Does the public see tax rises as the answer to NHS funding pressures?

As part of our project on the changing relationship between the public and the NHS, The King’s Fund has analysed the latest data from the British Social Attitudes (BSA) survey on public attitudes to NHS funding and the quality of care provided by the NHS.

The survey was conducted between July and October 2017 with a representative sample of adults in England, Scotland and Wales. The King’s Fund sponsors a selection of questions in the survey, including the ones presented here.

Key messages

• With the Prime Minister having announced that a new long-term plan for the NHS will be published, backed by a multi-year funding settlement, our new analysis shows that the public are increasingly anxious about the state of the NHS and that there is widespread support for tax rises to increase funding.

• There is a growing consensus that the NHS is facing a funding crisis. The percentage of respondents to the 2017 survey saying that the service faces a major or severe funding problem has increased by 14 percentage points since 2014 to 86 per cent.

• Some 61 per cent of respondents support tax rises to increase NHS funding, an increase of 21 percentage points from 2014 and 12 percentage points from 2016.

• Breaking down support for tax rises, 35 per cent supported a separate tax that would go direct to the NHS and 26 per cent would be happy to pay more through their existing taxes.

• A majority of respondents support tax increases to pay for the NHS across all age and income groups, including 61 per cent of the highest earners.

• Notably, in 2017 56 per cent of Conservative Party supporters backed a tax rise to pay for the NHS, up from 33 per cent in 2014. Support among Labour Party supporters stood at 68 per cent in 2017.

• The proportion of the public who thought NHS care had got worse over the past five years has been steadily increasing since 2010, reaching 45 per cent in 2017. In contrast, just 17 per cent thought that care had improved over the past five years, the lowest level in two decades.

• Pessimism about the future has increased significantly. In 2017, 56 per cent of people expected standards of care to get worse over the next five years, an increase of 21 percentage points since 2014. Just 20 per cent expected standards of care to improve.

Feeling the pressure: the public and funding

With health services facing unprecedented financial and operational pressures, the future of the NHS has risen to the top of the political agenda. In March 2017, the Prime Minister announced that a new long term plan for the NHS will be published, backed by a multi-year funding settlement. After a decade of historically low funding increases and amid calls for an increase in funding from across the political spectrum, what do the public think about NHS funding and how these pressures should be addressed?

Since 2014, The King’s Fund has sponsored questions in the BSA survey asking the public about their views on current levels of funding in the NHS. The proportion of respondents saying that the NHS has a major or severe funding problem grew from 72 per cent in 2014 to 86 per cent in 2017. The proportion thinking the NHS has ‘severe’ funding problems has nearly doubled, from 19 per cent in 2014 to 37 per cent in 2017. In contrast, the proportion thinking the NHS faces a minor or no funding problem has almost halved since 2014 (from 24 per cent to 13 per cent).

While a large majority of all age groups were likely to think there was a funding problem in the NHS, those aged 18-34 were less likely than all other age groups to think this problem is major or severe (78 per cent of 18–34 year-olds, compared with 87–90 per cent for other age groups). There was consensus across supporters of all parties that there was a funding issue in the NHS, with no statistically significant difference between the proportion of Labour and Conservative supporters who thought the NHS was facing a major or severe funding problem.

How does the public want to pay for the NHS?

Calls for an increase in funding have come from across the political spectrum. Much of this discussion has focused on so-called ‘hypothecation’ – ringfencing taxes for a specific purpose. For example, earlier this year, an expert panel established by the Liberal Democrats called for the introduction of a ring-fenced health and care tax built around reforms to National Insurance. The Conservative MP, Nick Boles, also recently put forward proposals for a hypothecated payroll tax in place of National Insurance, while the cross-bench peer and former Permanent Secretary to the Treasury, Lord Macpherson, is among those who have also backed a hypothecated tax for the NHS. Nearly 100 MPs from all sides of the House of Commons recently wrote to the Prime Minister urging a long-term approach to health and social care funding based on a cross-party approach.

We asked the public which financial measures they would be prepared to accept if the NHS needed more money. They were given a range of choices including raising taxes or increasing costs to service users – for example, through paying for appointments – and were asked to select one.

The proportion prepared to accept higher taxes has risen 21 percentage points between 2014 and 2017, from 41 per cent to 61 per cent. In the past year alone, the proportion of people who said they were willing to pay more in taxes for the NHS has risen 12 percentage points.

Figure 2: If the NHS needed more money, which of the following do you think you would be prepared to accept?

Base: approx. 1,000 British adults, aged 18+ / Source: The King’s Fund analysis of NatCen’s British Social Attitudes survey data

This question about higher taxes also has separate options available for ‘paying more through taxes I currently pay’ and ‘paying more through a separate tax that would go directly to the NHS’. The latter option, which is closer to hypothecation, has always been more popular than paying more through general taxation. In the latest survey, 35 per cent of those surveyed said they would be willing to pay into an NHS-specific tax, while 26 per cent said they would be willing to pay more through the general taxation system.

Other recent polling supports these findings: last year’s polling by The King’s Fund/Ipsos MORI showed a similar proportion of respondents in favour of increasing taxes to maintain NHS spending. This poll included a split sample exercise, which showed that people were as likely to support increases in taxes in a question response that highlighted to respondents that they would ‘personally’ be required to pay more tax, compared with a response that just indicated general increases in tax.

Previous work by The King’s Fund on analysing long-term BSA trends showed that health has consistently been the public’s number one priority for public spending, but that the proportion prioritising health spending has been rising since 2011. In March 2018, the Ipsos MORI issues index showed continued high levels of concern about the NHS.

Other possible solutions to solving funding pressures have decreased in popularity: acceptance of the introduction of increased costs to service users has decreased by nine percentage points since 2016 to 21 per cent in 2017, and the percentage that believe the NHS needs to ‘live within its budget’ has decreased by five percentage points since 2016 to 15 per cent.

The BSA survey goes on to ask what the NHS should do if it cannot meet demand for services within its current funding settlement and gives participants several options, from which they choose the most important. Since 2014, the most popular cost-saving choice has been to stop providing poor-value treatments, with between 43 and 49 per cent of respondents opting for this. The second most popular cost-saving measure, restricting access to non-emergency treatment, has declined in popularity by six percentage points since 2016 to 22 per cent. But overall the order of the options chosen has been the same since 2014, including the 16 per cent of people who said ‘none of the above’ (which is not a listed option).

Who supports tax rises?

The overall majority of survey respondents were in favour of raising taxes to increase funding for the NHS, so how does this break down by age and income groups?

More than half of respondents across all household income groups were willing to accept tax rises to pay for the NHS, including 54 per cent of respondents from the lowest earning households.

Raising taxes had majority support across age groups, with people aged 18–34 as likely to support raising taxes as other groups. Tax increases are often seen as putting a burden on younger taxpayers to pay for the care of the older generations; there was no evidence from the BSA survey that young people see it in this way.

There is a precedent for raising taxes to increase funding for the NHS: in 2002 the public broadly supported Gordon Brown’s National Insurance rise to pay for the NHS. An ICM poll in April 2002, following Brown’s Budget announcement, demonstrated that the 2002 tax rises had majority support from the major parties including 54 per cent of Conservative voters.

In 2017, the BSA survey found that 56 per cent of Conservative supporters were in favour of raising taxes to pay for the NHS; in 2016 this figure was 43 per cent and in 2014 it was just 33 per cent, a full 23 percentage points lower than in 2017. Support for tax rises has generally been higher among Labour supporters, with 68 per cent supporting rises in 2017.

Quality of care in the past and in the future

Since 1995, some BSA surveys have asked the public whether they think the standard of care provided by the NHS has got better or worse over the past five years.

The proportion of respondents who thought that the quality of care had got worse has been steadily increasing since 2010. In 2015, 35 per cent felt that care had got worse over the previous five years; in 2017 this rose to 45 per cent. In 2017, for the first time in more than a decade, the percentage of people who felt that NHS care had been getting worse outnumbered those that felt NHS care had remained the same (36 per cent). This is the higher than the level of negativity in the early 2000s, when the Labour government responded to public concerns about the NHS by providing high increases in NHS funding over a sustained period.

Correspondingly, the proportion that thought NHS care had got better has more than halved since 2010 and has dropped substantially since 2015. In 2015, 25 per cent of respondents thought the quality of care had got better, but this fell to only 17 per cent in 2017, its lowest level in two decades.

Comparing age groups, 36 per cent of those aged over 65 thought the quality of care had got worse compared with 50 per cent of those aged 18–34. There were no differences by income.

Conservative supporters were more likely than Labour supporters to say that the quality of care had improved (23 per cent compared with 13 per cent).

Since 2011, most BSA surveys have included a supplementary question asking the public whether they expected the standard of NHS care to get better or worse over the next five years. Pessimism for the future has grown since 2014: in 2015, 47 per cent of respondents expected quality of care to get worse over the next five years; this rose to 56 per cent in 2017. Between 2011 and 2014 pessimism fluctuated, rising in 2012 and ebbing in 2014, though pessimism in 2017 was higher than at any point since the question was first asked in 2011. An Ipsos MORI poll in March 2017 found that public pessimism about the quality of care in the future was at its highest level since 2002 (when the question was first included in the poll).

Breaking this down by age group, in 2017 those aged 18–34 were less likely to think that care would get worse over the next five years (48 per cent) than others of working age (63 per cent of those aged 35-54 and 58 per cent of those aged 55–64).

Conservative and Labour supporters were equally likely to think the quality of care will get better (24 per cent and 18 per cent, respectively), though Labour supporters were more likely to think the quality of care will get worse in the future (62 per cent compared with 50 per cent of Conservative supporters).

Conclusion

There is mounting public concern that quality of care in the NHS is deteriorating and the public think that things are not going to get better any time soon.

The last time we saw similar levels of public concern about the NHS was in the early 2000s and the Labour government responded by providing a significant funding increase for the NHS, which was sustained over a number of years. This included an increase in National Insurance contributions specifically for NHS funding, which was strongly supported by different sections of society and supporters of all political parties. We are seeing the same patterns in public opinion now, with a majority of supporters of both main political parties in favour of tax increases for the NHS. The gold-standard methodology of the BSA survey means that we are as sure as we can be that these findings reflect a genuine shift in the public’s opinion.

This is the context for the Prime Minister’s commitment to publish a new long-term plan and multi-year funding settlement for the NHS. With the public firmly wedded to the founding principles of the NHS, public satisfaction with the service falling and a majority of supporters of all the main political parties in favour of tax rises to increase NHS funding, the stakes could not be higher.