Satisfaction with the NHS and its standards of
We begin with an examination of the public's views on how well the NHS is performing. To do so we use people's responses to the latest British Social Attitudes survey including their replies to questions asked as part of the International Social Survey Programme.1
In most years since 1983 British Social Attitudes has asked the public:
All in all, how satisfied or dissatisfied would you say you are with the way in which the National Health Service runs nowadays?
In our previous survey, carried out in 2010, the public expressed the highest level of satisfaction yet recorded by the study, with 70 per cent saying they were "very" or "quite" satisfied with the NHS. Our most recent reading (Figure 5.1) shows that satisfaction has fallen since then by 12 percentage points to 58 per cent.
The decline in satisfaction with the NHS overall is broadly reflected in views about different NHS services with a decline in satisfaction with GPs, Inpatients, Outpatients and Accident and emergency services between 2010 and 2011 (Table 5.1). Conversely, satisfaction with dentistry increased, rising five percentage points to 56 per cent in 2011. This has been attributed to increased funding and efforts to improve access following the Steele review of NHS dental services (Steele, 2009; Appleby, 2012b).
How can we explain this decline in overall satisfaction and with many NHS services? Firstly, it may well be that respondents are expressing greater dissatisfaction with the NHS as a proxy for their dissatisfaction with other matters - such as the coalition government itself or its wider policies. Previous surveys have shown us that people who identify with a particular political party tend to voice greater satisfaction with the NHS when that party is in power - and vice versa (Appleby and Alvarez-Rosete, 2003). However, while we see Labour supporters' satisfaction fall by 17 percentage points a year after the 2010 election - reflecting an expected partisanship - we also see Conservative and Liberal Democrat satisfaction fall. So while there is a degree of partisanship apparent, and this can explain some of the decline, the fact that even supporters of the governing parties recorded a decline in satisfaction suggests a more complicated story. There were no significant differences by other demographic indicators - satisfaction levels fell among all age groups, income bands and educational qualifications.
Part of the story could be that expectations of good service from the NHS have increased disproportionately compared with the quality of service being delivered. Public expectations of the quality of the services the NHS provides can be expected to go on increasing over time. But there seems little reason (or evidence) to suppose that rising expectations outstripped NHS performance to the extent that they alone could account for the biggest fall in satisfaction since the survey began in 1983.
Alternatively, falling satisfaction might reflect an actual deterioration of the quality of service people receive. British Social Attitudes asks for people's perceptions of whether the general standard of health care in the NHS has been getting better or worse "over the last five years". Comparing responses to the latest survey with replies obtained in 1995, we see a picture of perceived improvement. Three in ten now say the NHS has got better in the last five years, compared with one in six when the question was first asked (Table 5.2). However, in line with the decline in current satisfaction, we see that there has been a fall of nine percentage points since 2010 in the proportion thinking there have been improvements. The proportion who say that the standard of health care has got worse has, meanwhile, increased by 11 percentage points to 27 per cent.
Interestingly, other recent surveys (Care Quality Commission, 2012a, 2012b; Department of Health, 2012b) have not recorded a decline in the public's actual experience of the NHS. Key performance data collected on waiting times and health care-related infections have also generally been good (Appleby et al., 2012). Evidently, though, there is now a perception among the general public that improvements made over the last few years are not being sustained.
A further possible explanation for declining satisfaction is that people are responding to negative media coverage of the NHS rather than thinking of their own experiences of health care. To investigate this we compare respondents with experience of hospital services in the last 12 months against those without.2 While both groups' satisfaction with the NHS is likely to be influenced by media stories, it might be expected that those with recent experience of the NHS will, in addition, take account of their own personal experience. In 2009 those with recent experience of hospital services expressed higher levels of satisfaction with the NHS overall than those with no recent experience (68 per cent and 61 per cent respectively). This remains the case in the latest survey, with 62 per cent recent hospital service users expressing satisfaction, compared with 56 per cent of non-users (though the difference is no longer statistically significant, likely due to the smaller base size). Importantly, however, as satisfaction fell by similar amounts for both groups we are not able unequivocally to conclude that a decline in satisfaction was due either to media influence or actual experience.
Finally, decline in satisfaction might be explained by the ambient effect of an intense political and media debate about the NHS that was taking place during the summer and autumn of 2011 when the British Social Attitudes questions were asked, and also worries for the future of the NHS arising both from the government's reform plans and well-publicised funding pressures. Not only was there continuing strong criticism of the Health and Social Care Bill from the British Medical Association and other health professionals, but the government was also facing renewed objections in the House of Lords after it had felt obliged to 'pause' the Bill's progress for a month of consultation. The declining satisfaction identified by our survey may, therefore, reflect uncertainty surrounding the future of the NHS and widespread antipathy to the proposed reforms. These may be reinforced by an impression that the NHS is coming under financial pressure (see Appleby, 2012b).
However, if we think that controversy surrounding the Coalition's health reforms is largely responsible for the sharp decline in satisfaction, it is important to remember that the new legislation applies only to England. This makes it potentially surprising that satisfaction levels also fell in Scotland (by 17 percentage points to just 50 per cent) and Wales (by nine percentage points, to 55 per cent), where governments have devolved powers over the NHS. The lower number of interviews in Scotland and Wales means we must interpret our figures with caution. However, we have seen in previous years that attitudes in Scotland tend to parallel those in England (Curtice and Ormston, 2011) and with both Scotland and Wales enduring a tighter squeeze on NHS funding than England, declines in satisfaction are perhaps to be expected.
In order to untangle what factors are affecting people's reported levels of satisfaction with the NHS we ran a logistic regression (full results can be seen in the appendix to this chapter). Through this we can see that, after controlling for a range of respondent characteristics, there are certain attitudes that are strongly linked with satisfaction. For example, as might be expected, those who thought that services had got better in the last five years were more likely to express satisfaction overall. Also, satisfaction with certain services, notably GPs, Inpatients and Outpatients, was linked with satisfaction with the service overall. Further, those who believe the NHS will remain freely accessible in 10 years' time (dealt with later in the chapter) are more likely to express satisfaction with the NHS now.
In summary, it seems likely that a decline in overall satisfaction with the NHS can be explained by several different factors. Of these, anxieties about the government's far-reaching reforms to the organisation of the NHS and - to an extent - worries arising from the slow-down in funding growth are likely to play a prominent role.
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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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