The NHS in the UK has come in for a lot of bashing of late, especially from politicians and the media. The former do so for largely ideological reasons, while I fear the latter often report the exceptions that sell papers.
We mustn’t forget that there are about a million NHS consultations every day. The overwhelming majority of these are of good quality, even if they don’t necessary give desired news to the patient. And despite the efforts of the media and politicians, most of us are generally happy with the way the NHS operates.
The British Social Attitudes report, published today, shows exactly that. There have been some changes over the past three decades, but we are generally satisfied with the NHS.
What is ‘satisfaction’?
A common sense definition of satisfaction is “a judgement about whether expectations have been met”. But a recent Health Technology Assessment review suggests that this common sense understanding is too simple.
If meeting expectation is the key, we could increase satisfaction in two major ways: either meet people’s expectations by offering better services or lower people’s expectations.
But patient satisfaction is actually more complex. It’s influenced by other factors such as the actual standards of care received; expectations; patients’ dispositions; time passed since care took place and previous experiences.
Together with colleagues I’ve previously argued that patients often cannot assess the quality of the care they receive; they suffer from the dilemma that “what is, must be best”. In other words, the drugs or treatment prescribed by the doctor must be good because they prescribed it. Patients are more likely to assess the hospital where they received treatment on its parking facilities, food or visiting times, rather than their treatment.
Older people happier
The British Social Attitudes Report’s headlines are that public satisfaction with the NHS is higher now than it has been for most of the past three decades. To be precise, 61% were satisfied with the NHS in 2012, compared with only 34% in 1997 and a peak of 70% in 2010. The report authors remind us that not all parts of the NHS do equally well, since in-patient care scores lower than community care including general practice.
Another headline is that older people (aged 75 and over) are more satisfied than their younger counterparts; 75% of the over 75s versus 63% of those aged between 18 and 24.
Today’s tabloid newspapers and the two-minutes piece on TV news channels no doubt highlights the headline findings of the report. There won’t be much space to look into some of the more sophisticated explanations provided by the authors of the variations in the trends in satisfaction levels.
For example, the survey authors have looked at the correlation between satisfaction levels and people’s political affiliation. Are party members of the ruling party (or parties in the current coalition government) more satisfied with the NHS than those whose party isn’t in power?
The statistics suggest that during the time Labour was in power (1997–2010) Labour supporters’ satisfaction tended to be higher than that of Conservative or Liberal Democrats. However, in the previous period (1983-1996) when the Tories were in power Conservative voters were more satisfied with the NHS than Labour or Liberal supporters.
The report concludes that over the past three decades the views of the Labour Party and Liberal Democrat supporters have been quite similar, much more so than the views of Labour and Conservative supporters.
Another headline finding worthy of further investigation is age. Over the past 30 years the proportion of people aged 75 and over who expressed satisfaction with the NHS was 15-25% higher than the proportion of 18 to 24 year olds who thought the same. The authors’ explanation includes the factor that older people are more frequent users of NHS services, and that NHS users are more likely to be satisfied with the NHS that non-users.
An often used argument is that the age difference in the levels of satisfaction reflects younger people’s higher expectations of the NHS, which makes them harder to satisfy than their parent or grandparents. Interestingly, a recent study by Bowling and colleagues in the Journal of the Royal Society of Medicine suggested this might not be the case. Instead, they argue that older patients are more satisfied with their care not because their expectations are lower, but older people believe that their high expectations are generally being met.
Link to quality?
It’s clear that satisfaction is a multi-dimensional concept determined by a variety of factors. Many scholars have commented that many satisfaction studies lack a conceptual or theoretical basis. They argue that (a) satisfaction studies shouldn’t be used to allocate resources, and (b) patients are unlikely to evaluate care in terms of satisfaction.
Without identifying the theoretical foundation of the concept of (patient) satisfaction it is debatable how we can link it usefully to the quality of the services provided. However, these academic considerations won’t stop hospital managers, politicians and the media using satisfaction studies.
The state-funded health care system that is the NHS is one of the best in the world so I’m not surprised that satisfaction levels are generally high - despite what the media and many right-wing politicians want us to believe.