Dan Wellings: The relationship between the NHS and the public

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  • Posted:Tuesday 07 November 2017

Speaking at the event Working with patients and the public: designing care around your population's needs, on 07 November 2017, Dan Wellings, Senior Fellow at The King’s Fund, shares initial findings from research into the relationship between the NHS and the public.


So I think we’ve been discussing lots around patients and users today and how we can ensure that that voice is heard in the system.  I think in this piece of work I was keen to place that in the wider context of where the public more generally is on the NHS and I think that’s one of the things that we need to think very carefully, which is how we’re asking people to provide their views.  Are we asking people as users, are we asking them as taxpayers, are we asking them as members of a local community, as friends and family, as people who know people who work in the NHS?  So hopefully some of the data I’m going to show is where is the NHS more generally.

I was looking back recently at a report that The King’s Fund did from 1971 and what is very interesting is how some of the debates we’re having now are exactly the same that we were having in 1971, and one of the things that the report finishes is that the standard of health care in this country is determined by public opinion and the ballet box.  So I think with that in mind we’ll look at where the public more generally is.

So the first thing I’m going to show you is, I used various different pieces of polling data for those interested in the sample, by sample I mean the people we went to, and this is what we call a representative sample of the British public, and in this case we went to a thousand people and this has been tracked since 1997.  What do you see as the most important issue facing Britain today and now this is the line for the NHS, and you look back in 1997 and what’s interesting is where are we coming to again now?  So look at the right of this slide and where we were here in April 2002 is just before Gordon Brown put £40 billion back into the NHS.  So what we can see, which is not the only effect but it’s one of the effects, of putting £40 billion pounds back into the NHS in terms of where public opinion goes and you can also see where we are starting to come back to in terms of where public opinion is now on the right hand side.  So around the election we were measuring one of the highest levels of concern we’ve seen since around 2002. 

Now this chart gets more complicated, I apologise in advance, but just to bring a few other things into play. This is the economy during the recession.  Even during the recession there is less concern with the economy than we reached for the NHS at this time. So I think from a political perspective it’s starting to look slightly worrying. There’s a slide that I’m not showing you today which shows that pessimism for the future is at the highest level recorded. 

Now why is this of relevance to us?  Because we need to understand we’re not just talking to people as patients and users we’re talking to them in the wider context of what is the NHS and what the media and other parties and the politics is around this, and it’s so important for us to understand that with the work that we’re doing in our local areas.

This is about satisfaction with the NHS, again this is a piece of work, this is the British Social Attitudes Survey, which has been tracking satisfaction since 1983 and the last time this was asked in 2016 it was around 63% which is the third highest level ever recorded for satisfaction with the NHS and again, think back historically to 1997, 34% in those days. It’s very easy I think in times where we’re concerned with what’s happening in the NHS to forget that actually there’s been times like this in the past and again it’s thinking about what that means for us.

The next slide I’m showing you is about support for the concept.  This one asks, which of the following statements best reflects your thinking about the NHS?  The NHS is crucial to British society we must do everything to maintain it, is the top line you can see there, the line below is, the NHS was a great project but we probably can’t maintain it in its current form.  Now think back to the two slides you’ve just seen and the huge shifts we’ve seen in public opinion.  The one shift we don’t see is in a dropping of support for the concept of the NHS.  So a quick straw poll of the audience, who thinks this view, the green line, is more likely to be held by older people?  Who thinks it’s more likely to be held by younger people?  Yes, it’s younger people. 

The challenge with this and with the next slide which is we were interested in, please tell me the extent to which you think the principles should still apply to the NHS services today, so coming up to the 70th birthday these were the founding principles upon which it was set up and we were interested 70 years on the extent to which they’re still supported.  I think it’s very easy to look at this slide and think, yes, I could have predicted that.

We had an American professor in The King’s Fund recently who said this is fairly unlikely to happen in the American health care system and this is extraordinary that there’s still that level of support for these founding principles. Again, for the comprehensive service that’s more likely that younger people will hold that view, again we may speculate that’s around who the NHS is for in a post Brexit world, but again it’s about the strong belief in the service. 

Now, there’s two ways of looking at this, one is that this is great, this is a public that’s hugely engaged with the NHS, the other way of looking at this is it makes change very difficult. It makes potentially necessary change extremely difficult because of our huge emotional attachment to the NHS. For you which object represents the NHS and someone said it’s an old teacup that’s battered and chipped and stained but I’d never use anything else, and the question for us I think working in this area, particularly around the NHS, is actually does this stop us making necessary change happen?  Does it stop us asking enough of the service as users of it?  Are we sufficiently demanding as users of this service or actually do we forgive it?  Do we forgive it a level of care because it is the NHS? 

So a recent study by Cambridge University on patient experience surveys shows that we would give very high levels of support or give very high experience levels for care which measured any other way is not great.  So they showed people videos of GP consultations and people would score them as very good and then afterwards they would say, they showed them the video back, and they’d say, “Did you think it was fine that the GP didn't look at you once for ten minutes during the consultation because they were on their computer?”  No. “Did you think it was fine,” and this is a real example, “That the GP was wearing their football kit and was clearly in a rush to play five a side?” These are really important points because what is the NHS for us and what is the change that we may be trying to make to it, to what extent does this hold us back, what we might call status quo bias. 

We’re also very keen to ask well there’s one solution which is pay more for the service, so we ask the question, would you be prepared to pay more taxes?  Now one of the ways this is done is that you could say to people, “Do you think people should pay more taxes for the NHS?” and the challenge with that question is people might say yes but they don’t mean them.  So we were very keen to do what we call a split sample, so we asked 500 people one question and 500 people another question, so half the sample said, “I would be willing to pay more taxes in order to maintain the level of spending needed,” and that was 66% against the increased taxes in order to maintain the level of spending.  So people mean their own money.  Now when you show this to various people there’s a few reactions, one is well they don’t mean that, they wouldn’t actually do it. My personal view is probably that that's not actually true, that we are in a position, if you look at where the politics is in this country and where we’re concerned about public services, where we may well pay more, and again in this room, you’re not what we call a representative sample, but again ask yourselves the same question.  I think that’s a very interesting way of looking at some of these polling questions.

So there's the local versus national and I think this is very relevant to this audience - thinking about the treatments and services that are available on the NHS which of these statements most closely matches your opinion? Treatments and services should only be available on the NHS if they’re available to everyone and not dependent on where you live – 67% of people hold that view; the availability of NHS treatments and services should be based on local need rather than a one size fits all approach across the country.  By any other name this is a postcode lottery question.  Now what’s very interesting is that this is where, and we’ve talked a lot about this today, what do different methods give you?  This gives you a top level instant reaction that someone would give to a polling question.  Now there’s a piece of work done a few years ago, qualitative, working with people in local areas and actually people can have a very reasonable question about what’s available.  So if you do this exercise in Eastbourne versus Brighton you will come up with different findings and again it’s getting beyond this is the challenge, it’s starting to have that conversation in a local area. 

This is about decision making and again I think relevant to this audience - who should be making decisions and thinking of how decisions about treatments and services should be made which of these statements most closely matches your opinion?  So, without going through them all, the top one is broadly that the health care professionals they’re trained they should make them, around 29%.  The middle option is betwixt and between, we want to be consulted but ultimately health care professionals can make the decision 56% and then more actively involved is 14%.  So what does this mean in terms of engagement?  I think it means a few things.  One is we’ve heard in Dorset earlier on how do you get to the silent majority?  How do you know who you’re engaging with? Are the actively involved someway systematically different from the rest of your population? Again that example came up for those of you who saw Dorset, how do you go about hearing from people?  Also if we’re listening to the 14%, how do we get them to think about how they represent other patients?  This is a real challenge for things like local health watch.  Who are you representing?  There’s a real challenge for people in this room from patient groups to think about how am I using other data, other information for me to represent a wider population in my work?

One of the things that I get slightly frustrated by is things like the five year forward view, that’s not the end of the sentence, but it is how … we talk a lot about aging populations, we talk about rising co-morbidities, we talk about all the challenges we’re facing and they always have footnotes against them, they always have lots of references and then we talk about rising patient expectations and there’s rarely ever any evidence beyond anecdotal evidence that starts to answer this question. Now, I’m not saying we’ve cracked this but what we try to do is start to ask the question.  How realistic, if at all, would you say people‘s expectations are of the service they should get from the NHS? Again 63% broadly saying realistic. Interestingly that 30% are also the people more likely to say we shouldn’t maintain it in its current form.  And they you say to what extent do you think they’re met?  Again 73% say met or exceeded expectations. Now, I think we often talk about the consumer right now society, certainly people at national levels will regularly talk about this, I’m not so such.  I think actually we give some leeway to the NHS that we don’t give to other areas of our life and I think we almost forgive it things that we wouldn’t forgive in other areas of our life.

I just want to read a quick story.  Now this is from a patient called Michael Wise, who’s in a report that we produced, he wants to start with ‘overall the care I have received from front line staff primarily from the NHS has been outstanding. I therefore have some reservations about describing the adverse findings as reported below because I do not want to detract from this overall excellence of care.  However, I think it’s important to point out some of the shortcomings and possible solutions based in my observations’. He then goes on ‘I had a cannula inserted for the administration of intravenous IV antibiotics, I knew it was not positioned into a vein but the nurse would not listen, I then had repeated IV infusions of antibiotics causing severe pain and swelling of my hand. It was only when I was seen later the next day by a consultant that the cannula was correctly placed. My trust in that nurse evaporated very rapidly. Patients do know when something is wrong and they should be listened to’. He then finishes it by reiterating his thanks for the hard work of the staff in the hospital.

So one of the questions I have around expectations is actually are our expectations too low and do we not place enough emphasis on changing the system?  Question for this audience. 

Finally, I’ll just come to a couple of other thoughts.  New ways of working and opportunities.  I could not believe strongly enough in this agenda that you need to understand who you work for. By that I mean patients and users. They are so many times during my career with the frustration that simple things that could be changed based on user feedback are not listened to. Al Mulley said recently at a King’s Fund event, “Any other industry not listening to your users would lead to bankruptcy,” and also remember that people have very, very good ideas if you take the time the time to listen. 

We’ve had lots of discussions today where I feel this agenda can feel the appendix to the NHS. It’s too easy to leave behind in straitened times.  How do you make it the beating heart of the NHS? How do you communicate that voice back in to make sure that change is driven by people who are using the service?  But I would also add there’s a challenge for patients and user groups on this one, which is how do they interact with the service, and I will be frank on this one, various experiences where if you are shouting at someone repeatedly that’s often driven by frustration and I understand that, but if you are shouting at someone repeatedly and they turn their back because they don’t want to be shouted at any more that’s also a reasonable reaction.  So this is both sides, and maybe sides is even the wrong word, this is about the system.

Now as we move towards ACL, and I’ll try not to use three letter acronyms, but as we move towards better system working we are bringing local government back in now, we are bringing the public health community back into health.  One of the key challenges right now is we know the problems on patient experience are between services but we measure by service. We know what’s happening in GPs, we know our inpatients, we know community services, we know social care, we don’t join it up.  If you’re responsible as a system there is a significant opportunity, how do we link up with the patient experience team in an acute trust?  How do we link up with the public health community within local government?  How do we link up with PPGs?  I think there’s a real challenge for this audience. 

We talked about resource and that’s a question, there are significant amounts of resource out there already or available things that we could be using. GP patient survey goes to 2.1 million people a year.  It gets 800,000 responses.  It is woefully underused.  That’s about how you make the case, that one in five people feel scared and alone in hospital, that’s statistically valid. Doctors are probably more likely to listen to that.  How do we use these combined?

The last one is language, we are not good at using language with the public. So certainly we talk about aging population, rising demand, increasing expectations, new technologies, integration, transforming at pace and scale is my least favourite one.  Actually if you listen to the public out there it’s waste in a post Brexit world, let’s be truthful about this one, there’s an immigration question whether we like it or not, postcode lottery, treating the wrong people, again that’s about rationing of care, and staff under pressure. Again it’s using the language earlier on.

The final example I give was the cervical screening letter used to go out for many years, I think it’s changed now, it says, ‘you’re due for cervical screening’.  A piece of research I did first question was to a woman in Tower Hamlets, “Do you go for cervical screening?” “No.” “Do you go for a smear test?” “Yes.” That’s value and the final thing I’ll see is there’s an economic case to be made here.  We too often ignore the fact that there is an economic cost benefit argument to be made for including patients.  Readmission for example, how do we understand what’s happening at discharge?  We know it’s not good and how do we link that in to readmission? If your finance director or CEO is not interested in this agenda through their heart how can you engage their mind and the account sheet? 

I’ll finish there and hand over to the panel.