This week: Ben Page, chief executive of pollsters Ipsos MORI
Why he matters: As well as rising through the ranks of Ipsos MORI for the last two decades, Ben Page has been advising prime ministers and health secretaries about public attitudes toward the NHS since 1997. From the Trades Union Congress to the Care Quality Commission, Mr Page’s deep understanding of the interplay between policy and public perception remains in high demand.
[This is part one of Bedpan’s interview with Mr Page. Part two – which focuses on how politicians can influence the public view of the NHS – will appear on Easter Sunday.]
“When the NHS cut [elective] waiting times from 12 months to six months, people noticed; when it got them down to three months it made no difference to overall perceptions [despite the] huge resources [used] to do that. When [at the end of the last decade average waits] got to eight weeks, suddenly people noticed [again] it [was] better.”
Spotting these “tipping points” is vital for politicians, says Ipsos MORI chief executive Ben Page, further illustrating his point in typically colourful manner by discussing the quandary facing the government as it decides what to do about targets for emergency care.
“It’s like the public is a vast gorilla sitting in the corner, chewing its leaves. You’ve missed your four-hour target or abandoned [it altogether] and it seems [you’re] getting away with it. Public opinion hasn’t moved too much and then you hit a certain point [in A&E performance] and suddenly the gorilla is awake and very interested in you. And at this point you’ve got a big problem.”
To interview the Ipsos MORI chief is to take a tour through the hive mind of the British public. When asked a question, he immediately dives for his laptop and pulls up a relevant piece of research from the last couple of decades.
It also leaves you with increased sympathy for politicians, as the sometimes strange and conflicting workings of national opinion are revealed.
Mr Page has been briefing prime ministers and health secretaries on the NHS for over two decades.
Asked what most strikes them about his presentations he says it is the fact that the public will not judge their stewardship of the NHS on “what’s actually happening in hospitals”. Prime ministers and their ministers are much more likely to influence the public by improving the “mood music” accompanying the NHS rather than, for example, reducing elective waiting times and improving safety.
Politicians also tend to be unhappy when they discover the public do not agree with them on how the service should be improved.
“All the politicians I’ve worked for over the last quarter of a century have tended to believe that reform, choice, competition, new forms of contracting [etc] is what’s necessary to drive effectiveness, performance and productivity in the system. The public [in contrast] tends to believe more money is the solution.
Reform? No thanks
“The number one and most consistent problem has been seen [by the public] as a lack of money. Even when the money was pouring in in 2006, it was still a lack of money [that the public selected as the service’s biggest challenge].”
Indeed, most people appear to believe the NHS never needs reform of any kind.
Declaring “this was the one that Tony Blair always wanted to change”, the Ipsos MORI chief executive pulls up a chart with two more or less flat lines running across it.
The chart covers the period spring 2000 to August 2017. The top line moves between 73 and 79 per cent and measures support for the statement: “The NHS is crucial to British society and we must do everything to maintain it.”
We once asked ‘should the grass in all parks be guaranteed to be two inches long?’ And two thirds of the public were quite keen on the government mandating that”
The bottom line moves between 19 and 25 per cent and records the proportion of people agreeing with the view that: “The NHS was a great project, but we probably can’t maintain in its current form.”
The smallest the gap between the two lines is in spring 2005 when it narrows to 48 percentage points. In August two years ago, it stood at 54 points.
Universal NHS service
“What Tony Blair wanted,” says Mr Page, “was the bottom line to go up, [for] people to accept that we needed to move perhaps to a German combination of state [funding] and insurance.”
The former PM eventually had to accept that as well as being “free” and “comprehensive”, most of the public believe the NHS “has to be funded through taxation rather than charges”.
There is also overwhelming public support for a universal NHS service offer.
“Two-thirds of people will say, if a service is available in Land’s End, it must be available in Glasgow.”
In fact, Mr Page reveals, the public is quite keen on standardisation full stop. “We once asked ‘should the grass in all parks be guaranteed to be two inches long?’ And two thirds of the public were quite keen on the government mandating that.”
The Ipsos chief says the public appear to be happy to live in denial about the many variations in existing NHS services and standards. “Top of things they want to know is ‘where do I get it?’ Bottom is, things like mortality rates and ‘where am I safest?”
This world view makes it difficult to discuss the centralisation of specialized services or the development of hot or cold sites, let alone the concept of choice as a service improver. “They just want a decent local hospital and [that view] doesn’t really change,” says Mr Page.
Unfortunately for both public and politicians there is little evidence services can be made more consistent.
“One of the classic things in public policy in my career,” he says, “has been finding a brilliant thing working [and thinking], ‘oh great, we’ll just make that work everywhere.’ Sadly, after doing this for a long time, we’ve come to realise [that doesn’t work] for all sorts of reasons.”
Referring to the innovative and highly praised work to improve public health in Wigan he adds: “There are lots of reasons why doing what Wigan has done would not necessarily be possible everywhere. There’s all-sorts of magic and alignment of personalities and cultures that happened to work out in Wigan.”
’Here’s a problem, you bastard’
If much in the previous few paragraphs makes difficult reading for those in the centre and on the right of politics, Mr Page has similarly bad news for the left.
While he says that people are generally “suspicious” about the outsourcing of public services, they do not mind “the idea of the profit motive” being a driver in healthcare. There is no significant “spontaneous concern” about NHS privatisation, he says.
Clicking to reveal yet another chart, he shows that the public divide into three groups.
“You’ve got about 25 per cent of the public who believe the private sector is generally more efficient than the public sector and should be allowed to provide services, and you’ve got about 10 per cent who will refuse [to be treated by anybody but the NHS].” The remainder are “pragmatic” and, if the care is free, will be content to be treated by private providers.
Meanwhile, despite funding being the public’s number one concern, the actual sums of money are “virtually meaningless” to them.
Even the record levels of investment provided by New Labour was doing the party no good by 2010.
“Gordon Brown got very little thanks, if any, for [the unprecedented improvements to the NHS]. And the reason for that, and this is the problem for all politicians, is that basically the way the public regard politicians is: ‘Here’s a problem, you bastard, please go and fix it’. And [when they’ve] fixed the NHS the public says, ‘yeah, that’s nice. Now the economy.’
“There’s no ‘oh, what a good job you’ve done’, they’re on to the next problem.”
In fact, the problem runs even deeper than that, in that the public seem unable or unwilling to engage with the financial aspects of operating the NHS.
Around half the public, explains Mr Page, believe the NHS “often wastes money”, but three-quarters think it “provides value for money” – meaning, of course, that a significant minority hold both views at the same time.
When it comes to funding medicines, the public view causes even more head scratching.
Mr Page says Ipsos Mori posed three questions, which asked that with the NHS under pressure, should the service just prescribe drugs:
- that work, no matter what they cost,
- that work if they are cost effective,
- or should we just prescribe all the drugs people want, whether they work and whatever they cost?
Two thirds of the public voted for the third option.
Outcomes don’t matter
Plunging ever deeper into the pollster’s archives, Mr Page pulls up research that reveals no correlation between public satisfaction and mortality rates or money spent per capita.
So, what does make a difference to public satisfaction?
Mr Page says seven factors matter more than any other. They are, in order:
- Your political views, especially whether you support the government
- Your age, with the satisfaction tending to increase as people grow older
- If you have had a poor recent experience in A&E
- If you have been exposed to staff “bad mouthing” the NHS
- Media coverage of the NHS
- Direct communications from the NHS
- A positive experience of inpatient care
To further illustrate the little weight the public puts on clinical outcomes, he displays another piece of polling.
This shows three factors account for 91 per cent of how people rate inpatient care. Fifty-nine per cent of satisfaction ratings are influenced by patients being treated with “dignity and respect”, 28 per cent with whether they are “involved in decisions”, and 13 per cent with how clean the ward was.
“Whether you had to come back in again because they put the hip joint in the wrong way around [has] no correlation [with patient satisfaction],” observes Mr Page.
He adds that when he shows these findings to hospital chiefs, he always tells them: “You’ve got to not just be clean but be seen to clean. Often, [cleaning is done] at night when nobody’s around. Actually, you should clean in the day.”
Next week: Ben Page, part two
Coming up: Knife crime campaigner and Labour shadow housing minister Sarah Jones
If there is any political figure you would like me to interview, please email email@example.com or if you are reading this on the website leave them in the comments box.
The past five Bedpans
You can read all 20 Bedpans here