Why is public satisfaction with the NHS still falling?

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Part of Public satisfaction with the NHS

In 2018, public satisfaction with the NHS was at its lowest level for more than a decade. The latest data from NatCen’s British Social Attitudes survey – a gold standard measure of public opinion – shows that satisfaction with ‘the way in which the NHS runs nowadays’ has fallen 16 percentage points since 2010, and dissatisfaction has doubled since 2014 (Figure 1).

Question asked: ‘All in all, how satisfied or dissatisfied would you say you are with the way in which the National Health Service runs nowadays?’ 
Notes: This question was not asked in 1985, 1988 and 1992; in 2018, n=2926; ‘Don’t know’ responses are not shown, in 2018 this response category was selected by less than 0.05 per cent of respondents.
Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

At first glance, this data is not surprising. NHS funding growth has been at historic lows since the turn of the decade; patients are waiting longer for hospital treatment, and GP appointments remain elusive. In line with this, when the survey asked respondents to explain why they were satisfied or dissatisfied, dissatisfied respondents identified resourcing issues and waiting times as the main reasons for their discontent (Figures 2 and 3).

Figure 2 Top five reasons for why people are satisfied with the NHS overall

Question asked: ‘You said you are satisfied with the way in which the National Health Service runs nowadays. Why do you say that? You can choose up to three answers.’ (Options presented on a card). 
Notes: This question was asked of a random third of those who said they were ‘quite’ or ‘very’ satisfied with the way the NHS runs nowadays.
Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

Figure 3 Top five reasons for why people are dissatisfied with the NHS overall

Question asked: ‘You said you are dissatisfied with the way in which the National Health Service runs nowadays. Why do you say that? You can choose up to three answers.’ (Options presented on a card).
Notes: This question was asked of a random third of those who said they were ‘quite’ or ‘very’ dissatisfied with the way the NHS runs nowadays
Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

What puzzles me about this data is why satisfaction has continued to fall. At the time when the public were being asked for their views (July 2018), the Prime Minister had just announced a funding boost for the NHS and 70th birthday celebrations were taking place across the country, accompanied by an outpouring of affection and pride for our ‘national treasure’. You might expect these positive events to engender higher levels of satisfaction – so why didn’t we see a ‘birthday bounce’?

We don’t know exactly what lies behind changes in levels of satisfaction, but ratings are likely to be affected by a range of factors.

Quality is part of the story – it’s the number one reason given by people who are satisfied with the NHS to explain their answer (Figure 2). But the Care Quality Commission (CQC) tells us that the quality of care provided in the NHS is going upnational patient survey data shows an upward trend in overall ratings of hospital services, and the BSA itself finds that public satisfaction ratings of inpatient and outpatient services are at their highest levels for decades. Other factors must also be at play.

Access is also a key contributor. Figure 3 shows that long waits are consistently the number one reason given for dissatisfaction with the NHS, and fewer people identified short waits as a reason for satisfaction in 2018 than did three years before. This is in line with data showing that the NHS is continuing to miss its hospital waiting times targets and patients are struggling to book GP appointments. Access issues are also likely to have contributed to the BSA’s GP satisfaction measure remaining at an all-time low in 2018.

What about media coverage? Very few respondents said media stories affected their satisfaction, but they may have had an indirect impact: some of the reasons given for satisfaction or dissatisfaction – like government reforms – are things respondents are most likely to have heard about in the media.

Debate about the link between public attitudes and media stories has been going on for years. It’s something The King’s Fund investigated 25 years ago by repeating the BSA NHS satisfaction question on a monthly survey, while monitoring the coverage of health issues in the newspapers and on television over the same period. They concluded that the media does have an impact on satisfaction ratings, but it is relatively small. 

Satisfaction ratings might also be a judgement on the government that is currently ‘running’ the service. In line with this, satisfaction tends to be higher among supporters of the party currently in power; in 2018, Conservative supporters did report higher levels of satisfaction (58 per cent) than Labour supporters (51 per cent).

High-profile political events may also play a part. A fall in dissatisfaction in 1991 was in part attributed to what was called the ‘Major effect’. This was the theory that John Major – who took over as Prime Minister in 1990 – had a more caring image than his predecessor, which quelled public concerns about the NHS. More recently, the big drop in satisfaction in 2011 was partly attributed to public reaction to the ‘Lansley reforms’, which were dominating health coverage at the time (although others contested this explanation).

Public support for the NHS as an institution is another likely aspect of this measure. Some of the top reasons people consistently give for being satisfied with the NHS reflect its founding principles of being comprehensive and free at the point of use.

So why did satisfaction continue to fall in 2018? My view is that people need to see real changes in the things they care about – like waiting times and staffing – before this measure will start an upward turn. The announcement of more money in 2018 did not stop the decline (although it might have attenuated it), and experience from the 2000s shows that investments take a few years to translate into higher satisfaction ratings. Events before the survey period may also have played a part: the debate about underfunding was raging for some time and other public polling shows the NHS vying was with Brexit as the biggest issue facing the country.

The big question now is: will the new funding, which will start to be funnelled into the service this year, be enough to change things? If satisfaction ratings continue to decline over the next few years, policy-makers and politicians should ask some searching questions about why. Was the money enough? Is it being spent wisely? And is the right workforce in place to deliver the improvements that patients and the public really want to see?

Comments

Terry

Position
Retired,
Comment date
07 March 2019

Most of the problems rest with managers - simply their inability to manage.
Problems are there for all to see but there seems to be little will, or more importantly hard sanctions against those who under perform. They stay in post or are promoted.
Time and time again when real problems are unearthed the stock phrase is used 'we are committed to......and have already put matters in hand to ensure change. It poses the question 'why wasn't the problem identified as part of normal management practices before'?
There is little stick but plenty of carrot coming at a time when a group hug is always the answer to most problems.
Yes I am being cynical but I have every reason to be. Good health is a very emotive subject - it is difficult to criticise when you are made to feel better or receiving good care but dispense of the emotion and hard facts emerge - more and more money does not, and has not, brought desired improvements.
Governments dodge saying too much too as the NHS wins votes and it just throws money at it as a result and in any event there is little public trust in its actions and promises I'm afraid.
Thank goodness for the committed NHS staff though (and some, albeit too few, managers) but patients are becoming weary of being told that they are at the centre of the NHS 'wheel' when they know that they are on the rim and many ready to fall off.

Simon O' Connor

Comment date
07 March 2019

what amazes me is that teh author of this blog has swallowed government propaganda about 'an extra 20 billion' and strangely expect that this promise, which amounts to a 3% increase a year in NHS funding after 9 year of virtually frozen funding) should somehow impact on satisfaction. Why would it? This money is a small fraction of the NHS budget and any minimal effect it has will be in the future in any case. People are being asked about their satisfaction with the NHS now, not in the future. 100,000 staff vacancies, long waiting times, impossibility of getting GP appointments and even more re-organisation (ICS, ACOS etc which the King's Fund seems to support uncritically. The public recognise what the government have done to the NHS and are deeply unhappy about it, which they should be.

Simon O' Connor

Comment date
07 March 2019

Sadly you have no idea what you are talking about. There has not been 'more and more' money. Funding has been virtually frozen sine 2010 and billions wasted in quasi privatisation of the NHS. 100,000 staff vacancies and the chronic underfunding - yet you roll out this old cliche about 'managers' being the problem. How absurd.

Ruth Robertson

Position
Senior fellow in health policy,
Organisation
The King's Fund
Comment date
08 March 2019

Simon, thank you for your comments (although perhaps not the bit where you say I don't know what i'm talking about :) ). On NHS funding - funding has been squeezed with growth of around 1 percent a year for most of this decade. It's going to rise to 3.4 percent a year from 2019/20. The King's Fund and others have highlighted the fact the the money going into the NHS isn't enough to maintain services while also transforming care. We'll have to wait and see whether this new money is enough to end the decline in public satisfaction - either way it takes time for money to filter through into real changes and for that to then result in a change in public attitudes. I agree that the NHS is under great pressure at the moment (as is the social care system). Money alone won't solve the problems, and as you point out there is an urgent need to address critical workforce shortages. We'll soon be publishing a report with the Health Foundation and Nuffield Trust looking at what is needed to address that challenge.

Gerald Rigler

Position
Volunteer,
Organisation
N A
Comment date
08 March 2019

One reason that seems to be overlooked for why we all are satisfied with a mutual and 'not-for-profit' NHS is that the UK does not have people that have been bankrupted by incurring a hospital / medical bill that was beyond the terms of their insurance policy - unlike other countries that have a different (non-mutual and profit orientated) healthcare model. Not only is that personally satisfying for individuals (and their families) but UK plc benefits from a less worried workforce. It is of concern that when people are led to believe that money can solve a healthcare issue that profiteering could become unmanageable if a 'not-for-profit' model is abandoned and controls on the pricing / availability of medicines weakened.

Andrew West

Position
Retired Consultant in Emergency Medicine,
Organisation
www.cddft.nhs.uk
Comment date
08 March 2019

The survey is about "public satisfaction". The public generally rate the NHS on access, especially GP access and waiting times, with outcomes being third. In spite of complications and mistakes the vast majority of patients have an uneventful journey through their NHS treatment. The public aren't concerned with funding as the NHS is "free". Naivety wins outright here unless a person is a 40% tax payer, but there are few of those so feature less in surveys. You just have to witness the reaction of a British Patient, as I did, when faced with a 100 Euro charge for a GP visit in the Netherlands, to see the naivety of UK citizens who think the NHS is "free". For people like me it is satisfaction in the NHS by those who work in the NHS that is important. A disgruntled, unappreciated workforce, that is patronised by Politicians who are only interested in uttering vote catching sound bites, is a threat to patient safety and efficiency. This is made worse when there is bullying coming down from the top, especially in the days of Jeremy Hunt who spoke everything but listened to nothing. Many years ago Tony Benn MP gave an illustration of a rowing boat race between the NHS and Japan that was spot on and reflected reality. The same can be said today. The real problem with the NHS is resources especially human resources. The amount of extra duty and overtime, clinical staff are expected to do, is crippling, damages moral and compromises patient safety due to long hours and little sleep. The public, who respond to satisfaction surveys, are blissfully unaware of this. This is all because the NHS managers don't want to employ enough staff because staff cost money (but overtime costs money too, something managers wilfully never acknowledge). The resource problem in the NHS can only be solved by those, who think the NHS is free, opening their purse or wallet and paying what it costs. Then another problem arises as it would cost votes for the government willing to address the REAL problem. That is why the REAL problem is never addressed.

John

Comment date
09 March 2019

From the perspective of the current government, falling levels of public satisfaction with the NHS is a success, as this makes privatisation of the NHS - and resulting super profits for their private sector backers - all the more lucrative and attractive.
Their financial claims are hog wash - just as in the education.
Growth in cash terms which fails to keep up with growing numbers and complexity in demands on the service is a clear recipe for real terms under-funding and service failure - just what the government ordered !!!

Simon O' Connor

Comment date
10 March 2019

Hi Ruth - I am puzzled why you are apparently surprised that a promise of a 3.4% increase for the NHS from 2019/20, after nine year of virtually frozen funding, would have an impact in public satisfaction. It is a tiny increase and has not yet even happened. If it did happen it would simply be a reversion to the historical average increase (without replacing the billions taken out from 2010-19). So the whole premise of your article in that sense is baffling and you seem to have swallowed the government lien that there is lots of new money for the NHS. There isn't.

Simon O' Connor

Comment date
10 March 2019

**not have an impact** that should be...

Simon O' Connor

Comment date
10 March 2019

Dear Ruth, I would also like to add, re media coverage: You state that

''What about media coverage? Very few respondents said media stories affected their satisfaction, but they may have had an indirect impact: some of the reasons given for satisfaction or dissatisfaction – like government reforms – are things respondents are most likely to have heard about in the media.''

I respectfully disagree. Pubic awareness of 'reforms' such as Health and Social Care Act, and now 'integrated care systems' etc is negligible. I would be surprised if 10% of the population could say anything meaningful about either. The proportion stating 'govt reforms' as cause of dissatisfaction has therefore hardly moved from 20%. The media has barely reported these huge upheavals of the NHS which have not been consulted on and have no democratic mandate (a belated consultation on ICS etc followed legal action by Allyon Pollock et al). If the public were aware they would be rightly worried and outraged that such huge changes were happening without their consent. King's Fund is fully on board with the governments' latest plans for destroying the NHS (ICS etc) despite a lack of evidence that these could being any benefits although certainly they bring huge risks. The media has been silent on all this.

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