Editorial Wednesday 19 December 2012: The Ipsos MORI 2012 Almanac and the NHS and healthcare

I may be a world-class curmudgeon, but I do take requests - especially when they come from my friend Alastair McLellan, editor of the indispensable Health Service Journal.

With that in mind, here are a few thoughts about top pollsters Ipsos MORI's 2012 Almanac.


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One of the first things to say is that (as Ipsos MORI's dynamic chief executive Ben Page has often admitted) all opinion polling is subject to cognitive biases, dissonance and plain ignorance.

I well remember Ben presenting some data at the 2008 NHS Alliance conference, which found that 31% of the public thought the NHS should offer any drugs and treatments even if ineffective, no matter what the costs.

That opinion is, to use a technical term, deeply stupid.

So opinion polling should be taken with a pinch of salt.

There's an interesting graphic on page 13, which shows that in the Ipsos MORI monthly issues index, the NHS has not been the most important issue among those surveyed since 2006.

This is congruent with the service's ongoing good performance against access targets - and despite The Nicholson Challenge.

The next page brings us census data to make actuaries shiver: "the largest ever percentage of the population aged 65 and over (16.4%). There were 430,000 people aged 90 and over in 2011 in England and Wales, compared with 340,000 in 2001 (and 13,000 in 1911). By 2035, it is estimated that there will be an eightfold increase in the number of people living beyond 100 (most of whom will be women)".

Health needs grow with age - though as the eminent gerontologist John Grimley Evans pointed out, we have long been assuming the elderly will bankrupt the NHS and it has not happened yet.

The report notes a polarity in those surveyed's attitudes on the self-reliance versus corporatism axis: "Britons, young and old, are also divided about what sort of society they want. Half want 'a society where individuals are encouraged to look after themselves', half 'a society which emphasises the social and collective provision of welfare'.

Politics and tipping points
The section on politics merits a lengthy extract, noting that 2012 marked "a significant movement in voting intentions, the first since the post- election readjustment, which happened over a short period in the spring and has been sustained ever since. Prior to this, Labour’s lead over the Conservatives was small – on average in our polls during 2011 just five percentage points. In the first three months of 2012 this situation continued, perhaps even eased fractionally for the government, with Conservative support averaging 36% (just one percentage point down on their general election share), Labour 39% (up 9 points) and the Liberal Democrats 12% (only half their general election share).

"But from April onwards, Conservative share has averaged 32%, Labour 42% and the Liberal Democrats 11%, a swing of 4% against the Coalition since the first quarter. It may be a small change, but the comparison with the immovable numbers of 2011 makes it feel bigger.

"As far as the Conservatives alone are concerned, their loss in support since March has been four times the size of their total loss of support in the previous 23 months since the general election; and, should things stay this way, the difference between a 3-point Labour lead and a 10-point Labour lead at the next election is the difference between a narrow win and a near landslide".

The next chapter's title is simple: "Public service reforms: are they working?" Its view is interesting, noting "despite dramatic reform programmes, patient satisfaction in the NHS has so far stayed much higher than in the past, and public satisfaction with it is only drifting down slowly in our tracking".

Mmmmm. This isn't quite what the British Social Attitudes survey has found with the one-year drop from 70% overall satisfied to 58%, although as Dan Wellings has pointed out, the sequence and content of questions in the BSA survey frame a certain context for the section asking about the NHS.

The chapter correctly notes that "public services were – in relative terms – well funded compared to the 1990s". But its point above about a "dramatic reform programme" lacks some salience because the reforms proper in the NHS have not really started yet.

The Nicholson Challenge has started.

The reforms don't fully kick in until April 1 2013, and their effects - positive and negative - will not be immediately apparent.

Right kind of choice; wrong kind of people
Its section on choice is interesting.

The report states that "the general public’s reluctance to make the most out of information about public services also has implications for exercising choice – a key theme of this and the Blair government. When it comes to healthcare, for example, people are increasingly positive about choice. A large majority (87%) of the public agree that patients should be involved in making decisions about the care that they receive from the NHS ...  In reality, though, people are still coming up against barriers such as not knowing what services exist to choose between, not having sufficient information on the relative strengths of different providers, or the service they require is not always available in the local area".

Yet the next paragraph states that "for many people access remains more important than choosing between different quality providers – when choosing a hospital being “close to home or work” received many more mentions (38%) than the second most picked option (personal experience – 24%) and only 2% picked cleanliness as the most important to them. Our qualitative research for 2020 Public Service Trust goes some way to explain this – it shows that people generally assume, and want to believe, that public services such as healthcare are uniform across different locations. They want choice to be about finding a conveniently located hospital with appointments at a time that suits, rather than having to take into consideration cleanliness and quality of care which they believe should be a given. Indeed, when asked whether people want services adapted to local needs, or standardised across the country, the majority always opt for universal standards. As such, while the proposals to increase choice were suggested as a way to develop a healthcare market to push up standards, in fact people are reluctant for choice to be used in this way".

In other words: the people are using choice incorrectly! Bring us a different people!

There is a rather confused section which argues "Government is really trying to change the way people relate to public services, and potentially the whole nature of our relationship to the state. But it is still the economy – and the government’s response to austerity – that is dominating the public agenda, and most public servants remain mainly obsessed with taking out cost in our surveys of them, rather than trying new ways of doing things".

Erm, if you're a local authority that has just lost 17% of your core funding and sees your potential to raise council tax capped, you've got a limited palate of options here. If you're an NHS manager who has to make a 2% surplus at year end or get sacked, ditto.

It's not quite as splendidly confused as the subsequent post hoc rationalisation about nationalisation of the water industry. ""Ipsos MORI advised the Thatcher government on their privatisation of the water industry. The idea of selling off national assets like reservoirs was in some ways as popular as the recently abandoned forestry sell off. But the minister Nicholas Ridley, ignored public concerns and protests – saying that “they’ll forget about it next year” – and as far as water privatisation was concerned he was right".

I love - absolutely love - the water privatisation example.

OK - here is what markets do well: they allocate resources pretty effectively where competition and diversity of supply and informed consumer choice are possible. Most people who are not Communists accept this to be so. It's why BT in telecommunications and British Airways have both been very well suited to privatisation.

But markets are also complex, and function within social and ethical contexts.
They have externalities, both positive and negative, which must be taken into account.

There are also Very Bad Things if you accept the logic of markets: these are called monopolies. Water and sewage are absolutely, intrinsically and unarguably natural monopolies.

Imagine for one second that we were to have real competition of supply. For meaningful choice, I need a plethora of water supplies and sewage arrangements to my property. This could be just the Keynesian boost to get the economy working again!

OK: let's say I need a dump. I log on to www.youpoo.com and compare the market for the cost of a flush. The SimonBurns4SOS Corporation - Service With A Yell Of 'Nye Bevan!' offers the best deal on accepting my detritus, but their two-for-one offer makes their water marginally more expensive than Cholera Anonymous, so I go with the latter to supply the flush and handwash ingredients.

That's probably not really very feasible, though. (Of course, I could buy all my water from a major supermarket - but where would I store it all? My every spare inch of the house is full of Simon Burns campaign literature: all great causes require sacrifice.)

Whether markets are appropriate also depends on whether the service in question is a fungible good. Water is pretty fungible, so long as you have a high level of reliable bureaucracy known as quality regulation. It's not optional in water supply and it's never going to be: ask John Snow why.

The fungibility question is why rail privatisation is largely a bad idea - for the vast majority of rail travel, there is no serious potential alternative. Think of the roads on a train or tube strike day: chaos. It is called public transport for a reason.

There has also been no 'disruptive innovation' by rail providers: they still run trains between stations in cities and from suburbs to cities - just like British Rail did. Zero innovation. Just private profit.

It concludes that "few are worried today or suggest reversing utility sell-offs. So health reform may be a damp squib". Fuel poverty has evidently rather passed the author by.

More to the point, utilities require fungibility of goods: a unit of water, gas or electricity is easily and empirically definable and measurable.

Healthcare is much less so.

To finish on a positive note, there are some good health stats towards the end:
98% believe that they are personally responsible for their own health. (5% also hold the Government responsible; 9% also hold the NHS responsible; 6% also hold food manufacturers responsible.)
91% know that eating lots of fruit & vegetables contributes to healthy eating.
85% know you should get active & be a healthy weight.
85% know you should cut down on saturated fat & sugar.

However, 65% think they don’t do enough exercise (and 17% admit that don’t do any exercise at all).