Published: 11/11/2004, Volume II4, No. 5931 Page 20 21 22

Choice at the point of referral will see trusts having to do much more to promote themselves to the public if they are to succeed in attracting a viable mixture of patients.So what drives public perceptions of the NHS, and how can local communications teams alter those perceptions?

When we look at what drives attitudes to the NHS, a number of factors stand out.

First, there is a gap between, at one extreme, the views of patients about their local hospital and, at the other, the views of the public as a whole (most who have not been an inpatient recently) about the NHS at national level.

There is a good deal of variation across Britain, with trusts that serve younger, more ethnically diverse populations achieving lower scores. But overall, local hospitals are rated far more highly by patients than the NHS as a whole.

In the NHS, the more 'local' something is, the better it is regarded. Although the NHS is an incredibly strong brand in terms of what it stands for nationally - free universal healthcare, part of the post-war consensus, and so on - it is disconnected from people's personal experience with a specific doctor or hospital.

The NHS that is debated nationally by the media and politicians is largely a way of talking about health services in the general sense. As a result, being a Labour voter is the biggest influence on whether someone is satisfied with the running of the NHS nationally - not the quality of care experienced or anything else directly related to the service.

Five other factors stand out as key to the reputation of both local trusts and the NHS as a whole:

The age of the population served - older people are uniformly positive.

Use of accident and emergency services. These are consistently the worst-rated parts of the NHS and one of the reasons why ratings are so much lower in London than elsewhere.

Staff bad-mouthing the service.

Media coverage.

Direct communications by the NHS itself.

With so much contact between patients and staff, the relationship between the two matters more for any NHS institution - and indeed the NHS as a whole - than it does for most other parts of the public sector.

Unfortunately it appears that the closer a person is to someone who works in the NHS, the less positive about the service they are likely to be.MORI's research for the Cabinet Office suggests the GPs are the most negative: up to a third are actively critical about NHS strategy.

Securing staff buy-in is therefore essential. Staff survey results show that there is a clear correlation between whether the staff are willing to use and/or speak up for their own trust, and what patients think (see figure 1, below).

Organisations that have staff who are willing to speak up for them, rather than put the boot in, tend to receive the highest ratings from patients.MORI's analysis of staff satisfaction for the Cabinet Office highlights the key drivers of advocacy - clear lines of responsibility, freedom to show initiative, customer focus, managers who listen, feedback on performance. The key drivers do not include levels of staff pay.

While staff matter, so does the fourth estate. The less direct contact with the NHS people have, the more they will rely on what others and the media are saying.

Back in 1998, MORI tracked the reputation of the NHS during its 50th anniversary.Media coverage peaked the weekend of the anniversary and public awareness rose (see figure 2 overleaf ). But so, too, did satisfaction - by 16 percentage points (see figure 3 overleaf ).No extra operations happened, care was no better or worse the weekend of the anniversary, but the media coverage had reminded the public of the establishment of the NHS, what had been achieved since 1948, and its underlying principles - they felt good about it.

The problem is that stories about many other aspects of the NHS - for example, waiting times - tend to do quite the opposite.

For example, even when the news is that waiting times are falling, the impact on public opinion is negative; media coverage reminds everybody that some people are waiting.

National media coverage of the NHS tends to have a negative impact.However, the regional press tend to give their local NHS a better deal, and readership of regional titles is growing.

Managers need to appreciate the impact that making friends with local journalists can have on their trust's reputation.

Finally, there is the issue of direct communications.All other things being equal, the trust that is better at explaining what services it provides, and how to access them, will be better regarded by the local community it serves (see figure 4).

Traditional forms of communication - leaflets in GP surgeries etc - although often successful, are not enough. There is a keen latent demand for more information that is supplied directly to the public, especially if it can be provided in more interesting formats than the service has traditionally used (see figure 5).

The key information people want is what primary care services are available, and how to access them.

Simple, practical information about opening hours, contact numbers and details of local support groups are seen as most useful, together with what money is being spent on.

Only a minority want to know about technical aspects of performance. For example, 55 per cent want to know how budgets break down, but only 10 per cent want to know about morbidity or mortality rates.

Marketing and communications matter, however pink and fluffy traditionalists may believe they are.With more competition between different units in the NHS, those who are better at promoting what they offer - all other things being equal - will be more successful.

Ben Page is director of MORI Social Research Institute.