Undoubtedly the most striking feature of this latest British Social Attitudes survey is the unprecedented drop in public satisfaction with the way the NHS runs compared to the all-time high recorded in 2010 (and following a decade of continuous increase). While satisfaction with many of its component services also fell, these reductions were on a smaller scale than for the NHS overall. This reinforces our hypothesis that the overall decrease in satisfaction reflects an increase in general concern about NHS services and their future augmented by specific worries about the government's controversial organisational reform of the NHS in England.
In line with the sudden drop in satisfaction, there has been a marked increase in the proportion of people saying that the general standard of care in the NHS over the last five years has deteriorated. Moreover, while just over a quarter anticipate that the standard of care in the NHS will get better in the next five years, more than a third think it will get worse.
Given this generally critical picture, it might not seem surprising that more than half the public thinks the NHS needs "a few changes" and another three in ten that it needs "many changes". Few, though, express the stronger view that the system needs to be completely changed. Meanwhile, as we have discussed, the NHS is currently facing major modifications, not least a virtual freeze in real funding growth for health care between 2011/2012 and 2014/2015 in England, and some real reductions for the NHS in Wales and Scotland. This can be considered relatively generous compared with the treatment accorded to other areas of government spending in these austere times, and an indication that government has recognised the public's view (confirmed by this latest survey) that the NHS is a top priority for spending. Nevertheless, a spending standstill amid increasing demands on the service cannot be said to compare favourably with the doubling in real NHS spending that occurred between 2000 and 2010. Hence scope has been created for the kind of public disquiet seen in our survey.
Although health remains the public's top spending priority, 2011 saw a continuation in the decline in the proportion of people according it top priority. An alternative to spending more on the NHS would be to curtail the cost to taxpayers by restricting access to NHS services and moving those who can afford to pay for their health care towards an insurance-based or privately-funded system. However, our findings show that most people (73 per cent) remain opposed to limiting the scope and funding of the NHS in this way, to an extent that is broadly unchanged since the 1980s. Yet we have also seen that mainstream opposition to fundamental changes does not mean that people are convinced that they won't ever happen. On the contrary, a significant minority (44 per cent) do not expect that in 10 years' time the NHS will still be paid for by taxes and free to all - which is almost as many as the 47 per cent who anticipate no change.
Aside from the spending squeeze, one other major change already affecting the NHS is implementation of the government's organisational reforms in England. clinical commissioning groups led by GPs are being created to buy health care services on behalf of their local populations in place of primary care trusts, and thus take control of around 60 per cent of the total NHS budget. Encouragingly for the government, our survey finds that a third of the population think their local GPs are the best people to decide how money is spent on their local NHS, while other options command less support. But this can scarcely be read as a ringing public endorsement of the reforms.
Meanwhile, as the NHS grapples with far-reaching organisational changes and a stringent financial climate, decisions about priorities and how to improve public health assume even greater importance. Local GP commissioners will have to make difficult decisions about how best to allocate a fixed budget between NHS services and patient groups in need of care. Interestingly, the results when we invite the public to tackle this problem (albeit for a much-limited range of services) suggest a marked preference for investing in community health services, exemplified by nursing care at home. In relation to wider government intervention to promote healthier lifestyles we have also seen how people are less keen on 'harder' financial inducements or recourse to the law (for example, to ban drinking in public places) than on 'softer' support, such as advice on healthy diets or how to give up smoking. In addition, little more than one in five of the population view the taxation of 'unhealthy things' (such as alcohol) as the best way to encourage healthy living. As policy makers confront the daunting challenge of extracting greater value from the strictly limited resources now available for the NHS, this is a reminder that the effectiveness and cost-effectiveness of treatments and services cannot be the only consideration. By promoting better public health they might reasonably hope to reduce the need for more expensive medical interventions. But they will also need to acknowledge people's awareness, demonstrated in our survey, of a balance between personal liberty and government action, which it could prove problematic to upset.
We await with interest the satisfaction levels recorded in 2012, which, given our suggested explanations for the precipitous drop in satisfaction in 2011, we might expect to have recovered somewhat as the intense debates surrounding the proposed plans subside. However, while the Health and Social Care Act has now progressed to the statute book, this is just the beginning of changes that will only start to take effect towards the end of 2012. Whether or not public satisfaction levels will return to their high of 70 per cent once the NHS reforms are in place remains to be seen.
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- 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
- 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
- The bases for Table 5.4 are as follows:
- 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.
- 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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