Public satisfaction with the NHS and social care in 2021: Results from the British Social Attitudes survey

Analysis of NatCen's 2021 British Social Attitudes survey by Nuffield Trust and The King's Fund shows a huge and unprecedented drop in public satisfaction with the NHS and its individual services, despite widespread support for the fundamental principles of the health service. So what's driving this change?

Since 1983, NatCen Social Research’s (NatCen’s) British Social Attitudes (BSA) survey has asked members of the public about their views on health and care services. NatCen carried out the most recent survey between 16 September and 31 October 2021 and asked a nationally representative sample (across England, Scotland and Wales) of 3,112 people about their satisfaction with the National Health Service (NHS) overall, and 1,039 people about their satisfaction with specific NHS and social care services, as well as their views on NHS funding. 

Key findings

Satisfaction with the NHS overall in 2021

  • Overall satisfaction with the NHS fell to 36% – an unprecedented 17 percentage point decrease on 2020. This is the lowest level of satisfaction recorded since 1997, when satisfaction fell to 34%. More people (41%) were dissatisfied with the NHS than satisfied.
  • This fall in satisfaction was seen across all ages, income groups, sexes and supporters of different political parties.
  • The main reason people gave for being dissatisfied with the NHS overall was waiting times for GP and hospital appointments (65%) followed by staff shortages (46%) and a view that the government does not spend enough money on the NHS (40%).
  • Of those who were satisfied with the NHS overall, the top reason was because the NHS is free at the point of use (78%), followed by the quality of NHS care (65%) and that it has a good range of services (58%).

Satisfaction with NHS and social care services in 2021 

  • Satisfaction with GP services fell to 38% – a 30 percentage point decrease compared to 2019. This is the lowest level of satisfaction recorded for GP services since the BSA survey began in 1983 and 25 percentage points lower than the previous lowest level – 63% – recorded in 2018. 2021 was the first year that the percentage of people dissatisfied with GP services (42%) was higher than the percentage satisfied.
  • Satisfaction with inpatient services fell from 64% in 2019 to 41% in 2021, a fall of 23 percentage points. Similarly, satisfaction with outpatient services fell from 71% in 2019 to 49% in 2021.  Satisfaction with both is at the lowest level since the BSA survey began.
  • Satisfaction with accident and emergency (A&E) services also fell sharply, a fall of 15 percentage points, from 54% to 39%. This is the lowest level recorded since a question on A&E was introduced in 1999.
  • Satisfaction with NHS dentistry services also fell significantly with 33% of respondents saying they were satisfied in 2021 compared to 60% in 2019. Again, the lowest level since the BSA survey started. 

Satisfaction with social care services in 2021

  • 15% of respondents said they were satisfied with social care services in 2021, while 50% said they were dissatisfied1[1]  
  • The main reasons people gave for being dissatisfied with social care were that the pay, working conditions and training for social care staff are bad (59%), that people don’t get all the social care they need (59%), and that social care is not affordable to those who need it (44%).

NHS funding, priorities and principles

  • In 2021, 80% of respondents believed that the NHS faced a ‘major’ or ‘severe’ funding problem. This was the same as recorded in 2019.
  • 46% of respondents would have preferred any extra funding that the NHS needed to come from taxes, down from 54% in 2019. 
  • The proportion of respondents saying the NHS should not be given extra money and that it should live within its budget has increased in recent years, from 15% in 2017 to 25% in 2021.
  • Asked what they thought the most important priorities for the NHS should be, the top three cited by survey respondents were: making it easier to get a GP appointment (48%), improving waiting times for planned operations (47%) and increasing the number of staff in the NHS (47%).  
  • The overwhelming majority of respondents agreed that the founding principles of the NHS should ‘definitely’ or ‘probably’ apply in 2021: that the NHS should be free of charge when you need it (94%), the NHS should primarily be funded through taxes (86%) and the NHS should be available to everyone (84%).
  • There were high levels of support for all three principles across both Labour and Conservative supporters, although Labour supporters were more likely to say they should ‘definitely’ apply.

The King’s Fund and Nuffield Trust jointly sponsored the 2021 BSA survey questions reported here. We added new questions in 2021 asking people about their views on what the priorities for the NHS should be and the extent to which they think the founding principles of the NHS should still apply.

The BSA is a ‘gold standard’ nationally representative survey that uses a robust methodology to explore public views on a wide range of issues. The methodology uses random probability sampling to select British households to take part. From 1983 until 2019 the survey was conducted through face-to-face interviews. This method was not possible in 2020 due to social distancing rules in place for Covid-19 and that year the BSA survey interviews were conducted primarily online with a telephone option also available. This new method continued in 2021, with households receiving a letter inviting up to two adults to take part online or over the phone if they preferred.

In 2020 the only question relating to the NHS that was asked was how satisfied or dissatisfied people are ‘with the way in which the NHS runs nowadays’. In 2021 the full range of NHS and social care questions was asked.

The change in method brings a risk that differences in attitudes between the BSA in 2020 and 2021 and earlier years may be a consequence of the change of methodology. However, the 2021 data has been carefully weighted to ensure this risk has been minimised. The methodology section explains further reasons to be confident in making comparisons between years.

How satisfied are the British public with the NHS overall?

These truly are unprecedented times for the NHS. Few people could have predicted the events that would occur between the last time the BSA survey was carried out in full in 2019, and the start of the fieldwork period for this year’s survey in mid-September 2021. 

The NHS, its staff and patients have faced new challenges as they have grappled with the Covid-19 pandemic. Health services had to rapidly re-adjust the way they delivered care to patients and users. New ways of working were introduced to accommodate social distancing and other infection control guidance, including a large increase in remote consultations for general practice and outpatient services. As treating Covid-19 patients became the priority, the NHS had to reprioritise care, leading to delays for patients who needed routine care. In addition, the NHS led the largest mass vaccination programme in its history. All this had a huge impact on patients and staff, many of whom were ill themselves or had to isolate at different times throughout the pandemic. 

As a result, pressures that existed before the pandemic were exacerbated. By October 2021 in England, for example, the waiting list for planned care had grown by more than a third (from 4.4 million in February 2020 to nearly 6 million); more patients than ever before (about 40%) were waiting longer than four hours in major A&E departments and patients in need of emergency care were waiting 30 minutes longer for an ambulance (NHS England and NHS Improvement, 2021). Similar lengthening waiting lists and times were experienced in Scotland (Public Health Scotland, 2022) and Wales (Welsh Government, 2021). Moreover, substantial NHS staff vacancies that were already putting significant strain on the system have been magnified by the pandemic. There were, for example, slightly more than 100,000 vacancies in the NHS in England in September 2021 (NHS Digital, 2021).

In addition, the NHS in England is now on the brink of major reform. The Health and Care Bill will bring an assortment of changes in England, including formalising new integrated care systems (The King’s Fund, 2021). In addition, the new Health and Social Care Levy is expected to generate £36 billion in additional funding over the next three years through a rise in taxes earmarked for the NHS and social care (Prime Minister’s Office and others, 2021). 

The events of the past two years have influenced the public’s perception of the NHS immensely. During the initial waves of the pandemic, there was a great deal of public gratitude towards the NHS and its staff, as demonstrated by the weekly ‘Clap for Carers’ and pride in the NHS has remained high (Gardner, 2021). However, by late 2020 there were indications that public satisfaction with how the NHS runs was falling, albeit still holding at relatively high levels historically (Wellings and Appleby, 2021). The 2021 BSA survey shows how people were feeling nearly two years on from the start of the pandemic – after a long period of disruption to health services.

Overall satisfaction with the NHS in 2021

For 39 years, the BSA survey has asked a representative sample of the public how satisfied or dissatisfied they are ‘with the way in which the NHS runs nowadays’.  

In 2021, 36% of the public were ‘very’ or ‘quite’ satisfied with the NHS (see Figure 1) a 17 percentage point decrease on the previous year. Only 6% out of the 36% were ‘very’ satisfied with the NHS. This fall in satisfaction mirrors the increase in public dissatisfaction with the NHS, which rose from 25% in 2020 to 41% in 2021.

The long-term view of this trend (see Figure 1) shows that this fall in satisfaction is exceptional. It is the largest year-on-year fall in satisfaction since the question was first asked in 1983.

Satisfaction was last at this level in the late 1990s, when it reached a low of 34% in 1997. Satisfaction recovered in the 2000s and increased by 28 percentage points over the decade. The only near comparable year-on-year fall in satisfaction to this year’s, was between 2010 and 2011, when satisfaction fell by 12 percentage points from 70% to 58%.  

For the first time since 2002, more people are dissatisfied with the NHS than satisfied. 

How does satisfaction vary by demographic group?

The decrease in satisfaction between 2020 and 2021 occurred in almost all demographic groups (see Figure 2). The decrease in satisfaction levels was statistically significant for adults aged 18 to 64 and over 65 (18 and 16 percentage points respectively); male and female respondents (17 and 18 percentage points respectively); and across supporters of all main political parties (Conservatives: 18 percentage points; Labour: 17 percentage points; Liberal Democrats: 26 percentage points). A decrease in satisfaction also occurred across all three nations covered by the survey revealing similar levels of satisfaction in England (36%), Scotland (33%) and Wales (34%). Respondents from all ethnic backgrounds reported low levels of satisfaction in 2021 (mixed/other: 33%; white: 36%; Asian: 37%; Black: 39% (these are the most granular levels of ethnicity captured in the survey)). However, only white respondents showed a statistically significant fall in satisfaction between 2020 and 2021. For other ethnic groups, the sample sizes were too small for the changes to be statistically significant.

However, while there were falls in satisfaction across the board, relative levels of satisfaction showed some variation depending on, for example, respondents’ age, political affiliation and sex. Figure 3 shows how satisfaction differed among different population groups and how satisfaction differed from the average for the whole survey.

As in previous years, satisfaction levels differ by age: respondents aged over 65 had higher levels of satisfaction (42%) than those aged 18 to 64 (34%). While other groups also showed differences in satisfaction levels relative to each other, these differences were not statistically significant. Figure 3 shows that while there were interesting gradients in satisfaction within some groups – for example, low- and high-income households tended to be more satisfied than middle-income households, and Black and Asian respondents more satisfied than other ethnic groups – these differences were not large enough given the size of the sample to reach statistical significance. 

While satisfaction fell for supporters of all political parties, there was still some variation in the level of satisfaction between parties. Respondents who supported the Conservative party had a slightly higher level of satisfaction (39%) than respondents who supported the Labour party (36%) (see Figure 4). This follows 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 the main opposition party (Appleby, 2021). It is noteworthy, however, that between 2019 and 2021 the difference between the two groups narrowed and is no longer statistically significant.

Why is the public satisfied or dissatisfied with the NHS?

Public views about the NHS are driven by a range of factors. Since 2015 the survey has included questions that explore what lies behind the overall levels of satisfaction and dissatisfaction with the NHS. Respondents are asked to pick up to three reasons for the answer they gave to the overall satisfaction question.  

These questions were not asked in 2020, so this is the first time since the start of the Covid-19 pandemic that the survey explored reasons for satisfaction or dissatisfaction with the NHS. 

As Figure 5 shows, of those who said they were satisfied, 78% said they were satisfied because NHS is free at the point of use, while 65% said it was because of the quality of care. 58% said they were satisfied because of the range of services and treatments available and 49% because of the attitudes and behaviour of NHS staff. 14% said that not having to wait long for a GP or hospital appointment was a reason for being satisfied with the NHS.

While the top five reasons for satisfaction have not changed since this question was introduced (see Figure 6), the order of them has and there have been some statistically significant changes between 2019 and 2021. For the first time, the top reason for satisfaction was that the NHS is free at the point of use – an 18 percentage point increase since 2019. The percentage of people citing waiting times as a reason for satisfaction saw an 11 percentage point decrease compared to 2019.

Those who were dissatisfied with the NHS were also asked why they were dissatisfied. The top three reasons given in 2021 by respondents related to access, staffing and funding (see Figure 7). 65% said they were dissatisfied because of long waiting times, while 46% chose staff shortages. 40% said they were dissatisfied due to a lack of government funding and 39% felt that money was wasted in the NHS. 26% identified government reforms that affect the NHS as a reason for dissatisfaction.

For the past three surveys, the top three reasons for dissatisfaction with the NHS have not changed: length of waiting times, staff shortages, and the government not spending enough money on the NHS (see Figure 8). However, this year there was a noticeable shift in the ranking. Dissatisfaction due to waiting times overtook concerns about staff shortages as the main reason for dissatisfaction, with an increase of 8 percentage points compared to 2019, although this is not statistically significant.

There was a significant increase (of 13 percentage points) in concern about money being wasted in the NHS among those who said they were dissatisfied. The 8 percentage point increase in concern around government reforms that affect the NHS is not significant.

As in previous surveys, very few people said their satisfaction or dissatisfaction was because of stories in the newspapers, radio or TV. This is despite widespread media coverage about pressures on the service, especially over the past two years (during the pandemic) and particularly during the fieldwork period for the survey (see box below).

Media stories at the time

Before the survey period

The continuation of the Covid-19 pandemic dominated headlines in the run up to the 2021 survey period. At the start of 2021 all eyes were on the vaccine roll-out as Boris Johnson announced a new lockdown due to record numbers of Covid-19 cases and deaths in the UK. The NHS and social care services were facing the most uniquely challenging winter in recent memory. There were also headlines throughout the year highlighting that NHS and social care services were struggling to have enough staff to deliver all the care people needed, with existing long-term workforce shortages significantly exacerbated by the pandemic.

During the survey period

Fieldwork for the BSA survey was carried out between 16 September to 31 October, during a period of significant developments in health and social care policy.

NHS waiting times and the care backlog created by the pandemic dominated the news from August, when it was announced that a record 5.45 million people were waiting for planned hospital care in England. In September the UK government announced a new National Insurance ‘levy’ intended to pay for clearing the waiting list backlog in the NHS and to put social care services on a more sustainable footing by reforming how social care in England is paid for. Media reaction was mixed, with some commentators outraged by the tax hike, and others questioning whether the levy would raise enough to ‘fix’ the health and social care system. 

One of the biggest health stories during the survey period was around the challenges many people faced in accessing GP services, particularly if they wanted a face-to-face appointment. This led to a polarised media debate, with some outlets criticising GPs and others reporting the abuse GPs were receiving. Into this toxic environment, the government published a plan to increase the number of appointments available, which was swiftly criticised by GP leaders as they argued GPs were already pushed to breaking point.

After the BSA fieldwork was completed, the Omicron variant of Covid-19 emerged. 2021 ended much as it had begun, with the news agenda dominated by fears about Covid-19, lockdown restrictions, and all hopes pinned on vaccines to help chart a path out of the pandemic.

How satisfied are the British public with different NHS services?

In addition to asking about overall satisfaction with the NHS, the BSA survey asks the public how satisfied or dissatisfied they are with different health and care services: general practice, dentistry, inpatient, outpatient, and A&E services. It is important to note that unprecedented changes took place in the delivery of these services in response to the pandemic, with, for example, general practice and outpatient consultations shifting from being face to face to being conducted remotely for most appointments, and routine NHS dentistry appointments temporarily pausing at the start of the pandemic.

General practice

In 2021, satisfaction with GP services fell significantly, by 30 percentage points, from 68% satisfied to 38%. This is the lowest level recorded since the survey began in 1983; the previous lowest figure recorded was 63% in 2018 (see Figure 10). While the overall trend over the past decade has seen satisfaction with GP services fall (from 80% in 2009 to 68% in 2019) with some fluctuations, the scale of the fall this year is unprecedented. While 30% of respondents were ‘quite’ satisfied, only 9% were ‘very’ satisfied. Satisfaction with GP services is now the lowest of any NHS service with the exception of dentistry. It had previously been the highest-rated service every single year until 2018, when it was overtaken by satisfaction with outpatient services.

Levels of dissatisfaction rose sharply. In 2019, 20% of respondents said they were dissatisfied with GP services, this increased to 42% in 2021 – a statistically significant increase.  

Dentistry

Over the past two decades, satisfaction with NHS dentistry services had risen from a low of around 42% in the mid-2000s to a level similar to satisfaction with the NHS as a whole in 2019 (60%) (see Figure 10). However, as with satisfaction with GP services, satisfaction with NHS dentistry services fell significantly with only 33% of respondents saying they were satisfied in 2021.

Levels of dissatisfaction rose significantly. In 2019, 15% of respondents said they were dissatisfied with dentistry services. This increased to 34% in 2021.

Inpatient and outpatient services

The BSA survey also asks about satisfaction with inpatient and outpatient services (see Figure 11). Satisfaction with inpatient services increased in the years before the pandemic to 64% in 2019. However, satisfaction has fallen by 23 percentage points since then, to 41%. Despite the significant decrease, the fall in satisfaction levels is less severe than for GP or dentistry services and is largely explained by the large increase in the proportion of people responding as neither satisfied nor dissatisfied, which rose from 22% in 2019 to 41% in 2021. Dissatisfaction with inpatient services did not change significantly at 11%.

Satisfaction with outpatient services remained consistently high in the years before the pandemic and reached its highest level since the survey began in 2019, at 71%. In 2021 satisfaction fell significantly, by 22 percentage points compared to 2019, with 49% of respondents saying they were satisfied. However, this is still the highest proportion of people satisfied compared to other NHS services (see Figure 9). As with inpatient services, the proportion of people responding as neither satisfied nor dissatisfied with outpatient services increased to 35% in 2021 compared to 17% in 2019. Dissatisfaction with outpatient services has remained relatively constant, at 14% compared to 11% in 2019.

Accident and emergency

Satisfaction with A&E services remained stable in the years 2015 to 2019, but, in lines with other services, fell significantly in 2021. 39% of respondents said they were satisfied with A&E in 2021, compared to 54% in 2019. Levels of dissatisfaction also rose from 23% to 29% of respondents saying they were dissatisfied.

How satisfied are the British public with social care services?

Overall satisfaction with social care

Social care has faced enormous challenges during the pandemic. The impact of Covid-19 on people drawing on social care and those delivering it has been widespread, with high numbers of deaths in care homes, severe restrictions on contacts with relatives and friends, and care staff under immense pressure to deliver safe services. Pre-existing pressures facing social care staffing were compounded during the pandemic, with, for example, more than 100,000 vacancies in social care  in England in 2020/21 (Skills for Care, 2021). As a result, social care needs are going unmet – for example, as of November 2021 an estimated 400,000 people in England were still waiting for an assessment of their needs (ADASS, 2021).

In 2021 the wording of the question on satisfaction with social care was changed so that it captured perceptions of all social care services rather than only those services provided by local authorities as asked in previous years (see methodology section for more details). For this reason, we are not presenting the time series as it is not comparable with previous years.

In 2021, 15% of respondents said they were satisfied with social care while 50% said they were dissatisfied.

Why is the public satisfied or dissatisfied with social care?

For the first time this year, the survey included questions that explored why respondents were satisfied or dissatisfied with social care by asking them to pick up to three reasons for the answer they gave to the overall satisfaction question.

Figure 13 shows that of those respondents who said they were satisfied with social care services (138 respondents), 57% said this was because people are treated with dignity and respect by social care staff, and 56% because the range of services and support available is good. 33% said they were satisfied because social care is affordable to those who need it, and because health and social care services work well together. Only 16% were satisfied because it is easy to understand how to get social care.

Figure 14 shows that of those respondents who said they were dissatisfied with social care (547 respondents), 59% said they were dissatisfied because the pay, working conditions and training for social care staff are bad, and the same number of people (59%) felt that people don’t get all the social care they need. 44% said they were dissatisfied because social care is not affordable to those who need it and 43% were dissatisfied because of a lack of support for unpaid carers. 14% of respondents said that people are not treated with dignity and respect by social care staff.

Does contact with a service make people more or less satisfied?

How many respondents had recently had contact with health and care services?

Findings from previous BSA surveys and other studies of satisfaction with the NHS and social care (Appleby and others2019Ipsos MORI, 2017) show that use of, or contact with, services – whether through personal experience or that of friends or family – is one of the factors that influences respondents’ satisfaction ratings. If respondents have had contact with a service they will be taking their experience into account when asked how satisfied or otherwise they are with that service. People who have not used a particular service will rely more on indirect information, such as media reports or anecdotal evidence from friends and relations. But to what extent does recent use or contact with a service make people more or less satisfied?

In 2021, 86% of people surveyed had used or had contact with general practice in the previous 12 months, but only 14% had used or had contact with social care services (see Figure 15).

Although the level of contact with general practice services was maintained in 2021, this was not the case for other NHS services. Between 2019 and 2021, the proportion of respondents who had used or had contact with health and care services decreased substantially for inpatients (12 percentage point decrease), outpatients (8 percentage point decrease), A&E (9 percentage point decrease), and dentistry (14 percentage point decrease). There was very little change in the proportion of respondents who said they had had contact with general practice.

This reflects changes in service use and access during the pandemic. When the 2021 survey was conducted, the number of GP appointments had recovered from the initial fall at the outset of the pandemic, but many appointments were being provided remotely, while hospital services were still caring for substantial numbers of Covid-19 patients and facing an increasing backlog of care. Similarly, access to dentistry was also badly affected by the pandemic.

How does recent contact affect satisfaction with a service?

The first thing to note is that contact or use of a service seems to crystallise people’s views about satisfaction or dissatisfaction. For example, a smaller percentage of respondents who had used or had contact with a service answered ‘neither satisfied nor dissatisfied’ compared to those who had not had contact. If respondents had used a service they were, unsurprisingly, more likely to have an opinion of it.

Overall, respondents who had used or had contact with a service tended to be more satisfied with that service than those who had not used or had contact with a service (see Figure 16). This was particularly the case for dentistry, inpatient and outpatient services. The difference was most pronounced for dentistry, where those who had used or had contact with dentistry services were statistically significantly more likely to be satisfied than those who had not (a difference of 31 percentage points). This may reflect the difficulties some people had in accessing an NHS dentist, with lower levels of satisfaction among non-users being a direct result of an inability to access a dentist.  

As Figure 16 shows, the highest level of satisfaction among respondents who had used or had contact with a service was for outpatient services (62%), while the lowest level of satisfaction was among respondents who had had contact with social care (18%). Social care also had the highest levels of dissatisfaction, 66% of respondents who had used or had contact with social care were dissatisfied compared to 49% of those who had not had contact.

General practice was the only NHS service where respondents who had used or had contact with the service reported higher levels of dissatisfaction than satisfaction. 42% of people who had used or had contact with their general practice in the previous 12 months said they were dissatisfied compared to 40% who said they were satisfied. This represents a significant change from 2019 when 70% of those who had used or had contact with general practice said they were satisfied, a drop of 31 percentage points in 2021. Dissatisfaction among people who had used or had contact with general practice has gone from 20% to 42% in the same period. That the vast majority of respondents had used or had contact with GP services underlines the significance of these findings.

Attitudes to NHS spending and sources of funding

Since 2014 the BSA survey has asked about the public’s views on NHS funding.  Respondents were asked whether the NHS was facing a funding problem and if so, whether it was ‘minor’, ‘moderate’ or ‘severe’. 

In 2021, 80% of respondents believed that the NHS faced a ‘major’ or ‘severe’ funding problem. This is the same figure as the last time the question was asked in 2019, though the proportion of respondents who believe the NHS faces a funding problem has fallen since 2018, when the government announced an increase in the NHS England budget of £20.5 billion to coincide with the 70th anniversary of the service (Health Foundation, 2018).

One of the questions in the BSA survey asks respondents how they think additional funds for the NHS should be raised if needed (see Figure 18). 

Of the six options respondents were given, the most popular choice was that extra funding should come from a separate tax for the NHS – however, the proportion of respondents choosing this option fell, from a high of 35% in 2017 to 26% in 2021, a statistically significant fall. 2021’s data was collected around the same time as the government first announced the Health and Social Care Levy (HM Customs & Revenue, 2021), a 1.25 percentage point increase in National Insurance to specifically fund additional resources for the NHS and social care services.

Although the majority of respondents to the previous question thought that the NHS faces a funding problem, as of 2021, 25% of respondents said the NHS should not be given extra money and that it should live within its budget. None of the changes in the responses to this question from 2019 to 2021 is statistically significant.

NHS priorities and principles

What do the British public think the priorities for the NHS should be?

A question posed for the first time in 2021 asked people what they thought the most important priorities for the NHS should be. The top three answers chosen were making it easier to get a GP appointment (48%), improving waiting times for planned operations (47%) and increasing the number of staff in the NHS (47%). 

There were some differences in response according to political affiliation: Labour supporters (23%) were more likely to say that improving the health of the most disadvantaged was a priority than Conservative supporters (11%).

There were also some statistically significant differences in the answers by those who said they were dissatisfied with how the NHS runs nowadays and those who said they were satisfied. 60% of those who said they were dissatisfied with how the NHS runs nowadays said that making it easier to get a GP appointment was a priority compared to 34% who said they were satisfied. 35% of those who said they were dissatisfied with how the NHS runs today said helping people to stay healthy and preventing illness was a priority compared to 47% of people who said they were satisfied.

Do the British public agree with the principles of the NHS?

Another question appearing for the first time in the survey in 2021 asked people about the extent to which they thought the founding principles of the NHS should still apply today. These principles are:

  • the NHS should be free of charge when you need it
  • the NHS should be available to everyone
  • the NHS should primarily be funded through taxes.

Overall, most respondents supported all three principles. 76% of respondents said that the NHS should be free of charge when you need it should ‘definitely’ apply while 18% said it should ‘probably’ apply. Figure 21 shows that Labour supporters were more likely than Conservative supporters to say it should ‘definitely’ apply (86% compared to 66% which is statistically significant). Only 6% of respondents overall answered that this principle should ‘probably’ or ‘definitely’ not apply.

When asked whether the NHS should be available to everyone, 67% of respondents said this should ‘definitely’ apply and 17% said it should ‘probably’ apply. Again, there was a difference by political affiliation with Labour supporters more likely to say it should ‘definitely’ apply compared to Conservative supporters (79% compared to 56% and statistically significant). 16% of respondents overall said this should either ‘probably’ not apply (10%) or should ‘definitely’ not apply (6%). 

Finally, when asked whether the NHS should primarily be funded through taxes 54% said this principle should ‘definitely’ apply and 33% said it should ‘probably’ apply. As before there was a statistically significant difference between Labour and Conservative supporters with Labour supporters more likely to say it should ‘definitely’ apply (68%) compared to Conservative voters (48%). While there was no statistically significant difference by age on the first two principles, there was on whether the NHS should primarily be funded through taxes with over 65s more likely to say it should ‘definitely’ apply (68%) compared to 18–64 year-olds (48%). As with the two previous principles a relatively small number said this should ‘probably’ (8%) or ‘definitely’ not apply (4%).

Conclusion

The most striking result to emerge from the BSA survey in 2021 is the huge fall in overall satisfaction with the NHS. 36% respondents said they are ‘very’ or ‘quite’ satisfied: a decrease of 17 percentage points on 2020 and a 24 percentage point decrease compared to the pre-pandemic 2019 survey. And for the first time since 2002 the BSA survey recorded more people expressing dissatisfaction than satisfaction.

The fall in satisfaction was also universal. Satisfaction fell across all ages, household incomes, sexes and political affiliation. It was also mirrored in different health and care services – general practice, A&E, inpatients, outpatients, dentistry and social care. The falls in satisfaction levels across all these services were significant and unprecedented. In particular, satisfaction with GP services – traditionally very high – is now only 38%, 25 percentage points lower than the previous lowest level (recorded in 1983).

But we also know from the survey that support for the basic principles of the NHS – free at the point of use, available to all and collectively funded from general taxes – is high, with around nine in ten people saying these principles ‘definitely’ or ‘probably’ should still apply. But if the public has not fallen out of love with the fundamental principles of the NHS what lies behind the fall in satisfaction?

The answer lies in the extraordinary events of the past two years. Covid-19 has put health and care services under pressure in ways not experienced in their history. Coping with the pandemic at a time when services were already under strain – struggling with waiting lists and staff vacancies across both health and social care, for example – has been enormously difficult and adversely affected care for users of services. 

Although the public have recognised the unprecedented nature of the pandemic and largely accepted the necessity for health and care services to reprioritise patients, restrict access and delay care for millions, it seems likely that this understanding and the support the public had shown during the early period of the pandemic has been overtaken by concerns people have about the impact these very actions are continuing to have. This is particularly the case with delays in getting access to care: currently, around 1 in 10 of the English population is on an NHS waiting list (NHS England and NHS Improvement, 2022), a similar proportion in Scotland (BBC News, 2022), and 1 in 5 of the Welsh population (Welsh Parliament, 2021). This means that many of those taking part in the survey would either have been on a waiting list or knew someone who was.

The challenges being faced in primary care, particularly around access, are also clear to see from the results of the survey, with only 40% of people who had used or had contact with their general practice saying they were satisfied with GP services and 42% saying they were dissatisfied. General practice is the service used by the largest number of people and if people were facing problems here it is likely to have had a significant impact on overall satisfaction with the NHS.  

It is perhaps no surprise then that having to wait too long for a GP or hospital appointment was the most popular reason given for dissatisfaction with the NHS and that the two most favoured priorities for the NHS were making it easier to get a GP appointment and improving waiting times for planned operations. Similarly, for social care, where, as well as concern for pay and working conditions for care staff, the fact that people do not get the care they need was also a key reason for dissatisfaction.

Is more money the answer? 80% of those surveyed still think the NHS has a severe or major funding problem, so the public’s answer is probably yes. But while many thought extra funding should be raised through taxation – either from current taxes or a separate NHS tax – 25% thought that the NHS needs to live within its budget. Moreover, concern about money being wasted by the NHS has also risen significantly among people who were dissatisfied with the service.

As, hopefully, Britain begins to emerge from the pandemic emergency, elective recovery plans for health and care services to tackle the backlog of care and to reduce waiting lists and times are being put in place. But, as the Secretary of State for Health and Social Care, Sajid Javid, has admitted, waiting lists will get worse over the next year or so before starting to fall in 2024 (Javid, 2022). And even if all goes to plan, this ambition will only return services to the pre-pandemic situation in which nearly all headline waiting times were being missed nationally for A&E, planned operations and cancer services.

Moreover, the unprecedented levels of dissatisfaction with GP services underline that action to tackle waiting times for planned care is unlikely to be enough for public satisfaction with the NHS to recover. Addressing pressures on general practice and improving access for patients will be key if satisfaction is to rise in future years. 

Previous trends from the BSA survey suggest that recovering from a low point in the public’s satisfaction with the NHS and care services will take time. Future BSA surveys will track the public’s satisfaction as plans unfold and as health and care services tackle the job of recovery.

Methodology

Sample and approach

From 1983 to 2019, NatCen Social Research selected addresses at random from the postcode address file (a list of all mail delivery points in Great Britain, kept by the Royal Mail) and a NatCen Social Research interviewer visited the address. After randomly selecting one adult at the address, the interviewer carried out an hour-long interview. The participant answered most questions by selecting an answer from a list on show cards.

With the need to move to remote completion of the questionnaire while social distancing measures remained in place, in 2020 participants continued to be selected at random from the postcode address file as before but were then sent an invitation asking up to two adults to participate via an online survey or over the telephone if they preferred (or were unable to take part online). In 2021 the fieldwork for the survey was conducted between 16 September and 31 October, with participants again offered the option of taking part online or by telephone only.

Although it is not possible to know exactly what impact this change has had on the 2021 BSA results, there are reasons to believe they are broadly a true reflection of public attitudes. For example, the results reflect findings from other recent surveys of public opinion, with research conducted by Ipsos for the Health Foundation (2021) and by Britainthinks for The Richmond Group of Charities (2021) also finding the public’s opinion of the quality of NHS services falling from the end of the first quarter of 2021.

In addition, NatCen Social Research, the survey organiser, has made efforts to minimise possible impacts of the change in survey methodology. The data is weighted to correct for any unequal probabilities of selection, and for biases caused by non-response from different households offered the survey. The weighted sample was calibrated to match the population in terms of age, sex, education, ethnicity and region.

Additionally, the 2020 and 2021 surveys were conducted on the same methodology and so are directly comparable and showed a fall in overall satisfaction with the NHS of 18 percentage points, the largest in the survey’s history. The falls in satisfaction with individual services are consistent with this overall fall in satisfaction. For these reasons, in this report we feel confident in making comparisons with earlier years of the BSA survey. But as ever with any sample surveys, readers should exercise general caution in comparing results with earlier years.

The achieved sample size for the overall NHS satisfaction question was 3,112[1] in 2021. For questions about satisfaction with specific NHS and social care services, the sample size was 1,039.

Statistical significance

If a change or difference in attitudes is statistically significant, 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. 

Topics

The topics covered by the BSA 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 others are asked less frequently.

Funding

The survey is funded by a range of charitable, academic 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.

Questions

The exact wording of the social care satisfaction question has changed over the years. Questions asked were:

  • 2021: 'From your own experience, or from what you have heard, how satisfied or dissatisfied are you with social care for people who cannot look after themselves because of illness, disability or old age?’ 
  • 2012–19: ‘And how satisfied or dissatisfied are you with social care provided by local authorities for people who cannot look after themselves because of illness, disability or old age?’

Corresponding changes were made to the ‘contact with services’ question.

Acknowledgements

Many thanks to colleagues at NatCen Social Research for its work on the survey and the data, particularly Sarah Frankenburg and Hannah Morgan. Also to Sophie Anderton and the press and public affairs team at The King’s Fund for analysis of the media stories during the fieldwork period, and to colleagues at The King’s Fund and Nuffield Trust who provided helpful comments on earlier drafts and helped with the editing, digital content and launch of this report. Most importantly, we would like to thank members of the British public for the time they took to complete the BSA survey and for providing us with this fascinating dataset.

 

[1] Sample sizes for the overall NHS satisfaction question by nation are England: 2,709; Scotland: 272; Wales: 131.

Partners

The King's Fund

Suggested citation

Wellings D, Jefferies D, Maguire D, Appleby J, Hemmings N, Morris J and Schlepper L (2022) Public satisfaction with the NHS and social care in 2021: Results from the British Social Attitudes survey. Report, King's Fund and Nuffield Trust.