The public and the NHS: what's the deal?

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Part of The public and the NHS

The NHS is under financial pressure with growing demand for services. As the NHS reaches its 70th birthday, The King’s Fund has been exploring how the public views its relationship with the NHS. In March 2018, in partnership with Ipsos MORI, we carried out three ‘deliberative workshops’ to explore this issue.

  • We found that the relationship between the public and the NHS is strong, and people were committed to its founding principles. However, there were several areas where the NHS could improve – not least around waste.

  • While there was a feeling that some people take the NHS for granted and demand too much, participants felt that their expectations of the NHS were largely being met and that those expectations were realistic.

  • Lack of funding was seen as a problem and government was seen as responsible. Most people would be willing to pay more tax to maintain the NHS, and many people favoured a dedicated NHS tax.

  • There was recognition that NHS services were sometimes used inappropriately, which placed additional pressure on the system. However, the NHS could do more to support responsible use of the service.

  • Individuals have a key role in keeping themselves healthy but there were mixed views about the role of the NHS – and wider government – in addressing this issue.

  • While there was mistrust of a ‘nanny state’, people often supported specific government interventions such as the smoking ban. 

  • There was broad agreement for the concept of a contract or deal in clarifying the balance between an individual’s responsibility for their health and the government’s and the NHS’s responsibility.

The public and the NHS

It is well known that the public places great value on the NHS and wants to maintain the current system. That is not to say, however, that the relationship between the public and the NHS is straightforward.

Over time, the nature of the relationship between the public and the NHS has changed. For example, in recent years the NHS has placed an increasing emphasis on people taking responsibility for staying healthy. But it is not clear how people feel about this and how the NHS supports it.

As the NHS reaches its 70th birthday, the system is facing severe financial and performance pressures as well as increasing demand. So how does the public view its relationship with the NHS – and what might this relationship look like over the next 70 years?

Our project

In March 2018, as part of a wider programme of work, The King’s Fund and Ipsos MORI undertook some work to understand people’s views on the following questions.

  • What is the NHS for? What is its role in Britain today?
  • What do people expect of NHS services? Are these expectations realistic, or does the population expect too much/too little?
  • What is the balance of responsibility between the individual and the NHS (and government), particularly in terms of:
    • prevention and keeping people healthy
    • use of NHS services
    • funding NHS services.

We also wanted to explore people’s views on a ‘deal’ between the NHS and the public: whether people envisage it as a two-way relationship and, if so, what they think this ‘deal’ should look like?

Deliberative events

We held three facilitated workshops, or ‘deliberative events’, in London, Nuneaton and Preston, each involving approximately 25 people. Participants were recruited to reflect a mix of people, including in terms of NHS service use, satisfaction with the NHS, and political affiliation. During the events, participants were split into groups of between 7 and 10 people according to age. Discussions within these groups were facilitated by a moderator.

Participants were given background information on issues such as the challenges facing the NHS and different views on respective responsibilities.

Online community

Participants were also invited to contribute to an online community that was intended to help participants engage with the topic before the events and to reflect on the discussions afterwards.


Group discussions were recorded. These notes and the comments made through the online community were analysed.

What did we find?

The NHS at 70

Participants were asked for their general views on what they thought of the founding principles of the NHS and what they considered its role to be in Britain today.

Most people described the NHS as a key part of society that they were proud of and felt lucky to have. There was also broad support for the founding principles of the NHS: that it should be a comprehensive service available to all, free at the point of delivery and primarily funded through taxation.

Despite this, some people were negative about their day-to-day interactions with the service. People are aware that the challenges the NHS faces, particularly around funding, staff shortages and waiting times, could impact negatively on their experiences. People felt there was too much waste in the NHS and that the service was not managed as well as it could be. However, there was also a strong sense that the NHS is underfunded.

Expectations of the NHS

Participants were invited to discuss expectations of the NHS – whether these were too high or too low, and whether or not the NHS met them or fell short. Participants were encouraged to think about their own expectations, as well as the those of the public more widely.

Many people felt that the public sometimes takes the NHS for granted and that, compared to health care systems in other countries (particularly the United States), the NHS delivers a good service. For the most part, people felt that the NHS met or exceeded their expectations. However, they also felt that some people had unrealistic expectations – for example, expecting to be seen straight away – that could contribute to pressures on the service.

Many people talked about their own experiences of occasions when their expectations had not been met, but these negative experiences of care did not seem to lead to negative perceptions of the NHS as a whole.

While people felt that expectations were realistic, some questioned whether the service they were getting was as good as it could be, and whether the fact that it was ‘free’ meant that people did not demand enough of it. Some felt that if they had to pay for it directly their expectations might rise.

Some participants noted that because the NHS is so well liked, people were less likely to complain about the service they received. People did not see their relationship with the NHS as being the same as the one they hold with private companies; there was more of a sense of give and take.

Prevention and keeping people healthy

There was a clear recognition that more could be done to prevent ill health and promote healthy lifestyles to relieve pressure on the NHS. Participants placed much of the responsibility for staying healthy, for example by eating healthily, on individuals, though they also recognised that this is more difficult for some groups than others, particularly vulnerable individuals.

They also saw a role for both the NHS and the government, for example, feeling that more information and support could be provided to help people live healthier lives. People saw the role of the NHS as a balance between keeping people healthy and treating people when they became ill.

People felt uncomfortable about the idea of limiting treatment for those who were unwell due to lifestyle choices. However, some thought the NHS and the government should adopt a harder line, although it was difficult for people to agree on what this might look like, and there were concerns about where this approach might end.

In general, there was mistrust of a ‘nanny state’ approach to health, although when asked about specific interventions (such as the smoking ban), people saw these as positive.

How people use NHS services

There was a widespread perception that some people use services inappropriately on some occasions, for example, by attending A&E following excessive alcohol consumption. There was a recognition that this placed additional pressure on NHS services.

Some participants felt that inappropriate use of services was partly driven by the fact that the NHS is free at the point of delivery, and people take it for granted and there was also some feeling that it was being used by people who were not entitled to free care. However, there was also a sense that some people attended A&E because they could not be seen elsewhere or were not aware of alternatives.

There was also a strong feeling that the NHS itself did not always act responsibly – for example, cancelling appointments at short notice. People thought that GPs were difficult to access and, while they were generally positive about using their pharmacy, had mixed views about NHS 111.

There was quite a lot of support for the idea of imposing consequences on people who misused services, but a lack of agreement on what those might be. Views on whether people should be fined for missing appointments, for example, were mixed.


There was widespread recognition that the NHS is underfunded, which people largely felt was a result of the government not giving it enough money. However, it was also widely agreed that the NHS does not spend the money it does receive well, and that there is a lot of waste in the system. Outsourcing NHS care to the private sector and the legacy of private finance initiatives were cited as examples of waste.

Ways of saving money, for example, reducing the number of managers, were suggested but participants found it difficult to agree on how the NHS could save money.

There was support for the idea of increasing taxes to pay for the NHS. However, many participants felt that they would want to see improvements in the service and also that tax increases would definitely go to the NHS, rather than being diverted to other government budgets. For this reason, many of those willing to pay more tax favoured a dedicated NHS tax, though some questioned the added complexity it would bring.

Others highlighted alternative sources of revenue such as the money the UK would get from leaving the European Union, reducing spending on other government budgets, or introducing charges for some NHS services.

Developing a deal

The concept of a deal between the public and the NHS was introduced in a presentation during the workshop. Participants discussed their views on a deal, and were asked to design their own deal, allocating rights and responsibilities to each side.

There was widespread agreement that a deal could be valuable in clarifying the balance in responsibility between the individual and the NHS. However, some questioned how this would work in practice, and there was general resistance to any deal being too formal or punitive.

When participants developed their own deals within their groups, some common themes emerged.

Participants saw the NHS/government as having a responsibility to:

  • provide services that are easy to access – including expanding services to meet demand
  • use resources efficiently and reduce waste – including considering new funding options, and being more transparent about how money is spent
  • employ enough staff and treat them fairly – including valuing staff and ensuring appropriate training
  • provide support and advice to people to help them stay healthy – such as information on eating healthily
  • treat all patients equally.

In return, the public’s responsibilities lie in:

  • using NHS services responsibly – including keeping appointments, and using the right services at the right time
  • staying healthy – for example, by eating healthily and doing enough exercise
  • paying for the NHS through taxes – for some this meant paying more taxes
  • supporting the community – acknowledging, for example, the role of the community in promoting good health
  • valuing the NHS – including not taking the NHS for granted.

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Judith Joy

retired OT,
Comment date
27 July 2018

I totally agree with Veronica Burton and found the report of the discussions bland to the point of obfuscation. Like the glossy PR brochures our Trusts produce - all good stuff but no reality on show. Where were the real issues around deliberate policy to introduce US style Accountable Care Organisations - renamed Integrated Care Systems by NHS England but remaining the same cost controlled, care rationed methods of America's health businesses. Why not be independent in mounting such discussions and allow the full facts to be examined? Post the true costs of privatisation, reorganisation, consultancy fees etc. That might prove of some value in helping to restoring the NHS principles your participants and the public value most highly.

Richard Eaton

Lead for Complementary Medicine at the College of Medicine, London,
The College of Medicine, London
Comment date
07 July 2018

Clinical Commissioning Groups and other health and social care stakeholders need to engage now with Complementary Medicine practitioners and their professional organisations and regulators, including those accredited by the Professional Standards Authority. These practitioners provide a qualified, insured but 'untapped' workforce that is available to the public health (including the NHS) and social care sectors. Please refer to my "December 2017 Complementary Medicine Roundup" blog written for the 'Complementary' webpage of The College of Medicine, London, at:…

mary dejevsky

Comment date
29 June 2018

private v public: privatised services are not necessarily a bad thing. here is a mini example from my experience:

nhs outsourced to private v nhs in Westminster, London.
7 years ago I was referred for a dexa scan by my GP. the service was then outsourced to a private provider. the appointment came within a couple of weeks. it was at a pleasant clinic in Harley street, the scan was on time and did both hips and lower spine. I was given a print out of the results on the spot and they were sent electronically to my GP.
this year I was referred for another dexa scan. by now the service was provided by Chelsea and Westminster nhs hospital. there was a two month wait for the appointment. there was almost no privacy, everyone waiting in hospital gowns after changing in a rudimentary cubicle. the nurse was perfunctory to rude. they scan only one hip, not both. I was told this was routine. when the results were sent to my gp, the note just said 'osteoporosis' - which we knew. the whole point of having the scan was to find out the progression, if any. it then took another 6 weeks of repeated requests and a complaint to get the full results.
which service was a. the more efficient? b. taking all (GP time making repeat requests, patient waiting time etc) into account, the cheaper?; c. the better experience for the patient? no contest, I think.

in france a lot of health services, incl ambulances, are privately provided but accessed through the health insurance system. service standards and outcomes often superior to ours.

Veronica Burton

Reired neonatal/paediatric nurse,
Comment date
28 June 2018

Cameron's 2012 Health and Social Care Act was a complete betrayal of the people and of our democratic principles. He lied about his intentions. The Act lay the foundations for much more privatisation, despite the fact that it is not what the public want. A huge amount of money has gone out of the NHS to pay the costs of out-sourcing to private companies. Repeated re-tendering is vastly expensive and it must all be a real jamboree for the lawyers. Outsourcing treatment to private hospitals also leaves the NHS the massive loser. The Conservatives are privatising the NHS on principle without any regard to the damage it is doing or to the fac that it is not what people want.

Gordon Read

Former Chief Probation Officer,
Comment date
28 June 2018

I was surprised that there was no mention of the dilemmas that cause the NHS so much difficulty; that is Social Care and and the collapse of social housing. Both are left to impoverished Local Authorities to cope with. Recent neo-liberal policies have been been undermining public provision in the NHS, and Social and Housing Care in the faulty expectation that privatisation will handle it when privatisation of many activities are collapsing around us.

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