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

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?

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.

Analysis

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

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.

Funding

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.

• Discussion guide (PDF)
• Workshop slides (PowerPoint download)
• 'Visual recording' of discussion at the London workshop on 15 March (PDF)
• 'Visual recording' of discussion at the Preston workshop on 22 March (PDF)