Worries are mounting that support for the NHS is dwindling among young people. But the evidence suggests the truth is more complicated, says Shirley McIver

NHS leaders seem to believe that young people are less in favour of the NHS than other age groups and that this lack of support is growing. In a speech made to the Public Management and Policy Association in March, shortly after announcing his resignation as NHS chief executive, Sir Alan Langlands said: 'My suspicion would be that thirtysomethings with young children are not terribly supportive of the NHS.'

Politicians appear to share this view, with several commentators reporting that the prime minister is concerned about trends in opinion polls that show the young are less attracted to the NHS than other age groups.

Jeremy Laurance, health editor of The Independent, wrote in July: 'When Tony Blair and Alan Milburn conceived of the national plan for the NHS earlier this year, a key trigger was the evidence of declining support for the service among younger people. . . Mr Blair, who, uniquely for a prime minister, is leading the project to rescue the NHS, has repeatedly made clear that if support continues to dwindle, the NHS is doomed.'

Such views have led to a campaign to win back public trust in the NHS and have provided ammunition to fuel the modernisation agenda on the assumption that if the NHS is not brought up to date to meet the expectations of current and future users, people will turn to private healthcare.

Warnings about an erosion of support for the NHS among young people can be traced back at least 10 years and possibly further. A news focus in HSJ (22 June 1989) contained an analysis of opinion polls commissioned by the magazine, the National Association of Health Authorities and the Society of Family Practitioner Committees each year between 1985 and 1989. It showed that not only did fewer young people hold a good opinion of the NHS than other age groups but the percentage had declined over the five years from 79 per cent to 61 per cent (table 1).

This apparent decline in the number of young people rating the NHS highly confirmed a trend going back some years. The article's author, Peter Davies, then deputy and now editor of HSJ, commented at the time: 'The patients of the future - the young - have always been less complacent about the NHS than their elders, consistently recording fewer good opinions and lower satisfaction.'

The trend may not have continued into the 1990s, however. Responses to a similar question asking about satisfaction with the overall running of the NHS during a British Social Attitudes Survey by Social and Community Planning Research in 1996 show that young people are no different from those in the middle-age group. The marked differences here are between all age groups and elderly people and between men and women (table 2).

It is worth noting that the age groups are split in a different way in this analysis and so any differences between the under and over-25 age groups may have been lost. Other surveys also point to a different picture, however. An analysis of the responses to an identical question added by the King's Fund to an Omnibus survey carried out monthly by the Office for National Statistics in 1991-92 and 1996-97 shows that young people are less rather than more likely to be dissatisfied with the overall running of the NHS.

2Jo-Ann Mulligan and Ken Judge carried out a special type of analysis on the responses received for these two time periods to examine the odds of a particular view being associated with a specific variable such as age, gender or location. They found that young people aged 16-24 and those respondents who were retired had a relatively low probability of reporting dissatisfaction compared with those of middle age.

One consistency in all these different types of surveys is that levels of dissatisfaction with the general running of the NHS have continued to increase during the 1990s. This is clearly shown by a comparison of responses to the same question asked in the British Social Attitudes Survey between 1983 and 1996 (table 3).

Whether or not young people are more likely to be dissatisfied in the 1990s is less clear because the NAHA/HSJ surveys were discontinued and it is notoriously difficult to compare findings across different surveys.

This is because responses are likely to be influenced by changes in question wording and context, as well as by differences in analysis, such as the different age groupings referred to above.

A survey carried out by MORI for the British Medical Association in November seems to confirm the link between age and level of satisfaction, with a steady increase in the percentage of those satisfied as age increases: 44 per cent of the 18-24 age group were 'very' or 'fairly' satisfied and this rose to 73 per cent in the 65+ age group.

However, although most respondents thought the NHS needed improvement, those in the 15-24 age group were more likely to think it was in need of 'some' rather than 'much' improvement: only 35 per cent of 15-24 year-olds thought the NHS needed 'much' improvement compared with 51 per cent of 25-34 yearolds, 56 per cent of 35-44 year olds, 53 per cent of 45-54 year-olds, 47 per cent of 5564 year-olds and 40 per cent of over-65s.

This may indicate that dissatisfaction among the youngest age group is of a different nature to that of others, perhaps due to factors such as lack of experience of services, limited opportunity to debate issues or a tendency to express critical viewpoints.

Again, differences in age groups and question wording makes it difficult to compare these findings with earlier ones. The most that can be said is that dissatisfaction with the NHS appears to be growing and dissatisfaction among young and middle-aged people is greater than that among the elderly. If this is the case, how can the evidence be interpreted? Is it correct to suggest this implies that support for the NHS is declining?

Some writers have argued that survey results on the attitudes of young people towards government, citizenship and community can be interpreted as showing a rejection of these institutions because they are outdated. In The Big Turn-off, published this year by the Adam Smith Institute, Madsen Pirie and Robert Worcester argue that young people see citizenship in terms of how they treat others, and what they are entitled to, rather than as something in which they participate by, for example, being active in the community.

3They conclude that young people reject politics, government institutions and community activism because these evolved in a different time to meet different circumstances and thus 'young people regard them as no longer relevant'.

The 16th report of the British Social Attitudes Survey (1999-2000) confirms that levels of interest in mainstream politics have fallen among the young but it would be wrong to generalise from this apparent lack of support for political institutions to a lack of support for institutions such as the NHS.

4Indeed, the survey results published in The Big Turn-off show that 69 per cent of young people list the NHS as one of their rights as a citizen.

Dissatisfaction with the running of the NHS is much more likely to be linked to changing expectations than a lack of social solidarity. There is little evidence that young people are less interested in other social activities such as sport, music festivals and pubs or collective issues such as environmental concerns and animal rights. On the other hand, international data suggests that attitudes to healthcare are changing.

Studies have shown that those who want a more active role in treatment decisions are likely to be younger. For example, research by the Swedish Institute for Health Economics has shown that younger respondents make stronger demands for participation and dialogue in the healthcare process: 'They want more information on treatment alternatives and healthcare producers, and they are more interested than older citizens in choosing among treatment alternatives.Younger patients are more dissatisfied with healthcare experiences and they are more inclined to lodge complaints.'

5Loss of faith One argument taking these rising expectations into account would be that young people have lost faith in the ability of the NHS to satisfy their needs. A survey of how the British see the future, commissioned by the Adam Smith Institute from MORI, seems at first to support this suggestion.

The survey found low expectations of the future survival of the welfare state. Based on the views of 1,020 adults, it found that more people believed in the survival of the monarchy than free NHS services. While a majority of three to one believed there would be a monarchy in 2050, 56 per cent believed that most people would have to pay for private healthcare.

6But increasing pessimism about the future of the NHS is not the same as declining support. The 14th British Social Attitudes Survey (1997-98) showed that opposition to an NHS increasingly funded by private insurance was high. People were asked if they supported the suggestion that NHS services and dental services should be available only to those with lower incomes so that taxes could be lower and most people would take out reduced medical insurance to cover treatment costs. Only 21 per cent were in support.

When these figures were compared with the findings for the same question in 1983, the results showed a fall in support of 9 per cent, indicating that support for the NHS is growing, not declining.

The picture is complex, though, because British Social Attitudes Survey figures show that more people are taking out private health insurance.

The proportion of people who took it out rose from 11 per cent in 1983 to 17 per cent in 1996. As many as one in five of those aged 35-54 take out private health insurance compared with one in six of 18-34 year-olds and one in eight of those over 55. Although this is not associated with dissatisfaction with the NHS, there is some suggestion that increasing private health insurance could undermine support for the NHS.

Jo-Ann Mulligan's King's Fund study quotes from Brook et al, who found that when the tax implications were made clear, those with private health insurance were less inclined to see higher public health spending as in their own interests and only 54 per cent supported higher spending compared with 67 per cent of those without private health insurance. From this evidence, Ms Mulligan argues: 'These respondents may see themselves as paying twice for health and so be more likely to resist increasing health spending.

This implies that a growing private sector will eventually undermine support for the NHS. But an increase in private insurance could result in more pressure for lower spending and hence deeper reductions in service quality. This suggests the possibility of a downward spiral in which support for the NHS is eventually eroded.

Yet, looking back over the past 20 years the evidence for this is lacking.'

1In conclusion, there is no evidence that support for the NHS is declining among the young or any other age group. It is possible that private health insurance might undermine support in an indirect way, but at present this is only speculation.

Clearly, though, expectations of the NHS are changing among younger people and there is little doubt that this is causing increasing levels of dissatisfaction with the way the NHS is run. This lack of fit between expectations and service delivery can be addressed in two ways: putting more money into changing services to meet rising public expectations, and having a public discussion about what it is realistic to expect. The government appears to doing more of the former, but perhaps it is time to change the balance.

REFERENCES

1 Mulligan J. Attitudes Towards The NHS and its Alternatives, 1983-96. In: Health Care UK 1997/98. King's Fund, 1998.

2 Mulligan J, Judge K. Public Opinion And The NHS. In: Health Care UK 1996-97. King's Fund, 1997.

3 Madsen P, Worcester R. The Big Turn-Off. Adam Smith Institute, February 2000.

4 Jowell R et al. British Social Attitudes 16th Report. National Centre for Social Research (formerly SCPR), 2000.

5 Rosen P. Decision-makers' and Citizens' Views on Rationing. Paper presented at the Third International Conference on Priorities in Health Care, Amsterdam, 22-24 November, 2000.

6 Frean A. Poll Predicts End of Welfare State and NHS by 2050. The Times, 16 September, 2000.