Every year since 1983 the British Social Attitudes (BSA) survey, carried out by NatCen Social research, has also been asking the public about its views on the NHS and other public services. How has Britain’s unofficial religion fared over this time and what does this tell us about the future? Our new briefing presents the key findings and I am going to add a set of messages here.
First, while the BSA survey does not ask the public a comprehensive set of questions testing their loyalty to the core principles of the NHS, there are some that test some aspects of this and these show a remarkable enduring faith in these principles. Hence, asked whether health care definitely or probably should be a government responsibility, a whopping 98 per cent agreed it should be in 1985 and 96 per cent still did so in 2016. Similarly asked whether the NHS should only be available to those on lower incomes (ie, means-tested), the ’no’ vote has been very stable and the latest available results, from 2015, were no exception at more than 70 per cent1. These results seem unmoved by the booms and busts in NHS funding; the political colour of the government of the day or indeed by the wider changes in society.
Second, does this faith in the principles of the NHS mean the public is blind to its strengths and weaknesses? Absolutely not – the NHS has been through extended periods (including much of the 1980s and 1990s) when net public satisfaction with services was negative. After 2001, this began to change with the percentage expressing satisfaction rising from 38 per cent to 70 per cent in 2010, mirrored (largely) by a fall in those not satisfied. At least on the surface, the explanation looks straightforward: negative opinions about NHS performance in the 1990s occurred when waiting times for surgery were measured in months and years and the winter crisis that is so shocking to us in 2018 was a routine annual occurrence. The public remained loyal to the concept of the NHS (and its staff) while being profoundly unhappy with the actuality of the service.
In 2000, facing criticism for a struggling NHS, Tony Blair committed to match EU levels of funding for health care, and as sustained real-terms growth in spending began to increase staff numbers and cut waiting times (among other things), as the BSA results show, the public did notice. However, this positive shift in opinion did not start when politicians announced things would improve (politicians often announce improvements to come) but when the service actually began to improve. Since 2010, though satisfaction has fallen it still remains very high by historical standards.
This may feel surprising to those working in the service, as they have worked harder and harder to maintain standards. While this hard work has increased the pressure on NHS staff (leading to increasing numbers wanting to leave the NHS), it also means that the declines in performance have been, until recently, relatively minor by historical standards. As the winter crisis bites, this is becoming less true at least in A&E.
Third, is the NHS unusual when we look across attitudes to wider public services, taxes and benefits over the past three decades? The answer here is more mixed. While the NHS has consistently been the public’s top priority for government spending, the public did appear to notice the big increase in spending in the early part of the 2000s as the percentage supporting more government spending on health dropped from 90 per cent in 1996 to 78 per cent in 2006 (admittedly still high). Unsurprisingly support for increasing spending on health care has risen again since then. More striking though are the shifts in public opinion about other services and benefits. For example, the Resolution Foundation, among others, has expressed rising concerns about intergenerational fairness as younger generations have lost out financially compared to the old. Since 2006 (just before the global financial crisis kicked off the current economic malaise that has contributed to these trends), net support for more government spending on benefits for the retired has dropped by more than 25 per cent (the equivalent of a quarter of the population changing their minds). This changing attitude is something the government will need to consider as it develops its policy proposals for social care funding (much of which is spent on older people) in the forthcoming Green Paper.
Looking to the future, these are my top three take-aways from this data.
- The public remains extremely supportive of the principles and core purpose of the NHS with a consistency in its responses since 1983 that is remarkable. Those that fear a shift toward a more US-style system based on private spending should take some comfort from these results as they suggest this would be deeply unpopular with the public. That the public remain committed to the NHS is confirmed in other, more detailed, polling from 2017.
- The public does respond to significant changes in NHS performance and those who describe the NHS as a bottomless pit that provides no return on investment do so unfairly: the rise in spending after 2000 was linked to a major and sustained (at least until 2016) improvement in the public’s view of the performance of the NHS. We may now be at a turning point as these historical gains begin to fade away and once again, this carries political risks for any government: loyalty to the principles of the NHS does not blind the public to poor performance.
- While the New Romantics of 1983 have been replaced by the hipsters of Hoxton, it seems that no matter what the changes in wider society and attitudes to other areas of public spending, the NHS remains the public’s number one priority for funding.
- 1. Question asked: ‘It has been suggested that the NHS should be available only to those with lower incomes. This would mean that contributions and taxes could be lower and most people would then take out medical insurance or pay for health care. Do you support (a lot or a little) or oppose (a lot or a little) this idea?’