As the NHS approaches its 70th birthday, it continues to occupy a unique place in public consciousness. However, it is under significant pressure and facing perhaps its biggest challenges since it was established. With some questioning whether the NHS can be maintained in its current form, we want to initiate a debate about the ‘contract’ between the NHS and the public – what people can expect from the service and what their obligations are in return.
Through our project on the changing relationship between the public and the NHS, we will explore what the public thinks about the NHS. Over the next few months, we will be asking:
what do the public think the NHS is for?
how has this changed over time?
what drives the relationship between the NHS and the public?
are public expectations changing?
where does the balance of responsibility for health lie between the NHS and the individual?
To begin this process, we commissioned Ipsos MORI to conduct a survey on the public’s attitude to the NHS. Do the public believe the NHS should be maintained? Do they still believe in its founding principles? What do they see as their responsibility when it comes to their own health? Do they want a say in how decisions that affect the NHS are made? Do they think people’s expectations of the service are realistic and do they think those expectations are being met?
Interviews were carried out on Capibus, Ipsos MORI’s face-to-face omnibus survey. A total of 1,151 adults aged 15 and over in England were interviewed between 4 and 10 August 2017 in their homes using computer-aided personal interviewing methodology.
Data is weighted to reflect the population profile in England. Data is weighted to age, region, working status and social grade within gender, as well as household tenure and participant ethnicity using rim weighting.
Where relevant we have compared the findings from this survey to findings from previous research to understand how attitudes have changed over time.
Below is a brief summary of the key messages from this piece.
As the NHS approaches its 70th birthday, it is facing significant challenges. Despite this, it continues to enjoy unwavering support among the public which endures across the generations.
Seventy-seven per cent of the public believe the NHS should be maintained in its current form. This level of support has remained consistent over almost two decades despite widespread social, economic and political change.
Around 90 per cent of people support the founding principles of the NHS, indicating that these principles are just as relevant today as when the NHS was established.
A clear majority (66 per cent) of adults are willing to pay more of their own taxes to fund the NHS, underlining growing support among the public for tax rises to increase NHS funding.
Sixty-seven per cent think that treatments and services should only be available on the NHS if they are available to everyone and not dependent on where people live, while 31 per cent think that treatments and services should be based on local need.
While some people (29 per cent) say decisions about the availability of treatments and services should be left to qualified health professionals, 56 per cent at least want to be consulted and a minority (14 per cent) want to be actively involved. This underlines the importance of engaging the public and ensuring that service changes are supported and led by clinicians.
Sixty-five per cent believe that keeping healthy is primarily down to the individual, with just 7 per cent placing this responsibility with the NHS. While this only skims the surface of very a complex issue, it suggests there is a debate to be had about what people can expect from the NHS and their obligations in return.
Over the coming months, we will undertake further work to explore the relationship between the NHS and the public with the aim of initiating a debate about the future of the NHS and the choices that need to be made to sustain it.
The founding principles of the NHS
We asked a set of questions to explore the participants’ general support for the NHS, as well as their support for the original principles that underpin it.
Strong support to maintain the NHS in its current form
Almost four out of five people (77 per cent) believe that ‘the NHS is crucial to British society and we must do everything we can to maintain it’. Although this question has not been asked by Ipsos MORI since 2007, the chart below shows that this view appears to have changed little since then, or indeed since the question was first asked in 2000.
Remarkably, this support has remained constant despite widespread social change, fluctuations in the economy and changes in government. It has also withstood a period of significant reform during which public satisfaction with the NHS has seen scores ranging from 38 per cent to 70 per cent, according to the British Social Attitudes survey. We might have expected to see a relationship between fluctuations in satisfaction and appetite for change but this does not appear to be the case.
It is interesting to note that younger people are more likely to say that we must do everything we can to maintain the NHS (81 per cent of 15–34 year-olds said this best reflected their thinking against 74 per cent of those aged 55 or over). These findings suggest a deep and enduring belief across the generations in the concept of the NHS, whatever the challenges it has faced.
As the 70th birthday of the NHS approaches, we wanted to understand what level of support there is for the founding principles of the NHS:
that the NHS should be free at the point of delivery
that the NHS should provide a comprehensive service available to everyone
that the NHS should be primarily funded through taxation.
The figure below shows the findings.
Around 90 per cent of people think that each of the three principles should still apply to NHS services today, with a particularly striking number saying they should definitely still apply. There are similarly high levels of support for these founding principles across age groups.
Young people are more likely to feel that the NHS should definitely provide a comprehensive service to everyone than other ages groups: 71 per cent of 15–34 year-olds compared with 62 per cent of over 55s.
This level of public support for principles that are nearly 70 years old is further proof of the strong attachment to the NHS across the generations. Some may view this as evidence that the NHS is ‘untouchable’: certainly policy-makers and local leaders who have tried to implement changes to the service would agree that public support for maintaining services as they are makes this very difficult. It is possible that public desire to maintain the status quo has made it challenging to implement significant change. However, the NHS has constantly evolved throughout its history and today is almost unrecognisable as the service that was established nearly 70 years ago. This suggests that change is possible albeit challenging, as long as it does not encroach on these fundamental principles.
Public willing to pay more in taxes to maintain current services
The NHS is under significant financial pressure and is struggling to maintain standards of care in the face of rising demand for services and the longest funding squeeze in its history. The public understands this. In 2016, the British Social Attitudes survey found that 82 per cent of people think there is a major or severe funding problem in the NHS, an increase of 10 per cent over the two previous years. Furthermore, the same survey showed that the proportion of people who would be prepared to accept paying more through taxation increased to 49 per cent, up 8 percentage points on the previous year. The counter to this is that the public might be happy to support tax increases, as long as it is other people that have to pay. Support, the hypothesis runs, might not be so high if it is clear that people’s own taxes would need to increase.
To further understand whether people’s support for increased taxes includes paying more themselves, we split our survey sample in half and asked a slightly different question to each half. Respondents were asked which of the following options they would most like to see.
Increase taxes in order to maintain the level of spending needed (seen by half of respondents).
I would be willing to pay more taxes in order to maintain the level of spending needed (seen by half of respondents).
Reduce spending on other services, such as education and welfare (seen by all respondents).
Reduce the level of care and services provided by the NHS (seen by all respondents).
None of these options (seen by all respondents).
The findings indicate that increasing taxes is the preferred option to fund the NHS for almost two-thirds of the public. When we looked at the findings across the split sample the public are just as willing to commit to paying more themselves (66 per cent) as to support an increase generally (62 per cent).1 Older people are more likely to say they are willing to pay more (71 per cent of over 55s being willing to pay more, compared with 58 per cent of 18–34 year-olds).
These findings add weight to the argument that the public are ready for a debate about increasing taxation to pay for the NHS and what form these tax increases might take, with previous research suggesting that increasing National Insurance may be more popular than raising Income Tax. In their election manifestos, both Labour and the Conservatives pledged modest increases in NHS funding but neither linked these to increases in the basic rate of Income Tax or increases to National Insurance. This suggests that the opinions of politicians and the public may not be aligned on this issue. It is worth noting that when Gordon Brown raised National Insurance in 2002 to fund the NHS, a poll at the time found that 76 per cent of the public supported the move.
Local versus national provision of treatment and services
One of the challenges for the NHS is how it reconciles local decision-making with one of its underlying principles: that people should receive the same level of care and services across the country regardless of where they live. One commonly expressed concern is that a localist approach to decision-making can lead to a ‘postcode lottery’ with access to services dependent on where people live. Set against this is the fact that the population in different areas of the country will have different health needs reflecting local factors.
Two-thirds think treatment should be available to everyone – and not just based on local need
Our findings show that a large proportion (67 per cent) of the public believe that ‘treatments and services should only be available on the NHS if they are available to everyone and not dependent on where you live’. This figure is the same as in 2011, when Ipsos MORI last asked this question. Thirty-one per cent think that ‘the availability of NHS treatments and services should be based on local needs rather than a “one size fits all” approach’. There has been a shift in opinion since 2008 when 23 per cent of adults favoured a local approach to treatments and services. More people now say that treatments and services should be based on local needs – although this is still very much a minority view.
This suggests that moving beyond delivering access to treatments and services uniformly across the country is fraught with difficultly and the headlines that accompany the phrase ‘postcode lottery’ reflect the challenges.
However, this is where we have to look beyond the polling data. Qualitative research carried out with members of the public shows that public views are more nuanced than the headlines suggest, indicating that people will accept some variation in access to care as a trade-off for more efficient services tailored to their needs.
Public want to be involved but final decisions should be made by health professionals
The evidence above would suggest that local conversations with communities and the public should take place to determine what a fair allocation of services should look like. We wanted to explore the extent to which people want to be consulted on decisions about the availability of NHS treatments and services.
The majority (56 per cent) say that the public should be consulted but that the final decisions should be taken by qualified health professionals. This is unchanged from the last time Ipsos MORI asked this question in 2008 as part of its work for the Social Market Foundation. Compared with 2008, an increased proportion think that decisions should be made solely by qualified health professionals (20 per cent in 2008, rising to 29 per cent in 2017). This is matched by a corresponding reduction in the proportion that think the general public should be much more actively involved in decisions about treatments and services (from 20 per cent in 2008 to 14 per cent in 2017).
While 14 per cent still represents a significant proportion of the population the results of this question suggest that for the most part people trust health professionals to make the final decisions. However, 56 per cent of people want to at least be consulted, if not be more actively involved, so if decision-making is not transparent and people do not at least have the opportunity to engage, it is hardly surprising if problems and opposition to change arise.
These results should also make us reflect on the methods the NHS uses to engage people. Open processes such as public meetings and self-selecting surveys may provide a biased perspective of what the public generally think of services. These methods of engagement are likely to disproportionately involve those who want to be actively engaged (a self-selected minority of people), meaning the NHS is missing the opportunity to proactively gather views from less active parts of the population. Does using these methods of engagement mean the NHS is only hearing from vested interests? To what extent do self-selected groups represent wider views? This is not to dismiss these methods but we should be aware of their limitations when using the insight they produce. Who are we not hearing from is a key question to ask.
This is highlighted by findings that show black and minority ethnic respondents (BME) are more likely than white respondents (including non-British white) to feel that the general public should be much more actively involved in shaping decisions. Twenty-eight per cent of BME adults think that the general public should be much more actively involved, compared with 12 per cent of white adults. This shows how important it is to consider whether we are capturing views from all groups when we are collecting insight from patients and the public.
Where does the balance of responsibility for health lie between the NHS and the individual?
Fundamental to the concept of the contract between the NHS and the people it treats is who is responsible for keeping people healthy. This is relevant to key agendas in the NHS around prevention and self-care. Chapter two of the NHS five year forward view stressed the need for a ‘radical upgrade’ in prevention and a new relationship with patients and communities. We wanted to start to explore this by asking the public where they think this responsibility lies.
We asked the public to score on a scale of 1–10 whether they felt that it is the job of the NHS to keep people healthy (1) or whether it is the individual’s responsibility to keep themselves healthy (10).
Two-thirds of the public (65 per cent) agree that keeping healthy is primarily the responsibility of the individual (scores between 7 and 10), while just 7 per cent put this responsibility on the NHS (scores 4 or lower). At the extreme ends of the scale, 36 per cent of adults feel that responsibility lies strongly with the individual (scoring 9 or 10), and just 3 per cent feel responsibility lies strongly with the NHS (scoring 1 or 2).
This question has been asked twice before by Ipsos MORI. After a shift in 2013, when more people saw responsibility lying with the NHS, the findings are now more in line with where they were in 2010. Younger people are less likely to give a score of 9 or 10 than older people: 29 per cent of 15–34 year-olds gave a score of 9 or 10, compared with 40 per cent of those aged over 55.
This question only skims the surface of complex issues. Given high levels of obesity, alcohol-related harm and other lifestyle problems, it raises questions about the extent to which people do take individual responsibility for their health and what role the NHS could play. We hope to explore these issues in more detail in later phases of this project.
One hypothesis for why pressure on the NHS is growing is that public expectations are changing and becoming harder to meet. However, there is relatively little concrete evidence to back up this claim from a patient perspective. Often people talk about rising expectations and make comparisons about how we interact with other services, such as banking or hotels, but can this be quantified? Certainly, expectations and how they may be changing are hard to measure.
Majority think that people’s expectations of the NHS are realistic
To start to explore this, we tried to identify how expectations are perceived by the public. A majority (63 per cent) feel that people’s expectations of the service they should get from the NHS are very or fairly realistic, while a third (36 per cent) feel that people’s expectations are not very or not at all realistic. It is worth noting that those people who say they are not realistic are also more likely to say that the NHS was a great project but we probably can’t maintain it in its current form.
Majority think NHS meets or exceeds expectations
In terms of whether these expectations are met, a majority of the public (53 per cent) feel that the NHS generally meets expectations, while 20 per cent feel that the NHS exceeds their expectations, and a further 18 per cent feel that the NHS tends to fall short of expectations.
These findings suggest that generally public expectations of the NHS are broadly seen as realistic and for the most part are met or exceeded. This might be seen as good news. Alongside currently high levels of public satisfaction, it suggests that the NHS is providing the right level of service for most people. However, there is another hypothesis which asks whether the public are asking enough of the NHS? Does our attachment to the NHS lead to us accepting a level of service that we would not accept in other areas of our lives? We hope to explore these issues in more detail during later phases of this project.
This research indicates that public support for the NHS remains as strong as ever. It is worth reflecting again on the very high levels of support for the founding principles and the extent to which the public think they should still apply to the modern NHS. It is hard to think of another public service or national institution that would produce similar findings.
The polling suggests that there is scope for a serious debate about raising taxes to increase spending on the NHS, and about what people can expect from the NHS, their own obligations and responsibilities. With the NHS going through a period of significant change, it also suggests that it will be vital to involve the public in these changes and to ensure that they are supported and led by clinicians.
A survey of the public can, clearly, only scratch the surface of these issues. We hope to explore a number of topics during this project including the following.
People seem willing to pay more through their taxes to maintain the NHS. How much more are they willing to pay, and by what means? And are there conditions attached to how extra money is spent?
The individual should take responsibility for their own health, but we also expect the NHS to step in when we need it. What is the role of the NHS in keeping people healthy? Where is it acceptable to increase individual responsibility, and reduce NHS involvement?
The public want to be involved in decisions about health services but to leave final decisions to health professionals. When and how should the public be consulted about changes to services? When, if ever, should their view outweigh that of experts?
Expectations of the NHS are seen as realistic and are largely being met. But are people’s expectations too low? How will expectations change as new treatments, technologies and care models are implemented?
To explore these questions, we are commissioning a series of articles highlighting different perspectives on the relationship between public and the NHS. Following this, we will be analysing the British Social Attitudes survey for more evidence about people’s attitudes towards the service.