Giving it some attitude: feedback for health policy from 2009 British Social Attitudes report - Health Policy Today,30th January

The new British Social Attitudes Report was published this week. It offers fascinating feedback for the health policy community – for example, that satisfaction with outpatient services is rising while satisfaction with inpatient services is falling.

It reveals surprisingly positive attitudes towards the NHS as a whole and surprisingly strong support for public over private provision. It adds important detail to debate about both.

The surprisingly good news

One of the headlines of the report is that the British public is more satisfied with the National Health Service than at any time since 1984. It confirms a previous finding, that people with recent experiences of the NHS tend to be far more satisfied with it than those who have had no contact.

The report is the 25th, so one of the useful things it can do is track changing attitudes and according to the report, 'the British public is more satisfied with the National Health Service than at any time since 1984'. I am personally surprised that the government has not made more of this report. The following could have come from the mouth of Alan Johnson himself.

"Over the past seven years, there has been a massive increase in public spending on the NHS, along with increases in staffing and reduced waiting times. This is reflected in changing public attitudes to the NHS:

• One in two people (51%) are 'very satisfied' or 'quite satisfied' with the NHS, up 17 percentage points since 1997 (when 34% were satisfied) and 9 points since 2000 (when 42% were satisfied).

• Dissatisfaction is at its lowest level since 1984: 30%, down from 50% in 1997".

And how about this next bit? The civil servants in Whitehall could learn a thing or two from prose like this:

"The NHS seems to be its own best advocate: having personal experience of the NHS is associated with higher rates of satisfaction. It is people who have not had recent contact who express the lowest levels of satisfaction with various services. This suggests that the NHS might make more effort to get its message across to those who have not had to use its services."

Being specific about satisfaction

The level of detail in the survey is very interesting. "Public satisfaction levels also vary according to the particular service (%s for the public as a whole):

• As always, the highest satisfaction levels are for GPs: 76%.

• Satisfaction with outpatient services – 60% – is now at the level found in 1983, following nearly two decades below this.

• Satisfaction with inpatient services has fallen: from 74% in 1983 to 49% now."

What about the feedback for policy?

The report offers some really interesting insights into policy. The one that excites me the most is the potential for quality, after many attempts, to become a driving force for change in the NHS (rather than quasi-market competition). The professional community is concerned with quality, and many believe that NHS managers are not.

The current push to focus NHS management on quality and to embed associated organisational systems will only work with social support. Some of the detail of the report, such as differentiating between inpatient and outpatient services, offersuseful insight.

"The relatively low satisfaction with inpatient services seems to reflect concerns about the quality of medical treatment and nursing care in hospitals:

• Concern about the quality of medical treatment in hospitals increased from 32% to 52% between 1999 and 2001, and remains high, at 49%."

King's Fund chief economist and co-author, John Appleby, explains "satisfaction with inpatient services has been falling in recent years, linked in part to the view that the quality of medical treatment and nursing care in hospital are in need of improvement".

The public do like choice

The report confirms that the public do like choice. "The report finds considerable public support for choice when accessing public services:

• More than eight out of ten people (81%) believe that parents should have 'a great deal' or 'quite a lot' of choice about which state secondary school their child attends.

• Equally, three quarters (75%) feel that people should be able to exercise 'a great deal' or 'quite a lot' of choice about which hospital they attend."

I asked earlier why the government had not made more of this report. An answer might be that some of the attitudes go against the grain of social opinion. People like choice, but don't equate it necessarily with private provision,

"There is widespread support for choice when accessing public services, but little enthusiasm for these services being run by a diverse range of providers. Only 19% believe private companies should run state schools (while 55% are opposed)."

The public like diversity and choice, but do not translate this to mean private and public providers

Some forms of diverse provision within the state sector are popular.

• Well over half of people (58%) support the idea of schools specialising in particular subjects, such as maths or music.

Diversity can be delivered in different ways.

The public are not comfortable with private providers

The report states, "'contrary to the arguments put forward by advocates of public service reform, this does not necessarily mean the public want public services to be run by a diverse range of providers.

"Only just over one in five people (22%) support the idea of private companies running NHS hospitals (57% are opposed)."

Interestingly, there is more support for charities running public bodies - just over a third (36% in both cases) support the idea of charities running state schools or NHS hospitals.

And devolution doesn't have as big an effect as you might expect.

The report says, "even though various forms of private provision are more common in England than elsewhere in the UK, support for the idea is only a little higher there. Just over one in five people in England (23%) support private companies running NHS hospitals, compared with just over one in six in Scotland (17%), Wales (18%) or Northern Ireland (17%)".

Burrowing below the surface of 'social' attitudes

"The two ideas – choice and competition – attract most support from different kinds of people:

• Choice is most popular among people on low incomes, whereas letting private companies run schools and hospitals is most popular among people on high incomes."

There is some political difference:

• "Labour supporters are as keen as Conservative supporters on the idea of choice. But Labour supporters are notably less keen on using private companies to run public services".


What are the implications for health policy?

John Curtice says, "the UK Labour government's promotion of choice and competition in England – a policy largely ignored or opposed in the rest of the UK – can be expected to remain contentious".

Some final thoughts

The report is well worth reading for its non-health policy content. For example, it is also good to know that though headlines have not recently been good for prime ministers, GPs, NHS managers or members of the House of Lords, they all probably have got someone to talk to.

"Most people have someone they can rely on for emotional support when they feel worried, stressed or down. Seven in ten (70%) feel they have at least three people that they can talk to when they are feeling this way".

And on a final, final note. I found someone to talk to about a mouth infection that has been worrying me. The dentist I saw was the most amazingly gentle and open health professional I have ever consulted. I learned a lot.

But this puts my experience at odds with most, according to the report. Though the NHS is doing very well in general, this is not true in dentistry. In fact, the general trend in satisfaction is reversed. "Two-thirds (65%) of people with recent personal experience of NHS dentists are satisfied with this aspect of the NHS, well over double the rate among those who have had no recent experience (only 26% of whom are satisfied)".

I said earlier that the report confirms the finding that those with direct experience of the NHS give higher satisfaction ratings. Isn't the following finding interesting:"'even having a friend or relative who has had recent contact with a particular service improves satisfaction, but not as much as having direct contact oneself.'"?

It makes you think that if we deal with patients well, we might be able to change the whole of society's attitude to the NHS?