In advance of the 2017 election The King’s Fund published an article on the politics of health , exploring the role the NHS might play at the ballot box, how satisfied people were with the service and what was driving this. As we headed towards another general election in late 2019, we revisited that article, to once again ask where is the public on the NHS? And what, if anything, has changed?
It seems hard to believe now but at the time of the 2017 election the Ipsos MORI Issues Index had 61 per cent of people identifying the NHS as one of the most important issues facing the country, 16 percentage points above ‘Brexit/Europe’ (see Figure 1). Now Brexit/Europe is the issue that dominates all others; it has been the number one issue for the public since June 2018. However, while it might be eclipsing every other issue in public debate right now, concern for the NHS has not gone away. It is still the second most important issue (43 per cent of respondents citing it as one of the most important issues facing Britain today), above crime and law and order, concern for which has been rising sharply over the past couple of years. Concern for the NHS cuts across political divides. It is also a far bigger concern among women (50 per cent) than men (35 per cent), for whom it is almost on a par with Brexit (52 per cent).
We wrote in 2017, ‘Surveys published over the past couple of years indicate that patient experience and public satisfaction with the NHS are holding up remarkably well given the widely reported pressures on the system.’ This is no longer the case and across a range of measures pressures such as staffing levels, waiting times and access to services appear to be having an impact both on people’s experience of services and their overall perception of the NHS. So, what do the numbers tell us?
Patient and public perceptions of the NHS
Public views on the NHS overall
The British Social Attitudes (BSA) Survey1 – a gold standard measure of public opinion for the past 35 years – is one of the best measures we have for exploring how public views of the NHS have changed over time. The latest figures show that in 2018 public satisfaction with ‘the way the NHS runs nowadays’ was at its lowest level for more than a decade (see Figure 2), driven by concerns about long waits for appointments, staff shortages and a lack of funding.
However, this deterioration has not been linear: after a big drop in public satisfaction in 2011 (likely to be at least partly linked to the change in government and the coalition’s proposed health reforms, which were causing controversy at the time), satisfaction levels held up fairly well for the next five years. 2017 marked the start of a downward trend, with satisfaction falling by 10 per cent over two years.
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?’
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.
This measure comes from a survey of the public rather than patients. Although the majority of respondents will have used the NHS in some form in the previous year, their responses are likely to have also been influenced by a range of other factors, including their views on the government in power, stories in the press about the health service and what they hear from friends and family who work in the NHS as well as their personal experience. To understand how patients’ experiences have changed we need to look at findings from the national NHS patient survey programme. This rich data source collects information on the experiences of hundreds of thousands of patients every year. And when you look at that data, you can’t escape the fact that people are reporting a worse overall experience than they were in the past across a range of measures and services.
What do patients think about general practice?
The latest results from the national GP patient survey show that although general practice is still rated highly by patients – 83 per cent described their overall experience of the GP surgery as ‘very good’ or ‘fairly good’ in 2019 – these ratings have been declining for several years. This is driven by difficulties patients face getting into their practice, rather than the experience they have once they get through the door. The proportion of patients who rated the experience of making an appointment as ‘good’ in 2019 was 12 percentage points lower than in 2012 and it is increasingly difficult for them to get through to the practice on the phone (one in three respondents had difficulties with this in 2019 compared to one in five in 2012). These difficulties are likely to be one of the reasons why, in 2018, the BSA survey recorded public satisfaction with general practice of 63 per cent, the lowest level since the survey began in 1983.
At the same time, patients continue to be positive about the interactions they have with GPs and other primary care professionals once in the surgery.
It is therefore unsurprising that in his first speech as Prime Minister, Boris Johnson picked up on public concerns about access, saying ‘My job is to make sure you don’t have to wait three weeks to see your GP.’
What about hospital services?
Patients’ overall experience in NHS hospital services had been holding up surprisingly well until recently, given the widespread pressures on the system. In 2017, results of the national NHS inpatient survey showed improvements across a range of measures of patient experience from the previous year. However, the latest data suggests pressures caused by increased demand and staff shortages may be finally starting to bite. In 2018, there was a deterioration in patients’ ratings of their overall experience as an inpatient, the length of their wait and the support they received after discharge (suggesting pressures on community-based health services and social care are starting to affect patient experience).
The national maternity services survey shows a similar trend, with most measures showing small improvements between 2013 and 2017, but very few continuing this trend into 2018.
What is driving public concern?
Last time the answer to this question was cuts, funding and staff shortages. So, what is driving these deteriorating figures two years on? The answer has not really changed despite some major announcements in the intervening period. It is perhaps only the relative significance of each that has shifted.
Last year the NHS celebrated its 70th birthday and Theresa May announced a long-term funding boost for the service. However, so far, this has had little effect on public opinion and it is too early to say whether it will be enough to halt the decline we have outlined above. The last wave of the BSA survey suggested the announcement of extra funding hadn’t had much immediate impact (the fieldwork period for the survey was shortly after the announcement). There was a drop in overall public satisfaction and concern about funding is still historically high – in 2018, 83 per cent of survey respondents felt that there was a major or severe funding problem in the NHS, compared with 72 per cent back in 2014. The change in concern between 2017 and 2018 (after the announcement) was not statistically significant.
More recently, in August this year, the government announced additional money was being made available for hospital upgrades. Polling by Ipsos MORI at the time showed that more than half of people (54 per cent) welcomed the money but thought more was needed, while a third (33 per cent) said they thought the NHS required a lot more money than was promised. Only 7 per cent said this announcement shows the government is going to make sure the NHS gets all the money it needs. At the Conservative party conference another tranche of money was announced for hospital upgrades. It remains to be seen whether this will have a greater impact on the public’s views of NHS funding than the previous announcement.
There is a school of thought that says that however much money the government puts in to the NHS it will never be enough and the trends seen from survey data certainly suggest that announcements on increased funding have limited impact in the short term. In 2001, before the funding increases introduced by the Labour government, only a third (38 per cent) of people were satisfied with the running of the NHS. Over the next decade, as the additional funding started to have an effect on services and waiting times for hospital treatment fell dramatically, this number climbed steadily to reach an all-time high of 70 per cent in 2010. People need to see the difference the money is making before shifting their views and this can take some time. Public opinion on the NHS has a large turning circle.
When we asked people in 2018 why they were dissatisfied with the NHS the top two answers were waiting times and there not being enough staff, and when we look at other data sources we can see they have a point. There are currently just under 100,000 vacant posts in NHS trusts, with more in general practice. In July 2019 there were 4.5 million people on waiting lists for hospital treatment. While rising demand for services means that the NHS is treating more people than ever before, patients are waiting longer for the care they need. Many of the flagship national standards such as the four-hour waiting time standard for accident and emergency have not been met for several years, eroding improvements that were made between 2002 and 2010, the period where we saw public satisfaction rise. Of particular concern to politicians will be the figures around access to GPs given this is the interaction most voters will have with the NHS.
So far, so bleak, but you might look at these figures and argue that it is a surprise that some of the measures around patient experience and public satisfaction we have referred to are not worse given the overall picture. Affection for the NHS remains strong, particularly towards staff, who people realise are doing the best they can in difficult circumstances.
Last time we wrote that ‘while public and patient satisfaction with health services remains high, the public are increasingly pessimistic about the future of the NHS.’ It looks like they were right. We are now in that future and the question is whether the increased funding will be sufficient for people to see enough improvement to drive satisfaction back up. History suggests this may take some time.