Tell me the worst: public opinion on the NHS leaves little choice but honesty for the government

Last week’s Spring Statement showed a government seriously squeezed against the financial rules it has set itself. Today’s British Social Attitudes survey numbers show where voters are applying the pressure. There is an overwhelming desire to see more spent on a National Health Service that the public cares about deeply and sees as running poorly. But this is far from an easy way to win back confidence and support.

I want some more

The consensus that the NHS is underfunded emerged repeatedly in earlier years of the BSA, as respondents told us the service faced a funding crisis. This year we asked more directly whether the government spent enough, too little, or too much, and received a clear response.

Only 8% of respondents said the government spent too much or far too much money on the NHS. 69% said it spent too little or far too little. There is a remarkably wide consensus on this matter. Majorities of supporters of every political party say too little is spent. The fifth of the population still satisfied believe that not enough money is being put in: the three-fifths who are now dissatisfied believe this even more overwhelmingly.

Most people seem to agree with the government that the NHS is “broken”, and a large majority think lack of money is part of the problem and more of it is the solution. This seems to reflect a general prioritisation of the health service against other public services on which the government spends money, shown in polling by Ipsos MORI for the Health Foundation.

Our results also seem consistently to suggest an underlying frustration and anger that people feel about how difficult it has become to access care in the NHS. A simple reading across our results is that the public firmly favour anything that will just allow more care to be delivered – money, staff, bearing down on waste.

There is a convincing case from history that an NHS awash with cash would be genuinely popular. Public satisfaction rose at an unprecedented rate in the 2000s when huge budget increases, sometimes more than 10% a year, were commonplace. Research by the King’s Fund points out that money was not the only factor in reducing waiting lists, but the ever-growing amounts certainly allowed governments to reform and expand services with far fewer difficult questions than we can imagine today. From 2010 onwards, satisfaction levelled off across a decade of more modest increases. It then sharply collapsed from 2019 as a Covid-19 funding boost was followed by a desperate attempt to rein in spending.

Paying the price

But with a government facing little wriggle room against its own borrowing rules, and the global economy constantly shaken by trade wars and real wars, the difficult question is where the money can come from. The vast majority of the public remain committed to the principle that the NHS should primarily be funded by taxes. But are they willing to see those taxes rise?

The most common answer we received is yes: 46% of people favour increasing taxes and spending more on the NHS. Even years into a cost-of-living crisis, tax rises are by no means anathema to the British public.

But 41% favoured keeping taxes and spending on the NHS at the same level as now, while 8% would prefer to reduce taxes and spend less on the NHS. This is an apparently less strong consensus than exists in support of higher spending more generally. Reform party supporters are far more likely to back outright cuts (though still only 22% believe this), and they represent an important margin where the government will fear that it is losing votes it must win back.

There is every reason to believe that the path from here is for enthusiasm for higher taxes to grow weaker. This polling took place before tax increases in last year’s Budget, and as taxes go up appetite for more often goes down – the public mood tends to swing back and forth to counter governments when they grow or shrink the size of the state.

Waste not, want not

The tightness of the public finances is only one reason that turning on the spending taps may not be an easy path to restore confidence. The public think the NHS is wasteful. Our results show that only one in seven (14%) agree that it spends the money it has efficiently. People see inefficiencies when they try to book NHS care and walk through NHS wards. They have a deep-seated suspicion of managers and bureaucrats, and they may be quick to suspect funding has been frittered away.

The recently announced abolition of NHS England, framed by the government as avoiding duplication and reducing unnecessary waste, is clearly aimed at tackling this perception. But it delivers only small savings set against the vast scale of the NHS budget. Big reorganisations can quickly become an unappealing spectacle garnering widespread public disapproval, as the current governing party saw when they stood in opposition to the messy reforms of 2012 and 2013.

Miraculous and immediate boosts in efficiency as a cure for the NHS financial bind have been the refrain of successive governments for years. The NHS has repeatedly signed up to savings targets it can’t meet on an almost annual cycle of blind optimism, contributing to the massive, repeated overspends that have been monitored by the Nuffield Trust. Understandably, this seems to have done the opposite of building public confidence.

The best policy

The government’s choices at the Spending Review in June will not be enviable. They face a public dismayed at the state of the NHS, keen for more to be spent on it, yet uncertain about whether it would be wasted and divided on whether they are willing to see taxes raised to support it.

Previous governments have tried to handle this through significant but slow spending increases, by promising more than could be delivered, and by overblown rhetoric on efficiency. This strategy ended in this moment of widespread public unhappiness. If politicians feel that public opinion has them trapped, it may be worth admitting rather than denying that this is a difficult situation, requiring difficult choices for gradual improvements.