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

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Part of The public and the NHS

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

Every year since 1983 the BSA survey, conducted by NatCen Social Research, has been asking members of the British public for their views on what it’s like to live in Britain and what they think about how Britain is run. The results give a snapshot of attitudes from a representative sample of more than 3,000 adults in Britain selected at random each year.1 The survey also provides valuable long-term trend data because some of the questions are asked every year.

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

As part of our wider project on the public and the NHS we have taken the opportunity to step back and look at 34 years of published BSA data. We draw on data from 1983 up to and including 2016.2 What can the BSA tell us about the public’s relationship with the health service and how it is viewed alongside other publicly funded services? Here are our reflections on the top four issues.

  • 1. More than 3,000 people each year are asked to complete the BSA survey, but there are some questions where a smaller sample of about 1,000 people is selected to respond.
  • 2. The results of the most recent British Social Attitudes survey, its 35th report, will be published by NatCen Social Research in summer 2018.

Government spending

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

 

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


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

Question asked*: ‘Here are some items of government spending. Which of them, if any, would be your highest priority for extra spending? And which next?’

- Education
- Defence
- Health
- Housing
- Public transport
- Roads
- Police and prisons
- Social security benefits
- Help for industry
- Overseas aid        


*This question was not asked in 1988, 1992 and 1998

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


Source: Curtice 2017

Question asked*: ‘Suppose the government had to choose between the three options on this card. Which do you think it should choose?’

- Reduce taxes and spend less on health, education and social benefits.
- Keep taxes and spend on these services at the same level as now.
- Increase taxes and spend more on health, education and social benefits. 


*This question was not asked in 1988 and 1992.

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

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

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

Table 1 The public’s view of government spending levels in different policy areas, 1996, 2006 and 2016
Percentage in favour of more government spending199620062016
Health907883
Education826971
Police and law enforcement705857
Old-age pensions766955
Environment415341
Military and defence172839
Unemployment benefits331316
Culture and the arts61013
Unweighted base9899301563

Source: Curtice 2017

Question asked: ‘Listed below are various areas of government spending. Please show whether you would like to see more or less government spending in each area. Remember that if you say “much more” it might require a tax increase to pay for it.’

The table shows the proportion who said that the government should spend either ‘much more’ or ‘more’ combined.

Responsibility for health care provision

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

 

The BSA survey has regularly asked members of the British public for their views on what should or should not be a government responsibility. Whenever this question has been asked, the overwhelming majority (more than 90 per cent) have supported the view that provision of health care is a government responsibility. In 2016, respondents placed health at the top of the list of areas that should be a government responsibility (see Figure 3). The public has maintained this view consistently over the past three decades (with 98 per cent ‘definitely’ or ‘probably’ agreeing that health care should be a government responsibility in 1985, the first time this question was asked, and 96 per cent in 2016). This is in marked contrast with other areas of public policy over the same period. For example, the public’s belief that it is the government’s responsibility to provide for those without a job has declined: 81 per cent thought it was a government responsibility to provide a decent standard of living for the unemployed in 1985 and this had fallen to 60 per cent in 2012.3
 


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

Question asked: ‘On the whole, do you think it should or should not be the government's responsibility to…’

  • 3. In 2006 and 2016 this question was asked in a different order: it was preceded by a question on government spending and included a reference to taxation levels. Figures for 2006 and 2016 should therefore be treated with caution because the question on responsibility was asked in a different context in 2006 and 2016 compared with 1996, 2002 and 2012, and this may have affected responses.

Health care and welfare

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

 

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


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

Question asked: ‘It has been suggested that the NHS should be available only to those with lower incomes. This would mean that contributions and taxes could be lower and most people would then take out medical insurance or pay for health care. Do you support (a lot or a little) or oppose (a lot or a little) this idea?’

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


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

Question asked: ‘It has been suggested that the NHS should be available only to those with lower incomes. This would mean that contributions and taxes could be lower and most people would then take out medical insurance or pay for health care. Do you support or oppose this idea?’

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

Table 2: Public attitudes to government spending on different benefits, 1998–2015
 19982002200420062008201120132015
Percentage that would like to see more government spending on benefits for...        
…people who care for those who are sick or disabled 8282818283747375
…parents who work on very low incomes 6869626667585961
…disabled people who cannot work 7269636261535461
...retired people7173737272574849
...single parents3439353837293136
...unemployed people2221151614151517
 19982002200420062008201120132015
Percentage that would like to see less government spending on benefits for...        
…people who care for those who are sick or disabled 11111112
…parents who work on very low incomes 34444555
…disabled people who cannot work 22334543
...retired people22222377
...single parents2118181917211916
...unemployed people3536444554514945

Source: Clery 2016

Question asked: ‘Some people think that there should be more government spending on social security, while other people disagree. For each of the groups I read out please say whether you would like to see more or less government spending on them than now. Bear in mind that if you want more spending, this would probably mean that you would have to pay more taxes. If you want less spending, this would probably mean paying less taxes.’

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


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

Question asked: ‘Which, if any, of these would be your highest priority for extra spending?’

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

Public satisfaction

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

 

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


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

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.

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

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

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

Conclusion

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

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

Join the debate – leave a comment below or contribute on Twitter, using #KFpublic.

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Comments

Jane

Organisation
NHS
Comment date
05 February 2018

It is very interesting to think about how these views and stats map onto who is in power in government at the time... #justsayin ....

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