The topline results and satisfaction trends relating to the NHS and health care issues from the British Social Attitudes survey 2011.
Since 1983 the British Social Attitudes survey has asked a sample of the public about their views and feeling towards the NHS and health care issues generally. This survey was carried out over the summer of 2011 and provides an important snapshot of satisfaction with the way in which the NHS runs and with important parts of its services such as general practice, inpatients and outpatients.
Here we present the topline results and satisfaction trends from the survey, and explore possible reasons for changes in satisfaction in 2011. These, and the results from a number of other health and health care questions (as well as the rest of the survey questions), will be published later in 2012 in the British Social Attitudes 29th report.
Satisfaction with the NHS overall
Overall, satisfaction with the way the NHS across Britain runs nowadays fell by 12 percentage points from 70 per cent in 2010 to 58 per cent in 2011. This is the biggest fall in one year since the British Social Attitudes survey began in 1983, although this still remains the third highest recorded level of satisfaction in the history of the survey.
Trends in satisfaction with the NHS since 1983
Figure 1: How satisfied or dissatisfied would you say you are with the way in which the National Health Service runs nowadays?
The graph above shows trends in satisfaction with the NHS since 1983. Apart from two of the earliest years (1983 and 1984), satisfaction (ie, those who say they are either quite satisfied or very satisfied with the NHS) fluctuated between 34 per cent and 44 per cent. Between 1997 (the year the new Labour government took office) and 1999, satisfaction rose from 34 to 46 per cent then fell back to 39 per cent in 2001 (an indication that the possible 'honeymoon' period for the Labour government had ended). But from then, overall satisfaction with the NHS rose to an all-time high of 70 per cent in 2010 – reflecting rising funding levels and improvements in the things patients and the public cared about (such as shorter waiting times (Appleby and Robertson 2010). This increase in satisfaction was generally mirrored by a decline in dissatisfaction, with less switching between satisfaction and 'neither satisfied nor dissatisfied' from year to year.
The latest results for 2011, however, show a marked drop in overall satisfaction – from 70 per cent to 58 per cent. While this level of satisfaction remains the third highest since 1983, this fall is the largest drop in satisfaction in one year since the British Social Attitudes survey started. The results also show rises in dissatisfaction – from an all-time low of around 18 per cent in 2010 to 24 per cent, and a rise in more equivocal attitudes (from 12 per cent to 18 per cent).
Net satisfaction with the NHS
The bar chart below provides an alternative summary measure of trends in satisfaction: net satisfaction, based on the difference between very and quite satisfied and very and quite dissatisfied.
Figure 2: Net satisfaction* with the NHS overall**
In a total of eight years since 1983 respondents recorded net dissatisfaction with the NHS overall. Since 2003, net satisfaction has been generally growing each year – although despite an increase in satisfaction in 2006, a larger increase in dissatisfaction meant a fall in net satisfaction. In 2011 net satisfaction – although remaining high by historical standards – fell from 52 to 34 percentage points – a combination of a 12 point fall in satisfaction and a 6 point rise in dissatisfaction.
Satisfaction with NHS services
The British Social Attitudes survey also asked about satisfaction with individual NHS services. Satisfaction with individual NHS services also fell - for GPs, by 4 percentage points, for inpatient services by 5 points, for outpatient services by 6 points, and for accident and emergency services by 7 points (see Figure 4). Satisfaction with dental services, on the other hand, rose by 5 percentage points.
Trends for satisfaction with GP and NHS dentistry services
Figure 3: Satisfaction* with GP and NHS dentistry services: 1983-2011**
The graph above shows trends for satisfaction with GP and NHS dentistry services. Satisfaction with general practitioner services has traditionally been high – around 70 per cent to just over 80 per cent. From a low in 2001 of 71 per cent, satisfaction rose to 80 per cent in 2009. However, it fell in 2010 by 3 percentage points, and the latest results show a further fall of 4 percentage points (to 73 per cent).
By contrast, and apart from one year (2000), satisfaction with dentistry had been in long-term decline until 2009, when satisfaction increased from 42 per cent (in 2008) to 48 per cent. There was a further increase in 2010 and the latest results for 2011 show that this continued, with satisfaction reaching 56 per cent.
Why has satisfaction with NHS dentistry risen?
Bucking the general trend, satisfaction with dentistry rose in 2011 for the third successive year – up five points to 56 per cent. And dissatisfaction has now dropped from 37 per cent in 2006 to 21 per cent in 2011. What might explain this?
One answer is a turnaround in a particular problem with dentistry, namely, access to a dentist who carries out NHS work. As the 2009 Steele review of dentistry noted, 'By the mid-1990s access to an NHS dentist was entering the public consciousness as a political issue' (Steele 2009).
Despite various attempts to address this problem – including some increased funding, targets set for PCTs to improve access, a growth in the number of dentists carrying out NHS work and a new contract introduced in 2006, problems persisted (particularly in some areas of the country). As the Steele review further noted about the new 2006 contract, 'Some dentists were uncomfortable and insecure about the new arrangements and chose to convert to private care. While the lost capacity was fairly small (about 4 per cent of provision) it exacerbated the access problems that had been growing since the early 1990s.' Indeed, in the year after the new contract, access, as measured by NHS courses of treatment, fell.
As improvements in satisfaction with dentistry started in 2009 – too early for the recommendations of the Steele review to have been implemented – one presumption is that satisfaction lagged behind the implementation of other changes preceding the review – including increases in funding for dentistry and specific efforts to improve access, as noted above.
Satisfaction trends with three hospital-based services
Questions concerning satisfaction with three hospital-based services – inpatients, outpatients and accident and emergency services – have also been included in the British Social Attitudes survey for a number of years.
Figure 4: Satisfaction* with inpatients, outpatients and accident and emergency services: 1983-2011**
The graph above shows trends for three hospital-based services between 1983 and 2011.
As with dentistry, and with occasional upturns, satisfaction with inpatient services had been in long-term decline between 1983 and 2006. Satisfaction then rose in the four years to 2010 to reach 59 per cent. However, results for 2011 show a drop to 55 per cent.
Satisfaction with outpatient services has fluctuated between 50 and 60 per cent between 1983 and 2001, since when (and apart from 2006) it rose from 50 to 68 per cent in 2010. Again, however, the latest results for 2011 reveal a drop in satisfaction, to 61 per cent.
Finally, satisfaction with accident and emergency services (trends begin in 1999) rose continuously from 2001 (apart from 2006) from 43 to 61 per cent in 2010. However, as with inpatients and outpatients, satisfaction fell in 2011 to 54 per cent.
Why has satisfaction fallen between 2010 and 2011?
For all services apart from dentistry and for the NHS overall, satisfaction fell. Why might this have happened and what might it indicate about the quality of NHS services as perceived by the public?
There are a number of possible explanations that we have examined in turn, and, where possible, attempted to triangulate results with other surveys and data sources.
Expectations have increased
Satisfaction is a relative concept that may change as the public's expectations of the NHS change. If expectations of what constitutes a good service increase, satisfaction may decline if the NHS fails to keep pace with such changes.
It is generally presumed that, over time, what the public expects in terms of the quality of service – not just from the NHS, but from public services more generally – has been increasing. If this is the case, then a fall in satisfaction may be, in part, the result of the NHS failing to keep up with expectations (rather than a fall in the quality of services). However, while there is no evidence either way, it is improbable that the public’s expectations of the NHS would increase to the extent that would be necessary, and over just one year, to account for the 12 percentage point drop in satisfaction with the NHS overall.
An actual reduction in the quality
One straightforward explanation for the fall in satisfaction is that NHS services deteriorated between 2010 and 2011 to the extent that this was noticed or felt by at least some of the public and to the extent that this reduced satisfaction.
There is no evidence of a real decline in service quality or performance, however. At national level, key measures of performance such as waiting times and health care acquired infection rates have not noticeably deteriorated – remaining relatively stable in the case of most measures of waiting times or, in the case of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C difficile), reducing (Appleby et al 2012).
Other surveys – such as those carried out nationally by the NHS, for example, patient experience surveys of inpatients (Care Quality Commission 2012a), outpatients (Care Quality Commission 2012b) and the GP Patient Survey (Department of Health 2012) also show little or no significant reduction in general measures of the quality of the experience patients report. For example, 43 per cent of respondents to the 2011 NHS inpatient survey rated the care they received as 'excellent', 35 per cent as 'very good', 14 per cent as 'good', 6 per cent as 'fair', and 3 per cent as 'poor'. The only change since 2010 was a slight decrease in the proportion rating their care as 'good' (though the difference was so small it was lost in the rounding of the results).
Similarly, Ipsos MORI's regular issues survey investigating current concerns among the public shows an association with the British Social Attitudes survey satisfaction results, particularly from 2001 onwards (see graph below, Ipsos MORI 2012b). A similar 'concerns' tracker poll by YouGov suggests the NHS fell back slightly as one of the most important issues facing the country between 2010 and 2011 (YouGov 2012a). It should be noted that both this and the Ipsos MORI issues polls ask an implicitly relative question; concern about the NHS, for example, will in part be influenced by the strength of concern about other issues – such as the economy or education.
It is worth noting that while national performance measures – such as waiting times – have been relatively stable over the last few years, key national figures will mask local variations, with some hospitals failing to meet national performance standards. However, there is little evidence that this variation changed substantially between 2010 and 2011.
Figure 5: Ipsos MORI ‘Issues facing Britain’ survey vs British Social Attitudes survey dissatisfaction with the NHS (1983-2011)
A perceived reduction in quality
One way to tease out some of the difference between perception and reality of the quality of NHS services is to examine satisfaction by those respondents who have had recent personal contact with the NHS (in particular inpatients or outpatient services) and compare their reported satisfaction levels with the NHS overall with those without recent contact.
Figure 6: Satisfaction* with NHS overall: Recent contact/no contact** with outpatient services
It might be expected that the satisfaction of people with recent actual experience of the NHS would be better aligned with the reality of the quality (at least as they experienced it) of NHS care. The graph above shows trends in satisfaction with the NHS overall for those with and without recent contact with outpatient services (similar trends are apparent for those with and without recent contact with inpatients). As no data on contact was collected in 2010, satisfaction rates for all contact/no contact groups have been imputed (see note to figure).
This suggests – based on the imputed figures – a fall in satisfaction with the NHS overall of 11 and 6 percentage points for contact and no contact groups respectively. These falls might seem to provide some evidence of a real reduction in the quality of NHS services. However, it is not conclusive; other things (including external factors such as media stories and more internal factors such as NHS staff attitudes and behaviour) will impinge on patients' views of their stay in hospital, which will be independent of the actual quality of their care.
A 'surrogate' vote
Alternatively, or in addition, it may be the case that some or all respondents have expressed a view about the NHS based on their views about something else – in particular about the government and/or its policies concerning the NHS.
Figure 7: Satisfaction* with the NHS overall by party identification
Previous analyses of British Social Attitudes survey satisfaction results have noted that there is a tendency for levels of satisfaction with the NHS overall to correlate with the party in government, with supporters of the party in power expressing greater satisfaction than non-supporters. And other surveys (for example, Ipsos MORI (2012a)) tend to show that the public trust Conservative less than Labour administrations with respect to the running of the NHS.
However, while Figure 7 to an extent at least confirms this, and although there is a noticeable drop in satisfaction as expressed by Labour party supporters in 2011 (following a flattening of satisfaction in the election year of 2010), there are also falls in satisfaction for Conservative and Liberal Democrat supporters. These later falls followed on from increases in satisfaction for both groups in the election year of 2010.
A vote on NHS reform and the funding squeeze?
The drop in satisfaction among Conservative and Liberal Democrat supporters in 2011 (following the rise in 2010) perhaps suggests other factors at work in 2011. What may have coloured people's attitudes towards the NHS were views about the government's proposed reforms for the NHS in England.
Fieldwork for the British Social Attitudes survey took place from 4 July to 10 November 2011. This followed a sustained period of negative media coverage driven by concerns about the Health and Social Care Bill.
These concerns culminated in a pause in the Bill’s parliamentary passage and the NHS Future Forum's report in June 2011, which led to significant amendments being made to it (NHS Future Forum 2011). During the period the interviews were carried out, the BMA stepped up their campaign against the reforms and a number of high-profile peers voiced concerns when the Bill reached the House of Lords in September.
At the same time, in order to make the case for the reforms, the government focused on how the NHS needed to improve, arguing that it performs badly on key outcomes such as cancer survival rates compared to health systems in other countries. This was accompanied by strong ministerial rhetoric about ‘bureaucracy’ and the need to cut the number of NHS managers.
Although some months after the British Social Attitudes survey fieldwork in 2011, a poll by YouGov in February 2012 indicated that around 48 per cent of those surveyed opposed the government's reforms while 18 per cent supported them (YouGov 2012b). Support for the reforms was, at 45 per cent, not particularly high among Conservative supporters, and among Liberal Democrat supporters fairly low at just 17 per cent (with 49 per cent opposed). Across the whole poll there were a large proportion of 'don't knows' (34 per cent) – including Conservative and Liberal Democrats (37 and 34 per cent respectively).
Opposition to the government’s NHS reform plans for England and the sometimes less-than-positive rhetoric from ministers to justify their plans may in part at least have influenced the reduced satisfaction with the NHS.
Figure 8: Satisfaction* with the NHS overall by country**
A partial counter to this is the fact that satisfaction with the NHS also fell significantly in Scotland and Wales (see the graph above). This does not necessarily mean that views about the English NHS reforms did not influence (English respondents') satisfaction rates; other factors may have been at play in Wales and Scotland (funding, for example, which in both countries reduced in real terms between 2010/11 and 2011/12 ). However, there may also have been a 'spill over' effect in Scotland and Wales, with the debate about the English reform proposals having a (negative) impact in these countries too.
At the same time, the media also carried a number of stories about performance and financial pressures associated with the financial squeeze. The year 2011 was the first following the 2010 spending review which, in England, provided for a near real terms freeze in health spending and, as noted, real cuts in Scotland and Wales. Associated with the settlement in England in particular, was a high-profile policy to improve productivity (generally, though not exclusively, through cost reduction). The extent to which the public understood that the £20 billion productivity improvement programme was simply a cut in services and quality is unknown.
However, it seems likely that regardless of its impact within the NHS, the public will have viewed the productivity improvement programme as a sign of the NHS being under pressure financially and this may well have affected their level of satisfaction with it.
As with any survey, the ordering of questions, the size of the sample and so on may affect the responses received. Changes in these and other factors from one year’s survey to another may account for some of the difference in results.
The British Social Attitudes survey is seen as a 'gold standard' methodologically. Nevertheless, surveys are based on samples and so results will always be subject to some uncertainty. In addition, differences between years in, for example, the ordering of questions may affect responses.
In 2011 the health care questions were asked of a third of respondents (1,096), whereas in previous years they were asked of two-thirds or the full sample (which equates roughly to 2,200 and 3,300 respondents respectively). Thus the margin of error associated with the results obtained in 2011 is higher, at +/- 3 to 5 percentage points, compared with around +/- 1 to 2 points in previous years. Nevertheless, even at the extremes of this margin, the satisfaction results for the NHS overall, for example, remain statistically significantly different from those in 2010.
In terms of any 'ordering effects' these are not thought by the survey designers to apply in this case – questions about satisfaction with the NHS are always asked in the same order during the face-to-face interviews and no impact on the results is believed to arise from slight changes to preceding topics asked as part of the wider survey.
While absolute certainty is not possible in interpreting results from any survey, technical and statistical issues are very unlikely to account for the change in satisfaction in 2011. The extent to which these results reflect a real reduction in NHS performance and the things the public value is hard to judge.
However, triangulation with actual performance measures such as waiting times and health care acquired infection rates and with other surveys of patient experience of the NHS do not suggest an actual drop in performance. While this does not rule out a perception of a poorer service or variations in performance at local level, a more likely explanation is a combination of other factors.
As with previous surveys, the change in government appears to have exerted some influence on peoples views. Satisfaction among Conservative and Liberal Democrat supporters rose – as might be expected – in the coalition’s first year in office in 2010, and flattened off (as might also be expected) in that year among Labour supporters. The marked fall in satisfaction among Labour supporters in 2011 – which coincided with the Party’s opposition to the Health and Social Care Bill – suggests an element of political partisanship. Nevertheless, the fall among all groups in 2011 suggests that other factors coloured the public’s attitudes towards the NHS.
It may be that the answer lies in the question. This asked how satisfied people are with the way the NHS runs. The word ‘runs’ may commonly be understood to refer to performance, but may also capture views about the management and stewardship of the NHS (ie, in the sense of how is the NHS run). It may be that a combination of ministerial rhetoric to justify the reforms, concern about the reforms themselves and reaction to the funding squeeze combined to create generalised worries about the NHS and to dent public perception that it is being run well.