If the last few years have taught us anything about public opinion, it is that second guessing it is a fool’s errand, and so it proved this year with the 2019 British Social Attitudes survey. After falling for the previous two years, public satisfaction with the NHS rose significantly from 53% in 2018 to 60% in 2019. It is a result that very few people working in health policy would have predicted at the time.
The current Covid-19 crisis will have a significant effect on public attitudes to the NHS. However, over the past few years the NHS story has been one of missed targets, funding challenges, longer waiting times and staff shortages. The previous two years of the British Social Attitudes survey had seen significant falls in satisfaction and most, including those of us working on it, assumed it would fall again in 2019.
So what has led to the upturn in satisfaction? As with all such surveys, there is never only one explanation but if we look closely at the data, and place the findings in the wider context, the clues are there.
What has caused the increase in public satisfaction with the NHS?
Let’s look at what might be driving the increase in satisfaction with the NHS, starting with how people experience it as patients. Has patient experience been improving?
More people than ever are using the NHS, and for the most part those experiences are still positive despite the well-documented pressures on the system. If you look across a range of patient experience surveys, more people might be waiting longer and finding it more difficult to get an appointment, but once they are in, the NHS still largely works for them. However, while patient experience has for the most part been holding up, it has not improved in the last year so it is unlikely to be this that led to the increase in overall public satisfaction between 2018 and 2019.
What are people who work in the NHS saying about it to their friends and family? What people we know tell us about where they work, whether good or bad, will have an influence on our perception of it. There are 1.3 million NHS workers, so what they say will have an impact. The NHS Staff Survey does suggest improvements on this over the last year. More staff would recommend their organisation as a place to work, and say they would be happy with the standard of care provided by their organisation for a friend or relative needing treatment.
So this may be a factor, but these improvements have been seen year on year since 2015 and do not explain the fluctuations in public satisfaction over the last few years, nor do they explain the size of the increase we have seen this year.
Another factor that can influence the results is political affiliation. There is 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 opposition parties, and so it proved again this time. Respondents who support the Conservative party did have a higher level of satisfaction (68%) than respondents who support the Labour party (57%) and the Liberal Democrats (60%).
Interestingly though, satisfaction has increased significantly across supporters of all the main political parties. It increased by 10 percentage points among both Conservatives and Liberal Democrats, while it also increased by six percentage points among Labour supporters. The cause of the increase in overall satisfaction seems to have support from across the political spectrum, which shouldn’t be attributed to election manifesto promises as the survey took place between July and October before the December general election was called. So what has changed this year to cause this increase? What might have made a difference is the additional money promised to the NHS.
What impact has the promise of increased funding had?
The 2018 survey was conducted just after Theresa May, at the time of the NHS’s 70th birthday, announced a funding increase for the NHS. After the longest sustained funding squeeze since the health service was established, the then Prime Minister 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. This announcement was reiterated in the 2018 Budget in October of that year, and again in August 2019 by the new Prime Minister Boris Johnson, who also announced money was being made available for hospital upgrades. These announcements may well have made the difference.
Over the last two years, we have seen a drop in the number of people who said the NHS was facing a major or severe funding problem. Between 2014 and 2017, the proportion saying the NHS faced a major or severe problem increased from 72% to 86%, during a period where NHS funding rose but at historically low levels. In 2018, this figure fell by 3% and it fell another 3% in 2019 to 80%. The year-on-year changes are not statistically significant, but the 6% change over two years is.
That eight out of 10 people still think the NHS has a major or severe funding problem does not suggest people think the health service has what it needs. However, the fall in this number over the last two years does suggest that the series of funding announcements may have started to impact on public perceptions, most notably on their optimism for the future.
When asked whether they think the general standard of care provided by the NHS will get better or worse over the next five years, we can see a significant reduction between 2017 and 2019 in the number of people who think it will get worse, and an increase in the number of people who think it will get better. In 2017, 56% thought it would get worse and 20% said better. In 2019, these figures were 42% and 29%. Those are big swings. It seems the promise of increased funding may have led to renewed hope for the NHS’s future.
Where next for public satisfaction?
While government announcements of extra money for the health service are likely to have shifted public satisfaction with the NHS, this is only the first step. It’s how extra funds will be used to improve waiting times, recruit more staff and deliver better care in the longer term that will ensure growing satisfaction with the health service.
The Covid-19 outbreak will put the NHS under extraordinary strain over the coming months, and the impact of dealing with this crisis is likely to continue well beyond the point that 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 the NHS.
As yet, this impact is of course unknown. It may be that the images and experiences of health and care staff working to their utmost in the current crisis may only reinforce the public’s long-term support for the principles of the NHS and their willingness to pay for it.
Dan Wellings is a Senior Fellow at the King’s Fund and John Appleby is Chief Economist and Director of Research at the Nuffield Trust. They are both authors of new analysis published today on public satisfaction with the NHS, based on the 2019 British Social Attitudes survey.
Wellings D and Appleby J (2020) “Public satisfaction with the NHS rose sharply in 2019 – why?”, Nuffield Trust and King’s Fund comment.