Since 1983, NatCen Social Research’s British Social Attitudes (BSA) survey has asked members of the public – rather than only patients – in England, Scotland and Wales about their views on the NHS and health and care issues generally.
The latest survey was carried out between July and October 2018 and asked a nationally representative sample of 2,926 people about their satisfaction with the NHS overall, and 973 people about their satisfaction with individual NHS and social care services. The 2018 BSA survey questions reported here were jointly sponsored by the Nuffield Trust and The King’s Fund.
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 and the data provides a rich time trend going back to 1983, adding a depth and context to the findings that no other measure of NHS satisfaction provides. As a result, when satisfaction changes in the BSA, we are as confident as we can be that it reflects a genuine change in public attitudes.
In the analysis below, when we say satisfaction has gone up or down, the change is statistically significant at the 5 per cent level, unless otherwise stated. If a change or difference is statistically significant, this means 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. Where a change or difference is not statistically significant, we cannot be confident that it reflects a real change or difference in public views.
Methodology: The 2018 survey consisted of 3,879 interviews with a representative sample of adults in England, Scotland and Wales. Addresses are selected at random and visited by one of NatCen Social Research’s interviewers. After selecting (again at random) one adult (aged 18 or over) at the address, the interviewer carries out an hour-long interview. The participant answers most questions by selecting an answer from a set of cards.
The sample size for the overall NHS satisfaction question reported here was 2,926 in 2018; for questions about satisfaction with other NHS services and social care services, the sample size was 973. The data is weighted to correct for the unequal probabilities of selection, and for biases caused by differential non-response. The weighted sample is calibrated to match the population in terms of age, sex and region. The margin of error in 2018 for the health care questions was around +/- 1.5 to 3.7 percentage points.
The majority of fieldwork for the 2018 survey was conducted between July and October, with a small number of interviews taking place in November.
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 some 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.
Satisfaction with the NHS overall in 2018
- Public satisfaction with the NHS overall continued to fall in 2018. Overall satisfaction was 53 per cent – a 3 percentage point drop from the previous year and the lowest level since 2007.
- Older people were more satisfied than younger people: 61 per cent of those aged 65 and over were satisfied with the NHS compared to 51 per cent of those aged 18–64.
- Satisfaction levels also differed between supporters of different political parties: 58 per cent of supporters of the Conservative party were satisfied compared to 51 per cent of supporters of the Labour party.
- The four main reasons people gave for being satisfied with the NHS overall were: the quality of care; the fact that the NHS is free at the point of use; the range of services and treatments available; and the attitudes and behaviour of NHS staff.
- The four main reasons people gave for being dissatisfied with the NHS overall were: long waiting times; staff shortages; a lack of funding; and money being wasted.
Satisfaction with NHS and social care services in 2018
- Satisfaction with inpatient services was 63 per cent. Levels have fluctuated in recent years, but the 8 percentage point increase from the previous year takes satisfaction to its highest level since 1993.
- Satisfaction with outpatient services was 70 per cent. Again, levels have fluctuated in recent years, but the 5 percentage point increase from the previous year takes satisfaction to its highest level since the survey began.
- For the first time, outpatients was the highest-rated service in the survey.
- Satisfaction with both inpatient and outpatient services was higher among those who have used those services recently or have friends and family members who have done so.
- Satisfaction with accident and emergency (A&E) services was 53 per cent. The change in satisfaction from the previous year was not statistically significant.
- Satisfaction with GP services was 63 per cent. The change in satisfaction from the previous year was not statistically significant, and satisfaction remains at its lowest level since the survey began in 1983.
- Satisfaction with NHS dentistry services was 58 per cent. The change in satisfaction from the previous year was not statistically significant.
- Satisfaction with social care services was 26 per cent. Again, the change in satisfaction from the previous year was not statistically significant.
How satisfied is the British public with the NHS overall?
This year, the NHS embarks on implementing a new 10-year plan, accompanied by its most generous funding settlement for almost a decade, albeit below what we think is needed to maintain and improve services (NHS England 2019; The King’s Fund et al 2017). As it starts this new chapter, the NHS’s report card is mixed. Although it is one of the most equitable systems in the world, it lags behind many comparable countries on key outcome measures for diseases like cancer, stroke and heart attack, as well as childhood mortality (Dayan et al 2018). So what do the British public think about the NHS and how has that changed over time?
For 36 years, the BSA survey has asked a sample of the public ‘how satisfied are you with the way the NHS runs nowadays?’ In 2018, public satisfaction with the NHS was 53 per cent; this combines people who say they are ‘very’ and ‘quite’ satisfied (Figure 1). This is a 3 percentage point drop from the previous year and continues a downward trend that takes satisfaction to its lowest level since 2007.
Public dissatisfaction with the NHS was 30 per cent in 2018. The change from 2017 was not statistically significant and this is the highest level of dissatisfaction with the NHS overall since 2007.
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 31 percentage points over the decade from 38 per cent (in 2001) to 70 per cent (in 2010). Conversely, the 2010s are characterised by decreasing satisfaction; although levels have fluctuated (including a 12 percentage point slump in 2011, and a 5 percentage point jump in 2014), the broad trend shows a falling level of satisfaction, which in 2018 was 16 percentage points lower than in 2010.
Public views of the NHS at 70
Various pieces of research conducted by The King’s Fund and Nuffield Trust for the NHS’s 70th birthday – including polling and in-depth workshops – explored changing public perceptions of the service (Burkitt et al 2018; McKenna 2018). Despite falling levels of satisfaction with the health service in 2018, the relationship between the public and the NHS remained strong.
People remained strongly committed to the founding principles of the NHS – free at the point of delivery, comprehensive and available to all, and funded through taxation.
The public said their expectations of the service were generally met and they felt that their expectations were, for the most part, realistic. They recognised that they have a role to play in keeping healthy but were also supportive of specific government interventions designed to promote healthy behaviours – such as the smoking ban and the soft drinks industry levy.
A lack of funding arose as a key concern – something that is backed up by BSA data collected in 2017, which shows that the vast majority of the British public believed the NHS had a funding problem, and most said that if the NHS needed more money, they would be willing to pay more in taxes (Evans 2018). More recent data on this from the 2018 BSA survey will be published soon.
In line with this, polls conducted after the prime minister’s announcement of extra money for the service in June 2018 showed strong support for a funding increase and for using tax rises to fund it (although a tax rise was not ultimately necessary) (NHS Confederation 2018; Smith 2018).
For a large part of the year, the NHS remained neck and neck with Brexit as the biggest concern for voters, although after the summer, concern for the NHS dropped off as Brexit worries moved to the fore (Ipsos MORI 2019).
Who is most satisfied with the NHS?
Figure 2 shows how satisfaction differs among different population groups. For each group we have included bars showing the 95 per cent confidence interval around their level of satisfaction. This is the range of values that, based on the survey data, we can be 95 per cent certain include the true satisfaction level for each group.Where the confidence intervals overlap between groups, we cannot be confident that the true satisfaction levels differ. As in previous years, satisfaction levels differ by age: respondents aged 65 and older have higher levels of satisfaction (61 per cent) than those aged 18–64 (51 per cent). And although not shown on the chart, those aged 75 and older have an even higher level of satisfaction (67 per cent).
There is also a difference in the satisfaction levels reported by supporters of different political parties. Respondents who support the Conservative party have a higher level of satisfaction (58 per cent) than respondents who support the Labour party (51 per cent). This follows a pattern seen in the BSA in most years, whereby supporters of the political party in power (ie, the party that is currently ‘running’ the NHS) report higher levels of satisfaction than supporters of the main opposition party.
Although there are differences in the satisfaction levels reported by other groups, they are not statistically significant. This means that we cannot be confident that the true levels of satisfaction for these groups actually differ; the survey results may be down to chance. Figure 2 shows that there are no statistically significant differences in satisfaction levels between men and women, across different income groups, between people of different ethnicities, and between those who have and have not had recent contact with NHS inpatient services in the past year.
Figure 3 shows how satisfaction levels for each population group changed between 2017 and 2018. Satisfaction levels decreased for most, but a lot of those changes were not statistically significant. On the chart, the changes that are statistically significant are marked with a ‘*’.
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. However, since 2015 we have included questions that explore what lies behind the overall levels of satisfaction and dissatisfaction reported in the survey. The questions ask respondents who are either ‘satisfied’ or ‘dissatisfied’ with the NHS to explain their answer by presenting nine possible reasons and asking them to select up to three. The lists of reasons were developed using answers to an open-ended question about why respondents were either satisfied or dissatisfied.
When we asked respondents who were satisfied with the NHS overall to explain their answer, the majority said they were satisfied because of the quality of care (71 per cent) and the NHS being free at the point of use (62 per cent) (Figure 4). Almost half said they were satisfied because of the good range of services available (46 per cent) and the attitudes and behaviour of NHS staff (44 per cent), and for almost a quarter (23 per cent), the length of waiting times was a factor.
Over the past four years, respondents have selected the same top five main reasons for being satisfied (Figure 5). There has been an increase in the proportion of respondents who cite quality of care as a factor, and a decrease in the proportion who say that they are satisfied because of short waiting times for a GP or hospital appointment.
Dissatisfaction is driven by a different set of factors (Figure 6). The top three reasons given by respondents who were dissatisfied with the NHS relate to access and resourcing. Around half said they were dissatisfied because of long waiting times (53 per cent), not enough staff in the NHS (52 per cent) and government funding for the service (49 per cent). A third (33 per cent) identified waste as a reason, and one in five (20 per cent) cited government reforms as the reason.
For the past two years, around half of respondents have selected three main reasons to explain their dissatisfaction: long waiting times, staff shortages and concerns about a lack of funding (Figure 7). Looking at how the drivers of dissatisfaction have changed since this question was first introduced in 2015, the proportion of respondents citing lack of funding and staff have increased, whereas the proportion citing waiting times remained constant.
A smaller proportion of respondents cited money being wasted in the NHS and government reforms throughout this period. But while 2017 saw a jump in the proportion of respondents citing government reforms as a reason, and a slump in the proportion of respondents citing waste as a reason, the latest data shows these reasons returning to levels similar to those reported in 2015 and 2016.
Very few people said their satisfaction or dissatisfaction was driven by stories in the media – despite widespread media coverage about the NHS’s 70th birthday and about pressures on the service (see Figure 8). 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.
How satisfied is the British public with different NHS and social care services?
Since 1983, the BSA survey has also asked the British public how satisfied they are with NHS general practice, dentistry, inpatient and outpatient services – and, more recently, A&E services (since 1999) and local authority social care services (since 2005). Many of these respondents will not have recently used all the services that they are being asked to comment on, so the results are likely to reflect the experiences of family and friends and information from other sources such as the media, as well as personal experience for those that have used them.
That said, the GP satisfaction measure is the closest the survey gets to a measure based on direct personal experience, as most people will have visited their GP in the past year for either themselves or a family member (NHS Digital 2009).
In 2018, satisfaction with NHS general practice services was 63 per cent. The change from the previous year was not statistically significant and satisfaction remains at its lowest level since the survey began in 1983. Looking over the longer term, satisfaction has decreased by 16 percentage points since 2009, when it was 80 per cent (Figure 9). Dissatisfaction with general practice in 2018 remains at its highest level since the survey began. Almost a quarter (24 per cent) of respondents reported being dissatisfied with their GP service – double the level of dissatisfaction reported in 2009.
NHS England’s national GP patient survey (which covers England, rather than Great Britain) includes questions that provide a useful triangulation for the BSA survey (Ipsos MORI and NHS England 2018). Patients registered with a GP are asked how they would rate their experience of their GP practice overall, and the proportion rating it as ‘good’ (‘very’ + ‘fairly’) has steadily decreased from 88 per cent in 2012 to 84 per cent in 2018. Similarly, the proportion who rated their overall experience of making an appointment as good has decreased from 79 per cent in 2012 to 69 per cent in 2018.1
Many of those who responded to the survey will have visited an NHS dentist fairly recently. Data from NHS Digital shows that half of adults in England saw an NHS dentist over a two-year period to June 2018 (NHS Digital 2018). Changes in satisfaction with NHS dentistry follow a very different pattern to satisfaction with GP services (Figure 9). In 2018, satisfaction with dentistry was 58 per cent, and the increase from the previous year was not statistically significant. Satisfaction with NHS dentistry has increased by 15 percentage points since 2008. The relatively high rates of satisfaction compared to the mid-2000s are likely to be partly explained by efforts to increase access to NHS dentistry services over the past decade.
Satisfaction with social care services provided by local authorities was 26 per cent in 2018, with no statistically significant change in satisfaction since 2015. Dissatisfaction with social care services was 34 per cent in 2018 – a 7 percentage point decrease from the previous year, taking dissatisfaction back to levels similar to those reported in 2016 and 2015.
When interpreting these results, it is important to take into account the lack of public understanding about social care services and about which services are funded by local authorities (as opposed to those purchased privately), as well as the fact that most respondents will not have any experience of using those services (Bottery et al 2018). This contributes to a higher proportion of respondents giving a neutral or ‘don’t know’ answer to the satisfaction question than for other services (see Figure 13). Data on the quality of social care services from the Care Quality Commission (CQC) suggests that ratings may be improving, but access to services is increasingly squeezed as local authorities tighten entitlements (Thorlby et al 2018; Care Quality Commission 2014).
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).
The survey also asks about satisfaction with inpatient and outpatient services, both of which increased in 2018 (Figure 11).
Satisfaction with inpatient services was 63 per cent – the highest level of satisfaction since 1993. Levels have fluctuated over the past three years: the 8 percentage point increase in 2018 takes satisfaction back to a level similar to 2016. Dissatisfaction with inpatient services was just 9 per cent – a drop of 5 percentage points from the previous year and the lowest level of dissatisfaction since 1983.
Satisfaction with outpatient services was 70 per cent in 2018 – the highest level since the survey began in 1983. As with inpatient services, satisfaction levels have fluctuated over the past three years: the 5 percentage point increase in 2018 takes satisfaction back to a level similar to 2016. Dissatisfaction with outpatient services was 11 per cent, and the change from the previous year was not statistically significant.
Satisfaction with A&E services (53 per cent in 2018) has not changed significantly since 2015.
The data on satisfaction with inpatient services shows a similar trend to the national NHS inpatient survey, which was conducted in 2017 (results of the 2018 survey are yet to be published) (CQC 2018). When asked to rate their experience of NHS inpatient services overall on a scale of 0 (very poor) to 10 (very good), almost half of respondents gave a score of 9 or 10 – a figure that has been gradually increasing since the question was first introduced in 2012. The latest emergency department national patient survey results from 2016 also show that around half of patients give the service an overall rating of 9 or 10, but changes to the survey sampling and analysis approach mean that this data cannot be compared to previous years (CQC 2017). There is no recent national patient survey data on outpatient services against which to compare these measures.
The trend of increasing satisfaction with inpatient and outpatient services is striking given that overall satisfaction with the NHS has been falling in recent years. Public satisfaction surveys like the BSA often find that the public give different ratings when they are asked about the NHS in general to when they are asked about specific services, and the former is not a sum of their views on the latter. It is beyond the scope of this survey to reveal the underlying reasons for the associations between these different satisfaction measures, but it is worth bearing in mind that respondents are likely to be considering a range of different factors and giving different weightings to each when expressing satisfaction with individual services and the NHS overall (Wellings 2012).
One factor that we know affects satisfaction ratings for hospital services is recent experience of using the service (Figure 12). As in previous years, the latest survey shows that satisfaction with inpatient services was higher among those who had used inpatient services in the past year (83 per cent) than among those who had not used the service themselves but had friends and family who had (69 per cent), and satisfaction was even lower among those who had had no contact with inpatient services either themselves or through their friends and family (57 per cent). Responses about outpatient services follow a similar pattern (Figure 12).
These differences remain when age is taken into account. So, for example, people aged over 65 who had been an NHS inpatient recently were more satisfied than people in the same age group who had not had recent experience of the service.
The survey does not tell us what lies behind these differences, but the findings at least suggest that people who use hospital services have positive feelings about the experience (be that because of the quality of care they receive, feelings of gratitude for the service or other things) and this contributes to them reporting higher levels of satisfaction. Those with no experience of the service may draw on a different set of information sources when deciding on their level of satisfaction. Their more negative responses might, for example, be more influenced by stories about hospitals in the media, which tend to be negative (Pinker 2018).
Figure 13 brings together public satisfaction data for health and social care services and the NHS overall in 2018. It shows that satisfaction with outpatient services is higher than for all other services included in the survey and for the NHS overall. This is the first time since the survey began in 1983 that a service other than general practice has received the highest satisfaction ratings (although in 2017 GP and outpatient services had the same level of satisfaction). This is the result of falling levels of satisfaction with general practice and increasing levels of satisfaction with outpatient services.
As in previous years, satisfaction with the social care services provided by local authorities is far lower than satisfaction with health care services.
When responding to the question on social care, 40 per cent of respondents said that they ‘don’t know’ how satisfied they are, or provide a neutral answer (‘neither satisfied nor dissatisfied’). This is higher than for other services, where the figure ranges from 13 per cent to 29 per cent, and is likely to reflect a lower level of understanding among the public about what social care services are, coupled with less experience of using them (Bottery et al 2018).
In 2018, net satisfaction with social care services (calculated as satisfaction minus dissatisfaction) was -8 per cent, whereas net satisfaction with the NHS overall and individual NHS services ranged from 23 per cent to 59 per cent.
In 2018, the outpouring of affection that accompanied the NHS’s 70th birthday did not stem falling levels of public satisfaction with the service. Satisfaction with the NHS sits at its lowest level for more than a decade, driven by concerns about a lack of money, staff shortages and mounting waiting times. The new funding settlement for the NHS and accompanying long-term plan have set the direction of travel for the next 10 years, but with less-firm commitments to reducing waiting times than there were in the past, and the government’s strategy for dealing with critical workforce issues still outstanding, we must wait to see when the decade-long slide in public satisfaction with the NHS will come to an end.
1. Changes were made to this survey in 2018, which mean trends between 2017 and 2018 should be treated with caution. Although the two questions reported here remain broadly unchanged, other questions in the survey were amended and this may have had an impact on responses.
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