Public satisfaction with the NHS and social care in 2019: Results from the British Social Attitudes survey

This content relates to the following topics:

Part of Public satisfaction with the NHS

Since 1983, NatCen Social Research’s British Social Attitudes (BSA) survey has asked members of the public in England, Scotland and Wales about their views on health and care services. The latest survey was carried out between July and October 2019 and asked a nationally representative sample of 3,224 people about their satisfaction with the NHS overall, and 1,075 people about their satisfaction with specific NHS and social care services. The 2019 BSA survey questions reported here were jointly sponsored by the Nuffield Trust and The King’s Fund.

We publish at a time of unprecedented crisis for health services, the economy and society in the form of the Covid-19 pandemic. It is important to bear in mind that the timing of the survey itself means the results reflect attitudes before the emergence of the novel coronavirus. How this pandemic unfolds over the coming months and the way the NHS and care organisations respond are important factors that are likely to influence results from future BSA surveys.

The BSA is a ‘gold standard’ survey that uses a robust methodology to explore public views. The methodology is based on a randomly selected sample of the British public, and is conducted via a face-to-face interview, with multiple follow-up requests to non-responders. The survey is conducted the same way every year, with some topics and questions changing from year to year. The results provide a rich time trend, adding a depth and context to the findings that no other measure of NHS satisfaction provides. 

If a change or difference in attitudes is statistically significant, we can be 95 per cent confident that the survey result reflects a real change or difference in public views, rather than being down to chance.

For the first time, the 2019 BSA survey measures whether there are differences in satisfaction between users and non-users of a range of health and care services. In addition, we include survey questions relating to funding of the NHS, which were previously published separately.

Key findings

Satisfaction with the NHS overall in 2019

  • After falling for the past two years, public satisfaction with the NHS overall rose significantly in 2019. Overall satisfaction was 60 per cent – a 7 percentage point increase from the previous year.
  • Older people were more satisfied than younger people: 68 per cent of those aged 65 and over were satisfied with the NHS compared to 58 per cent of those aged 18–64.
  • While satisfaction was highest among supporters of the Conservative party (at 68 per cent, a 10 percentage point increase compared to 2018), there were significant rises in satisfaction across supporters of all the main political parties (Liberal Democrats, 60 per cent, a 10 percentage point increase; Labour, 57 per cent, a 6 percentage point increase).
  • The top reason people gave for being satisfied with the NHS overall was the quality of NHS care (68 per cent), followed by the fact that the NHS is free at the point of use (60 per cent) and that it has a good range of services (49 per cent).
  • The main reason people gave for being dissatisfied with the NHS overall was staff shortages (62 per cent – an increase of 10 percentage points since 2018), followed by waiting times for GP and hospital appointments (57 per cent), and a view that the government doesn’t spend enough money on the NHS (49 per cent).
  • More people thought that the general standard of care provided by the NHS would get worse (42 per cent) rather than better (29 per cent) over the next five years. This is an improvement on the 2018 survey, where the majority of people (51 per cent) expected care to get worse.

Satisfaction with specific NHS and social care services in 2019

  • Satisfaction with GP services was 68 per cent in 2019 – a 5 percentage point increase on the previous year, taking satisfaction with GP services back to just below the level it was in 2015.
  • There was little change in satisfaction with inpatient (64 per cent) and outpatient services (71 per cent). Outpatients continue to be the highest-rated service in the survey.
  • There was also little change in satisfaction with accident and emergency (A&E) and NHS dentistry services. A&E remains the NHS service respondents are least satisfied with.
  • There was little change in satisfaction with social care services, which remains low at 29 per cent.
  • People who had used or had contact with individual NHS and social care services in the past year were more likely to express a view about their satisfaction or dissatisfaction with services than non-users, with both satisfaction and dissatisfaction being higher among users compared to non-users.

Funding for the NHS

  • As in the previous years, in 2019 most survey respondents (80 per cent) said that the NHS is facing a major or severe funding problem. However, this figure has fallen 6 per cent over the past two years (down from 86 per cent in 2017).
  • The majority (54 per cent) of people surveyed would prefer extra funding for the NHS to come from taxation, as opposed to, for example, increased patient charges.

Sample and approach

The 2019 survey consisted of 3,224 interviews with a representative sample of adults in England, Scotland and Wales. Addresses were selected at random and visited by one of NatCen Social Research’s interviewers. After randomly selecting one adult (aged 18 or over) at the address, the interviewer carried out an hour-long interview. The participant answered most questions by selecting an answer from a set of cards.

The sample size for the overall NHS satisfaction question was 3,224 in 2019. For questions about satisfaction with specific NHS and social care services, the sample size was 1,075. The data is weighted to correct for the unequal probabilities of selection, and for biases caused by differential non-response.

The weighted sample was calibrated to match the population in terms of age, sex and region. The margin of error in 2019 for the health questions was around +/- 1.5 to 3.7 percentage points.

The vast majority of fieldwork for the survey was conducted between July and October 2019.

Topics

The topics covered by the survey change from year to year, depending on the identities and interests of its funders. Some questions are asked every year, some are asked every couple of years, and others are asked less frequently.

Funding

The survey is funded by a range of charitable and government sources, which change from year to year. The survey is led by NatCen Social Research. NatCen carries out research in the fields of social and public policy.

Many thanks to colleagues at NatCen Social Research for their assistance, to Kirsty Ridyard and Mark Dayan for analysis of media stories during the field period, and to all of our colleagues at The King’s Fund and Nuffield Trust who provided helpful comments on earlier drafts and helped with the editing, digital content and launch of this report. Most importantly, we would like to thank members of the British public for the time they took to complete the British Social Attitudes survey and for providing us with this fascinating dataset.

How satisfied is the British public with the NHS overall?

As we enter a new decade, the NHS is facing significant levels of pressure and remains a top concern for the public (Ipsos MORI 2019). Workforce shortages are affecting patient care and staff experience (Beech et al 2019).

A&E waiting times are the worst they have been since current records began – a sign of a system that is struggling to keep up with demand (Morris and Davies 2020). Key targets are regularly being missed and the United Kingdom is performing less well than similar countries on some of the biggest causes of death, including cancer, heart attacks and stroke (Dayan et al 2018).

Nevertheless, the NHS continues to treat increasing numbers of patients, remains free at the point of use and, over the past two years, has been promised an increase in funding. Notably, in June 2018, the then Prime Minister Theresa May announced that the NHS in England would be given an extra £20 billion a year by 2023/24, with proportionate increases in other regions of the United Kingdom.

In 2019, the fieldwork period for this British Social Attitudes survey began in the same month that a new Prime Minister took office. In the months that followed, the extra funding for the NHS, which commenced in April 2019, was confirmed and promises were made for extra capital and hospital buildings. A general election was called at the end of the BSA survey fieldwork period.

So, what impact has all this had on the public’s overall satisfaction with the NHS? Is it possible that the new funding announcements will lead to improved satisfaction with the NHS, or will evidence of staff under pressure and continuing long waiting times see the recent declines in overall satisfaction continue?

Overall satisfaction with the NHS in 2019

For 37 years, the BSA survey has asked a sample of the public how satisfied or dissatisfied they are with the way in which the National Health Service runs nowadays.

In 2019, 60 per cent of the public were ‘very’ or ‘quite’ satisfied with the NHS (Figure 1). This 7 percentage point increase over the previous year is statistically significant.

Public dissatisfaction with the NHS was 25 per cent in 2019, down from 30 per cent in 2018. This fall was also statistically significant and is the lowest level of dissatisfaction reported since 2017.

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; in 2019, n=3224; ‘don’t know’ and ‘refusal’ responses are not shown. In 2019 these response categories were selected by less than 0.5% of respondents. | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

This data gives its richest insights when viewed over decades rather than years. Taking that long-term view, Figure 1 shows that the 2000s were characterised by increasing satisfaction, up by 28 percentage points over the decade – from 42 per cent in 2000 to 70 per cent in 2010. The 2010s started with a steep drop in overall satisfaction (from 70 per cent in 2010 to 58 per cent in 2011). Since then, levels of satisfaction have ebbed and flowed. However, falls in satisfaction in 2017 and 2018 were reversed in 2019.

Who is most satisfied with the NHS?

Looking below the headline figures on satisfaction with the NHS reveals a varied picture depending on, for example, respondents’ age, party political affiliation and sex. Figure 2 shows how satisfaction differs among different population groups and whether satisfaction is statistically different from the average for the whole survey, which is 60 per cent. As in previous years, satisfaction levels differ by age: respondents aged 65 and older have higher levels of satisfaction (68 per cent) than those aged 18–64 (58 per cent).

While other groups also show differences in satisfaction levels relative to each other, except for party political affiliation these differences are not statistically significant (the 95 per cent confidence intervals overlap) and are generally no different from the average for the whole survey.

Figure 2 also shows that while there are interesting gradients in satisfaction within some groups – for example, lower-income households tend to be more satisfied than higher-income households and White and Asian respondents tend to be more satisfied than Black and other minority ethnic groups – these differences are not large enough given the size of the sample to reach statistical significance, although the pattern is similar to previous years.

BSA figure 2

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?’  Vertical dashed lines denote 2019 overall satisfaction. *Low numbers mean these results should be viewed with caution. Black, n=99; Mixed/other, n=76. **The question on the Brexit vote was asked of a random third of the sample. | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

There are also differences in the satisfaction levels reported by supporters of political parties. Respondents who support the Conservative party have a higher level of satisfaction (68 per cent) than respondents who support the Labour party (57 per cent) (Figure 2). 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 (Figure 3). It is noteworthy, though, that between 2018 and 2019 satisfaction increased significantly across supporters of all main political parties (Conservative, Labour, Liberal Democrats).

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?’  | For 2019, n=2,977 | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

While there has been a significant increase in satisfaction across the whole BSA sample between 2018 and 2019, is this reflected across different sub-groups in the survey?

While satisfaction levels have indeed increased across almost all groups, not all of these changes were statistically significant (ie, it is possible that the changes in the 2019 data were due to chance) (Figure 4). Statistically significant changes in satisfaction were found for people aged 18 to 64 (increasing from 51 per cent in 2018 to 58 per cent in 2019), men (from 53 per cent to 60 per cent), and from 54 per cent to 61 per cent, and satisfaction increased across all main political parties (Conservatives, 58 per cent to 68 per cent; Liberal Democrats, 51 per cent to 60 per cent; Labour, 51 per cent to 57 per cent).

BSA figure 4

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?’ | ‘◊’ denotes difference is statistically significant at 5% level. While some changes in satisfaction may be large, given the size of the group in the sample and other characteristics of the spread of satisfaction levels, for example, changes may not be statistically significant. *denotes low base sizes, so the results should be viewed with caution. **The question on the Brexit vote was asked of a random third of the sample. 2019: Black, n=99; Mixed/other, n=76; 2018: Black n=91; Mixed/other n=56 | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

Why is the public satisfied or dissatisfied with the NHS?

We know that public views about the NHS are driven by a range of factors, and that the precise reasons for changes in public satisfaction over time are difficult to pin down (Robertson 2019). However, since 2015 we have included questions that explore what lies behind the overall levels of satisfaction and dissatisfaction with the NHS reported in the survey by asking respondents to pick up to three reasons for the answer they gave to the overall satisfaction question.1

As Figure 5 shows, more than two-thirds (68 per cent) said they were satisfied because of the quality of care, while six out of 10 said it was because the NHS is free at the point of use. Almost half said they were satisfied because of the range of services available (49 per cent) and the attitudes and behaviour of NHS staff (43 per cent). For just more than a quarter (26 per cent), they were satisfied with how long they had to wait for a GP or hospital appointment.

Question asked: ‘You said you are satisfied with the way in which the National Health Service runs nowadays. Why do you say that? You can choose up to three options.’ (Options presented on a card.) | This question was asked of a random third of those who said they were ‘quite’ or ‘very’ satisfied with the way the NHS runs nowadays, n=653. | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

While there have been some small but statistically insignificant changes between 2018 and 2019, the top five reasons given have not changed over the past five years (Figure 6).

Question asked: ‘You said you are satisfied with the way in which the National Health Service runs nowadays. Why do you say that? You can choose up to three options.’ (Options presented on a card.)  | This question was asked of a random third of those who said they were ‘quite’ or ‘very’ satisfied with the way the NHS runs nowadays, n=653 | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

In 2019, the top three reasons given by respondents who were dissatisfied with the NHS related to staffing, access and resourcing (Figure 7). Almost two- thirds of people (62 per cent) said they were they were dissatisfied because of staff shortages, while more than half cited long waiting times (57 per cent). Around half said they were dissatisfied due to a lack of government funding (49 per cent). A quarter (26 per cent) identified waste of money as a reason, while one in five (21 per cent) cited the quality of care.

Question asked: ‘You said you are dissatisfied with the way in which the National Health Service runs nowadays. Why do you say that? You can choose up to three options.’ (Options presented on a card.) | This question was asked of a random third of those who said they were ‘quite’ or ‘very’ dissatisfied with the way the NHS runs nowadays, n=276. | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

For the past three years of the survey, the top three reasons for dissatisfaction with the NHS have not changed: staff shortages, length of waiting times and money being wasted in the NHS (Figure 8). Looking at how reasons for dissatisfaction have changed, concerns about staff shortages have overtaken dissatisfaction due to waiting times as the main reason for dissatisfaction, with a statistically significant increase of 10 percentage points to 62 per cent in 2019.

The proportion of respondents citing a lack of funding as a reason for dissatisfaction has remained relatively constant over the past three years.

Question asked: ‘You said you are dissatisfied with the way in which the National Health Service runs nowadays. Why do you say that? You can choose up to three options.’ (Options presented on a card.)   This question was asked of a random third of those who said they were ‘quite’ or ‘very’ dissatisfied with the way the NHS runs nowadays, n=276. | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

As in previous surveys, very few people said their satisfaction or dissatisfaction was affected by stories in the media – despite widespread media coverage about pressures on the service including staff shortages. However, previous studies have identified links between public levels of satisfaction with the NHS and media coverage (Judge and Solomon 1993; Judge et al 1992). It may be that media stories have an indirect impact on underlying attitudes, which is not immediately obvious to the respondent.

  • 1. The lists of reasons were originally developed with the public by using answers to an open-ended question about why respondents were either satisfied or dissatisfied.

How satisfied is the British public with different NHS and social care services?

In addition to asking about overall satisfaction with the NHS, the BSA survey asks the public how satisfied or dissatisfied they are with different NHS services: general practice, dentistry, inpatient and outpatient services.

Questions were added in 1999 for A&E services, and in 2005 for local authority social care services.

GP services

Over the past few years satisfaction with GP services has been falling, although satisfaction has remained relatively high compared to most other services. In 2016, 72 per cent of those surveyed said they were either ‘very’ or ‘quite’ satisfied with GP services. This dropped to 63 per cent in 2018 – the lowest level recorded since the survey began. This trend was reversed in 2019 with a significant increase in satisfaction of 5 percentage points, bringing it to 68 per cent (Figure 9).

Levels of dissatisfaction have also fallen. In 2018 almost a quarter (24 per cent) of respondents said they were dissatisfied with GP services. This fell to one in five (20 per cent) in 2019. 

Despite the significant change in 2019, it should be noted that this level of satisfaction is still one of the three lowest figures recorded since the survey began in 1983, and some way below the recent high in 2009, when 80 per cent said they were satisfied with GP services.

Questions asked: GP satisfaction: ‘From your own experience, or from what you have heard, please say how satisfied or dissatisfied you are with the way in which each of these parts of the National Health Service runs nowadays. First, local doctors or GPs?’ (this question was not asked in 1984, 1985, 1988, 1992 and 1997); NHS dentistry satisfaction: ‘…National Health Service dentists?’ (this question was not asked in 1984, 1985, 1988, 1992 and 1997); Overall satisfaction: ‘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). | For 2019, n= 1,075 | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

The GP Patient Survey – which hears from almost 800,000 people every year – has seen similar declines over the past few years, particularly concerning overall experience and most notably patients’ overall experience of making an appointment.

Dentistry

Over the past decade, changes in satisfaction with NHS dentistry services have followed a very different pattern to that for GP services (Figure 9), with satisfaction rising from a low of around 42 per cent in the early-to-mid 2000s to a level similar to the NHS as a whole in 2019.

Inpatient and outpatient services

The survey also asks about satisfaction with inpatient and outpatient services (Figure 10). Satisfaction in 2019 with inpatient services remained constant at 64 per cent – its highest level since 1993. Dissatisfaction with inpatient services remained at 9 per cent.

Satisfaction with outpatient services remained consistently high at 71 per cent in 2019 – the highest level since the survey began in 1983. Similarly, dissatisfaction has remained at the same level as 2018, at 11 per cent.

Accident and emergency services

Satisfaction with A&E services was at 54 per cent in 2019 and has not changed significantly since 2018. Levels have remained at similar levels since 2015 and are lower than other NHS services.

Questions asked: ‘From your own experience, or from what you have heard, please say how satisfied or dissatisfied you are with the way in which each of these parts of the National Health Service runs nowadays… being in hospital as an inpatient?… attending hospital as an outpatient?… accident and emergency departments?’. Overall satisfaction: ‘All in all, how satisfied or dissatisfied would you say you are with the way in which the National Health Service runs nowadays?’ (Questions about outpatients, inpatients and the NHS overall were not asked in 1984, 1985, 1988, 1992; questions on outpatients and inpatients were not asked in 1997; questions on accident and emergency were first asked in 1999). | For 2019, n= 1,075 | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

Social care

Satisfaction with social care services provided by local authorities was 29 per cent in 2019 (Figure 11), and dissatisfaction with social care services was 37 per cent. Both results are consistent with the previous year.

It is noteworthy that, when asked about their satisfaction with social care, 35 per cent of respondents either said they ‘don’t know’ or that they were ‘neither satisfied nor dissatisfied’ – a much higher proportion than chose these responses for NHS services (Figure 12).2

When reviewing quantitative survey questions about social care, it is important to note that public understanding of social care is relatively limited compared to people’s understanding of NHS services (Bottery et al 2018). Some caution should therefore be applied when interpreting the data: the high numbers of respondents stating they ‘don’t know’ (8 per cent) or saying they are ‘neither satisfied nor dissatisfied’ (2 per cent) when asked about their satisfaction with social care reflects both this lack of understanding and the fact that only 14 per cent of those surveyed had had some contact with social care services in the past year (compared to 87 per cent who had seen a GP and 54 per cent a dentist, for example).

Questions asked: ‘And  how satisfied or dissatisfied are you with social care provided by local authorities for people who cannot look after themselves because of illness, disability or old age?’ [2012–2019]; ‘At some point in their lives people can need regular help looking after themselves because of illness, disability or old age… From your own experience, or from what you have heard, please say how satisfied or dissatisfied you are with the services provided to people who need this kind of regular help with looking after themselves, whose family cannot provide it?’ [2005, 2007]. Question not asked 2006 and 2008–2011. | For 2019, n=1,075 | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

NB: For each service area, n=1,075 | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

  • 2. The survey question about social care services has been asked since 2005, although the first two years’ data is based on a question with slightly different wording, which does not mention local authorities in its definition of social care (see notes under Figure 10 for more detail on question wording).

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

Findings from previous BSA surveys and other studies of satisfaction with the NHS and social care (Robertson et al 2019Ipsos 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 to say 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 previous years, the BSA survey only asked whether people had used inpatient or outpatient services recently. For the 2019 survey, we added questions to help us understand the relationship between satisfaction and use of other services, including GPs and social care.

For the 2019 survey we introduced new questions asking whether respondents had used or had contact with a wide range of health and care services in the past 12 months, either personally or on behalf of someone else (see Figure 13 notes).

Figure 13 shows the percentage of respondents who had had contact with each of the respective services. Unsurprisingly, NHS GPs are the service the vast majority (87 per cent) of respondents reported having contact with, while social care is the service with the lowest reported contact levels (14 per cent). Overall, only 4.5 per cent of respondents reported having no contact with any of the services.

Question asked: ‘Here is a list of NHS services. In the past twelve months, that is, since (interview month 2018), have you used or had contact with any of the following services? This could be for yourself or someone else.’ | n=1,075 for each category. | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

How does recent contact with a service affect satisfaction with that service?

Overall, as shown in Figure 14, those who have used or had contact with a service tend to be more satisfied than non-users across all services. This is particularly the case for dentistry, inpatient and outpatient services, where the difference in satisfaction between users and non-users is statistically significant. The highest levels of satisfaction among users were for outpatients (78  per cent), dentistry (77 per cent) and inpatient services (76 per cent).

The difference in satisfaction between those who had had contact and those who had not had any contact (net satisfaction) was greatest for dentistry, with a 37 per cent difference.

Questions asked: ‘From your own experience, or from what you have heard, please say how satisfied or dissatisfied you are with the way in which each of these parts of the National Health Service runs nowadays. First, local doctors or GPs?… National Health Service dentists? …being in hospital as an inpatient?… attending hospital as an outpatient?… accident and emergency departments? And how satisfied or dissatisfied are you with social care provided by local authorities for people who cannot look after themselves because of illness, disability or old age?’ Contact with services: ‘In the past 12 months… have you used or had contact with any of the following services? This could be for yourself or someone else.’  | General practice: contact n=939, no contact n=136; Dentist: contact n=580, no contact n=495; Inpatient: contact n=353, no contact n=722; Outpatient: contact n=615, no contact n=460; A&E: contact n=413, no contact n=662; Social care: contact n=149, no contact n=926. NB: Filled net contact points indicate statistically significant difference in satisfaction | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

So, use of contact with services suggests that people who have had contact are likely to be more satisfied than people who have not had contact. However, as Figure 15 shows, it is also true that apart from dentistry, those who had contact with services were also more likely to be dissatisfied across all the services. In particular, it is notable that dissatisfaction with social care services was high for both those with and those without recent contact compared to other health services.

However, the difference in dissatisfaction between users and non-users was only statistically significant for dentistry and A&E services.

The dissatisfaction with dentistry is interesting, since it is the only service where dissatisfaction among those who had not had contact in the past 12 months was higher than those who had had contact. This may reflect the difficulties some people experience in accessing an NHS dentist, with the higher levels of dissatisfaction among non-users being a direct result of an inability to access a dentist. Previous research has found that around a quarter of adults do not use dentistry services because they are unable to find an NHS dentist (Appleby et al 2017).

So, how can it be true that those who have had contact with a service can be both more satisfied and more dissatisfied?

The answer probably lies in the fact that those who have used a service tend to have an opinion on satisfaction, one way or the other, while those who have not tend to take a more neutral position (or say they ‘don’t know’). For example, when asked about satisfaction with inpatient services, 34 per cent of those who had had no contact answered ‘neither satisfied nor dissatisfied’ or ‘don’t know’ – as opposed to 12 per cent of those who had had contact. For dentistry, 41 per cent of those who had had no contact answered ‘neither satisfied or dissatisfied’ or ‘don’t know’, whereas the equivalent figure for those who had had contact was 11 per cent.

Questions asked: ‘From your own experience, or from what you have heard, please say how satisfied or dissatisfied you are with the way in which each of these parts of the National Health Service runs nowadays. First, local doctors or GPs?… National Health Service dentists? …being in hospital as an inpatient?… attending hospital as an outpatient?… accident and emergency departments? And how satisfied or dissatisfied are you with social care provided by local authorities for people who cannot look after themselves because of illness, disability or old age?’ Contact with services: ‘In the past 12 months… have you used or had contact with any of the following services? This could be for yourself or someone else.’  | General practice: contact n=939, no contact n=136; Dentist: contact n=580, no contact n=495; Inpatient: contact n=353, no contact n=722; Outpatient: contact n=615, no contact n=460; A&E: contact n=413, no contact n=662; Social care: contact n=149, no contact n=926. NB: Filled net contact points indicate statistically significant difference in dissatisfaction | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

Attitudes to NHS spending and sources of funding

Since 2014, the BSA survey has asked the public about their views on whether the NHS was facing a funding problem, and if so, whether it was minor, moderate or severe (or whether it did not have a funding problem). Between 2014 and 2017 the proportion saying that the NHS faced a major or severe funding problem rose from 72 per cent to 86 per cent. But this fell in 2018 to 83 per cent and now, in the latest survey, it has again fallen, to 80 perc ent. Although this latest drop is not statistically significant, the reduction over the two years from 2017 is significant (Figure 16).

While concern about funding remains very high, the reduction of around 6 percentage points over the past two years coincides with the announcement of increased funding for the NHS by the then Prime Minister Theresa May in the summer of 2018 (then since re-announced during 2019).

Question asked: ‘In your opinion, is the NHS facing…no funding problem, a minor funding problem, a major funding problem, a severe funding problem?’  | In 2019, n=1,075 | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

This drop in the proportion of respondents expressing worries about funding is also reflected in responses to a related question asking, if the NHS needed more money, how this should be raised for the NHS – a question which has been asked each year since 2014.

Of the six options respondents are given, the proportion saying the NHS should not be given extra money and that it should live within its budget has continued to increase, from 15 per cent in 2017, to 17 per cent in 2018 and now to 20 per centin 2019 (Figure 17). At the same time, while remaining the most popular choice, the proportion saying extra funding could come from an earmarked tax for the NHS has dropped significantly, from 34 per cent in 2018 to 29 per cent in 2019.

Overall, paying more through some form of tax (either a separate tax that goes directly to the NHS or through current taxes) remains the view of the majority (54 per cent) of those surveyed, with other options such as a £10 charge for GP or A&E visits (11 per cent), paying for non-medical costs in hospital (9 per cent) or ending exemptions for patient charges such as prescriptions (3 per cent) remaining least favoured.

Question asked: ‘If the NHS needed more money, which of the following do you think you would be prepared to accept? Pay more through the taxes I currently pay, Pay more through a separate tax that would go directly to the NHS, Pay for non-medical costs in hospital, like food and laundry, Pay £10 for each visit to a GP or local A&E department, Ending exceptions from current charges (eg, prescription charges for children, pregnant women, retired people), None of the above; the NHS needs to live within its budget’.  | In 2019, n=1,075 | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

Views about past and future general standards of care in the NHS

As Figure 18 shows, between 2008 and 2011, those surveyed who said that standards of care were getting better over the past five years outweighed those saying it was getting worse. However, between 2014 and 2017 this reversed. In 2017, only 17 per cent said standards had got better and 45 per cent said it had for worse (a net low of –28 per cent).

However, the proportion thinking the NHS had got better started to increase in 2018 (to 20 per cent), and those thinking it had got worse reduced (to 39 per cent). The latest results again show a slight increase in those thinking standards had got better (21 per cent), and a 3 percentage point fall in those thinking they had got worse (to 36 per cent). The changes over the two years from 2017 to 2019 were statistically significant, but it remains the case that the net view remains negative (–15 per cent).

Question asked: ‘Please say how much better or worse you think the general standard of health care on the NHS has been getting over the last five years? Much better, Better, About the same, Worse, Much worse.’  | NB: question was not asked 1996-2000, 2002-2007, 2012-2013 and 2016. | In 2019, n=1,075 | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

When asked a similar question about standards of care – but over the next five years – similar increases in optimism seem to be emerging over the past two surveys (Figure 19). In 2017, 56 per cent thought standards would get worse over the next five years, and just 20 per cent thought they would get better (a net figure of –36 per cent, the lowest since this question was first asked in 2011).

However, in 2018 this view improved, with a 5 percentage point rise in those thinking things would get better and a similar percentage reduction in those thinking things would get worse. The latest results for 2019 show a rise in the former to 29 per cent and a reduction in the latter to 42 per cent. Nevertheless, the net view remains negative (–14 per cent).

Overall, while people still seem fairly pessimistic both about past and future standards of care, there is evidence of a positive shift in opinion.

Question asked: ‘Thinking about the general standard of care on the NHS, over the next five years do you expect this to get better or worse? Much better, Better, About the same, Worse, Much worse.’  | In 2019, n=1,075. NB: question not asked  in 2016 | Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s BSA survey data

Conclusion

The Covid-19 outbreak will put the NHS and social care services under extraordinary strain over the coming months, and the impact of dealing with this crisis is likely to continue well beyond the point where the virus is under control. Covid-19 and the response to it is changing the NHS and wider society in ways no one foresaw, and it will undoubtedly have a longer-term impact on public attitudes to both the NHS and social care. As yet, this impact is, of course, unknown. It may be that images and experiences of health and care staff working to their utmost capacity in the current crisis will only reinforce the public’s long-term support for the principles of the NHS and their willingness to pay for it. Just possibly, it could also begin to extend some of that concern to social care as well.

In light of the above, what does the 2019 British Social Attitudes survey tell us about the view of the public in the period before the Covid-19 outbreak?

Given the well-publicised and continued failings of the NHS to meet headline targets such as waiting times for elective, emergency and cancer treatments in the period leading up to the survey (Morris and Davies 2020), it may seem paradoxical that the latest results for overall satisfaction with the NHS show a significant rise – from 53 per cent to 60 per cent. But we know from previous surveys not to assume that satisfaction reflects views about the current performance of the NHS. How the British public responds reflects a more complicated set of factors – some based on personal experience, some on politics and others subject to beliefs about the nature of the NHS as an institution.

Apart from the NHS increasingly making headlines for failing to hit targets, the other piece of news (aside from Brexit) before and during the period covered by this research was a series of announcements of higher funding for the NHS. Breaking with a decade of austerity, in the summer of 2018 – the year of the NHS’s 70th anniversary – the then Prime Minister Theresa May announced a new five-year settlement for the NHS that would see its funding increase by £33.9 billion in cash terms by 2023/24 – equivalent to a real increase of £20.5 billion (GOV.UK 2018). This announcement was reiterated in the 2018 Budget in October of that year (HM Treasury 2018), then again in August 2019 by the new Prime Minister Boris Johnson (GOV.UK 2019).

These announcements (and associated promises of more staff, shorter waits for GPs, etc) could be key in explaining the upturn in satisfaction with the NHS and some of its services. Improving views since 2017 about future standards of care in the NHS and its funding needs support an interpretation that the public have understood (and believed) that NHS funding is increasing and that this in turn has fed through to an increased optimism about the future of the service and the difference the money could make.

However, the satisfaction rating for social care remains stubbornly low (at 29 per cent), and some way below that of any of the NHS services. Moreover, users of social care were more dissatisfied than users of any other service, with almost one in two (47 per cent) saying they were dissatisfied. This and many other governments have promised to ‘fix’ social care, but so far these have remained only promises, and there has been no actual reform of an increasingly challenged sector.

While government announcements of extra money for the NHS may have shifted public satisfaction with the NHS, this is only the first step. It is the way extra funds are used to deliver falling waiting times and better care in the medium term that will ensure growing satisfaction with the NHS. This challenge should not be underestimated. There is now rising concern from the public about staff shortages and recognition that this is the biggest problem facing the NHS, so delivering on commitments to increase nurses, GPs and other staff will be key to further improving overall satisfaction.

Appleby J, Reed R, Merry L (2017). Root causes: quality and inequality in dental health. QualityWatch. London: Nuffield Trust and Health Foundation. www.nuffieldtrust.org.uk/files/2018-10/1540139783_ qualitywatch-root-causes-dental-health-report.pdf

Beech J, Bottery S, Charlesworth A, Evans H, Gershlick B, Hemmings N, Imison C, Kahtan P, McKenna H, Murray R , Palmer W (2019). Closing the gap: key areas for action on the health and care workforce. London: The Health Foundation, The King’s Fund and the Nuffield Trust. www. kingsfund.org.uk/publications/closing-gap-health-care-workforce

Bottery S, Varrow M, Thorlby R, Wellings D (2018). A fork in the road: next steps for social care funding reform. The costs of social care funding options, public attitudes to them – and the implications for policy reform. London: The King’s Fund and the Health Foundation. www.kingsfund.org.uk/publications/ fork-road-social-care-funding-reform

Dayan M, Ward D, Gardner T, Kelly E (2018). How good is the NHS? London: The Health Foundation, the Institute for Fiscal Studies, The King’s Fund and the Nuffield Trust. www.nuffieldtrust.org.uk/research/ the-nhs-at-70-how-good-is-the-nhs

GOV.UK (2018). ‘PM speech on the NHS: 18 June 2018’. Speech, 18 June. www.gov.uk/government/speeches/pm-speech-on-the-nhs-18-june-2018 

GOV.UK (2019). ‘PM announces extra £1.8 billion for NHS frontline services’. Speech, 5 August. www.gov.uk/government/news/ pm-announces-extra-18-billion-for-nhs-frontline-services

HM Treasury (2018). Budget 2018. London: HM Treasury. https://assets.publishing.service.gov.uk/ government/uploads/system/uploads/attachment_data/file/752202/ Budget_2018_red_web.pdf 

Ipsos MORI (2017). Public perceptions of the NHS and social care survey: an ongoing tracking study for the Department of Health, winter 2016 wave. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/707682/Public_Perceptions_of_the_ NHS_and_Social_Care_survey_-_Winter_2016.pdf

Ipsos MORI (2019). Issues Index: December 2019www.ipsos.com/ sites/default/files/ct/news/documents/2020-01/issues_index_ december2019_v1_public.pdf

Judge K, Solomon M, Miller D, Philo G (1992). ‘Public opinion, the NHS, and the media: changing patterns and perspectives’. BMJ (Clinical Research ed.),  vol 304, no 6831, pp 892–5.

Judge K, Solomon M (1993). ‘Public opinion and the National Health Service: patterns and perspectives in consumer satisfaction’, Journal of Social Policy, vol 22, no 3, pp 299–327.

The King’s Fund, Nuffield Trust,  the Health Foundation (2018). ‘An open letter: a long-term funding settlement for the NHS’. Letter. www. kingsfund.org.uk/publications/pm-letter-funding-settlement-nhs

Morris J, Davies J (2020). ‘Combined performance summary: November–December 2019’. Blog, QualityWatch. www.nuffieldtrust.org.uk/news-item/combined-performance-summary-november-december-2019 

Robertson R (2019). ‘Why is public satisfaction with the NHS still falling?’ Blog, The King’s Fund. www.kingsfund.org.uk/blog/2019/03/ why-public-satisfaction-nhs-still-falling

Robertson R, Appleby J, Evans H, Hemmings N (2019). Public satisfaction with the NHS and social care in 2018: Results from the British Social Attitudes survey. London: The King’s Fund and the Nuffield Trust. www.nuffieldtrust.org.uk/research/ public-satisfaction-with-the-nhs-and-social-care-in-2018

Comments

Add your comment