Health and care finance tracker

Manifesto spending commitments

With election manifestos for the three largest parties in England now published, we have analysed how NHS spending commitments made by each compare.

The chart below takes the costed commitments in each party’s manifesto and looks at how each of them would affect the trajectory of NHS funding up to 2028/29. In the absence of detail or clarity from any of the parties, we have based our analysis on the assumption that all parties take as a base case that total health spending in England will increase by an average 0.8% real terms each year, with their “extra” commitments coming on top.

It is clear from this analysis that these increases would make the next few years the tightest period of funding in NHS history – the manifestos imply annual increases between 2024/25 and 2028/29 of 1.5% for the Liberal Democrats, 0.9% for the Conservatives, and 1.1% for Labour. This would mark an unprecedented slowdown in NHS finances, and it is inconceivable that it would accompany the dramatic recovery all are promising, let alone keep up with rising levels of demand.

This is particularly the case as the funding plans follow three years in which the NHS’s finances have already been considerably squeezed, implying that under any of the three parties, NHS funding between 2022/23 and 2028/29 would grow at a slower rate than the recent rate of population growth. 

For further detail on the NHS funding commitments made by the parties in their election manifestos, read our explainer 'How much spending on the NHS have the major parties committed to in their election manifestos? '

NHS spending over the past decade

In this analysis we have constructed a time series of spending in the NHS in England going back a full decade. We look specifically at the planned and actual spending on day-to-day resources in England, covering the NHS’s consumable costs – predominantly staff salaries, medicines, clinical supplies and fuel.

We show that NHS resource spending – currently set to be £170 billion this year (on a like-for-like basis) – has grown by an average of 3.1% a year in real terms between 2013-14 and 2023-24 – a rate which is around half a percentage point slower than the long-term average.

We examine actual NHS spending compared to the two multi-year plans set out for it, one at the 2015 Spending Review and one in 2018 around the NHS Long Term Plan, showing how one-off adjustments and in-year funding boosts have affected overall spend.

Our analysis reveals that, due to the policy directive to the NHS to 'converge' spending back to plan following rapid increases during the pandemic, the NHS has experienced an essentially flat funding outlook for the past few years, with funding this year leaving the NHS with £1.8 billion less than it would have received had pre-pandemic funding plans been rolled forward one more year.

For the full analysis and methodology, read our explainer, 'NHS spending plans over the past decade'. 

Tracking NHS spend by sector

There is little readily available information on how NHS funding breaks down by different sectors within the NHS – and what information we do have fails to take into account the impact of in-year or one-off top-ups that come to NHS England from the wider Department of Health and Social Care budget.

To address this, our analysis draws on the detailed annual accounts of all 212 NHS provider trusts, supplemented with information from NHS England’s annual accounts to provide a comprehensive look at how funding breaks down by sector over seven years (with 2016/17 being the first year spending is available in this form).

On overall real-terms funding, we find that of the nine different forms of care examined, four experienced real-terms increases over the period (acute services (4.4%), mental health (5.3%), ambulances (5.2%), and general practice primary care (3.3%)); four experienced real-terms funding cuts (public health (-3.9%), dentistry (-2.2%), ophthalmic and pharmacy spend (-2%)); and two experienced largely flat funding (community services (0.5%) and prescribing (–0.5%)) over this period.

When we take into account the relative levels of need in the population (by adjusting for age and sex-related estimates of need), these figures reveal an even more striking pattern: real-terms funding for NHS community services per head of need ended 2022–23 around 4.2% below the level of 2016/17, with even sharper falls for dental, pharmacy and ophthalmic spending. Local authority spend per head (non-adjusted) was 24% lower in 2022/23 than in 2016/17.

This suggests that the policy aim to move care into our communities and away from hospital has not been met with the funding needed for this change.

Our analysis also looks at how NHS spending on outsourced care has changed over time, highlighting a steady increase in the proportion of overall NHS spend on private or voluntary providers.

For the full analysis and methodology on NHS spend by sector, read our explainer, 'Where does the NHS money go?'

The deficit

Our work has documented the gap between the amount of funding provided for health care and the amount that the NHS spends – known as the deficit. Previous work has highlighted a significant underlying deficit affecting the NHS provider sector.

In November 2023 we published new analysis as part of the tracker which examines the deficit for the 2023/24 financial year. In it, we highlighted that a £4.2 billion gap between funding and spending levels was likely to end the 2023/24 financial year as a £1.3 billion deficit, assuming industrial action did not continue.

Since that analysis was published, a number of adjustments were made both to NHS financial plans and to the budget for the year. We will provide a further update on the size of the deficit in the 2024/25 financial year as part of this tracker. In the meantime, read our 2023/24 deficit explainer, 'Understanding the NHS's financial deficit this year' here. 

*The Nuffield Foundation is an independent charitable trust with a mission to advance social well-being. It funds research that informs social policy, primarily in Education, Welfare, and Justice. The Nuffield Foundation is the founder and co-funder of the Nuffield Council on Bioethics, the Ada Lovelace Institute and the Nuffield Family Justice Observatory. The Foundation has funded this project, but the views expressed are those of the authors and not necessarily the Foundation. www.nuffieldfoundation.org; @NuffieldFound