Attitudes to taxation and spending on the NHS

Public satisfaction with the NHS has fluctuated over time. Although, in 2012, it was at its third highest point since British Social Attitudes began in 1983, the last 30 years have seen substantial peaks and troughs in levels of satisfaction. It appears that satisfaction is to some extent linked to government spending and policies around health care - but these are by no means the only factors affecting public views. So, how has the public felt about government spending on health care over the same period? More specifically, we return to the two questions we raised at the start of the chapter:

• Over the past 30 years, has the British public continued to support the founding principle of the NHS as a health care system which is funded collectively on the basis of ability to pay through taxation, but accessible to all on the basis of need and regardless of income? 
• How far has the British public supported government policies around spending on the NHS, and where has there been a divergence of views?

The answer to the first question appears to be yes. Historically, Britain has prided itself on its health care system. Support for the twin founding principles of inequity in financing and equity in provision has survived throughout the 30 year period. In virtually every year since 1983, we have asked:

It has been suggested that the National Health Service should be available only to those with lower incomes. This would mean that contributions and taxes could be lower and most people would then take out medical insurance or pay for health care. Do you support or oppose this idea?

Figure 4.9 shows that, consistently over the past 30 years, at least twice as many people have opposed this idea as supported it. (The question was not asked in 2012, so the most recent findings are from the 2011 survey.) Since 1989, the proportion opposing it each year has remained above 70 per cent. (As reported in Appleby and Lee (2012), the lowest level of opposition - and highest level of support - was recorded back in 1983 when then Prime Minister, Margaret Thatcher, was at her most popular.) There has only ever been minority
support for the idea of an NHS restricted to those on low
incomes: always less than 30 per cent.

The answer to the second question on public support for government spending on the NHS is a little more complex. As we have noted, total spending on the NHS across the UK has more than trebled in real terms over the last 30 years as successive governments - particularly the Labour governments in the first decade of the 21st century - took decisions to increase spending not only ahead of inflation but faster than general economic growth, increasing health spending as a proportion of GDP. Extra spending for health has been achieved in part by decreases in other government spending (such as defence) but also by increases in taxation (and borrowing). Do these decisions appear to concur with the public's views about taxation and government spending over the last 30 years?

The British public places a high priority on government spending on health care, over all other areas of government spending. Each year, we ask respondents to choose, from a list of 10 areas, their first and second priority for extra government spending:

Here are some items of government spending. Which of them, if any, would be your highest priority for extra spending? And which next? 

Education; defence; health; housing; public transport; roads; police and prisons; social security benefits; help for industry; overseas aid

Every year since 1983 the public has put health at the top of its priority list for extra government spending. Figure 4.10 shows the proportion of people who put health as their first or second priority, together with education and the public's third and fourth priorities in 2012: housing and help for industry. Since 1985, at least 70 per cent of the public has prioritised the NHS (as either their first or second choice) for extra government spending. Along with education, support for extra spending on health far outstrips support for extra government funding in any other area. 

The public's view may not be, however, totally impervious to the huge additional investment in the NHS since 2000. Although health remains the public's top priority for extra spending, the last decade has seen a steady decline in support for additional spending on health care, from 83 per cent in 2001 to 71 in 2012, to the point that, in the last three years, support for extra spending on education, people's second highest priority, is almost as high as support for extra spending on health. Nevertheless, health remains a popular spending priority for the public - support for the relative protection that the NHS has received (in England at least) in recent government spending decisions.

A second question which has also been asked in British Social Attitudes most years since 1983 can shed further light on this issue: 

Suppose the government had to choose between the three options on this card. Which do you think it should choose?

Reduce taxes and spend less on health, education and social benefits

Keep taxes and spending on these services at the same level as now

Increase taxes and spend more on health, education and social benefits

Figure 4.11 shows trends in responses to this question since 1983. Over the 30 year period, the general preference of the public has been either to increase taxes or to keep them at prevailing levels; a relatively small minority has opted for cutting tax and spending. However, there are perhaps three notably different periods over the last 30 years. From 1983 to 1991 there was a more or less continuous upward trend in the proportion of people agreeing that taxes and spending should rise. In fact, over this period the proportion of people supporting increased taxation and spending doubled from 32 per cent to 65 per cent. For the decade from 1992 to 2002 however - and apart from a significant fall in 2000 - the trend remained broadly flat at the relatively high level of around 60 per cent opting for higher taxation and spending. Since then, support for higher taxes and spending has slumped - from 63 per cent in 2002 to 34 per cent in 2012 - back to a level similar to that found in 1983.

It seems that the public's views on whether more state funding is needed is, to some degree, responsive to the level of NHS spending, in terms of average annual real NHS spending shown in Figure 4.11. In the period between 1983 and 1991, when there were relatively small increases in NHS funding, the public thought that there should be increased taxation and spending. Conversely, over the period of higher spending between 2002 and 2009, support for increased taxation and spending dropped, with increasing proportions of the public thinking that the government had it about right in terms of taxation and spending. That said, the public's view does not always seem to be associated with what was happening to NHS funding: the period from 1991 to 2002 was also a relatively high spending period on average, but saw continued high levels of support for further taxation and spending. This may be because the public continued to perceive the need for improvements in the NHS (only met in the last decade, meaning that further increases in investment were not required). Alternatively, it may reflect the fact that the question covers not only health but also education and social benefits: to some extent these trends may reflect what was happening in terms of these policy areas over that period. 

We reported earlier on the fact that there appeared to be some link, at least in broad trend terms, between public satisfaction with the NHS and actual NHS funding, and with key measures of NHS performance such as waiting list times. It seems plausible therefore that the public will adjust its views on the need for additional government spending on the basis of their level of satisfaction with the NHS at any given time. Figure 4.11 suggests that this is indeed the case. In periods of lower satisfaction, the public is more likely to think that the government should be raising taxes and spending more on health, education and social benefits. And when satisfaction is higher, the public is less likely to think that additional taxation and spending is required, presumably because it thinks that the NHS is doing well under current spending levels. For instance, in 1989, 37 per cent of the public was satisfied with the NHS and 56 per cent thought that taxes and spending should rise. In 2010, with 70 per cent of people satisfied with the NHS, the proportion wanting increased taxation and spending was only 31 per cent.[8]