How well is the NHS meeting public expectations?

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Part of Time to Think Differently

You worry about the NHS. I worry about the NHS. But most of the general public in fact don’t. The public is very clear that the key challenge facing Britain right now is the economy – it has been number one in the Ipsos MORI Issues Index for 50 consecutive months. Despite plenty of excitement in the media, among the unions and professions and political parties, general anxiety about the NHS remains much lower than in the recent past.

 

In a poll by Ipsos MORI in 2012, respondents thought the most important issue facing Britain today is the economy.

Source: Ipsos MORI (2012). Report. Britain 2012: who do we think we are?

It is a common belief in health care circles that expectations of health services are rising rapidly – patients are less deferential, empowered by the availability of more information, particularly over the web, and are demanding more and more.

In fact one of the challenges for the NHS is that expectations of it are in some ways not high enough, and also that patients cling to what they have been used to – ’the status quo’ normative bias. For example, there is very little relationship between standardised mortality rates and patient satisfaction; no matter how likely their hospital is to kill them, patient satisfaction varies relatively little. It is ‘softer’ measures like ‘dignity and respect’ that correlate much more strongly with patient satisfaction.

When we ask what factors patients reflect on in choosing a hospital, quality of care, cleanliness and speed of access all feature highly – but if we ask them to choose a single factor, geographical proximity is number one. If people are concerned most about ease of access, overall expectations of care do not seem to be rising inexorably,.

It is also a common place belief that the public has no respect for any one in authority any more. While public expectations of clinicians have evolved from the 1940s in terms of openness and communications, trust in doctors and nurses has been high – and shows little sign of falling – for decades. In contrast trust in politicians has been low since polling began.

There are some signs that despite the cherished status of the NHS, the public is becoming more realistic in its expectations of NHS funding, no longer seeing it as a bottomless pit. Our latest wave of the Public Perceptions of the NHS, conducted for the Department of Health, shows that 58 per cent of people agree that there should be limits on what is spent in the NHS, up from 44 per cent in 2006. But, and it is a sizeable but, there is no indication that the full scale of the funding challenge is understood. 

Most people do not think their own health is the sole responsibility of the NHS (only 5 per cent do).  Far more think it is mostly their own responsibility (39 per cent) to manage their health, the rest think it is a shared responsibility. And perhaps because of this, people are willing – at least in principle – to see some conditionality attached to what the NHS will provide in future. As we found in Public Perceptions of the NHS, younger people are most likely to agree that if people don’t look after themselves – by drinking too much, for example – the NHS could in principle limit free treatments for conditions caused by their behaviour.

However, parliamentarians are more anxious about this approach. Perhaps because of the totemic significance of free universal access – we found most Labour and Lib Dem MPs opposed, and Conservatives divided, to ideas about restricting treatments to those who take more responsibility for their health.

There is some willingness among the population to be more pragmatic about the NHS – but this pragmatism can be drowned out by a minority of vocal activists, and by assumptions that the media, pundits and politicians have about public attitudes. We have known for decades that the NHS needs to move towards providing a different sort of service to cope with the demands placed on it. But making the changes to achieve that is hard even when money is flowing. The challenge is to ’nudge’, shove and cajole the public – and the media – towards an acceptance of  the NHS of the future. Changes in public opinion can and do happen, and can be led, but it will require boldness and dedication to make the change – at a time when politicians already have plenty of other battles to fight.

Ben Page is Chief Executive at Ipsos MORI. A frequent writer and speaker on leadership and performance management, he has directed hundreds of surveys examining service delivery, customer care and communications.

Comments

Richard Powderhill

Position
Disabled & Retired,
Organisation
Disabled Motoring, Disabled Go
Comment date
23 November 2012
The past year or so whereby the ambulance service has been put in the hands of non-medically qualified people in regard to out-patient transport decisions has on more than one occasion threatened patients lives. This `procedure` is without any legal or medical ethical backing, and should be stopped.

Helena

Organisation
www.sleepio.com
Comment date
23 November 2012
Do you agree then that we are then seeing a shift in people taking responsibility for their health in their own hands and, furthermore, taking their health in their own hands?

A very interesting read overall. I welcome the move of this discussion in healthcare from 'what NHS can do/improve' to 'what its users need/should expect' and agree that this is where the challenge is and the media is probably our best bet of getting it on the public agenda.

elodie kraker

Position
gp,
Comment date
23 November 2012
the challenge is still the same as 25 y ago: how to provide more to those who really need the health care and less to those who access health care inappropriately due to lack of self care and taking responsibility for their own health. about 30% of 'urgent' phone calls could be answered by NHS direct or common sense. expectations on the health service to 'fix' problems are often unrealistic leading to an attitude of 'demand'. To develop a nation wide culture of 'self care' needs to be top of the agenda if the NHS is to be effective in the future.

Mary E Hoult

Position
community volunteer,
Comment date
23 November 2012
There has been to much change in a short period of time for the community to feel comfortable.There is much support for more community based and GP lead commissioning but it is let down by poor public health plans which have come too late to support GP commissioning.It is like putting the cart before the horse and people will suffer.

Craig Wakeham

Position
GP,
Organisation
Dorset
Comment date
24 November 2012
In principle I agree...In practice I am faced with the daily reality of people who can't (or won't) take responsibility. I replied to another piece in this series last week, when I stated that I am all for collaboration between healthcare professionals and patients, indeed I strive to achieve this on a daily basis. When this does happen it is a win-win situation with both professional and patient happy and satisfied. I see my vocation as one of helping people to achieve what they can, passive reception of an instruction or a treatment is never going to solve anything. I have daily experience in both my clinical and commissioning work where there is no common understanding, let alone collaboration, between patients and professionals, and even more worryingly between professionals. As a generalist I see the harm caused by the attitude condemned by Archie Cochrane, summed up by the quote from T S Elliot "Not for the good that it will do, but we will have left nothing untried on the margin of the impossible". There is a further issue summed up by the paradox of choice: What people say they want in abstract and the way they behave when confronted with the reality of a serous medical (and even not so serious) condition can be two different things. The system is challenged but I've yet to see any challenge to the system that has improved it...rather the opposite. We all need to work together to find solutions, rather than expecting someone to apply their 'fix'. Let’s have some proper systems thinking.

john watson

Position
Manager,
Organisation
NHS
Comment date
27 November 2012
What is irresponsible behaviour and thus justifies some co-payment or no access to an NHS service is much more difficult to define than imagined. Is the rugby player who's concussed in a game, or the skiier who's torn their ACL, or the motorcyclist involved in an accident, or the person who's not maintained a 5 a day fruit and veg regime, or the person attending an STD clinic, or someone needing a termination meeting the 'responsibility' criteria anymore than the bariatric patient? Who would determine this? Where are these god-like judgement specialists? Would not the weakest and least articulate, inevitably lose out more than they already do? Would the bureacracy and appeals process associated save more than it costs? Subjective prejudice is easy. A workable deserving/non deserving approach to public policy has been grappled with for 200 years and if it was simple we'd have found the answer by now. Don't over-simplify it as the weakest then suffer the most.

Melvin Daniels

Position
Management Consultant,
Organisation
Freelance
Comment date
28 November 2012
Having spent over 30 years in the NHS, mainly mental health, I have been seeing a real willingness to embrace the need to improve productivity (quality/volume/cost). However, this is still in its infancy in the NHS and I welcome austerity for the need it brings for everyone to think and make the changes required to deliver this improvement - for the benefit of all (patients, staff and the public purse) - apart from those that do not want to change!

Fliss

Position
Freelance Editor,
Comment date
28 November 2012
Interesting blog and great comments.

Self-care may be perceived as a simple solution, but the behaviours deemed responsible for certain conditions may be complicated and require understanding, not judgement. I like ‘cajole’ here, especially in combination with ‘dignity and respect’; perhaps media efforts to change attitudes to healthcare should be mindful that a top–down approach is unlikely to win–win. Dr Wakeham’s right: we need to work together.

Dr Michael Crawford

Comment date
29 November 2012
The emphasis on geographical proximity does not surprise me at all. I couldn't find the social breakdown of the responsents to this question but consider the following scenario. It helps if you are familiar with the current story line in BBC Radio 4 "The Archers" where Ed & Emma and their two young children are facing severe finacnial hardship because he is a dairy farmer and teh milk price has collapsed. It would help even more if you have real life expeience of teh problems of rural poverty.

In North Yorkshire there is a plan to withdraw children's services from Northallerton and to concentrate them in Middlesbrough. Imagine what that means for the dairy (and sheep) farming families of Swaledale and Wensleydale.

Memo to the King's Fund. This proposal is driven by the fact that north Yorkhshire & York PCT is on its beam ends finacially. This in turn is associated with the funding formula for the NHS which allocates little money to PCTs that have a high proportion of affluent people and low proportion of deprived people. This sounds fair but more effective use of the NHS by the former means they out-compete the latter. Only Nigel Hawkes, writing in the BMJ, has spotted this.

Think differently. Is the formula for funding fit for purpose?

Mark Buckle

Position
Management Consultant,
Organisation
JOURNEY
Comment date
04 December 2012
I think a distinction needs to be drawn here between the 'political' expectations of the Great British Public (i.e. the extent to which we are prepared to support the NHS as an institution) and the reasonable expectations we have of the service it provides (the 'S' in NHS, lest we should forget...)

I have just completed a piece of work in one of the UK's largest acute Trusts where we have measured the SERVICE expectations of the public in the catchment area of the Trust and then gone on to measure the experience among those who have recently been treated; both sets of measures were carried out across 35 aspects of service experience. I can confirm that in this particular evaluation the gap between expectation (reasonable or otherwise) and experience is significant - and is far greater with younger service users.

Interestingly, when asked to prioritise in importance those aspects of 'service' that needed to improve (i.e. driving satisfaction), users ranked 'responsiveness' and 'reliability' ahead of 'clinical assurance', 'empathy' and what we termed 'hotel factors' (environment.) So, unsurprisingly to some of us, NHS acutes are no different to any other service sector.

My sense is that the quicker the NHS leadership (and politicians for that matter) understand that they are running a service business (whether publicly or privately run), the greater the possibility of the NHS as an institution responding to public expectations more generally. And, of course, like hotels, that includes the thorny issue of access!

Anonymous taxp…

Comment date
09 December 2012
As an American/British dual national now living permanently in the UK and therefore having a view of both the NHS and market-based health provision, the "totemic" significance of a National Health Service, funded by our taxes and free to all at the point of service is a matter of collective decency to our fellow (British) citizens. This is what is lacking in the United States, where provision of health care is driven by profit.

Obviously, there *should* be limits on what is spent on the NHS. I don't think anyone has ever seen it as having a bottomless pit of money. However, this should be governed by a cost-benefit analysis considering expense and clinical efficacy. This is what NICE does. It should not be governed by political posturing and mob rule, or by profit. The price for the peace of mind afforded by a service free at the point of service, is that we will sometimes pay for services for the "undeserving". The answer to that problem lies in cultural change (for example, drinking), not provision of health care by public opinion of what is or is not "deserving".

The greatest threat to the NHS, as I see it, is the introduction of the profit motive, and fragmentation of services, CAUSED by the marketisation of services and the enactment of the Health and Social Care Act. My family and I have seen the effects of this. Money is being spent on reorganisation, rather than health care.

The public are of course preoccupied with the parlous state of the economy more so than the state of the NHS. I suggest another poll be conducted once the public wake up to what is being done to their 60-year experiment in public decency.

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