Satisfaction with the NHS

Virtually every year since 1983, we have included a question on overall satisfaction with the NHS, providing an overarching measure of health service performance: 

All in all, how satisfied or dissatisfied would you say you are with the way in which the National Health Service runs nowadays?

By looking at the way in which people have responded to this question each year over the past 30 years, we can answer a number of the questions we posed above:

• How satisfied has the public been with the NHS over the past 30 years?
• How closely does public satisfaction with the NHS appear to be aligned with government health care policies and government spending on the NHS? What policies have proved more or less popular with the public?
• How far are people's views simply reflecting their views more widely about the political party in power? 
• To what extent might changes in levels of public satisfaction with the NHS reflect the fact that Britain has an ageing society? 

The answers to these questions are not necessarily easy to predict, given the potentially competing issues at work. As we have shown, spending on the NHS has increased hugely over the last 30 years, and on a key performance measure - hospital waiting times - there have also been significant improvements. It would be surprising if these developments had not had some positive impact on public satisfaction with the NHS. Added to this, the fact that we are an ageing society might lead us to predict, for two reasons, that levels of satisfaction with the NHS have gone up. Firstly, older people are more frequent users of NHS services, and, secondly, NHS users, on average, are more likely to report being satisfied with the NHS (Appleby and Phillips, 2009). Conversely, with a state-funded health care system which has been the norm for over 60 years, it may well be that the public's expectations of the NHS have also increased, making them harder to please: this might suggest a drop in, or levelling out of, satisfaction levels. It is also possible that people's perceptions of the NHS will be coloured by the political party in power. Health care in Britain, as in most countries, is an intensely political issue, as every government which has tried to change or reform the NHS can attest. It is possible that satisfaction with the NHS is associated with people's party political affiliations and whether they support the government in power.

Trends in satisfaction with the NHS 

Our first question is: how satisfied has the public been with the NHS over the past 30 years? Figure 4.3 shows levels of public satisfaction from 1983 to 2012, with one line showing the percentage in each year who reported being "very" or "quite satisfied" with the way in which the NHS runs, and the other showing the percentage who reported being "very" or "quite dissatisfied".

In 1983, at the start of the time-series, 55 per cent of the public were satisfied with the NHS, twice the proportion (26 per cent) who felt dissatisfied with how it was run. Three years later, in 1986, satisfaction levels had dropped to only 40 per cent of the population, with equal proportions expressing dissatisfaction. Over the subsequent decade and a half, to 2001, while levels of satisfaction fluctuated a little, the broad trend was relatively flat (the lowest point was in 1997 when only 34 per cent of the population was satisfied and half (50 per cent) reported being dissatisfied). Then, between 2001 and 2010, satisfaction rose, with 2010 seeing 70 per cent of the British population satisfied with the NHS, nearly four times the number of people who were dissatisfied. In the last two years, satisfaction levels with the NHS have dropped dramatically, to 61 per cent in 2012. That said, compared with the 1980s and 1990s, public satisfaction with the NHS is still high: satisfaction in 2012 remains at its third highest level since 1983.

Are the trends in satisfaction connected with government
funding and policies?

The fluctuations in levels of satisfaction with the NHS suggest that public opinion is associated with what is happening within the NHS during any given period (or in the recent past, given we might expect changes in satisfaction to lag somewhat behind events). Any changes attributable to demographic shifts in the population would tend to show up as smooth - or linear - slopes in the line graph, rather than the peaks and troughs we saw in Figure 4.3. In order to unpick what might be affecting public satisfaction, we look firstly at the relationship between levels of government spending on the NHS and public satisfaction (Figure 4.4), and then at potential associations between government policy and satisfaction. As well as looking at overall satisfaction with the NHS, we report on trends in satisfaction with individual elements of the NHS, to see if they can help explain the fluctuations in the overall trend. 

As Figure 4.4 suggests, it is hard to discern any consistent association between annual changes in real funding and levels of satisfaction with the NHS. (Indeed, this is confirmed statistically, with a correlation coefficient of just 0.1 between spending and satisfaction across the whole period from 1983 to 2012.) Given the likelihood that details of changes in real NHS spending from year to year are almost certainly unknown to most people, the lack of a relationship between the two is perhaps not surprising. Nevertheless, it is in the decade from around 1999 to 2009 when NHS spending increased at a new and accelerated rate that satisfaction too recorded its most consistent increases. While the public may not have known about the detail of spending changes over time, it may have been more aware of the broader upward trend.

Alternatively, the rise in public satisfaction with the NHS may have been a result of the tangible effects of the extra spending. By way of example, and as Figure 4.2 showed, over the period between 2003 and 2010 the proportion of inpatients waiting over three months for admission to hospital fell from around 49 per cent to nine per cent. If we look at this in relation to public satisfaction, we see that levels of satisfaction started to rise at the same time as long waits started to decrease. 

We can try to unpick the relationship between government policy and public satisfaction further by looking at a set of questions, again asked on British Social Attitudes virtually annually since 1983, on satisfaction with key parts of the NHS: general practice (GPs), dentistry, inpatients, outpatients and accident and emergency (A&E) departments.[3]

Looking firstly at satisfaction with hospital services in Figure 4.5, while satisfaction with outpatient and A&E services broadly mirror the fluctuations in levels of overall satisfaction with the NHS, for inpatient services there has been a long-term general decline in satisfaction. Although levels of satisfaction with inpatient services rose for a period between 2004 and 2010 (at the time when overall satisfaction was rising rapidly, as was spending on the NHS), in the 30 year period between 1983 and 2012, the proportion of the public satisfied with inpatient services fell by 22 percentage points from 74 per cent to 52 per cent.

Unlike other NHS services and the NHS overall, trends in satisfaction with GPs have remained relatively constant since 1983, continuing to be one of the most highly rated parts of the NHS. Satisfaction with NHS dentists on the other hand was in long-term decline between 1983 and 2005, then recovering to some extent from 2008 - a change most likely linked to government attempts to improve accessibility to NHS dentistry (Appleby, 2012) (Figure 4.6).

Are the trends in satisfaction connected with affiliations with
the party in power?

The origins and funding of the NHS, not to mention its direct accountability to ministers, have meant that it has remained for all of its history intensely political. And it has been clear since the earliest British Social Attitudes surveys that there has been a link between people's party political identification and their satisfaction with the NHS. So, with seven changes of government over the last 30 years - two continuous periods of rule by the Conservative Party and the Labour Party respectively, and latterly a Conservative/Liberal Democrat coalition government - to what extent can changes in the public's satisfaction with the NHS be accounted for by affiliation with the party in power?

Figure 4.7 shows how satisfaction levels with the NHS have fluctuated over the 30 year period among Conservative, Labour and Liberal Democrat identifiers. The timeline is split into periods of Conservative, Labour and coalition government and, within these, into each parliament. It is clear that supporters of the party in power tend to rate their satisfaction with the NHS as higher than those who support the opposition. So, during the period of Conservative government from 1983 to 1996, Conservative supporters expressed greater satisfaction with the NHS than supporters of either the Labour or Liberal Democrat parties. For most of this period, the gap between Conservative and Labour/Liberal Democrat identifiers averaged around 12 percentage points. And in the period of the Labour governments (1997-2010) Labour supporters' satisfaction tended to be higher than that of Conservative or Liberal Democrats (although the gap tended to be smaller than that between Conservative and Labour supporters between 1983 and 1996). Statistically, the correlation over the years 1983 to 2012 is strongest between Labour and the Liberal Democrats and weakest between the Conservatives and Labour.[4] That is, the views of Labour party and Liberal Democrat supporters are quite similar, much more so than the views of Labour and Conservative supporters.

However, while party affiliation is clearly influencing levels of satisfaction, it does not explain the general trends in satisfaction with the NHS. It is clear that other, non-party political, factors influence satisfaction with the NHS among supporters of different parties. Fluctuations in the levels of satisfaction from supporters of all three political parties follow a very similar pattern. For instance, satisfaction with the NHS from supporters of all three parties fell in the years leading up to the switch from the Conservative to Labour government in 1997. And satisfaction with the NHS rose among supporters of all three parties during Labour's reign. While there is general evidence of satisfaction levels being higher among those identifying with the party of government, and of satisfaction among those identifying with the party in power rising more quickly once they come to power than supporters of other parties (for instance, satisfaction among Labour supporters rose more quickly and more steeply than satisfaction among Conservative supporters after Labour came to power in 1997), there are clearly factors other than party affiliation affecting satisfaction with the NHS.

How and why does satisfaction vary across age groups?

We have established that trends in satisfaction with the NHS are explained to a certain extent by the political landscape in general and policies around the NHS in particular. However, that is not to say that there have not been more linear changes in trends caused by wider societal changes over the past 30 years. There is a long-established link between age and satisfaction with the NHS, with older groups tending to express more satisfaction with the NHS than younger groups. Figure 4.8 shows trends in satisfaction levels for those aged 18 to 24 and those aged 75 and over. Clearly, satisfaction among both age groups fluctuates in line with the overall trend[5] showing that satisfaction among both age groups is being affected by the changes in external factors we describe above. This is often referred to as a 'period effect', where there are factors or shifts in attitudes affecting all age groups. However, while the size of the gap between the two groups fluctuates, the proportion of people aged 75 and over who express satisfaction with the NHS is 15 to 25 percentage points higher than the proportion of 18 to 24 year olds who say they are satisfied. We look now at differences in satisfaction levels by age over the past 30 years, and what the causes of these might be.

Some suggest that the difference in the views of younger and older people reflects younger people's higher expectations of the NHS, which makes them harder to please than their older counterparts. This could be down to someone's life stage (a so-called 'lifecycle effect'), with satisfaction increasing naturally as people age. Conversely, differences in expectations or satisfaction levels with the NHS could be due to the generation in which people were born (a 'generational effect'). If that is the case, older people may be more favourably disposed to the NHS because of their greater experience of life before it. There is also a further plausible reason why older people express higher levels of satisfaction than their younger counterparts: people make greater use of the NHS as they age, and we know that satisfaction is generally higher among those with recent experience of the NHS (Appleby, 2013). 

Table 4.1 disentangles some of these potential effects by looking at changes in satisfaction by 10-year birth cohorts between 1983 and 2012 (see the Technical details chapter for detail on this type of analysis). The first row shows that, overall, satisfaction with the NHS increased by six percentage points between these two years. The subsequent rows show the views of the different cohorts. The table points to evidence of a period effect and of a lifecycle effect, with little evidence of there being a generational effect. 

Looking firstly for period effects - or shifts in attitudes over time across the whole population - it is clear that, across all age cohorts, the proportion satisfied with the NHS in 1983 and in 2012 has increased, as seen in our column showing difference between 1983 and 2012. For example, among the cohort born in the 1950s, 49 per cent were satisfied with the NHS in 1983 (when they were aged between 24 and 33) and 56 per cent were satisfied 2012 (when they were aged 53 to 62), an increase of seven percentage points across this time period.

Evidence of a lifecycle effect comes from the fact that, both in 1983 and in 2012, as people get older, they express higher levels of satisfaction with the NHS than their younger counterparts. Both in 1983 and in 2012, there was a step-change in the proportion of people satisfied with the NHS as they got older. However, it appears that this change happened later in life in 2012 than it did in 1983. In 1983, 48 per cent of people aged 54 to 63 were satisfied with the NHS compared with 67 per cent of those aged 64 to 73 and 72 per cent of those aged 74 to 83 - so the step-change was between the first two of those age groups. The parallel figures in 2012 were 56 per cent, 63 per cent and 76 per cent, with the substantial rise in satisfaction happening as people move into the 73 to 82 group.

There is little evidence to suggest that differences in satisfaction levels are due to the generation to which people belong. That is, there is little evidence of a generational or cohort effect. This may be because now, 60 years since the start of the NHS, there are few people who fully remember Britain without it.