotted on local authorities provide insights for new ways of approaching socio-geography, economic structure, and health. These are fundamental in the future planning of services based on broadly integrated approaches tackling inequalities and health outcomes.

Surveys measuring attitudes show a striking responsiveness of the public to challenges such as lack of funding, staff shortages, poor management, and lack of clarity of governmental policies.  The public are more willing to share their data with the NHS than any other governmental or commercial organisation, despite not knowing how the NHS would use their data. This points toward trust in the NHS yet expresses concern about the lived experience of services provision and coordination. The experiences of elderly people about digital exclusion (Access Denied), are a warning to consider when planning care services now and in the longer run, given the challenges of rurality, digital divide, and demography.

Nigel Crisp’s commentary on the relevance and strength of the founding NHS principles has outlined a suggestion for the UK version of “health for all” policy. He calls for considering and building on public health and wellbeing as a societal matter interlinking community; businesses, public institutions, as an economic matter driving the future of the economy; and as a matter of our planet – no wellbeing or health can be achieved without consideration of the health of the planet.


1.1. Health care spending and budgets


Health spending planned to fall in England and Scotland in 2024–25, a top-up likely

Institute for Fiscal Studies (IFS), 4th March 2024

The UK government, Scottish Government and Welsh Government have each now published their final updated budgets for the current financial year, 2023–24 confirming top-ups to health spending (budgets linked in the article).

New analysis by IFS researchers of these updated budgets and published spending plans for 2024–25 shows that, as a result:

health spending is currently budgeted to fall in real terms in the coming financial year in both England and Scotland but increase modestly in Wales.

Currently planned spending in 2024–25 will almost certainly need to be topped up if cuts to staffing and service provision are to be avoided: especially in England where day-to-day spending cuts are planned. The UK Government is currently holding back spending to make top-ups as needed – which creates issues in planning for managers.

Under the compared budgets – the set of responsibilities under these budget headings are not perfectly aligned (more social care spending is included in Scotland and Wales than in England). Findings:

  • There have been sizeable in-year top-ups to initial health budgets in each country in 2023–24, to cover the costs of pay deals, and ongoing pressures on NHS services.
  • £4.4 billion in England, £605 million in Scotland and £629 million in Wales. This is equivalent to a 2.5% (£75 per person) top-up in England, a 3.4% (£110 per person) top-up in Scotland, and a 6.2% (£200 per person) top-up in Wales.
    • Plans for health spending in 2024–25 imply a 2.4% real-terms year-on-year cut in England, compared with a 0.75% cut for Scotland and a 0.7% increase for Wales. Figures for England and Wales do not adjust for any additional funding from the immigration health surcharge
  • Scotland’s published plans for 2024–25  includean allowance of £200 million for funding that will be provided from the proceeds of the immigration health surcharge (a fee paid by short-term immigrants or their employers).
  • A real-term reduction in health spending would require some combination of reductions in staffing, pay and service provision.
    • In contrast, the English NHS long-term workforce plan implies increases in staffing of 4% in 2024, and tackling waiting lists will require an increase in the number of appointments and procedures
  • Top-ups to English NHS spending will generate additional funding for the Scottish Government and Welsh Government via the Barnett formula.


1.2. Demography and Health


England and Wales Mortality Monitor end of 2023

Institute and Faculty of Actuaries

  • Revised population estimates following the 2021 census, published in November 2023.
  • Based on provisional weekly deaths, data published by the Office for National Statistics (ONS) up to 5 January 2024.
  • In 2023: Cumulative mortality rates for the combined 20-100 age group are lower than the 2013-2022 average, but there is considerable variation by age.
    • Mortality for males and females aged 20-44 is higher than in any of the previous ten years other than 2021, but
    • mortality for the 75-84 age group is lower than any of the previous years except 2019.
    • Cumulative mortality improvements for most age groups are modest, but towards the bottom of the range of the previous ten years.


Deaths Registered in England and Wales:  2022

Office for National Statistics (ONS), released 15 December 2023, ONS website, statistical bulletin, Deaths registered in England and Wales: 2022

In 2022, there were 577,160 deaths registered in England and Wales, which was a decrease of 1.6% compared with 2021 (586,334 deaths).

  • In part due to the higher number of Coronavirus rates in males (2020, 2021).
  • There were more male deaths registered than female deaths (292,064 male and 285,096 female) for the third consecutive year; before 2020 this was last the case in 1981.
  • The leading cause of death in 2022 was dementia and Alzheimer’s disease, which accounted for a higher proportion of deaths in females.

Deaths registered in England and Wales by Deprivation – ONS

All data available for 2020, 2021, 2022, by ONS.


1.3. Social Care, Primary Care – Challenges and Avenues


Ministerial Priorities for the NHS in Wales

An equal partnership between the NHS and social care organisations,  focused on people receiving a consistent standard of community care across Wales.

Aim: organisations and other key partners, to have regions and localities working towards the national service specification and workforce model.


  • A closer relationship between the NHS and local governmentto tackle delayed transfers of care, and an effort to move further and to deliver an integrated community care service for Wales is essential. Work is ongoing across health and social care to introduce the Pathways of Care Reporting framework for delayed transfers of care in 2023. Health boards will be expected to use this to monitor discharges. All organisations must deliver care closer to home.
  • Improving access to general practice, dentistry, optometry and pharmacy.This will include independent prescribing and increasing self-referral to a wider range of community-based allied health professionals, including rehabilitation, mental health and audiology.
  • Urgent and emergency caremust focus on the effective management of people with urgent care needs in the community 24/7, and help more people to safely access alternatives to hospital-based care, for example through robust, seven-day same-day emergency care services and integrated health and social care community response models.
  • Planned care and recoveryis being led by the National Recovery Programme, which will set specific requirements for health boards. Meeting these requirements must be a priority. Regional diagnostic centres and treatment centres should be at the forefront of organisations’ plans. Actions to move services, workforce and funding from hospitals into the community.
  • Cancer servicesmust enact the quality statement on cancer and ensure there is a reduction in the backlog of patients waiting too long on the cancer pathway.
  • Mental health and child and adolescent mental health services:there must be improvements across all age services and equity and parity between physical and mental health services. Health boards must plan to expand tier 0/1 support to provide easy access to population-level support for lower-level mental health issues, and improve services across CAMHS, adults and older adult services:
    • Reconfiguring eating disorder services to target earlier intervention;
    • Improving memory assessment services to obtain a timely diagnosis and treatment;
    • Improved access to full range of all age mental health and wellbeing services, particularly for children and young people, de-medicalise the approach to mental health services.


Access Denied: Older people’s experiences of digital exclusion in Wales

30 January 2024.

A growing number of older people in Wales are at risk of social exclusion and being left behind as the use of digital technology continues to play an even greater role in our everyday lives (Older People’s Commissioner for Wales).


  • There are different levels of digital exclusion, not just binary online-offline:
    • people may choose to use the internet for certain activities, such as keeping in touch with friends or family via social media, but not others, such as banking or shopping.
  • Access is not the same as inclusion: people may be online but may still find themselves digitally excluded in some way.
    • Research shows that older people are most at risk of digital exclusion, while there are other factors – such as not working, being amongst the most financially vulnerable and living with a condition that limits or impairs the use of digital communications.
    • 31% of over 75s (95,069 people) do not have access to the internet at home
    • 33% of over 75s (101,200) do not use the internet
    • Older people are far less likely to have accomplished the 5 Basic Digital Skills (handling information and content, communicating, transacting, problem solving and being safe and legal online) compared to other age groups.
  • All local authorities and health boards highlighted the measures they currently had in place or planned to provide to faciliate access to information by non-digital means, and to support older people to get online.


  • The report is based on responses shared by 159 older people From July to November 2023. The vast majority of responses were written/sent by older people themselves,
    • by telephoning the Commissioner’s office, or by completing a paper or online form, and adverts were placed in newspapers throughout Wales to encourage people to respond.
  • A simple framework was used to capture people’s voices and experiences, based around three questions: • What were your experiences? • What impact did this have and how did this make you feel? • What needs to happen to prevent others experiencing this kind of thing in the future?

Further Findings and Implications

  • Barriers: costs, security, chose not to be online, language etc.
  • Impact: frustration, mental health, difficulties in getting support
  • Suggestions by elderly people: importance of choice, e.g. NHS/ Social services with phone number, cash or card option, training
  • Examples shared by local authorities and health boards included in the report


Building Capacity through Community Care – Further Faster

Welsh Government Statement of Intent

Whole-system-based care that enables older people, and people living with frailty to live their best life in their community.

The Welsh Government, local government and the NHS will provide leadership together, working constructively with partners.


Embedding Prevention in Primary and Community Care Report 47.

PHW, Dec. 2023.International Scanning and Horizon Scanning and Learning Report

Summary of concepts, findings and data sources.


Welsh Government’s Rebalancing care and support programme

Senedd Research, September 2023

Recent resources in the field of care in Wales:


Supporting Healthy Behaviours – A guide for General Practice

Public Health Wales

In line with Healthier Wales plan

The Primary Care Hub in Public Health Wales is producing a series of resources, designed to equip the primary and community care workforce to have conversations with individuals about adopting healthy behaviours. The first two resources in this series have been tailored to staff working in (1) general practice and (2) optometry, with versions bespoke to community pharmacy and community dental services in development.

  • Areas for quality improvement activities
  • Links to training and resources for the workforce
  • Brief information about the benefits of adopting healthy behaviours and harms of unhealthy behaviours
  • Signposting information for individuals to access further support


1.4. Sustainability


Sustainable health care – Position Statement of the Welsh Government

March 6th, 2024

This Position Statement calls for action health from professionals to support climate action, through linking with and learning from local health boards and trusts and exploring sustainable practices with clinical teams. The Call prioritises environmental sustainability for creating a healthier future aligning with public efforts to address climate change. A prudent approach is incorporated into the ‘need for collective action’ of the call.


Digital Medicines Transformation Portfolio – Review

DHCW, 2024, Haimish Lang

Annual review on medicines – measurement, sustainability, and digital transformation.

DMTP was created by Welsh Government in 2022.

Numbers about prescriptions, e-prescription services, and compliance with the e-digital medicines plan, set out in 2021: here.


1.5. Public Attitudes


International survey asks people for their view on the NHS in Wales

The Report is due shortly – in 2024.

An international population survey, in which Wales is the only home nation to take part, is asking people in Wales what it is like to use the NHS.

Dr Sally Lewis, is director of the Welsh Value in Health Centre, which is coordinating the survey on behalf of NHS Wales and the Welsh Government


2.1. Health Outcomes and Impact


Unpacking why health outcomes in the UK compare poorly with peers

A recent report from The King’s Fund that compared health care system performance in the UK with 18 similar countries, concluded that overall the UK is neither a leader nor a laggard. However, the UK does compare less well on measures of health status and health outcomes. The latest data from OECD (including for the pandemic years 2020 and 2021) in Health at a Glance 2023 can help to unpack why health outcomes are worse in the UK.


Economic Inactivity due to Long-term Sickness – recent ONS data

Labour market overview UK 2024

ONS stats

The UK economic inactivity rate (21.9%) for those aged 16 to 64 years was largely unchanged in the latest quarter but is above estimates a year ago (October to December 2022). The annual increase was driven by those inactive because they were long-term sick, which remains at historically high levels. Vacancies fell in the quarter for the 19th consecutive period but are still above pre Coronavirus (COVID-19) pandemic levels.

Employment and unemployment rate is below pre-pandemic rates, inactivity is up the pre-pandemic rates.


the Health Foundation responds

February 2024. Christopher Rocks, Lead Economist for the Health Foundation, Commission for Healthier working life

  • 8 million people aged 16-64 are not in the workforce due to ill health
  • 6% of 16-64-year-olds are now economically inactive for health reasons, a record high since 1993

The economic consequences are significant, with worsening working-age health since early 2020 already adding £16 billion to annual borrowing through higher welfare spending and foregone tax receipts.


Rising ill-health and economic inactivity because of long-term sickness, UK: 2019 to 2023: Experimental stats estimating the different health conditions – and trends.

There was a peak of over 2.8 million people not working due to long-term sickness in the UK in November 2023.

  • Those economically inactive because of long-term sickness, nearly two-fifths (38%) reported having five or more health conditions (up from 34% in 2019), suggesting that many have interlinked and complex health issues
  • 53% of those inactive because of long-term sickness reported that they had depression, bad nerves or anxiety – as a secondary condition
  • Of those who had a main health condition that was musculoskeletal in nature, over 70% reported that they had more than one type of musculoskeletal condition


2.2. Inequalities


Infant mortality plotted on local authorities

A new methodology analysed data from 2017.


How can local government better use its data to address inequalities?

The Health Foundation, 8th February

A dozen analysts and decision-makers in local government across England were interviewed, to understand the capacity of local government to apply quality analyses and uncover insights about the building blocks of health – warm houses, secure and flexible jobs, that pay even when we need to care for loved ones, and having enough money for food and prescriptionsand the inequalities found therein. Findings:

  • Many analysts in local government are spending most of their time focusing on ‘lifting and shifting’ data from one system or spreadsheet to another:
    • tasks like this would benefit most from automation, so that analyst time could be freed up to create more valuable work, such as upskilling, learning from colleagues in different departments or local authorities, or developing new analyses and findings.
  • Short-termism hinders progress. Work to understand the impact of the building blocks of health – and importantly where action is needed – requires long-term investment in data collection, analysis and development of the analytical workforce alongside long-term monitoring to understand changes in wellbeing.
    • Short-term projects that promise impact more quickly are often favoured over this kind of longer-term work that might be more complex but have a greater impact over time. This is becoming increasingly acute as more councils struggle to balance the books.
  • Analyst teams in local government have faced deep cuts, the ring-fenced public health grant means public health analysts have been well protected relative to the near dissolution of analyst teams in housing, social care and education departments.
    • This results in a lack of collaboration across departments and siloed analyses that lack the comprehensiveness that would unearth new insights about how the wider determinants interact with one another to impact health.
  • There are networks of analysts working together regionally and across the country that facilitate peer learning and sharing of tools and resources, including the:
    • Advanced and Predictive Analytics Network;
    • Data Science for Health Equity and the
    • Association of Professional Heath and Care Analysts.
    • These networks could play an important role in advocating for better investment and diffusing tools and approaches to improve analytical capability.


Health Inequalities in a Nutshell – Key data explained

The new feature of the Evidence Hub.

Health inequalities are experienced between different groups of people and are often analysed across four main categories: socio-economic factors (for example, income); geography (for example, region); specific characteristics (for example, ethnicity or sexuality); and socially excluded groups (for example, people who are seeking asylum or experiencing homelessness). The effects of inequality are multiplied for those who have more than one type of disadvantage.

The reading covers measurements with maps and data:

  • Differences in health outcomes among different groups of people
  • dDeprivation gap: the gap between people living in the most deprived and the least deprived areas
  • Interaction between factors – risky health-related behaviours, income, housing, environment, work, transportation
  • Effect of Covid-19: widening inequalities further


Chris Whitty: Health inequalities, past, present and future

Lecture on youtube

Chris Whitty uses:

  • Deprivation/socio-geography vs relative mortality/diseases/ lifestyle overlay – UK-wide stats, based on ONS stats
  • Chief Medical Officers’ Annual Report 2021
  • Cassel and others 2018
  • Mortality rates Wales/England -ONS stats


2.3. Social Care, Primary Care, Prevention


Making Care closer to home a reality

King’s Fund Report, February 2024

General practice, integrated care, community services

To shift focus away from hospital care to primary and community services if it is to be effective and sustainable in England: Advocating for a wholesale shift in the focus towards primary and community health and care across the domains of leadership, culture and implementation.

This research explored the underlying factors that have prevented change, analysed published evidence and national datasets, and interviewed stakeholders across the health and care system.


  • reviewed existing research and evidence from the past 30 years;
  • gathered perspectives from people across health and care, including people who use services. interviews with stakeholders across diverse roles relating to health and care;
  • workshops to test and refine initial findings.


  • There is a ‘cycle of invisibility’ for primary and community health and care services; they are hard to quantify and easy to overlook.
  • Hierarchies of care mean that urgent problems take priority over longer-term issues, for example, treatments for urgent medical problems take priority over services that prevent the development of problems.
  • There are misconceptions about how the public thinks health and care services should be prioritised.
  • The financial architecture for health and care does not support a focus on primary and community health and care.
  • The health and care system – including the way the workforce is trained and organised – is not set up to deal with the complexity of people’s needs.
  • In practice there are several different sets of assumptions, aims and asks about why the focus of the system needs to shift to primary and community services. The reasons:
    • reducing demand on hospitals (waiting lists, emergency admissions);
    • cost savings;
    • better experiences and outcomes for people who use health and care services;
    • improved service alignment or integration and
    • developing population health and prevention at scale, including wellbeing, and tackling inequalities.
  • What’s next?
    • Policy-alignment, maintain the vision long-term, equipped workforce, increased generalism in the system, training of practitioners and managers focusing on primary care
  • Actions NOT to be taken:
    • structural reorganisation: restructuring the current system is not necessary and risks reinforcing a hospital-centric health and care system;
    • expecting short-term financial savings as a result of moving activity away from hospitals and abandoning plans if they do not materialise;
    • only partially implementing the vision with individual policies.


Social care funding reform in England

The Health Foundation, Jan 2024

The crisis in social care also has knock-on effects for the NHS and pressures in hospitals. Estimations, projections, and scenarios below.

Choices for the next governments:

  • Providing basic protection for all against some care costs, with a Scottish-style model of ‘free personal care’ in England, could cost around £6bn extra in 2026/27, rising to £7bn by 2035/36
  • Introducing an NHS-style model of universal and comprehensive care could cost around £17bn in additional funding by 2035/36.
  • Protecting people with the greatest lifetime care needs against catastrophic costs, by introducing a Dilnot-style ‘cap’ set at £86,000, could cost an additional £0.5bn in 2026/27, rising to around £3.5bn by 2035/36.


Targeting the Health of the Nation – Mandatory Health Targets for Grocery Retailers

Policy Recommendation for health targets to reduce obesity in Britain by 23%

Nesta, 2024

  • 3 in 5 people are obese/overweight in the UK – doubled since the 1990s.
  • UK Government should implement mandatory health targets for the 11 largest grocery retailers,
  • measured by a nutrient profile score (based on energy, sugar, saturated fat, sodium, protein, fruit, vegetables and nuts, and fibre) nutritional quality should be increased
  • economic assessment suggests it is unlikely to have a significant cost to business or consumers.
  • TARGETS including all food sales must be set for retailers to make impact.
  • Flexibility for how they would achieve the nutrient profile score with their offer: reformulation, stock purchasing, product placement, etc.
    • could reduce calorie purchase among the population around 80kcal/p/day;
    • health metrics: sales weighted by volume.


Seeing Same GP cuts workload and boosts health – Continuity of Care Increases Physician Productivity in Primary Care

Management Science, Jan. 2024. Summary here Harshita Kajaria-Montag, Michael Freeman, Stefan Scholtes 

The study reveals the effect of declining care continuity on the productivity of physicians by analysing data of over 10 million consultations in 381 English primary care practices over a period of 11 years. between 1 January 2007 and 31 December 2017. It was found that:

  • the time to a patient’s next visit is substantially longer when the patient sees the doctor they have seen most frequently over the past two years – it could be the equivalent of increasing the GP workforce by five percent, which would significantly benefit both patients and the NHS,
    • a long-term relationship between a patient and their doctor could both improve patient health and reduce workload for GPs.
  • When patients were able to see their regular doctor for a consultation – a model known as continuity of care – they waited on average 18% longer between visits, compared to patients who saw a different doctor.
    • The productivity benefit of continuity of care was larger for older patients, those with multiple chronic conditions, and individuals with mental health conditions.
  • This productivity differential would translate to an estimated 5% reduction in consultations if all practices in England were providing the level of care continuity of the best 10% of practices.
  • “Productivity is a huge problem across all the whole of the UK – we wanted to see how that’s been playing out in GP practices,” said Dr Harshita Kajaria-Montag, the study’s lead author.
  • “You can measure the productivity of GP surgeries in two ways:
    • how many patients can you see in a day, or how much health can you provide in a day for those patients,” said co-author Professor Stefan Scholtes from Cambridge Judge Business School.
    • “Some GP surgeries are industrialised in their approach: each patient will get seven or ten minutes before the GP has to move on to the next one.”
  • Problem: according to the Health Foundation and the Nuffield Trust,
    • there is a significant shortfall of GPs in England, with a projected 15% increase required in the workforce. 


The future of cancer care in the UK ­– time for a radical and sustainable National Cancer Plan

The Lancet, Nov. 2023.

Ajay Aggarwal, FRCR 
Ananya Choudhury, FRCR 
Nicola Fearnhead, FRCS 
Prof Pam Kearns, FRCP 
Anna Kirby, FRCR 
Prof Mark Lawler, FRC Path 
Sarah Quinlan, LLM 
Carlo Palmieri, FRCP 
Tom Roques, FRCR 
Prof Richard Simcock, FRCR 
Prof Fiona M Walter, FRCGP 
Prof Pat Price, MD *

Prof Richard Sullivan, MD Metrics


  • The UK National Health Service is facing major workforce deficits and cancer services have struggled to recover after the COVID-19 pandemic, with waiting times for cancer care becoming the worst on record.
  • The loss of a dedicated National Cancer Control Plan in England and Wales, poor operationalisation of plans elsewhere in the UK, and the closure of the National Cancer Research Institute have all added to a sense of strategic misdirection.
  • In this Policy Review, the authors describe the challenges and opportunities that are needed to develop radical, yet sustainable plans, which are comprehensive, evidence-based, integrated, patient-outcome focused, and deliver value for money.


Creative Health Toolkit – For Integrated Care System

Embedding the benefits of creativity in all health and social care systems, from integrated care system planning to delivery by grass roots organisations, the toolkit will support commissioners, link workers and the voluntary community social enterprise sector to work collaboratively and deliver better health outcomes for communities and individuals.

  • TThe he toolkit considers the enablers and barriers and is structured so as to illustrate how systems can deliver against the forthcoming NHS England Maturity Matrix for Social Prescribing, with reference to five domains: Leadership, Strategy & Governance; Planning & Commissioning; Workforce Development; Digital & Technology; and Evidence & Impact.
  • The toolkit has been developed in partnership with NHS England Personalised Care Team and Integrated Care Systems (ICSs) in Gloucestershire; Shropshire, Telford and Wrekin; Suffolk and North East Essex; and West Yorkshire, as a tool to support other ICSs to embed creative health in their systems.

The aim of the programme is to further embed creative health within health and care systems. Each Associate is responding to the priorities within their local Integrated Care System. Tthere are a couple of themes that run across the programme:

  • mental health and wellbeing, particularly of children and young people;
  • health inequalities, with a focus on particular groups such as refugees and asylum seekers, or people with protected characteristics or looking at the health inequalities that exist between neighbourhoods and places within Integrated Care Board areas.


2.4. The NHS


NHS Workforce in numbers England

Nuffield Trust

With projections to the future of the workforce. The NHS is one of the world’s largest employers (compared to India’s Ministry of Defense or Walmart, and bigger than Amazon).

  • Heavily reliant on professionally qualified clinical staff, which account for around half of all employees. Other key staff groups include those working in central functions, dealing with the NHS’s property and estates, and supporting clinical staff.
  • 4 million people – work in ‘hospital and community services’ as direct employees of NHS trusts, providing ambulance, mental health and community and hospital services.
  • One quarter (25%) of NHS staff report being of Asian, black or another minority ethnicity, compared to 13% of all working-age adults in the UK.
    • These proportions vary considerably by staff group. For example, while 39% of nursing staff report being of a minority ethnicity, only 7% of ambulance staff do.
  • In May 2021, an estimated four in five registered nurse vacancies and seven in eight doctor vacancies were being filled by temporary staff, either through an agency or using their ‘bank’ (the NHS in-house equivalent of an agency).
  • The clinical support workforce are front-line staff who are typically not registered professionals, but deliver a large proportion of hands-on patient care – the number has risen by 40% since 2010.
  • Scientific workforce accounts for a large proportion of hospital and community staff, with around 163,000 “scientific, therapeutic and technical” full-time in June 2023.
  • There has been no progress against the target set by the UK government to increase the number of GPs by 6,000 between 2019 and 2024.
  • Despite ambitions to move more care to the community, the NHS nursing workforce in this setting does not appear to have kept pace – community health nurses fall short in numbers.

Negative impacts:

  • The level of clinical staff can affect the quality and safety of care being delivered.
  • Workforce shortages can lead to higher costs. While many ‘vacancies’ are filled with temporary staff day to day, using temporary staff can be expensive.
  • Staff shortages are also a vicious cycle. A parliamentary report highlighted the link between vacancies and staff burnout, overstretched staff taking on additional hours to fill current staff gaps.

The root of the problem: shortage of domestic supply, and heavy reliance on international recruitment, Brexit, and low retention.

Comparison: While it appears the UK as a whole have relatively few staff in key groups compared to other developed countries, different countries have different levels of skill mix, with the UK (particularly in England) employing more support staff per head compared with other countries.


NHS staff earnings variation

Nuffield Trust, Palmer W (2024), Charter of the week.

Earnings by staff group, data 2022.

  • Many individual clinicians’ pay packets differ substantially from the average pay across their peers.
  • The very notable differences in pay between staff groups is a problem due to the move towards multi-disciplinary team workingand the changing mix of professions.
  • There are many consultants earning more in a day than nurses in their team will earn in a week.
  • Addressing variation in pay is important given theimportance of perceptions of relative as well as absolute 
  • This level of disparity is not commoninternationally – see the review here.


The NHS founding principles are still appropriate today and provide a strong foundation for the future

Nigel Crisp, BMJ, Jan 2024

A note on the relevance of the founding principles, adapted to new societal challenges, and the ’national health and care emergency’.

Comprehensiveness to be maintained to spur innovation, being free at the point of need promotes equity and is a practical and appropriate approach to improving the health of the population.

Governments should give immediate priority to tackling inequalities in access and outcomes and pay particular attention to the disadvantage and racism suffered by different ethnic groups both as patients and staff of the NHS.

Learning from others: the NHS is not unique; most western European systems are based on comprehensiveness and universality and have different ways of managing the issues raised here. Private and insurance based systems, as in the US, ration by the ability to pay and often do not cover vital areas such as mental health. Other systems combine public and private health approaches and have many exclusions and co-payments. Meanwhile, the lowest income countries have predominantly out-of-pocket payment systems.

The solution is a health solution, financial comes only after that.

UK version of “health for all” policy:

  1. Healthy homes bill: strengthening the roles of all parts of society—government, families, businesses, communities, schools, and more—in promoting health and wellbeing, protecting the public, and preventing disease.
  2. The health of an individual is intimately linked to the health of their family, community, the health of wider society, and the health of the planet, and introducing measures to promote health and wellbeing at all these levels.
  3. Promoting and creating health and wellbeing (social networks, purpose in life, autonomy, access to nature, etc.), as well as tackling the causes of disease and preventing disease and injury. Health is not simply the absence of disease.
  4. Treating improved health and wellbeing as a positive contributor to the country’s economy and not, as too often happens, a cost.


Patients and the public can play a greater role in the design and evaluation of NHS services.

The importance of technology can be exaggerated. Data can generate more knowledge.

Artificial intelligence could also be used for private gain or disruptive purposes, and this relates directly to issues of trust and confidence in the NHS.

Mitigating these risks requires the NHS to adopt a principle of values-based innovation and to put in place robust governance arrangements to protect the core principles and values from trade-offs and dilution.


2.5. Public Attitudes

Exploring public attitudes towards the use of digital health technologies and data

The Health Foundation

The NHS is looking to advances in digital health technologies and data to help tackle current pressures and meet rising demand.

Survey of 7,100 (March 2023) nationally representative members of the public (aged 16 years and older) to investigate their attitudes to uses of health technologies and data, and the key factors affecting their views:

  • The public trusts NHS organisations more with their health data than government or commercial organisations.
  • Nearly two-thirds of the public know very little or nothing at all about how the NHS is using the health data it collects.
  • Overall, the public thinks technology improves the quality of health care and is supportive of its many possible uses. But not all technologies are equally liked: those that empower people to manage their health and better connect them with the NHS seem to be more popular, while those that could be seen to ‘come between’ the clinician and patient – like chatbots or care robots – are least popular.
  • Women and those most likely to be on low or no income were significantly less positive about the use of health care technology than men or those more likely to be on higher incomes.
  • The public is, on balance, happy with a range of ways its data could be used outside direct care, such as for research or to develop new medicines.
    • with around 1 in 5 people resistant to their data being used in these ways, it is clear that policymakers, health care organisations, researchers and industry must work to grow trust in the use of health data.


Respondents who thought the following reasons had caused the strain on NHS services in the United Kingdom as of 2023

Statista Research Department, published February, 2024.

According to a survey (2450 respondents May 5-10, 2023) carried out in the United Kingdom in 2023, 40% of respondents believed poor funding was the main reason in causing the increased strain on NHS services. Furthermore, staff shortages and inadequate government policy were also seen as large contributors to the strain on NHS services:

  • 40% lack of funding
  • 38% staff shortages
  • 35% poor government policy
  • 29% poor NHS management
  • 24% increased demands from an ageing population
  • 20% lack of capacity of social care system
  • 18% Covid-19
  • 18% NHS inefficiency
  • 16% Brexit
  • 14% Misuse of services by the public
  • 13% increased immigration
  • 8% NHS strikes

7% increased cost of providing treatment


3.1. Social Care, Integrated Care


Theories, models and frameworks for health systems integration. A scoping review

Health Policy, 2024

The review identifies and provides a comprehensive analysis of health system integration theories, models and frameworks.

  • Key strategies and components are identified to aid health system integration efforts.
  • Context-aware policies are crucial for effective health system integration.
  • Stakeholders and patient engagement in policy-making drives tailored, patient-centric care.


Financial incentives for integrated care: A scoping review and lessons for evidence-based design

Health Policy, 2024

Studies before 2021, and from NL and US are reviewed.

  • Integration of care for patients with common chronic conditions.
  • Four financial incentives identified: pay for coordination, pay for performance, bundled payments and shared savings.
  • Analysis of evidence for the (cost-)effectiveness of these financial incentives took place.
  • Facilitators and barriers to the implementation of these financial incentives were identified.


3.2. Climate, Sustainability and Health


Climate conscious health equity is essential to achieve climate-resilient digital healthcare

Journal of Climate Change and Health, 2024

The role of digital health equity in supporting climate-resilient digital healthcare pathways for global communities experiencing the health crisis exacerbated by climate change and environmental degradation.

  • Specifically, to design digital health responsibly to support climate change adaptation as an inclusive, equitable, human-centred process means acknowledging the interconnectedness of human healthand the health of the natural environment.
  • A more integrated and participatory approach to the dimensions of ecological and environmental determinants of healthand ethical representation of diverse and vulnerable voices is recommended.


Approaches to Spread, Scale-Up, and Sustainability

Cambridge, January 2024.

From the Abstract: Drawing on a focused review of academic and grey literature, the authors outline how spread, scale-up, and sustainability have been defined and operationalised, highlighting areas of ambiguity and contention. Following an overview of relevant frameworks and models, they focus on three specific approaches and unpack their theoretical assumptions and practical implications: the Dynamic Sustainability Framework, the 3S (structure, strategy, supports) infrastructure approach for scale-up, and the NASSS (non-adoption, abandonment, and challenges to scale-up, spread, and sustainability) framework.


3.3. Health Systems


Working together to advance resilient health systems across the OECD

Health ministers of the OECD Jan 23, 2024, concluded:

  • Policies needed to strengthen he resilience of health system.
  • Preparedness for a shock like the COVID-19
    • medical supply chains and health workforce are vulnerable;
    • investment is needed in health systems, workforce should not be exacerbated;
    • care backlog – systems are still struggling;
    • mental ill-health – increasing salience.
  • Reconsider sharing of tasks and responsibilities – optimum use of all available talents and skills: international reform is needed.
  • Knowledge is needed – howow to boost investment in health system resilience at a time of rising health-care costs and economic constraints?
  • Health system performance assessment FW 2023 OECD new(!) – informs decisions on future investment priorities.
  • Addressing ill-health determinants, environments, behaviours – obesity (tripled since 1975).
  • Partnerships with populations – to address social determinants of health.
  • People-centred care
  • Commercial determinants of health – OECD and WHO regulations and evidence: EU legislation for internal market (taxation, health warnings, regulation of ads, nutrition labelling and age limits).
  • Policies to address health inequalities and gender biases.
  • Increase the healthy life-years in the population – through the use of AI and other digital solutions, policy reform is needed to address the delivery of healthcare transformation.