Things can only get better? But this is not the 1990s

When confronted with the staggeringly low levels of public satisfaction with the NHS today, it is tempting to look back to the late 1990s for reassurance that, in the words of D:Ream, “things can only get better”.

After all, when Labour came to power in 1997 at the height of the Britpop era, just 34% of the public said they were satisfied with the NHS, while half were dissatisfied. Thirteen years later, satisfaction had reached 70% – the highest level ever recorded by the British Social Attitudes survey.

A new BSA chapter published this week, led by Sir John Curtice at NatCen and co-authored by our BSA team at the Nuffield Trust and the King’s Fund, explores what that experience can tell us about the challenge facing the NHS today. Unfortunately for D:Ream fans – and anyone concerned with the public’s perceptions of the NHS – its findings suggest that the parallels only take us so far. 

Tell me what you want, what you really, really want

One similarity between the two periods is what the public really (really) wants from the NHS: to be able to get into it. Long waits for hospital care were a major source of dissatisfaction in the late 1990s, just as concern about access to services tops both the public’s reasons for dissatisfaction and their priorities for reform today.

But there is an important difference. In the 1990s, dissatisfaction did not apply to all parts of the NHS. On the eve of Blair’s historic election, 77% were satisfied with GP services, and more people than not were satisfied with dentistry and hospital care. Today, satisfaction across GP, A&E, dentistry and hospital services is at or close to historic lows. The new analysis also finds that views of general practice and A&E have become more closely associated with overall NHS satisfaction, alongside hospital services.

People turn to the NHS at moments when they are frightened, anxious or vulnerable: when they are ill, in pain, or worried about someone they love. The fear that the NHS might not be there when you need it can be damaging in its own right, quite apart from the quality of the care you eventually receive. Indeed, people remain considerably more positive about the quality of NHS care than they are about their ability to access it.

The government therefore must do two things at once: reform the NHS for the future while making access to services visibly better now. And this will be considerably harder this time around.

Something Changed

A major reason for that is the impact of Covid. 

Despite public services having faced a decade of austerity, NHS satisfaction held up remarkably well throughout the 2010s. In 2019, six in 10 people were still satisfied with the NHS and almost seven in 10 with GP services. 

But the NHS itself went into the 2020s on the back foot. Nuffield Trust analysis has shown that, compared with health systems in similar countries, the NHS entered the decade with fewer resources in some key areas, while performance on measures such as waiting times had already been deteriorating. 

Then came the pandemic. The public made enormous sacrifices, staying at home and away from services to protect the NHS, while showing extraordinary goodwill towards its staff. And, as taxpayers, people contributed a huge amount of additional funding to shore up the health service. But they also experienced a health service that became much harder to access. Some services – like NHS dentistry – literally closed their doors to the public. Others felt less accessible, operations were cancelled, and usual routes into care were disrupted.

Covid ushered in the biggest collapse in NHS satisfaction ever recorded by BSA, with falls across every NHS service the survey asks about. And the pandemic seems to have damaged confidence in something very fundamental: that when you need the health service, it will be there for you. 

The NHS has also been slower to recover from the pandemic than many comparable health systems. While we are now seeing real signs of improvement – in both patient experience surveys and the BSA itself – those improvements come from a very low base, and there is still a long road to recovery ahead.

A Design for Life

Another reason things are tougher for Burnham’s government than Blair’s is that the NHS is now having to design care for very different lives. 

We have an older population, with more people living for longer with multiple long-term conditions. The NHS offers – and is expected to offer – much more for people with mental health problems and neurodevelopmental conditions that were much less well understood 30 years ago. And the repeated failure to put social care on a sustainable footing continues to make the NHS’s job harder.

Increasingly, patients need support from different parts of a health and care system that still struggles to join itself up. So improving access is not simply a question of doing more of the same. The NHS has to recover performance while also changing the way it delivers care.

The drugs do work, but someone has to pay for them

A further complication for the Burnham government is the fiscal and financial picture facing the UK. 

The last Labour government eventually combined reform and tough performance targets with historically large increases in NHS funding. After 2000, annual real-terms increases of more than 8% were not unusual. And the financial starting point was very different: total UK health care spending accounted for 6.9% of GDP in 1997, compared with 11.1% in 2024.

Medical innovation means the NHS can do far more for patients than it could in 1997, but those advances come with competing demands on a finite budget. 

And the recent UK/US trade deal explicitly commits the UK to spending more money on new branded medicines. The unspoken trade-off implicit in this deal is that these will be paid for by sacrificing more established forms of health care – likely to be the same GP services and hospital services that BSA respondents are frustrated at being unable to access. 

The NHS is therefore being asked to recover yesterday’s performance, meet today’s more complex needs and pay for tomorrow’s medicine, but without anything resembling the economic growth available to its 1997 predecessor.

NHS satisfaction got knocked down, but it got up again

So how much reassurance should the government take from the experience of the last Labour government? Well, NHS dissatisfaction is not set in stone – it has recovered before, even if that recovery took over a decade. And there are tentative signs of improvements today too: the latest BSA recorded a statistically significant increase in satisfaction, alongside the biggest fall in dissatisfaction for 25 years.

But the real differences between the two periods should dampen that reassurance. Today the public’s concerns extend much further across the NHS. The public finances are in a dire state. And, with the benefit of hindsight, we know that New Labour had time on its side: it took 13 years to turn public attitudes around. Burnham’s government has around three years before it has to face the electorate again, and will do so with arguably less confidence about winning another term than its New Labour predecessor did. 

That makes the political test not simply whether the NHS can recover, but whether enough of that recovery can be felt quickly enough. People will need to notice the difference when they call their GP, need urgent care or are waiting for treatment – even as the government pursues reforms whose benefits may take much longer to emerge.

Things can get better. But this is not the 1990s.