How well is the NHS meeting public expectations?

You worry about the NHS. I worry about the NHS. But most of the general public in fact don’t. The public is very clear that the key challenge facing Britain right now is the economy – it has been number one in the Ipsos MORI Issues Index for 50 consecutive months. Despite plenty of excitement in the media, among the unions and professions and political parties, general anxiety about the NHS remains much lower than in the recent past.


Source: Ipsos MORI (2012). Report. Britain 2012: who do we think we are?

It is a common belief in health care circles that expectations of health services are rising rapidly – patients are less deferential, empowered by the availability of more information, particularly over the web, and are demanding more and more.

In fact one of the challenges for the NHS is that expectations of it are in some ways not high enough, and also that patients cling to what they have been used to – ’the status quo’ normative bias. For example, there is very little relationship between standardised mortality rates and patient satisfaction; no matter how likely their hospital is to kill them, patient satisfaction varies relatively little. It is ‘softer’ measures like ‘dignity and respect’ that correlate much more strongly with patient satisfaction.

When we ask what factors patients reflect on in choosing a hospital, quality of care, cleanliness and speed of access all feature highly – but if we ask them to choose a single factor, geographical proximity is number one. If people are concerned most about ease of access, overall expectations of care do not seem to be rising inexorably,.

It is also a common place belief that the public has no respect for any one in authority any more. While public expectations of clinicians have evolved from the 1940s in terms of openness and communications, trust in doctors and nurses has been high – and shows little sign of falling – for decades. In contrast trust in politicians has been low since polling began.

There are some signs that despite the cherished status of the NHS, the public is becoming more realistic in its expectations of NHS funding, no longer seeing it as a bottomless pit. Our latest wave of the Public Perceptions of the NHS, conducted for the Department of Health, shows that 58 per cent of people agree that there should be limits on what is spent in the NHS, up from 44 per cent in 2006. But, and it is a sizeable but, there is no indication that the full scale of the funding challenge is understood. 

Most people do not think their own health is the sole responsibility of the NHS (only 5 per cent do).  Far more think it is mostly their own responsibility (39 per cent) to manage their health, the rest think it is a shared responsibility. And perhaps because of this, people are willing – at least in principle – to see some conditionality attached to what the NHS will provide in future. As we found in Public Perceptions of the NHS, younger people are most likely to agree that if people don’t look after themselves – by drinking too much, for example – the NHS could in principle limit free treatments for conditions caused by their behaviour.

However, parliamentarians are more anxious about this approach. Perhaps because of the totemic significance of free universal access – we found most Labour and Lib Dem MPs opposed, and Conservatives divided, to ideas about restricting treatments to those who take more responsibility for their health.

There is some willingness among the population to be more pragmatic about the NHS – but this pragmatism can be drowned out by a minority of vocal activists, and by assumptions that the media, pundits and politicians have about public attitudes. We have known for decades that the NHS needs to move towards providing a different sort of service to cope with the demands placed on it. But making the changes to achieve that is hard even when money is flowing. The challenge is to ’nudge’, shove and cajole the public – and the media – towards an acceptance of  the NHS of the future. Changes in public opinion can and do happen, and can be led, but it will require boldness and dedication to make the change – at a time when politicians already have plenty of other battles to fight.

Ben Page is Chief Executive at Ipsos MORI. A frequent writer and speaker on leadership and performance management, he has directed hundreds of surveys examining service delivery, customer care and communications.