While optimism over the NHS is low, the public's feelings about services and choice are more positive. These contradictory perceptions mean GPs, managers and the DH have their work cut out ensuring patients 'interpret' reforms favourably, write MORI's Ben Page and Jonathan Nichols

While optimism over the NHS is low, the public's feelings about services and choice are more positive. These contradictory perceptions mean GPs, managers and the DoH have their work cut out ensuring patients 'interpret' reforms favourably, write MORI's Ben Page and Jonathan Nichols

The headlines of the last few months have been depressing for the NHS, for the Department of Health and for the general public.

Optimism about the future of healthcare in Britain is now the lowest it has been since pollsters Ipsos MORI began measuring it in 2002. News of ward closures, redundancies and cutbacks - despite record investment and significant reforms - are to blame.

A year ago, more people expected an improvement than a decline (net score of +9%) in health services in Britain. Now, most expect the NHS will get worse (net score of -23%), with just over one in 10 of the population expecting the NHS to get much worse (see chart).

The headlines are bleak, but dig a little deeper and there are some positive messages for NHS leaders. For those who believe in the NHS, the hope has to be that the current turbulence - and there's more pain to come - does not fundamentally alter public confidence in the principle of the NHS. So far that has not happened.

In our monthly tracking of the most important issues facing the country, the NHS has been the key issue for much of Labour's time in office, although it gradually receded as investment went in - until recently. Concern rose through the first three months of 2006, with a leap of 10 points in April, with 47 per cent seeing the health service as one of the country's key issues.

The biggest public concerns remain a lack of resources and investment - ironic after the extra billions in funding, but linked to a long-standing belief that there is still a shortage of doctors and nurses, and the concerns about bureaucracy and top-heavy management.

Some of these views are strongly linked to political beliefs. Conservative voters are far more likely to feel the issue is bureaucracy, for example, but everyone is worried about staffing levels.

Reality check

How much of this view is based on reality? The challenge facing the NHS is that in terms of public and patient confidence, the national picture is nearly always much worse than the local one.

If one moves from looking at anxieties about the direction the health service is moving nationally, satisfaction levels for actual healthcare tell a more positive story.

Since winter 2002, overall public satisfaction with the NHS has averaged around 60 per cent and has been rising gradually. The proportion satisfied with GPs is even higher, averaging around 81 per cent.

The news is also positive for hospitals: net satisfaction (per cent satisfied minus percent dissatisfied) with outpatient, inpatient and accident and emergency services all show positive trends.

Furthermore, the trends show consistently that the people who have actually used NHS services are more positive than the public in general: even if the media is affecting the reputation of the NHS, people are having a better experience of NHS healthcare than the media might tell them to expect.

Despite the furore in the Labour Party and the professions about many reforms, the public broadly backs them.

A study last year for Birmingham and the Black Country strategic health authority found that 71 per cent of people were happy to be treated in the private sector, provided the NHS pays.

And the Pfizer/Ipsos MORI health choice index found that 59 per cent believe that increasing choice will have a positive impact on the quality of healthcare. Furthermore, a study for one trust found that around three-quarters of people felt that if they had to go to hospital, they wanted to be able to choose which one (albeit that many felt they needed advice to help them make that choice).

So there is evidence that people are still having positive and improving experiences of the NHS, and that there is public goodwill towards key aspects of the reform agenda: while the public still want a range of service improvements, the evidence is that over the last year, the direction of travel has been good.

The acid test of course is whether the funding problems in a minority of trusts - the staff cuts that are happening in some places - are actually impacting on patient experience overall.

It may be that the recent bad press, and the associated public concern about the health service, will knock this off course.

The bad press may be transient - and if so, there is every chance that the public concerns about the NHS will fall back to their 2005 levels. So far the optimists can continue to keep their fingers crossed.

Until the end of last year, patient experience kept on improving - if patient care ratings continue to improve, the DoH can breathe a sigh of relief. If the gains of the last six years go into reverse, all bets are off.

Another key factor will be how NHS reforms will affect the patient's healthcare experience. In our tracking research for the DoH, what we have seen since 2000 is slowly rising patient and public satisfaction with specific local services. More primary care-based triage means fewer people going to hospitals.

This is great for demand management - and potentially good for patients: quicker diagnosis, more primary care facilities, treatment closer to home. But the downside of choice might be - if it really happens - that patients find that (as parents already do in many parts of the country) they can't get their first choice.

Patients may not be so sanguine if they feel 'they won't give me a hospital bed where I want'. It will be important to keep this under review - but we also must not over-egg the pudding; the vast majority who are being referred into the acute sector by GPs still say they are not being offered a choice of specific hospitals, and are generally still very positive about their treatment overall.

GPs the key

In all this, a central player and interlocutor in whether or not many of these reforms work are GPs. Most people see a GP at least once a year, and GPs remain one of the most trusted professional groups in the eyes of the public. Four times more people think they tell the truth than think the same of government ministers. They have been paid a lot more recently, but remain the single most negative group of staff in the whole NHS about reform.

So how GPs present the reforms will be critical in how the public interpret the healthcare they are receiving, and therefore how satisfied they remain. Keeping GPs on board, tracking how they view the NHS reforms and understanding how they present them to the public will therefore be key challenges for health managers and policy makers over the next few years. If they do not want to refer to a particular trust in future, it will need to know why. Trusts will need to become much more responsive to both individual GPs and the new PCTs in terms of the way they are delivering services.

And the biggest challenge for the DoH - after spending hundreds of millions on extra pay and injecting new resources? Taking staff with them in future, being seen to listen, and making change coherent and consistent. One of the problems facing the NHS as a whole is that its staff overall, despite lots more money, are so negative about their leadership.

With around a million people going home every night and 'telling it like it is' to friends and family, making sure managers really understand what builds motivation, and what destroys it, will be vital. As the NHS so far shows, and indeed so does all the textbook research on employee motivation, increasing pay does not build motivation. Showing that you value, respect, and listen to people, and have a clear and simple narrative about the organisation, is much more effective.

This is now moving up the agenda at the DoH - and rightly so. On it hinges a lot - staff and public confidence in the service - and also perceptions of government competence on public services generally.

Ben Page is chair and Jonathan Nichols head of health research at Ipsos MORI's Social Research Institute.