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Why is public satisfaction with the NHS still falling?

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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 11).

Figure 1: Public satisfaction with the NHS 1983-2018

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 22 and 33).

Figure 2: Top five reasons why people are satisfied with the NHS overall Figure 3: Top five reasons why people are dissatisfied with the NHS overall

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?