I can’t get no satisfaction (ratings). Does public satisfaction with the NHS relate to how much the Government spends on it?

First of all an apology. There is a lot on at work, and a lot of stuff happening behind the scenes, and this has got in the way of blogging.

The data from the last set Social Attitudes Survey is out, and people aren’t happy with the NHS.

This might not come as a surprise to people because it is pretty well known that the last 8 years have been lean years for the NHS in terms of funding increases. In fact this has been the longest period of funding restraint in the Service’s history, so no surprise people aren’t happy

Lets have a look at a graph shall we?

There is a really stark difference between the 2 halves of the graph. The left hand side reflects the Conservative administrations of Margaret Thatcher and John Major, the right hand side of the graph the New Labour years, then the Coalition, and, finally, the Cameron and May Conservative years. People are much happier on the right hand side of the graph.

The really good scores are from the era was when I was a senior NHS manager. Definitely not a co-incidence

There are three things that really jump out at me.

Firstly that while the Labour Party started spending serious amounts of money on the NHS from 2000 onwards (the publication of The New NHS: Modern and Dependable), the improvement in patient satisfaction is a few years later. Patient satisfaction is clearly a lagging indicator.

If you want to test that against against funding this is a neat graph from the Institute of Fiscal Studies which shows a similar pattern, although it covers a longer time period

Secondly satisfaction doesn’t correlate with the number of Doctors. Patients love Doctors, in fact they love all clinical staff, and I did wonder if there was a correlation between Doctors per head of Population and patient satisfaction (apologies to Nurses and AHPs for using Doctors/Population as a proxy for Clinical Staff)

I’m a bit confounded by that graph which came from the BMJ, which shows that increasing Doctors numbers doesn’t seem to have any relationship with patient satisfaction.

Finally the numbers for the Coalition and the Conservatives are much better than I expected. Given the awful levels of funding increases we saw under Cameron and May I would have expected . People were happier with the NHS when Cameron and Osborne were putting in less than 2% per a year, than they were when Thatcher was putting in 2.5%.

There are 2 possible explanations for this.

One is that the big cash increases that came during the New Labour years uplifted the baseline level of satisfaction and it will take a long time for this to decline. The other is that the NHS has done something, probably during the Blair years, that made it more customer friendly. This seems unlikely, but I do think that the spending increases in the Blair years renewed Britains love affair with the NHS

Lots of my Clinical friends will of course want to ask the obvious question?

“Why does this matter”

And in one sense it doesn’t matter. No patients got better because of a good survey result, no lives got saved.

This is of course true, but it’s worth dodging back in time to the Blair Government’s decision to put a huge amount of extra cash into the NHS.

At the time the Government was worried that support for public services was in decline. People were getting a poor service from the NHS, from schools, from public services in general, and once Labour had been in power a couple of years it wasn’t tenable to keep blaming the Tories.

Labour were scared that public support for universal public services like the NHS was in such steep decline that it would threaten their existence. The great threat to the existence of the NHS isn’t privatisation (as many on social media claim) it is lack of public support.

Labour wanted universal public services, but also wanted to maintain public support for more money

The solution was more cash + more choice + higher levels of satisfaction.

This was the classic Blairite triangulation and it was applied across public services. Taxpayers were asked to put record amounts of cash into public services like the NHS, in return for which they were offered greater choice about how they accessed those services, including the opportunity to access private Hospitals paid for by the NHS. The end result was meant to be better results – better mortality and morbidity but also better satisfaction ratings.

The same troika applied to other public services like Education too.

That’s why this matters. Because looking at the right hand side of the graph May is pushing some decent sized increases of cash through the service over the next few years, not quite Blair levels, but well above the Thatcher/Major/Cameron settlements. A lot more than Corbyn offered too.

Getting this extra cash took years of fighting with Treasury, not just by Hunt, but by Simon Stevens and lots of other senior NHS managers.

I don’t know what promises were made to Treasury in order to get hold of the cash, but they are likely to be pretty strict.

At the same time performance targets have been suspended for A&E performance because overall performance has declined sharply. The 4hr wait target hasn’t been hit for a few years now.

More money + declining satisfaction + worse performance is a tough mix for the Service to handle. I am not sure that Matt Hancock is the kind of Consigliere that May needs to finesse this kind of funding and performance squeeze.

The NHS should have had an idea of what it had to achieve for the new money when the NHS Long Term plan was launched earlier this year, however the plan requires legislation, and more detail, and these are now logjammed by Brexit.

The Long Term Plan website is still describing the Plan as proposals, and there has been a subsequent Implementation document, which sets out further work that is needed. This is classed as an engagement document, which I think means that it is for consultation, but that DH reserve the right to ignore the results of the consultation if they don’t like it. This jumble is a big difference from the Publication of the NHS Plan in 2000

The whole thing looks like a political storm brewing for the Service, with more money, a lack of clear direction, worsening satisfaction, declining performance and an angry Treasury.

Hopefully back to more regular blogging soon!

https://www.nuffieldtrust.org.uk/news-item/70-years-of-nhs-spending

http://www.bsa.natcen.ac.uk/latest-report/british-social-attitudes-32/health.aspx

https://www.ifs.org.uk/uploads/publications/budgets/gb2017/gb2017ch5.pdf

https://www.ohe.org/publications/ohe-guide-uk-health-and-health-care-statistics

https://www.bmj.com/content/357/bmj.j2940

https://www.kingsfund.org.uk/publications/how-nhs-performing-december-2018

https://www.longtermplan.nhs.uk/

https://www.longtermplan.nhs.uk/wp-content/uploads/2019/02/nhs-legislation-engagement-document.pdf

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