Health / Change and the NHS

Does the NHS need to change and, if so, how?

So far we have seen that overall satisfaction with the NHS, although it remains quite high, has taken a sharp downturn since 2010. The proportion of the population who think the service has improved over the last five years has also declined. We look now at respondents' thoughts on the future of the NHS.

For the first time, the latest survey asked people if they thought the general standard of health care in the NHS would improve or get worse in the next five years. In line with our thesis that current dissatisfaction relates to the level of public uncertainty about NHS reform, more than a third believe that NHS health care will get worse (Table 5.3). They outnumber the roughly one in four who consider it will improve.
 

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This pessimistic view chimes with a Department of Health survey of NHS staff, which showed that 53 per cent of those surveyed in the winter of 2011 felt the standard of NHS care to patients would get worse - an increase over the result of the Winter 2010 survey (49 per cent) and the Spring 2009 survey (34 per cent) (Department of Health, 2012c: 21).

We then looked at what enthusiasm, if any, exists for changing the NHS by asking:

In general, would you say that the health care system in Britain needs no changes, needs a few changes, needs many changes, or, needs to be completely changed?

undefinedThe replies suggest an appetite for modest, though possibly not radical, reform. Over half (55 per cent) believe that "a few changes" are needed, and another third (32 per cent) that the NHS requires "many changes". Only five per cent say that no change is necessary - which is also the proportion who maintain that the service "needs to be changed completely". Since this question has not been asked in previous British Social Attitudes surveys we cannot assess how the public's view may have changed over time. Nevertheless, having established that most people favour at least some reform of the NHS, we move on to consider what types of change they are most likely to support.

Tax, public spending and the future of the NHS

Those who feel Britain's health system needs to be improved are faced with a number of choices as to how to do this. Three fundamental ones are what public spending priority to assign to health; what the scope of health services should be; and who should have access to them. We start by examining what spending priority the public assigns to health versus other areas of government spending, and people's personal willingness to pay more to improve health care. We also test people's confidence that a National Health Service funded through general taxation will remain the chosen model for providing health care in future. Since people generally favour reform, might not some believe that it is the NHS's founding ambition to provide a comprehensive, universal health care service that most needs to change?

As reported in the Welfare chapter, support for more taxation to pay for public services has been on the decline since 2002. Having stood at 63 per cent 10 years ago it has now fallen to 36 per cent in the latest survey (though this is up five percentage points from 2010). Correspondingly, there has been an increase in the proportion saying the government should "keep taxes and spending at the same level", from 31 per cent in 2002 to 54 per cent in the latest survey - a trend in part reflecting increases in spending in some key areas (such as the NHS) over this period: as more is spent, a decreasing proportion of the public see the need to spend even more.

undefinedBritish Social Attitudes also asks people to choose from a list one area of government spending they would prioritise for extra spending, and then to select an area as their second choice. As seen in Figure 5.2, when first and second choices are added together, health has consistently been the public's top priority, with 68 per cent choosing health in the current survey. Education comes a reliable second, while other areas of government spending such as police and prisons and housing (the third and fourth top priorities in 2011) are given much lower priority. The priority that the public accords to health can, in a sense, be said to accord with the coalition government's spending priorities, which are to hold level the amount of money going to the NHS, while other areas undergo extensive cuts. However, it is interesting to note the general decline in the priority given by the public to the NHS for extra funding since the turn of the century. As with the declining proportion of those who want higher taxes and more spending on public services in general, this is a trend that perhaps mirrors the funding increases the NHS has received since that time; as more money goes in, the public have perceived less need for increased funding. Of interest too is the fact that this decline in the priority accorded to the NHS continues in 2011. This might suggest that worries about funding are not in fact a significant factor explaining the fall in satisfaction with the NHS.
 

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Our next question investigates people's own willingness to pay higher taxes in order to improve the level of health care "for all people in Britain". In line with opinions on the question of whether taxation should rise to fund public services, we find that nearly four in ten (38 per cent) say they would be prepared to pay more. Another one in four (26 per cent) say they would be neither willing nor unwilling, while almost one in three (31 per cent) would be unwilling. We find a significant link (at the 90 per cent level) between satisfaction with the NHS and willingness to pay more to support the service. So it could be that steps to ease funding constraints would be a way to arrest the current decline in public satisfaction.

When we compare the answers to this and the previous question by demographic group, we find those who favour raising taxes to pay for public spending in general are outnumbered in most groups by those who would be willing to pay more tax to fund the NHS in particular (Table 5.4). Willingness to pay more tax to fund the NHS is especially strong among people aged 55 to 64, among Labour and Liberal Democrat supporters, and among those with higher academic qualifications. Conservative supporters, although least likely to give a positive answer to either question, are noticeably more likely to express willingness to pay more tax themselves to benefit the NHS than to support tax increases for public services in general.
 

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An alternative to 'tax and spend' could be to reduce the scope of what the NHS offers by limiting access. For example, we ask:

It has been suggested that the National Health Service should be available only to those with lower incomes. This would mean that contributions and taxes could be lower and most people would then take out medical insurance or pay for health care. Do you support or oppose this idea?4

The answers (Figure 5.3) show that, for more than 20 years now, the proportion opposing this suggestion "a lot" or "a little" has consistently remained at or above 70 per cent. (The lowest level of opposition - and the highest level of support - was recorded back in 1983 when the then Prime Minister, Margaret Thatcher, was at her most popular.) The latest survey does, however, show a dip in opposition, and an increase in support for a health care system based on medical insurance or direct payment. But the proportion in favour of changing the NHS funding model is still below 30 per cent.
 

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In a similar vein, but without referring to income, the latest British Social Attitudes survey also asks how much people agree or disagree that "the government should provide only limited health care services". Again, 73 per cent voice opposition to the proposition. However, the level of agreement is much lower than for the previous question at just nine per cent.

We also ask what people believe will happen in reality:

In ten years' time, do you think the NHS will still be paid for by taxes and free to all?

undefinedThe public is not overwhelmingly confident that the service's traditional funding model will survive. While just under half (47 per cent) reply "yes", a very similar proportion (44 per cent) say "no". When we look at this against people's reported levels of satisfaction with the NHS overall we see that those who think the NHS will not be free and available to all in 10 years' time are significantly less likely to express satisfaction with the service now (50 per cent, compared with 63 per cent of those who think the NHS will remain freely accessible). Whether a view that the NHS will not be tax-funded and free to all in future causes lower satisfaction now or vice versa is impossible to say. Furthermore, it cannot be assumed that everyone who thinks NHS funding and access will change in future necessarily regards this is a bad thing - although the responses to our previous question on limiting access to the NHS (Figure 5.3) do suggest that most would see this as a negative change.

While many feel the NHS needs to change to some degree, radical changes to its funding source and the scope of its services are not generally the kind of change they have in mind. Even so, a large minority think this is what will, in fact, happen.

Setting priorities and commissioning local health services

While the coalition government's reforms stop short of any fundamental changes to the NHS as a publicly-funded, universal and comprehensive service, the administrative changes it is implementing are nevertheless far-reaching. As previously noted, the key reform is the creation of local clinical commissioning groups run by GPs, replacing primary care trusts as the purchasers of secondary care. The central argument advanced for this change has been that GPs are better-placed to make decisions about priorities and spending as they are closer to patients. But who do the public think can best decide how NHS money is spent? What sort of service priorities do they think the NHS should pursue and - more broadly - what kind of public health measures do they favour for promoting healthier living?

We asked people who they think "should decide how money is spent on your local NHS" and offered them four options: "the government", "your local GPs", "your local council" and "local people". The responses (Table 5.5) show that there is no majority view. Around one in three say the spending decisions should be taken by local GPs, while just under a third consider that they should be the remit of central government, and around one in six choose "local people" or the "local council" respectively. Broadly then, there is some support - though not overwhelming - for the central plank of the government's reform programme to put GPs in charge of deciding how around 60 per cent of the NHS budget should be spent.
 

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Regardless of who makes the decisions about health care spending, any NHS service commissioner faces difficult choices about the priorities for that spending. To test public opinion about the types of health spending that should receive priority, given limited resources, we invited respondents to imagine they had charge of an NHS budget, with 40 "beans" or counters to allocate between four specific areas of spending. These were selected broadly to represent community services ("increase community nurses to support people with long term health problems in their own homes"), hospital care ("reduce hospital waiting times for people who need a hip operation"), mental health treatment ("expand access to counselling and 'talking therapies' for mild/moderate depression") and preventive public health services ("give more help for people who need to lose weight").

undefinedAggregating the way people allocated their beans across these four areas produces the distribution shown in Table 5.6. We see that respondents collectively earmark 38 per cent of the hypothetical health budget for community nursing services. Public support for this sort of service, helping people with long term conditions at home, chimes with professional efforts over many years to shift care provision towards the community where appropriate, rather than providing it in hospitals. The strength of support for more investment in community services may also reflect a feeling that, notwithstanding the long term shift in policy, such care continues to be underfunded. It is also interesting that despite substantial reductions in the waiting times for operations and other hospital treatments in recent years, the public votes to allocate as much as 30 per cent of its notional health budget to reduce the time that people need to wait for a hip operation.

Support for the mental health option is given less priority, attracting 20 per cent of the notional budget, while the lowest share (12 per cent) is given to support for public health through a weight loss programme. The low priority given to this last choice may, in part, reflect a feeling among some people that helping people who need to lose weight is not even an appropriate activity for the NHS: looking at the way individuals allocate their budget beans we find that as many as three out of 
ten respondents allocated none of them to the public health option.
 

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Ways to improve public health

To investigate further what kinds of public health intervention people consider more or less acceptable, we asked them to say what in their view would be "the best way for the government to help people to lead healthier lifestyles". The options they chose between were:

Leave people to make their own choices without interfering

Provide information (e.g. on healthy diets, how to give up smoking)

Pay people (e.g. to give up smoking or take more exercise)

Use the law (e.g. to ban drinking in public places)

Tax unhealthy things (e.g. alcohol and cigarettes)

undefinedIn general, as can be seen from Table 5.7, the public is less keen on what might be termed 'hard' interventions - such as using the law (nine per cent) or paying people in return for healthier behaviour (two per cent). The 'softer' approach that almost half say they favour is providing information on healthy diets. Despite the longstanding practice of governments in taxing alcohol and tobacco for avowedly 'health' as well as 'revenue' reasons, we also see that little more than one in five think it offers the best way to promote healthier lifestyles. Just under one in five, meanwhile, take a libertarian view, insisting that people should be left to make their own health choices without government interference.
 

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Notes
  1. The International Social Survey Programme is conducted annually in 48 countries. In Britain it is carried out as part of the British Social Attitudes study, with funding from the Economic and Social Research Council. For more details see the website: www.issp.org/index.php
  2. People with experience include those answering "Yes, just me", "Yes, not me, but a close family member or friend", and "Yes, both me and a close family member or friend" to questions about use of inpatients and/or outpatients in the last 12 months
  3. The bases for Table 5.4 are as follows:

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  4. There have been minor variations to this question over the years. From 1983 to 1994 the answer options were "support" and "oppose"; from 1995 to 2010 the answer options were "support a lot", "support a little", "oppose a lot" and "oppose a little", with respondents being prompted to say "a little" or "a lot". In 2011 the same four answer options were retained but presented to respondents on a showcard.
  5. Readings are indicated by data marker; the line indicates an overall pattern but where there is no data marker the line cannot be taken as a reading for that year.
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  • Notes
    1. The International Social Survey Programme is conducted annually in 48 countries. In Britain it is carried out as part of the British Social Attitudes study, with funding from the Economic and Social Research Council. For more details see the website: www.issp.org/index.php
    2. People with experience include those answering "Yes, just me", "Yes, not me, but a close family member or friend", and "Yes, both me and a close family member or friend" to questions about use of inpatients and/or outpatients in the last 12 months
    3. The bases for Table 5.4 are as follows:

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    4. There have been minor variations to this question over the years. From 1983 to 1994 the answer options were "support" and "oppose"; from 1995 to 2010 the answer options were "support a lot", "support a little", "oppose a lot" and "oppose a little", with respondents being prompted to say "a little" or "a lot". In 2011 the same four answer options were retained but presented to respondents on a showcard.
    5. Readings are indicated by data marker; the line indicates an overall pattern but where there is no data marker the line cannot be taken as a reading for that year.
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