Editorial Tuesday 12 June 2012: The British Social Attitudes NHS survey and the NHS staff survey

Health Policy Insightexclusively revealed last year that the Department of Health was discontinuing its funding of the health questions in the British Social Attitudes survey.

This morning, a discussion with the NatCen team who conduct the BSA survey confirmed that the DH was the only one of several sponsoring government departments to pull its funding for BSA survey questions.

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Click here for details of 'The Tao of Andrew Lansley', the new issue of subscription-based Health Policy Intelligence.

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The Kings Fund stepped into the breach, and have just released this year's findings, which were researched from July-November last year.

They are significant. Overall satisfaction with the NHS fell from an all-time high of 70% in 2011 to 58% this year. Even allowing for errors of measurement, a 12% fall in one year is a big shift.

Why the big shift?
The Kings Fund's own analysis looks at a number of possible contributing factors.

The first is simple error. As they note, "surveys are based on samples and so results will always be subject to some uncertainty. In addition, differences between years in, for example, the ordering of questions may affect responses.

"In 2011 the health care questions were asked of a third of respondents (1,096), whereas in previous years they were asked of two-thirds or the full sample (which equates roughly to 2,200 and 3,300 respondents respectively). Thus the margin of error associated with the results obtained in 2011 is higher, at +/- 3 to 5 percentage points, compared with around +/- 1 to 2 points in previous years. Nevertheless, even at the extremes of this margin, the satisfaction results for the NHS overall, for example, remain statistically significantly different from those in 2010".

So, has the NHS's performance become worse? Not according to useful proxy measures of healthcare-associated infections, or waiting times, as the Fund's analysis points out.

The commentary also observes that "patient experience surveys of inpatients (Care Quality Commission 2012a), outpatients (Care Quality Commission 2012b) and the GP Patient Survey (Department of Health 2012) also show little or no significant reduction in general measures of the quality of the experience patients report. For example, 43 per cent of respondents to the 2011 NHS inpatient survey rated the care they received as ‘excellent’, 35 per cent as ‘very good’, 14 per cent as ‘good’, 6 per cent as ‘fair’, and 3 per cent as ‘poor’. The only change since 2010 was a slight decrease in the proportion rating their care as ‘good’ (though the difference was so small it was lost in the rounding of the results).

"Similarly, Ipsos MORI’s regular issues survey investigating current concerns among the public shows an association with the British Social Attitudes survey satisfaction results, particularly from 2001 onwards (see graph below, Ipsos MORI 2012b). A similar ‘concerns’ tracker poll by YouGov suggests the NHS fell back slightly as one of the most important issues facing the country between 2010 and 2011 (YouGov 2012a)".

Moreover, the specific responses on the range of NHS services finds a decline with public satisfaction in each area, with the interesting exception of dentistry, which is up by 5%. Even satisfaction with general practice is down, which is unusual.

What is it all about?
The British Social Attitudes survey is not and does not purport to be the biggest nor most authoritative survey of NHS performance. In Ronseal terms, it does what it says on the tin: it reports on social attitudes. It has been run almost every year since 1983, and while it would be unwise to over-interpret one year's findings, the degree of overall drop is striking.

Is it about perception more than reality? The data includes imputed figures for 2010, but suggests "a fall in satisfaction with the NHS overall of 11 and 6 percentage points for contact and no contact groups respectively".

Can we blame respondents' politics?
The research also examines responses graded by respondents' declared politcal allegiances.

The analysis suggests that "although there is a noticeable drop in satisfaction as expressed by Labour party supporters in 2011 (following a flattening of satisfaction in the election year of 2010), there are also falls in satisfaction for Conservative and Liberal Democrat supporters. These later falls followed on from increases in satisfaction for both groups in the election year of 2010".

The finding is not too surprising, given the contentious nature of the Health Bill within the Conservative and especially Liberal Democrat parties.

Can we blame the media?
The legendary Health Minister Simon Burns today followed this analysis on the BBC Radio Four Today programme (2 hrs 37 mins in), suggesting that the political rows during the research period - "the height of the controversy over the Health Bill ... it was influenced by the noises-off in the political sphere - there was a lot of disinformation being put about with regard to by politicians and by some people in the medical profession who were fighting their corner".

It would be absurd to have taken a poll of British social attitudes about the NHS during that period and not to expect the wild unpopularity of the Health and Social Care Bill to have had an impact. So far, so much of a psalm from the Good Book Of Things That Are Not Surprising.

Yet Simon Burns rightly referred to previous controversial NHS reforms, by Kenneth Clarke in the early 1990s and by New Labour in 2003. Neither of these were associated with a vertiginous drops. Indeed, if you look at this figure, you will see that the 1990-1 and 2003 trends recorded saw public satisfaction among all three parties rising.

That is Quite Interesting.

As is Chart Five (p. 21) of the latest NHS staff survey, which reveals that the percentage of NHS staff who think that patient care will get worse over the coming few years rose from 34% in the summer of 2009 to 53% in winter 2011.

Chart 6 on the following page shows that all categories of NHS staff apart from clinical leaders and community workforce expect patient care to get worse.

It is unsurprising to see that NHS managers believe care will worsen, as so many of them will lose their jobs. However, the survey rightly notes on page 69 that "NHS managers continued to be the most likely to be aware of and supportive of NHS reforms ... (and) were less likely than average to agree that reducing targets will empower staff to provide better quality care (45% Winter 2011 compared with 53% on average in Winter 2010). They were however, more likely than average to agree that it will be possible to increase the quality of patient care whilst reducing costs (57% Winter 2011 compared with 40% on average Winter 2010)".

It is fascinating to see that 49% of GPs thought care would get worse in summer 2009, rising to a plateau of 63% in winter 2010, falling back to a scarcely-reassuring 61% in the winter 2011 polling.

On page 69, the document observes that "Clinical leaders were again as likely as NHS managers to be aware of the reforms, but they were amongst the most likely to say that changes to open up the provision of NHS services will have a negative impact on the quality of patient care (54% negative compared with 34% average)".

By interesting contrast, Charts 32 and 33 on pages 61-2 suggest that optimism is increasing about the perceived impact of the commissioning aspects of the reforms on quality of patient care (up from 34% in winter 2010 to 46% in winter 2011) and on effective and efficient NHS functioning (up from 34% in winter 2010 to 42% in winter 2011).

On page 40, the document notes that "views on the impact of the changes on the longer term stability of NHS organisations were generally not positive. Over a half (54%) thought that the changes would have a negative impact whilst only a quarter (27%) held a positive view (Chart 17). NHS Managers (74%) were amongst the most likely to think it would have a negative impact which is in contrast to their more usual positive outlook on NHS reform. Other staff groups who were more likely than average to be negative were:
 PCT Commissioners (88%)  Clinical Leaders (78%)  Senior Hospital Doctors (76%)  GPs (67%)".

On resources, the survey found that "three quarters (74%) of staff agreed that the NHS is under resourced; whilst almost nine in ten (87%) agreed that there is waste and inefficiency in the NHS. Views on both of these measures have remained consistent over time".

Elements of the reform strategy received mixed reviews (p. 49): "just over a half (53%) agreed in Winter 2011 that reducing targets would empower staff to provide better quality care for patients: down from 61% in Winter 2010 agreeing that removing targets would empower staff to provide better quality care for patients (Chart 23).

"A similar decline was evident in the proportion of staff who agreed that freeing providers from top down control would enable them to focus on improving quality of patient care (Chart 23). This fell from two thirds (67%) in Winter 2010 to more than a half (56%) in Winter 2011. ".

It also finds pessimism about achieving the reforms and the Nicholson Challenge (p. 50): "Only a quarter (24%) of staff agreed that the NHS would be able to make the necessary efficiency savings at the same time as delivering reform, but more than double this proportion (54%) disagreed, and 29% disagreed strongly".

The document is very positive on the power of information, recording that "Two thirds (64%) agreed that providing patients with information about how local health services are performing would help to drive improvement in the quality of patient care; but more than a half (55%) also thought it would cost the NHS more money.

"Three fifths (63%) felt the initiative to increase patient information and choice would have a positive impact on the quality of patient care, with a significant increase in those thinking it would have a great deal of impact (16% Winter 2011 compared with 8% Winter 2010). More than half (55%) felt the initiative to increase patient information and choice would have a positive impact on how effectively the NHS operates. Again the proportion feeling it would have a great deal of positive impact has increased over the past year (10% Winter 2011 compared with 4% Winter 2010)".