Editorial Wednesday 7 December 2011: British Social Attitudes 2010 survey finds record satisfaction with the NHS

The NHS is not perfect, and it needs to change seriously. We need to move care out of hospitals where appropriate, focus more on prevention and pay much closer scrutiny to the variations in activity and outcomes.

We also need to make the service considerably more patient-centred, and address significant issues around the care of the elderly co-morbid with dementia in hospitals and residential care.

Oh, and we also need to get people to take more preventative responsibility for their own health, as the new Cancer Research UK study shows.

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Click here for details of 'Flora Stalinism, leadership as partnership and loving the evil bastard. OF! There’s a nasty little sting in the Annex, too …', the new issue of subscription-based Health Policy Intelligence.

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It's easy enough to mis-read this as a reason for the current reforms, in the old Yes, Minister politician's syllogism:
1. Something must be done.
2. This is something.
3. Therefore this must be done.

That is not the point.

Once all this is said, the latest 28th British Social Attitudes survey, for which we exclusively revealed the Government is pulling its funding of the health questions and the Kings Fund is stepping in, has potentially problematic warnings for Our Saviour And Liberator, Health Secretary Andrew Lansley.

70% of respondents in 2010 reported that they were overall satisfied with the NHS. This is the highest figure ever recorded by the long-running survey - and for reference, the lowest was 34% in 1997, at the end of the Conservatives' 18-year tenure in office.

The report states that "satisfaction with most NHS services has not changed substantially since 2009. However, satisfaction with emergency services has increased in the last two years. For example, satisfaction with hospital accident and emergency departments now stands at 61%, up from 53% in 2008 and 43% in 2001".

The report also notes increased expectations of being seen in a timely way (within three months)  for a bad back has risen from 50% of respondents in 2006 to 71% in 2010. The author notes that "expectations about waiting times have improved dramatically over the last
decade. Positive views on waiting times are linked to satisfaction with the NHS overall, so this presents a challenge to the Coalition: how to maintain these high levels of satisfaction now that certain targets on waiting times have been dropped".

The politics of satisfaction
It is of course too soon to see a survey conducted in 2010, shortly after the election, as indicative of the Coalition's performance on the NHS, as the report's author Elizabeth Clery of NatCen notes: "However, throughout the chapter we look for any clues about whether the trends seen under Labour are set to continue or not; in particular, it may be that in a general election year people are more likely to take stock and think about public services, and different parties’ policies towards them. Our analysis will also give us baseline measures against which, in future reports, we can monitor attitude change over the course of the current administration".

Intriguingly, the report also observes that "Conservative and Liberal Democrat supporters’
satisfaction increased by eight and nine percentage points respectively between 2009 and 2010, while Labour supporters’ satisfaction levels remained stable". It would be fascinating to explore this finding further.

So why the rise in satisfaction?
Clery asks whether the 5% rise in satisfaction since the 2009 survey is "just a continuation of the upwards trend of the last five years? It is not simply the case that the proportion who are dissatisfied with the NHS has declined as the proportion who are satisfied has risen, though that has been the case in the past. Dissatisfaction levels were similar in 2009 and 2010 (19 and 18 per cent respectively).

"Conversely, it is the proportion saying “neither satisfied nor dissatisfied” that has reduced – from 16 per cent in 2009 to 12 per cent in 2010".

Clery points out that "party supporters are more satisfied with the NHS when ‘their’ party is in power; in the first two years of the Labour administration, elected in 1997, there was a surge in satisfaction among Labour supporters, while the satisfaction levels of Conservative supporters declined slightly (Appleby and Alvarez-Rosette, 2003).

"We see a similar effect in 2010, with the satisfaction levels of those supporting the incumbent coalition government increasing markedly (by nine percentage points for Conservative identifiers and eight percentage points for their Liberal Democrat counterparts). However, rather than declining (as in 1997), the satisfaction levels of the supporters of the losing party have remained stable".

She speculates that "perhaps Labour identifiers view the improvements in the NHS as a reflection of the ongoing legacy of their party’s term in office. If so, this may be a ‘cusp’ year, in which supporters of all the main parties had a reason to be satisfied. That suggests that the increase in satisfaction between 2009 and 2010 could be a temporary effect, rather
than simply a continuation of the upward trend of the last few years".

More detail
The chapter correctly notes that overall satisfaction is a useful but blunt measure, and the survey finds that, as in 2009, the picture is mixed across a range of responses.

It observes that "satisfaction with GPs initially fell under Labour, only starting to recover in 2005. Satisfaction with dentists was in long-term decline until 2004 where it flattened out, beginning to rise again in 2009. And, while satisfaction with outpatient departments rose in the last years of the Labour regime to their highest level to date, satisfaction with inpatient services were in decline for much of the period, only beginning to recover in 2007 (Appleby and Robertson, 2010).

"Between 2009 and 2010 satisfaction with GPs, NHS dentists, inpatient and outpatient services, diagnostic services and NHS Direct has remained reasonably steady, with minor, though not significant, fluctuations occurring in both directions.

"For two NHS services – ambulance services and hospital accident and emergency departments – satisfaction levels have increased substantially in recent years. We asked about NHS ambulance services for the first time in 2008, when six in ten (61 per cent) indicated they were “very” or “quite” satisfied. By 2010 this proportion has risen by seven percentage points, to 68 per cent. Satisfaction with hospital accident and emergency departments has been measured at regular intervals since 1999, when slightly more than half (53 per cent) were satisfied. After reaching a low point of 43 per cent in 2002 it has risen fairly consistently – back to its original level in 2008 (53 per cent) and reaching 61 per cent in 2010, an increase of eight percentage points".

Clery also observes that "These services were subject to waiting time targets introduced by Labour, and there is separate evidence that this resulted in real improvements (Department of Health, 2010). Although our data do not allow us to examine the link between satisfaction and waiting times for these particular services, we know from previous reports (Appleby and Robertson, 2010) that views on waiting times are closely linked to overall satisfaction levels. The fact that the Coalition has abandoned certain elements of the targets therefore raises a question about whether this trend is set to continue or not".

The study also examined public expectations in 2010 about waiting times. It found that "public expectations about waiting times and NHS performance in this area over time have greatly improved over the last few years. It seems likely that these changes are in response to the real improvements in waiting times that were a feature of the Labour administration. Clearly, we would anticipate a time-lag between the implementation of change and its impact on public attitudes and expectations. Nevertheless, it will be important to monitor these trends in the coming years, to assess the impact of the coalition government’s removal and revision of key waiting time targets on public attitudes to this issue".

The study concludes that "public satisfaction with the NHS is at an all-time high, continuing an upwards trend that started a decade ago. Alongside that, people’s expectations and perceptions about waiting times for various NHS services are far more positive than they were at the turn of the century. We have also seen rapid increases in satisfaction with accident and emergency services in the last two years".

It gives no picture (other than speculation) of the actual impact on the NHS of Mr Lansley's Health And Social Care Bill reforms. It does observe that "as we have seen with perceptions about waiting times, it seems clear that the public do notice real changes in service delivery, meaning that any perceived decline in the quality of services or speed with which they can be accessed has considerable potential to shift satisfaction downwards – given the very substantial degree to which it rose under Labour.

"What is clear is that we have a public who are very happy with the NHS and have high expectations about service delivery, and that will be challenging for the government to maintain as NHS reforms begin to take effect".

Thanks to the Kings Fund, the BSA survey will be watching public satisfaction with NHS performance closely in future studies which will cover the impact of the NHS reforms.

Time, and future editions of the British Social Attitudes survey, will tell.