Public satisfaction with the NHS and social care in 2021

Since 1983, NatCen Social Research’s (NatCen’s) British Social Attitudes (BSA) survey has asked members of the public about their views on health and care services. NatCen carried out the most recent survey between 16 September and 31 October 2021 and asked a nationally representative sample (across England, Scotland and Wales) of 3,112 people about their satisfaction with the National Health Service (NHS) overall, and 1,039 people about their satisfaction with specific NHS and social care services, as well as their views on NHS funding.

The King’s Fund and Nuffield Trust jointly sponsored the 2021 BSA survey questions reported here. We added new questions in 2021 asking people about their views on what the priorities for the NHS should be and the extent to which they think the founding principles of the NHS should still apply.

The BSA is a ‘gold standard’ nationally representative survey that uses a robust methodology to explore public views on a wide range of issues. The methodology uses random probability sampling to select British households to take part. From 1983 until 2019 the survey was conducted through face-to-face interviews. This method was not possible in 2020 due to social distancing rules in place for Covid-19 and that year the BSA survey interviews were conducted primarily online with a telephone option also available. This new method continued in 2021, with households receiving a letter inviting up to two adults to take part online or over the phone if they preferred.

In 2020 the only question relating to the NHS that was asked was how satisfied or dissatisfied people are ‘with the way in which the NHS runs nowadays’. In 2021 the full range of NHS and social care questions was asked.

The change in method brings a risk that differences in attitudes between the BSA in 2020 and 2021 and earlier years may be a consequence of the change of methodology. However, the 2021 data has been carefully weighted to ensure this risk has been minimised. The methodology section explains further reasons to be confident in making comparisons between years.

Key findings in 2021

Satisfaction with the NHS overall in 2021

• Overall satisfaction with the NHS fell to 36 per cent – an unprecedented 17 percentage point decrease on 2020. This is the lowest level of satisfaction recorded since 1997, when satisfaction fell to 34 per cent. More people (41 per cent) were dissatisfied with the NHS than satisfied.

• This fall in satisfaction was seen across all ages, income groups, sexes and supporters of different political parties.

• The main reason people gave for being dissatisfied with the NHS overall was waiting times for GP and hospital appointments (65 per cent) followed by staff shortages (46 per cent) and a view that the government does not spend enough money on the NHS (40 per cent).

• Of those who were satisfied with the NHS overall, the top reason was because the NHS is free at the point of use (78 per cent), followed by the quality of NHS care (65 per cent) and that it has a good range of services (58 per cent).

Satisfaction with NHS and social care services in 2021

• Satisfaction with GP services fell to 38 per cent – a 30 percentage point decrease compared to 2019. This is the lowest level of satisfaction recorded for GP services since the BSA survey began in 1983 and 25 percentage points lower than the previous lowest level – 63 per cent – recorded in 2018. 2021 was the first year that the percentage of people dissatisfied with GP services (42 per cent) was higher than the percentage satisfied.

• Satisfaction with inpatient services fell from 64 per cent in 2019 to 41 per cent in 2021, a fall of 23 percentage points. Similarly, satisfaction with outpatient services fell from 71 per cent in 2019 to 49 per cent in 2021.  Satisfaction with both is at the lowest level since the BSA survey began.

• Satisfaction with accident and emergency (A&E) services also fell sharply, a fall of 15 percentage points, from 54 per cent to 39 per cent. This is the lowest level recorded since a question on A&E was introduced in 1999.

• Satisfaction with NHS dentistry services also fell significantly with 33 per cent of respondents saying they were satisfied in 2021 compared to 60 per cent in 2019. Again, the lowest level since the BSA survey started.

Satisfaction with social care services in 2021

• 15 per cent of respondents said they were satisfied with social care services in 2021, while 50 per cent said they were dissatisfied.¹

• The main reasons people gave for being dissatisfied with social care were that the pay, working conditions and training for social care staff are bad (59 per cent), that people don’t get all the social care they need (59 per cent), and that social care is not affordable to those who need it (44 per cent).

NHS funding, priorities and principles in 2021

• In 2021, 80 per cent of respondents believed that the NHS faced a ‘major’ or ‘severe’ funding problem. This was the same as recorded in 2019.

• 46 per cent of respondents would have preferred any extra funding that the NHS needed to come from taxes, down from 54 per cent in 2019.

• The proportion of respondents saying the NHS should not be given extra money and that it should live within its budget has increased in recent years, from 15 per cent in 2017 to 25 per cent in 2021.

• Asked what they thought the most important priorities for the NHS should be, the top three cited by survey respondents were: making it easier to get a GP appointment (48 per cent), improving waiting times for planned operations (47 per cent) and increasing the number of staff in the NHS (47 per cent).

• The overwhelming majority of respondents agreed that the founding principles of the NHS should ‘definitely’ or ‘probably’ apply in 2021: that the NHS should be free of charge when you need it (94 per cent), the NHS should primarily be funded through taxes (86 per cent) and the NHS should be available to everyone (84 per cent).

• There were high levels of support for all three principles across both Labour and Conservative supporters, although Labour supporters were more likely to say they should ‘definitely’ apply.

How satisfied were the British public with the NHS overall in 2021?

These truly are unprecedented times for the NHS. Few people could have predicted the events that would occur between the last time the BSA survey was carried out in full in 2019, and the start of the fieldwork period for this year’s survey in mid-September 2021.

The NHS, its staff and patients have faced new challenges as they have grappled with the Covid-19 pandemic. Health services had to rapidly re-adjust the way they delivered care to patients and users. New ways of working were introduced to accommodate social distancing and other infection control guidance, including a large increase in remote consultations for general practice and outpatient services. As treating Covid-19 patients became the priority, the NHS had to reprioritise care, leading to delays for patients who needed routine care. In addition, the NHS led the largest mass vaccination programme in its history. All this had a huge impact on patients and staff, many of whom were ill themselves or had to isolate at different times throughout the pandemic.

As a result, pressures that existed before the pandemic were exacerbated. By October 2021 in England, for example, the waiting list for planned care had grown by more than a third (from 4.4 million in February 2020 to nearly 6 million); more patients than ever before (about 40 per cent) were waiting longer than four hours in major A&E departments and patients in need of emergency care were waiting 30 minutes longer for an ambulance (NHS England and NHS Improvement 2021). Similar lengthening waiting lists and times were experienced in Scotland (Public Health Scotland 2022) and Wales (Welsh Government 2021). Moreover, substantial NHS staff vacancies that were already putting significant strain on the system have been magnified by the pandemic. There were, for example, slightly more than 100,000 vacancies in the NHS in England in September 2021 (NHS Digital 2021).

In addition, the NHS in England is now on the brink of major reform. The Health and Care Bill will bring an assortment of changes in England, including formalising new integrated care systems (The King’s Fund 2021). In addition, the new Health and Social Care Levy is expected to generate £36 billion in additional funding over the next three years through a rise in taxes earmarked for the NHS and social care (Prime Minister’s Office et al 2021).

The events of the past two years have influenced the public’s perception of the NHS immensely. During the initial waves of the pandemic, there was a great deal of public gratitude towards the NHS and its staff, as demonstrated by the weekly ‘Clap for Carers’ and pride in the NHS has remained high (Gardner 2021). However, by late 2020 there were indications that public satisfaction with how the NHS runs was falling, albeit still holding at relatively high levels historically (Wellings and Appleby 2021). The 2021 BSA survey shows how people were feeling nearly two years on from the start of the pandemic – after a long period of disruption to health services.

Overall satisfaction with the NHS in 2021

For 39 years, the BSA survey has asked a representative sample of the public how satisfied or dissatisfied they are ‘with the way in which the NHS runs nowadays’.

In 2021, 36 per cent of the public were ‘very’ or ‘quite’ satisfied with the NHS (see Figure 1) a 17 percentage point decrease on the previous year. Only 6 per cent out of the 36 per cent were ‘very’ satisfied with the NHS. This fall in satisfaction mirrors the increase in public dissatisfaction with the NHS, which rose from 25 per cent in 2020 to 41 per cent in 2021.

The long-term view of this trend (see Figure 1) shows that this fall in satisfaction is exceptional. It is the largest year-on-year fall in satisfaction since the question was first asked in 1983.

Satisfaction was last at this level in the late 1990s, when it reached a low of 34 per cent in 1997. Satisfaction recovered in the 2000s and increased by 28 percentage points over the decade. The only near comparable year-on-year fall in satisfaction to this year’s, was between 2010 and 2011, when satisfaction fell by 12 percentage points from 70 per cent to 58 per cent.

For the first time since 2002, more people are dissatisfied with the NHS than satisfied.

How does satisfaction vary by demographic group in 2021?

The decrease in satisfaction between 2020 and 2021 occurred in almost all demographic groups (see Figure 2). The decrease in satisfaction levels was statistically significant for adults aged 18 to 64 and over 65 (18 and 16 percentage points respectively); male and female respondents (17 and 18 percentage points respectively); and across supporters of all main political parties (Conservatives: 18 percentage points; Labour: 17 percentage points; Liberal Democrats: 26 percentage points). A decrease in satisfaction also occurred across all three nations covered by the survey revealing similar levels of satisfaction in England (36 per cent), Scotland (33 per cent) and Wales (34 per cent). Respondents from all ethnic backgrounds reported low levels of satisfaction in 2021 (mixed/other: 33 per cent; white: 36 per cent; Asian: 37 per cent; Black: 39 per cent (these are the most granular levels of ethnicity captured in the survey)). However, only white respondents showed a statistically significant fall in satisfaction between 2020 and 2021. For other ethnic groups, the sample sizes were too small for the changes to be statistically significant.

However, while there were falls in satisfaction across the board, relative levels of satisfaction showed some variation depending on, for example, respondents’ age, political affiliation and sex. Figure 3 shows how satisfaction differed among different population groups and how satisfaction differed from the average for the whole survey.

As in previous years, satisfaction levels differ by age: respondents aged over 65 had higher levels of satisfaction (42 per cent) than those aged 18 to 64 (34 per cent). While other groups also showed differences in satisfaction levels relative to each other, these differences were not statistically significant. Figure 3 shows that while there were interesting gradients in satisfaction within some groups – for example, low- and high-income households tended to be more satisfied than middle-income households, and Black and Asian respondents more satisfied than other ethnic groups – these differences were not large enough given the size of the sample to reach statistical significance.

While satisfaction fell for supporters of all political parties, there was still some variation in the level of satisfaction between parties. Respondents who supported the Conservative party had a slightly higher level of satisfaction (39 per cent) than respondents who supported the Labour party (36 per cent) (see Figure 4). This follows a pattern seen in the BSA survey in most years, with supporters of the political party in power generally reporting higher levels of satisfaction than supporters of the main opposition party (Appleby 2021). It is noteworthy, however, that between 2019 and 2021 the difference between the two groups narrowed and is no longer statistically significant.

Why was the public satisfied or dissatisfied with the NHS in 2021?

Public views about the NHS are driven by a range of factors. Since 2015 the survey has included questions that explore what lies behind the overall levels of satisfaction and dissatisfaction with the NHS. Respondents are asked to pick up to three reasons for the answer they gave to the overall satisfaction question.

These questions were not asked in 2020, so this is the first time since the start of the Covid-19 pandemic that the survey explored reasons for satisfaction or dissatisfaction with the NHS.

As Figure 5 shows, of those who said they were satisfied, 78 per cent said they were satisfied because NHS is free at the point of use, while 65 per cent said it was because of the quality of care. 58 per cent said they were satisfied because of the range of services and treatments available and 49 per cent because of the attitudes and behaviour of NHS staff. 14 per cent said that not having to wait long for a GP or hospital appointment was a reason for being satisfied with the NHS.

While the top five reasons for satisfaction have not changed since this question was introduced (see Figure 6), the order of them has and there have been some statistically significant changes between 2019 and 2021. For the first time, the top reason for satisfaction was that the NHS is free at the point of use – an 18 percentage point increase since 2019. The percentage of people citing waiting times as a reason for satisfaction saw an 11 percentage point decrease compared to 2019.

Those who were dissatisfied with the NHS were also asked why they were dissatisfied. The top three reasons given in 2021 by respondents related to access, staffing and funding (see Figure 7). 65 per cent said they were dissatisfied because of long waiting times, while 46 per cent chose staff shortages. 40 per cent said they were dissatisfied due to a lack of government funding and 39 per cent felt that money was wasted in the NHS. 26 per cent identified government reforms that affect the NHS as a reason for dissatisfaction.

For the past three surveys, the top three reasons for dissatisfaction with the NHS have not changed: length of waiting times, staff shortages, and the government not spending enough money on the NHS (see Figure 8). However, this year there was a noticeable shift in the ranking. Dissatisfaction due to waiting times overtook concerns about staff shortages as the main reason for dissatisfaction, with an increase of 8 percentage points compared to 2019, although this is not statistically significant.

There was a significant increase (of 13 percentage points) in concern about money being wasted in the NHS among those who said they were dissatisfied. The 8 percentage point increase in concern around government reforms that affect the NHS is not significant.

As in previous surveys, very few people said their satisfaction or dissatisfaction was because of stories in the newspapers, radio or TV. This is despite widespread media coverage about pressures on the service, especially over the past two years (during the pandemic) and particularly during the fieldwork period for the survey (see the media box below).

How satisfied were the British public with different NHS services in 2021?

In addition to asking about overall satisfaction with the NHS, the BSA survey asks the public how satisfied or dissatisfied they are with different health and care services: general practice, dentistry, inpatient, outpatient, and A&E services. It is important to note that unprecedented changes took place in the delivery of these services in response to the pandemic, with, for example, general practice and outpatient consultations shifting from being face to face to being conducted remotely for most appointments, and routine NHS dentistry appointments temporarily pausing at the start of the pandemic.

General practice in 2021

In 2021, satisfaction with GP services fell significantly, by 30 percentage points, from 68 per cent satisfied to 38 per cent. This is the lowest level recorded since the survey began in 1983; the previous lowest figure recorded was 63 per cent in 2018 (see Figure 10). While the overall trend over the past decade has seen satisfaction with GP services fall (from 80 per cent in 2009 to 68 per cent in 2019) with some fluctuations, the scale of the fall this year is unprecedented. While 30 per cent of respondents were ‘quite’ satisfied, only 9 per cent were ‘very’ satisfied. Satisfaction with GP services is now the lowest of any NHS service with the exception of dentistry. It had previously been the highest-rated service every single year until 2018, when it was overtaken by satisfaction with outpatient services.

Levels of dissatisfaction rose sharply. In 2019, 20 per cent of respondents said they were dissatisfied with GP services, this increased to 42 per cent in 2021 – a statistically significant increase.

Dentistry in 2021

Over the past two decades, satisfaction with NHS dentistry services had risen from a low of around 42 per cent in the mid-2000s to a level similar to satisfaction with the NHS as a whole in 2019 (60 per cent) (see Figure 10). However, as with satisfaction with GP services, satisfaction with NHS dentistry services fell significantly with only 33 per cent of respondents saying they were satisfied in 2021.

Levels of dissatisfaction rose significantly. In 2019, 15 per cent of respondents said they were dissatisfied with dentistry services. This increased to 34 per cent in 2021.

Inpatient and outpatient services in 2021

The BSA survey also asks about satisfaction with inpatient and outpatient services (see Figure 11). Satisfaction with inpatient services increased in the years before the pandemic to 64 per cent in 2019. However, satisfaction has fallen by 23 percentage points since then, to 41 per cent. Despite the significant decrease, the fall in satisfaction levels is less severe than for GP or dentistry services and is largely explained by the large increase in the proportion of people responding as neither satisfied nor dissatisfied, which rose from 22 per cent in 2019 to 41 per cent in 2021. Dissatisfaction with inpatient services did not change significantly at 11 per cent.

Satisfaction with outpatient services remained consistently high in the years before the pandemic and reached its highest level since the survey began in 2019, at 71 per cent. In 2021 satisfaction fell significantly, by 22 percentage points compared to 2019, with 49 per cent of respondents saying they were satisfied. However, this is still the highest proportion of people satisfied compared to other NHS services (see Figure 9). As with inpatient services, the proportion of people responding as neither satisfied nor dissatisfied with outpatient services increased to 35 per cent in 2021 compared to 17 per cent in 2019. Dissatisfaction with outpatient services has remained relatively constant, at 14 per cent compared to 11 per cent in 2019.

Accident and emergency in 2021

Satisfaction with A&E services remained stable in the years 2015 to 2019, but, in lines with other services, fell significantly in 2021. 39 per cent of respondents said they were satisfied with A&E in 2021, compared to 54 per cent in 2019. 

Levels of dissatisfaction also rose from 23 per cent to 29 per cent of respondents saying they were dissatisfied.

How satisfied were the British public with social care services in 2021?

Overall satisfaction with social care in 2021

Social care has faced enormous challenges during the pandemic. The impact of Covid-19 on people drawing on social care and those delivering it has been widespread, with high numbers of deaths in care homes, severe restrictions on contacts with relatives and friends, and care staff under immense pressure to deliver safe services. Pre-existing pressures facing social care staffing were compounded during the pandemic, with, for example, more than 100,000 vacancies in social care in England in 2020/21 (Skills for Care 2021). As a result, social care needs are going unmet – for example, as of November 2021 an estimated 400,000 people in England were still waiting for an assessment of their needs (ADASS 2021).

In 2021 the wording of the question on satisfaction with social care was changed so that it captured perceptions of all social care services rather than only those services provided by local authorities as asked in previous years (see methodology section for more details). For this reason, we are not presenting the time series as it is not comparable with previous years.

In 2021, 15 per cent of respondents said they were satisfied with social care while 50 per cent said they were dissatisfied.

Why is the public satisfied or dissatisfied with social care in 2021?

For the first time this year, the survey included questions that explored why respondents were satisfied or dissatisfied with social care by asking them to pick up to three reasons for the answer they gave to the overall satisfaction question.

Figure 13 shows that of those respondents who said they were satisfied with social care services (138 respondents), 57 per cent said this was because people are treated with dignity and respect by social care staff, and 56 per cent because the range of services and support available is good. 33 per cent said they were satisfied because social care is affordable to those who need it, and because health and social care services work well together. Only 16 per cent were satisfied because it is easy to understand how to get social care.

Figure 14 shows that of those respondents who said they were dissatisfied with social care (547 respondents), 59 per cent said they were dissatisfied because the pay, working conditions and training for social care staff are bad, and the same number of people (59 per cent) felt that people don’t get all the social care they need. 44 per cent said they were dissatisfied because social care is not affordable to those who need it and 43 per cent were dissatisfied because of a lack of support for unpaid carers. 14 per cent of respondents said that people are not treated with dignity and respect by social care staff.

Does contact with a service make people more or less satisfied in 2021?

How many respondents had recently had contact with health and care services?

Findings from previous BSA surveys and other studies of satisfaction with the NHS and social care (Appleby et al 2019; Ipsos MORI 2017) show that use of, or contact with, services – whether through personal experience or that of friends or family – is one of the factors that influences respondents’ satisfaction ratings. If respondents have had contact with a service they will be taking their experience into account when asked how satisfied or otherwise they are with that service. People who have not used a particular service will rely more on indirect information, such as media reports or anecdotal evidence from friends and relations. But to what extent does recent use or contact with a service make people more or less satisfied?

In 2021, 86 per cent of people surveyed had used or had contact with general practice in the previous 12 months, but only 14 per cent had used or had contact with social care services (see Figure 15).

Although the level of contact with general practice services was maintained in 2021, this was not the case for other NHS services. Between 2019 and 2021, the proportion of respondents who had used or had contact with health and care services decreased substantially for inpatients (12 percentage point decrease), outpatients (8 percentage point decrease), A&E (9 percentage point decrease), and dentistry (14 percentage point decrease). There was very little change in the proportion of respondents who said they had had contact with general practice.

This reflects changes in service use and access during the pandemic. When the 2021 survey was conducted, the number of GP appointments had recovered from the initial fall at the outset of the pandemic, but many appointments were being provided remotely, while hospital services were still caring for substantial numbers of Covid-19 patients and facing an increasing backlog of care. Similarly, access to dentistry was also badly affected by the pandemic.

How does recent contact affect satisfaction with a service in 2021?

The first thing to note is that contact or use of a service seems to crystallise people’s views about satisfaction or dissatisfaction. For example, a smaller percentage of respondents who had used or had contact with a service answered ‘neither satisfied nor dissatisfied’ compared to those who had not had contact. If respondents had used a service they were, unsurprisingly, more likely to have an opinion of it.

Overall, respondents who had used or had contact with a service tended to be more satisfied with that service than those who had not used or had contact with a service (see Figure 16). This was particularly the case for dentistry, inpatient and outpatient services. The difference was most pronounced for dentistry, where those who had used or had contact with dentistry services were statistically significantly more likely to be satisfied than those who had not (a difference of 31 percentage points). This may reflect the difficulties some people had in accessing an NHS dentist, with lower levels of satisfaction among non-users being a direct result of an inability to access a dentist.

As Figure 16 shows, the highest level of satisfaction among respondents who had used or had contact with a service was for outpatient services (62 per cent), while the lowest level of satisfaction was among respondents who had had contact with social care (18 per cent). Social care also had the highest levels of dissatisfaction, 66 per cent of respondents who had used or had contact with social care were dissatisfied compared to 49 per cent of those who had not had contact.

General practice was the only NHS service where respondents who had used or had contact with the service reported higher levels of dissatisfaction than satisfaction. 42 per cent of people who had used or had contact with their general practice in the previous 12 months said they were dissatisfied compared to 40 per cent who said they were satisfied. This represents a significant change from 2019 when 70 per cent of those who had used or had contact with general practice said they were satisfied, a drop of 31 percentage points in 2021. Dissatisfaction among people who had used or had contact with general practice has gone from 20 per cent to 42 per cent in the same period. That the vast majority of respondents had used or had contact with GP services underlines the significance of these findings.

Attitudes to NHS spending and sources of funding in 2021

Since 2014 the BSA survey has asked about the public’s views on NHS funding.  Respondents were asked whether the NHS was facing a funding problem and if so, whether it was ‘minor’, ‘moderate’ or ‘severe’.

In 2021, 80 per cent of respondents believed that the NHS faced a ‘major’ or ‘severe’ funding problem. This is the same figure as the last time the question was asked in 2019, though the proportion of respondents who believe the NHS faces a funding problem has fallen since 2018, when the government announced an increase in the NHS England budget of £20.5 billion to coincide with the 70th anniversary of the service (Health Foundation 2018).

One of the questions in the BSA survey asks respondents how they think additional funds for the NHS should be raised if needed (see Figure 18).

Of the six options respondents were given, the most popular choice was that extra funding should come from a separate tax for the NHS – however, the proportion of respondents choosing this option fell, from a high of 35 per cent in 2017 to 26 per cent in 2021, a statistically significant fall. 2021’s data was collected around the same time as the government first announced the Health and Social Care Levy (HM Customs & Revenue 2021), a 1.25 percentage point increase in National Insurance to specifically fund additional resources for the NHS and social care services.

Although the majority of respondents to the previous question thought that the NHS faces a funding problem, as of 2021, 25 per cent of respondents said the NHS should not be given extra money and that it should live within its budget. None of the changes in the responses to this question from 2019 to 2021 is statistically significant.

NHS priorities and principles in 2021

What do the British public think the priorities for the NHS should be?

A question posed for the first time in 2021 asked people what they thought the most important priorities for the NHS should be. The top three answers chosen were making it easier to get a GP appointment (48 per cent), improving waiting times for planned operations (47 per cent) and increasing the number of staff in the NHS (47 per cent).

There were some differences in response according to political affiliation: Labour supporters (23 per cent) were more likely to say that improving the health of the most disadvantaged was a priority than Conservative supporters (11 per cent).

There were also some statistically significant differences in the answers by those who said they were dissatisfied with how the NHS runs nowadays and those who said they were satisfied. 60 per cent of those who said they were dissatisfied with how the NHS runs nowadays said that making it easier to get a GP appointment was a priority compared to 34 per cent who said they were satisfied. 35 per cent of those who said they were dissatisfied with how the NHS runs today said helping people to stay healthy and preventing illness was a priority compared to 47 per cent of people who said they were satisfied.

Do the British public agree with the principles of the NHS in 2021?

Another question appearing for the first time in the survey in 2021 asked people about the extent to which they thought the founding principles of the NHS should still apply today. These principles are:

• the NHS should be free of charge when you need it

• the NHS should be available to everyone

• the NHS should primarily be funded through taxes.

  

Overall, most respondents supported all three principles. 76 per cent of respondents said that the NHS should be free of charge when you need it should ‘definitely’ apply while 18 per cent said it should ‘probably’ apply. Figure 21 shows that Labour supporters were more likely than Conservative supporters to say it should ‘definitely’ apply (86 per cent compared to 66 per cent which is statistically significant). Only 6 per cent of respondents overall answered that this principle should ‘probably’ or ‘definitely’ not apply.

When asked whether the NHS should be available to everyone, 67 per cent of respondents said this should ‘definitely’ apply and 17 per cent said it should ‘probably’ apply. Again, there was a difference by political affiliation with Labour supporters more likely to say it should ‘definitely’ apply compared to Conservative supporters (79 per cent compared to 56 per cent and statistically significant). 16 per cent of respondents overall said this should either ‘probably’ not apply (10 per cent) or should ‘definitely’ not apply (6 per cent).

Finally, when asked whether the NHS should primarily be funded through taxes 54 per cent said this principle should ‘definitely’ apply and 33 per cent said it should ‘probably’ apply. As before there was a statistically significant difference between Labour and Conservative supporters with Labour supporters more likely to say it should ‘definitely’ apply (68 per cent) compared to Conservative voters (48 per cent). While there was no statistically significant difference by age on the first two principles, there was on whether the NHS should primarily be funded through taxes with over 65s more likely to say it should ‘definitely’ apply (68 per cent) compared to 18–64 year-olds (48 per cent). As with the two previous principles a relatively small number said this should ‘probably’ (8 per cent) or ‘definitely’ not apply (4 per cent).

Conclusion

The most striking result to emerge from the BSA survey in 2021 is the huge fall in overall satisfaction with the NHS. 36 per cent respondents said they are ‘very’ or ‘quite’ satisfied: a decrease of 17 percentage points on 2020 and a 24 percentage point decrease compared to the pre-pandemic 2019 survey. And for the first time since 2002 the BSA survey recorded more people expressing dissatisfaction than satisfaction.

The fall in satisfaction was also universal. Satisfaction fell across all ages, household incomes, sexes and political affiliation. It was also mirrored in different health and care services – general practice, A&E, inpatients, outpatients, dentistry and social care. The falls in satisfaction levels across all these services were significant and unprecedented. In particular, satisfaction with GP services – traditionally very high – is now only 38 per cent, 25 percentage points lower than the previous lowest level (recorded in 1983).

But we also know from the survey that support for the basic principles of the NHS – free at the point of use, available to all and collectively funded from general taxes – is high, with around nine in ten people saying these principles ‘definitely’ or ‘probably’ should still apply. But if the public has not fallen out of love with the fundamental principles of the NHS what lies behind the fall in satisfaction?

The answer lies in the extraordinary events of the past two years. Covid-19 has put health and care services under pressure in ways not experienced in their history. Coping with the pandemic at a time when services were already under strain – struggling with waiting lists and staff vacancies across both health and social care, for example – has been enormously difficult and adversely affected care for users of services.

Although the public have recognised the unprecedented nature of the pandemic and largely accepted the necessity for health and care services to reprioritise patients, restrict access and delay care for millions, it seems likely that this understanding and the support the public had shown during the early period of the pandemic has been overtaken by concerns people have about the impact these very actions are continuing to have. This is particularly the case with delays in getting access to care: currently, around 1 in 10 of the English population is on an NHS waiting list (NHS England and NHS Improvement 2022), a similar proportion in Scotland (BBC News 2022), and 1 in 5 of the Welsh population (Welsh Parliament 2021). This means that many of those taking part in the survey would either have been on a waiting list or knew someone who was.

The challenges being faced in primary care, particularly around access, are also clear to see from the results of the survey, with only 40 per cent of people who had used or had contact with their general practice saying they were satisfied with GP services and 42 per cent saying they were dissatisfied. General practice is the service used by the largest number of people and if people were facing problems here it is likely to have had a significant impact on overall satisfaction with the NHS.

It is perhaps no surprise then that having to wait too long for a GP or hospital appointment was the most popular reason given for dissatisfaction with the NHS and that the two most favoured priorities for the NHS were making it easier to get a GP appointment and improving waiting times for planned operations. Similarly, for social care, where, as well as concern for pay and working conditions for care staff, the fact that people do not get the care they need was also a key reason for dissatisfaction.

Is more money the answer? 80 per cent of those surveyed still think the NHS has a severe or major funding problem, so the public’s answer is probably yes. But while many thought extra funding should be raised through taxation – either from current taxes or a separate NHS tax – 25 per cent thought that the NHS needs to live within its budget. Moreover, concern about money being wasted by the NHS has also risen significantly among people who were dissatisfied with the service.

As, hopefully, Britain begins to emerge from the pandemic emergency, elective recovery plans for health and care services to tackle the backlog of care and to reduce waiting lists and times are being put in place. But, as the Secretary of State for Health and Social Care, Sajid Javid, has admitted, waiting lists will get worse over the next year or so before starting to fall in 2024 (Javid 2022). And even if all goes to plan, this ambition will only return services to the pre-pandemic situation in which nearly all headline waiting times were being missed nationally for A&E, planned operations and cancer services.

Moreover, the unprecedented levels of dissatisfaction with GP services underline that action to tackle waiting times for planned care is unlikely to be enough for public satisfaction with the NHS to recover. Addressing pressures on general practice and improving access for patients will be key if satisfaction is to rise in future years.

Previous trends from the BSA survey suggest that recovering from a low point in the public’s satisfaction with the NHS and care services will take time. Future BSA surveys will track the public’s satisfaction as plans unfold and as health and care services tackle the job of recovery.