Simon Stevens on winning hearts and minds

'NHS targets have not yet been tough enough (yes you read that right) to alter public perception'

'Iraq and the NHS' - the fact that these two subjects are bracketed for special consideration in the latest Guardian/ICM Omnibus poll is probably not intended as a compliment. But studying the polling cross-tabulations provides some interesting insights.

On these occasions we usually take solace from two 'well know facts'.

First is that the popularity of the government is as big an influence on perceptions of the NHS as the other way round. (Dissatisfaction with the NHS peaked in 1996, in line with negative public feelings about the Major administration). So, unsurprisingly, ICM finds that more Labour supporters think the NHS has improved; Conservatives think the opposite; and Lib Dems are split on the issue.

More interestingly, under half of each party's own supporters think their party can be 'trusted a lot' to run the NHS (49 per cent of Labour supporters, 41 per cent of Lib Dems and 38 per cent of Conservatives). And a surprising 61 per cent of Labour supporters - and 65 per cent of Lib Dems - say 'if I could afford private treatment I would pay for it'. In our anti-political age this probably reflects lack of trust in governments of any complexion and increased awareness of the limits of effective state action.

The second consolation comes from knowing that people are more positive about their own experience than about the NHS overall. While this oft-repeated dictum is certainly true, it is not the end of the story. The Healthcare Commission reports that patients with worse health are generally less positive about their experience of care.

And in my last HSJ column, I talked about how the ageing of the baby boomers will change the demands on healthcare systems across the West - how the 'long tail' of diverse needs and preferences will demand more responsive and plural services.

The latest poll provides some evidence of this. For example, asked whether the NHS is 'the envy of the world', half of people aged over 65 strongly agree, compared with just over a third of 35-64 year olds and only a fifth of 25-34 year olds. And as I've previously argued, the NHS isn't just about healthcare, it's about reassurance.

So it is unsettling to see that only 60 per cent of people believe that 'I can be certain that I will get the best possible care if I fall ill'. Again, that number has a sharp age gradient with baby boomers less likely to agree than current retirees.

One clue as to why this might be is that only a third of people believe they will be safe in hospital from MRSA and related infections. That is a fear that transcends social class and geographical region.

In the light of recent rows about rationing decisions by the National Institute for Health and Clinical Execellence, it is interesting that by a slim margin of 5:4 the public do nevertheless agree that some treatments are too expensive for taxpayers to fund, 'even if they save lives'. No stereotyping intended, but Lib Dem supporters are least likely to agree.

Headlines about hospital closures doubtless have a negative impact. As NHS founder Nye Bevan said: 'I would rather be kept alive in the efficient if cold altruism of a large hospital than expire in a gush of warm sympathy in a small one'.

Whether the public agrees with him is an open question, though history suggests that the impact of reconfigurations on public perceptions probably depends on how they are done, as much as whether they are done, given that the NHS has pretty much continuously been closing hospital beds since the day it was created: down from 480,000 in 1948 to 176,000 last year.

In fact, the rate of bed reductions has slowed markedly in recent years in comparison to the decade to 1997-98 when new treatment techniques meant 43,000 general and acute beds disappeared, equivalent to 86 district general hospitals.

So much will depend on how patients are helped to interpret these changes. And here the omens are not good. Recent Ipsos MORI polling shows that while patients - rightly - trust their family doctor, GPs are far more negative about the NHS than any other group of health staff. And that is despite huge pay rises and dramatically reduced out of hours commitments.

A further factor suggested by the polling is that NHS improvement targets have not yet been tough enough (yes I'm afraid you read that right) to really alter public perception. How patients experience accident and emergency departments is an important predictor of satisfaction, and here the four-hour maximum wait needs to be more like two hours.

Similarly the reductions in average waits as we now head to the 18-week maximum for elective services look likely to have a strong positive impact. And the public wants better access to GP services than GPs seem willing to volunteer, or that 'advanced access' modernisation is actually delivering, or that numerous hugely expensive direct incentive payments to GP have brought about. So it seems that only a hefty dose of alternative provider medical services competition will be sufficient to get this issue taken seriously.

What would the public think about this? Here the Guardian/ICM poll is fascinating, and it suggests the public are more supportive of the direction of NHS reform than at least some staff groups.

For example, it turns out that 70 per cent of our fellow citizens believe that 'private companies should be allowed to provide care for NHS patients', with support for this policy amazingly consistent across social class and region of the country.

But the fact that really got the Guardian leader writers choking on their cornflakes was that that 70 per cent support increases - and 73 per cent for Labour supporters. A newsworthy finding, which, for its own reasons, The Guardian decided not to give prominence to.

Simon Stevens is president of UnitedHealth Europe and visiting professor at the LSE. Simon_L_Stevens@uhc.com