Changes for the NHS between 1983 and 2012
Understanding how public perceptions of the NHS have evolved over the last 30 years requires us to consider how the NHS in particular and Britain more generally have changed over that period. Firstly, there have been changes in the size, age profile and health of the British population, affecting the demands on the NHS. Secondly, there have been major changes in government spending on health care, and in policies around the structure and management of the NHS. Table A.1 in the appendix to this chapter shows how Britain and the NHS have changed between 1983 and 2012, across a range of measures; key ones are described below.
Over the last 30 years there have been huge changes in the size of the population of Great Britain and in its demographic structure. Between 1983 and 2012, the British population grew by 6.7 million people - twice the population of Wales and equivalent to the creation of six new cities the size of Birmingham (Office for National Statistics, 2012). In terms of the number of people drawing on NHS services, demand has increased by 12 per cent over the period. In reality, however, the demand on NHS services has risen more than this, as the British population has also aged. Between 1983 and 2012 there was a historic switch in the demographic profile of NHS users, with the number of people of pensionable age overtaking the number of children in the population: the number of pensioners in Britain increased by 21 per cent, to 11.9 million (Office for National Statistics, 2011a, 2011b). Over the same period, greater wealth, lifestyle changes and increased funding for health care have also contributed to people living longer: life expectancy has increased from 90 to 94 years for women and from 85 to 91 years for men between 1983 and 2012 (Office for National Statistics, 2011c).
Spending on the NHS
Over the past 30 years, the UK economy has grown considerably: its Gross Domestic Product (GDP) per capita (an indicator of the country's standard of living) increased in real terms by 73 per cent over the period. Health care has been a major focus of government spending of this extra wealth, with spending on the NHS more than trebling in real terms between 1983 and 2012, from around £39 billion to nearly £120 billion. The government now spends an average of £2,054 per person on their NHS care, compared with only £737 in 1983 (the 1983 amount is inflated to reflect 2012 prices) (Organisation for Economic Co-operation and Development, 2013). Figure 4.1 shows how real spending has grown since 1983, with real increases in most years. While there have been year to year fluctuations in the change in real spending, average annual spending increases from 1983 to 1997 were generally smaller (+3.2 per cent) than the period from 1997 to 2009 (+5.9 per cent). The more recent impact of the spending restraint from 2010 onwards is also evident with a real average annual reduction in spending of around 0.8 per cent.
Extra spending on the NHS has led to increases in resources - the number of doctors for every 1,000 people in the population has more than doubled, for example. Together with changes in medical technology and new drugs, this has contributed to a fall in death rates by a quarter and a fall in infant mortality rates by 60 per cent (Office for National Statistics, 2013b). Importantly, factors other than health care - such as increased wealth and changes in lifestyle - have also made major contributions to improved health. For example, in 1983 37 per cent of men and 33 per cent of women smoked; by 2010 these figures had dropped to around 20 per cent for both sexes (Cancer Research UK, 2013).
Changes in the structure and management of the NHS
At the start of British Social Attitudes in 1983 there was a Conservative government. Over the period to the end of Conservative rule in 1997, the NHS was subject to a number of organisational changes. In 1984 for example, the general management restructuring following the Griffiths Inquiry (Griffiths, 1983) a year earlier was implemented together with changes in management and organisational layers in the NHS. Perhaps the most significant policy development of the period was the introduction in 1991 of an internal market into the NHS. The White paper Working for Patients, published in 1989, set out the basic idea of a separation between purchasers (health authorities and GP 'fundholders') and the providers of secondary care services (Department of Health, 1989). The competition between providers for contracts and patients was expected to improve quality and efficiency.
While the various structural reorganisations - including the internal market - kept the administrative and political groups busy, the impact of these changes on patients, the public and the performance of the NHS was more difficult to discern. On a key and high profile measure of NHS performance - hospital waiting times - the Conservative administrations from 1983 recorded some success, reducing the proportion of English inpatients (excluding day cases) waiting over 12 months from around 30 per cent in 1983 to just four per cent (including day cases) in the summer of 1997. Figure 4.2 shows trends in waiting times for inpatients and day cases on a consistent basis (Department of Health, 2010). But such success was largely a result of specific efforts, such as directing money through the waiting times initiative as well as setting targets for reductions via the Patients' Charter (Department of Health, 1991), rather than the various reorganisations of the NHS. And despite this, over the period from 1983 to 1997 the number of people on English NHS waiting lists grew and over a quarter of those on lists still waited over six months for admission to hospital.
In the year that the Labour Party regained power, spending on the NHS across the UK fell in real terms, the first time since the early 1950s. Waiting times were still an issue of concern for the public, to the extent that a promise was made as part of the Labour Party's 1997 'pledge card' to reduce the number of patients on NHS waiting lists by 100,000. While this missed the point that the public's concern was with waiting times rather than the length of the queue per se, over the next decade the Labour government achieved significant reductions in waiting times. However, as Figure 4.2 shows, it was only from 2003 that they made further inroads into reducing long waiting times.
Again, this success came not through large-scale organisational reform (although that too was to happen) but through tough targets and sanctions on hospitals and managers, coupled with increased spending and practical support to disseminate ways of managing patients through the system more speedily. By March 2010, just over nine in ten inpatients waited three months or less for admission and virtually no one waited more than six months (Figure 4.2).
The Labour government stuck with the spending plans of its Conservative predecessor until 1999, when the significant decision was taken to increase spending on the NHS (with the aim of eventually matching the average of those countries then constituting the European Union). Between 1997 and 2009, NHS spending increased from 5.4 per cent of GDP to 8.4 per cent, compared with virtually no change in spending as a proportion of GDP between 1983 and 1997. Higher spending allowed the NHS to employ more staff. While the number of NHS doctors per 1,000 population increased by 0.6 over the 16 years from 1983 to 1999, over the 11 years from 1999 to 2010 the number increased by 0.7 (Organisation for Economic Co-operation and Development, 2013).
More contentiously perhaps, the Labour Party's 1997 manifesto policy to abolish the internal market was, by 2000, revised and a more active approach was taken to encouraging competition within the NHS through greater formalisation of patient choice and the introduction of incentives to market entry from the independent sector. However, as a result of devolution, the NHS in Wales and Scotland took a different path, embarking on a more integrated and alternative approach to the use of competition.
When the coalition government came to power in 2010, Britain's economic problems necessitated a combination of tax rises and retrenchment of public spending in the wake of the global financial crisis and ensuing recession. Although spending on the NHS in England was ring-fenced, in practice this meant very small real rises compared with previous years, while in other parts of Britain, there were real cuts (in Wales) and zero real increases (in Scotland). Despite the squeeze on funding, in England at least, the historically low waiting times were more or less maintained.
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- Gross Domestic Product (GDP) is the monetary value of all goods and services produced in a country in a given year.
- Spending for 2012 based on spending plans for England, Wales, Scotland and Northern Ireland.
- The question on satisfaction with A&E departments was not introduced until 1999.
- Correlation between Labour and Liberal Democrats r=0.92; correlation between Conservative and Labour r=0.49.
- The correlation is very high between the two age groups: r=0.88.
- Weighted bases for Table 4.1 are as follows:
- There have been some minor variations to this question over the years. 1983-1994 the answer options were "support" and "oppose"; 1995-2010 the answer options were "support a lot", "support a little", "oppose a lot", "oppose a little", with respondents being prompted to say "a little" or "a lot"; in 2011 the same four answer options were retained but also added to a showcard.
- In statistical terms, there is a strong negative correlation between the level of satisfaction with the NHS and views on increasing taxation and spending (over the whole period from 1983 to 2012, r=-0.85). There is a similar, but positive, correlation with the opinions that taxes and spending should be kept the same (and with views on reducing taxes and spending).
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