It is time to ask whether people who do not look after themselves should pay or wait longer for treatment

As the NHS enters an era of belt-tightening, is now the time for a paradigm shift in how it provides healthcare? In David Cameron’s “big society”, how does the public want NHS resources spent? And how will public opinion shift as money gets tighter?

Younger people are more concerned about the need for personal responsibility and less willing to pay for others

There are already signs that public attitudes are changing, marked by an unwillingness to pay for the “irresponsible” actions of others. After all, if the local hospital is strapped for cash, why should we all pay for a drunken lout to attend accident and emergency?

Data confirms that society is becoming less willing to look after others. For example, in 1994, the British Social Attitudes Survey found that 85 per cent of us thought the government should provide a decent standard of living for the unemployed. This has now dropped to 55 per cent.

So, how will this play out in the NHS? Will the public demand that NHS resources are diverted away from those who bring their problems on themselves? It’s certainly something we’ve started tracking in our work.

For instance, our latest data suggests most people are inclined to support the principle. Two thirds agree that people have a responsibility to keep themselves healthy. Around half say the NHS should be able to limit the treatment it offers for free to people who don’t take responsibility (48 per cent) - just one in three disagrees (35 per cent). And there is some evidence the mood could shift further.

For instance, younger people are more concerned about the need for personal responsibility and less willing to pay for others. Our “futures” work has already shown this insecure, pressurised, overtaxed and debt-ridden - IPOD - generation are starting to question how public services are delivered.

The political context is changing too. In the run-up to the recent election, Conservative candidates were four times more likely than their Labour counterparts to say money should be spent on people who take responsibility for their own health.

So, does this mean the public wants the NHS to penalise those who don’t look after themselves? Well, not yet.

Even though half say the treatment offered for free should be limited, only 22 percent support the prospect of giving less priority to those who do not take care of their health.

Even among those who agree that people have a responsibility to look after their health, there is little change. So, while there are signs the public are buying into the concept of personal responsibility, most are not yet ready to see the NHS restricting treatment on this basis.

Maybe this isn’t surprising. The public have other targets in mind. For example, they would much rather get rid of bureaucrats than take responsibility for their own health (65 per cent support reducing the number of managers by a third). And they are not yet convinced there is a need for radical change.

Research conducted before the emergency Budget shows two thirds (64 per cent) still believe efficiency savings alone will be sufficient to pay off the national debt.

This is even truer in the NHS, where protecting budgets has been a consistent message. But this is starting to change, certainly for public services as a whole. Agreement with the need for cuts has increased from 39 per cent to 54 per cent in a year.

Imagine the NHS in five years time when tighter resources could mean that people are waiting twice as long for a hip replacement, while someone who has broken their leg on a drunken night out gets treated on the spot. Will the public continue to see this as reasonable and fair? Or will they start shouting louder that the Friday night drunks should pay for their care?

If the public do start calling for this, where will they draw the line? Should people pay more if they eat too much? What if they didn’t put on their seatbelt? Or broke their leg while skiing?

The public aren’t crying out for this yet, but they are making supportive noises. The NHS must consider how to engage the public on the issue.

Ipsos MORI has long demonstrated the value of involving the public in decisions about prioritising services. Some decisions could amplify feelings of unfairness and injustice more than others.

The first step is to be honest about the scale of the challenges ahead. Many people are simply unaware of the situation - particularly as NHS budgets are known to be “protected”.

While this remains the case, they may not understand the need for prioritisation, let alone offer opinions about how such decisions should be made. However, once they start feeling the pinch, their response could be strong. Delaying this debate may risk public support for the NHS in the future.

It’s public health, Jamie, but not as we know it…