How have public attitudes to the NHS changed over the past three decades?

If you want to know whether the British public has changed its views about health care over the past three decades, then there is no better place to look than the British Social Attitudes (BSA) survey.

Every year since 1983 the BSA survey, conducted by NatCen Social Research, has been asking members of the British public for their views on what it’s like to live in Britain and what they think about how Britain is run. The results give a snapshot of attitudes from a representative sample of more than 3,000 adults in Britain selected at random each year¹. The survey also provides valuable long-term trend data because some of the questions are asked every year.

It can be easy to overlook the historical perspective that the BSA survey affords – we tend to focus more on looking forward rather than back, particularly when there is a pressing need to focus on the future of the NHS rather than its past. With growing calls for a cross-party consensus on the funding of health and care, now is the perfect time to reflect on what the public has said about the NHS.

As part of our wider project on the public and the NHS we have taken the opportunity to step back and look at 34 years of published BSA data. We draw on data from 1983 up to and including 2016².  What can the BSA tell us about the public’s relationship with the health service and how it is viewed alongside other publicly funded services? Here are our reflections on the top four issues.

Government spending

The public wants the government to spend more on health care, putting it first in line for any extra government spending.

When people have been asked, ‘Which, if any, area of public spending would be your highest priority for extra spending, and which next?’, health has always been placed at the top of the list, with education a close second. In 2016, 79 per cent of respondents named health as a first or second priority for extra spending, and 60 per cent named education (see Figure 1). Health’s position as the number one priority for extra spending has remained unchanged despite significant changes over the same period in levels of investment in the service.

Source: The King’s Fund analysis of NatCen’s British Social Attitudes survey data

The BSA survey has also asked the public about tax and spending on three areas of public policy combined – health, education and social benefits. Respondents have been asked to select one of three options for how government supports these areas. As shown in Figure 2, respondents’ views on whether and how they think the government should adjust taxation – by increasing spend/tax, reducing spend/tax or keeping spend/tax at the same level – to fund health, education and social benefits have changed significantly over the past three decades.

Source: Curtice 2017

Members of the public have consistently rejected the idea of lowering tax and spend on these three areas, with less than 10 per cent supporting this option. This leaves a split between those who want to see ‘more tax and spend’ and those who want ‘tax and spend to remain at the same level’. There was a doubling in support for increasing tax/spend over the period from 1983 to 1991 (from 32 per cent to 65 per cent). Support fell back to 32 per cent by 2010 before beginning to rise again.

From 2007, public support for keeping tax and spend at current levels grew and remained the most popular option for almost a decade. However, in 2016, for the first time in a decade, more people (48 per cent) said they wanted to see an increase in tax and more government spending on health, education and social benefits than those that wanted it to remain at the same level (44 per cent) (Curtice 2017).

The public has prioritised health care as an area for extra government spending and, as shown in Table 1, they have also wanted the government to spend more on it. Support for spending more on health remains high (with 83 per cent in favour of more government spending in 2016) and has increased by 5 percentage points among respondents to the BSA survey between 2006 and 2016. The only other area that saw a larger rise in support over the same period was military and defence which increased by 11 percentage points (from 28 per cent in 2006 to 39 per cent of respondents in 2016) (see Table 1).

Table 1 The public’s view of government spending levels in different policy areas, 1996, 2006 and 2016

Source: Curtice 2017

Responsibility for health care provision

Most people want the government to be responsible for providing health care.

The BSA survey has regularly asked members of the British public for their views on what should or should not be a government responsibility. Whenever this question has been asked, the overwhelming majority (more than 90 per cent) have supported the view that provision of health care is a government responsibility. In 2016, respondents placed health at the top of the list of areas that should be a government responsibility (see Figure 3). The public has maintained this view consistently over the past three decades (with 98 per cent ‘definitely’ or ‘probably’ agreeing that health care should be a government responsibility in 1985, the first time this question was asked, and 96 per cent in 2016). This is in marked contrast with other areas of public policy over the same period. For example, the public’s belief that it is the government’s responsibility to provide for those without a job has declined: 81 per cent thought it was a government responsibility to provide a decent standard of living for the unemployed in 1985 and this had fallen to 60 per cent in 2012.

Source: The King’s Fund analysis of NatCen’s British Social Attitudes survey data

Health care and welfare

Over the period of the BSA survey, the public has supported a health service that is free at the point of access. In contrast, public thinking on how generous the welfare state should be has fluctuated.

Most people responding to the survey have supported the concept of a health service that is not means-tested. Over the years, two-thirds of respondents have consistently opposed the suggestion that the ‘NHS should be available only to those with lower incomes’ (see Figure 4).

Source: The King’s Fund analysis of NatCen’s British Social Attitudes survey data

This rejection of means-testing for health care is consistent across the political spectrum (Appleby et al 2015) and equally unpopular whether people were satisfied or dissatisfied with the NHS (Appleby et al 2016). Qualitative work with the public conducted by The King’s Fund and Ipsos MORI in 2013 is consistent with these results (Galea et al 2013). However, as shown in Figure 5, younger people have been more likely to support the view that NHS care should only be available to those with lower incomes (except in 1995, 1996 and 2013), although even in this age group the majority opposed the idea.

Source: The King’s Fund analysis of NatCen’s British Social Attitudes survey data

Respondents to the survey have been clear that they want a health system that is provided by government, is a top priority for any extra spending, and where access is not restricted by income. The same cannot be said about other public services, and in particular all forms of welfare provision (see Table 2). Three clear trends emerge when members of the public were asked for their views on benefits. First, support for spending more on benefits has declined across the board (with the exception of support for single parents, which has seen a 2 percentage point increase over the period 1998 to 2015, see Table 2). Second, there is a marked decline in support for spending more on those who have retired. The proportion of people who want the government to spend more on benefits for retired people dropped by 22 percentage points between 1998 and 2015 (from 71 per cent in 1998 to 49 per cent in 2015). Third, only a minority want to see more government spending on unemployment benefits. Since 1998, there have only been two years when more than a fifth said they wanted more spent on unemployed people, and a substantial number want the government to spend less on this group (45 per cent in 2015).

Table 2: Public attitudes to government spending on different benefits, 1998–2015

Source: Clery 2016

Further evidence of how attitudes towards benefits have changed can be seen when respondents were asked which, if any, of the groups receiving benefits would be their highest priority for extra government spending (see Figure 6). Historically, the British public has always prioritised pensions for older people, but in 2016, for the first time, the public showed more support for benefits for disabled people (65 per cent) than they did for older people (59 per cent). From 2000 onwards, members of the public gave their lowest priority ranking to benefits for the unemployed (although support appears to have risen slowly since 2007).

Source: The King’s Fund analysis of NatCen’s British Social Attitudes survey data

It is perhaps easier to interpret the public’s views about health care than its views on social benefits. Most people understand what health care is – they understand what the NHS is and what it provides. Health care is also a benefit that is used by everyone at some point in their lives. Social benefits encompass a range of benefits for the unemployed, carers and parents. It also includes pensions which many may not view as a ‘benefit’. Social benefits, and welfare more broadly, are concepts that some people may not think necessarily apply to them and their family (Clery 2016).

Public satisfaction

Levels of public satisfaction with the NHS have fluctuated over the past 34 years, but in 2016 the public reported high levels of satisfaction with the NHS.

While public attitudes towards the funding of the NHS and who is responsible for providing health care have remained relatively consistent over time, since 1983 public satisfaction with the NHS has fluctuated, sometimes quite substantially, from one year to the next (Figure 7).

Source: King's Fund analysis of NatCen's British Social Attitudes survey data

The most significant change has been in the proportion of the public who said they were ‘very’ or ‘quite’ satisfied from 2000 onwards. The percentage expressing satisfaction rose gradually from 39 per cent in 2001 to a peak of 70 per cent in 2010. There was a sharp drop in 2011 when satisfaction levels fell by 12 percentage points. This represented the biggest single-year drop in the survey’s history (Taylor et al 2012; Wellings 2012). Since then, satisfaction with the NHS has remained high. Mirroring this trend, the number of people who say they are ‘very’ or ‘quite’ dissatisfied fell from 41 per cent in 2001 to an all-time low of 15 per cent in 2014.

Over the years, there have been comprehensive attempts to identify any significant links between satisfaction levels and different socio-demographic factors such as gender, household income, or recent contact with the NHS (Appleby et al 2015; Appleby and Roberts 2013) But age is the only factor that is found to be consistently associated with satisfaction (but not dissatisfaction) levels when controlling for other factors. Older people tend to be more satisfied with the NHS than younger groups (Robertson 2017; Appleby et al 2016).

For a more detailed analysis of public satisfaction levels, look out for the latest satisfaction data from 2017 which we will be publishing, with the Nuffield Trust, later this month.

Conclusion

Through the BSA survey, the British public has shared its views on the NHS for the past 34 years, which covers almost half of the NHS’s 70-year history. Remarkably, despite substantial technological, economic and social change, the belief that the NHS should be available to all and free at the point of use has remained largely stable unlike views on welfare. In contrast, the public has also shown marked differences in their level of satisfaction with the NHS over the same period.

As the NHS turns 70, we want to explore further why the public feels the way it does. Later this year, The King’s Fund will be carrying out a series of deliberative events with the public, to explore the relationship between the public and the NHS. We will be asking people what their expectations of the NHS are, where responsibility for health should lie and what is the implicit contract between users and the health service in terms of rights and responsibilities? We hope to find out more about the public’s current relationship with the NHS and feed into the debate about what it might (or should) look like in future.