At various times in its 72-year history, the NHS – as a comprehensive, universal, taxpayer-funded service – has been said to be ‘unsustainable’. These arguments have tended to focus on population ageing, the increasing prevalence of chronic conditions and ever more expensive treatments as leading to an inexorable rise in demand. The amount we spend on the NHS – as a share of national income (GDP) – will therefore continue to increase and eventually reach a level that we, collectively as taxpayers, are not prepared to fund.

This may sound logical but it is an argument worth unpacking. First, it is true that health spending has risen and will continue to rise as the population changes – as technology and innovation make it possible to do more, and as our expectations rise. Since its inception, spending on the NHS has increased from 3.5% of GDP in 1949/50 to 7.2% in 2018/19. To meet growing demand, UK health spending would need to increase to 8.9% of GDP by 2033/34. That is even before accounting for the significant spending required to recover from the ongoing coronavirus (COVID-19) pandemic.

But although health spending is certain to rise, other wealthy countries spend a greater proportion of national income on health care and pay more in tax overall. In fact, the UK’s total health spending (beyond the NHS, including private spending) equated to 9.6% of GDP, which was ranked as the second lowest of the G7 countries.

Whether the NHS is sustained as a comprehensive, universal, taxpayer-funded service – at least over the next few decades – is down to our choices as a society, largely made at the ballot box. These include choices about what we want the NHS to do, how we want it to change and whether we are prepared to pay more for it through taxes.

A matter of choice

Opinion surveys have previously shown that we are prepared to pay more tax to maintain and improve the NHS but there is still concern about growing costs. This can lead to suggestions that the funding model for the NHS needs to be reformed. However, moving away from the NHS taxation-based funding model is not a panacea for cost control: across the OECD there is no simple direct link between spending as a share of GDP and the way health care is funded. And in the US, where private insurance plays a large role, health spending is 17.1% of GDP. Furthermore, as we get wealthier over time, we are inclined to spend more of our income on health care, because it can help us live longer and healthier lives

So, whether the NHS is sustained as a comprehensive, universal, taxpayer-funded service – at least over the next few decades – is down to our choices as a society, largely made at the ballot box. These include choices about what we want the NHS to do, how we want it to change and whether we are prepared to pay more for it through taxes.

But what determines these choices? Partly, the visions for the NHS set out by politicians, but also our perceptions of the NHS. Perceptions about how good it is compared to other countries, how much it costs us, how efficient it is and the quality of service compared with experiences in other areas of our lives, such as hospitality. Our perceptions influence the way we vote, governments and their policies and public debate. But our perceptions about the NHS may not always match reality. This may mean our choices about the NHS’s future are skewed.

Perceptions of the NHS

With this in mind, we commissioned the Policy Institute at King’s College London to survey public perceptions of the NHS in November 2020. The 2,056 adults in England who took part in this online survey were asked 34 questions in areas ranging from service quality to population health indicators.

The results showed strong support for the NHS, with 84% of people believing it to be one of the best health systems in the world. This has only grown stronger during the pandemic, with 44% saying they have become more satisfied with the running of the NHS as a result of the COVID-19 crisis.

In common with other surveys, the results showed strong support for the NHS, with 84% of people believing it to be one of the best health systems in the world. This has only grown stronger during the pandemic, with 44% saying they have become more satisfied with the running of the NHS as a result of the COVID-19 crisis. However, despite this, 31% of people do not believe that the NHS will exist in its current form by 2050 – a further 25% were not sure. Of those pessimistic about the NHS’s future, the majority believe it will no longer be free at the point of use.

Increased demand was cited as the biggest problem for maintaining the NHS in its current form – 83% of people reported it as a ‘very big’ or ‘fairly big’ problem. This is unsurprising given media coverage of population ageing and health risks such as obesity. It is worth noting however, that although increasing prevalence of poor health is a significant driver of demand, ageing itself only accounts for a quarter of the growth in NHS care since the turn of the century.

Perceptions of poor health as a driver of demand may also fit with the finding that people overestimate the proportion of the population that smoke. People placed the proportion of smokers in England at between 32% and 39%, compared with the reality of 17%. Even when told the proportion of adults that smoked in 2006, half of respondents still guessed that smoking had increased, pointing to a perception that the nation is getting less healthy.

In contrast, only 43% viewed decreased public support for the NHS as a serious problem. This is slightly surprising given misperceptions about service delivery were particularly negative. The public guessed 52% of people waited more than 18 weeks in 2019 after being referred to a hospital by their GP, when in fact it was only 17%. A similarly negative perception was reported for A&E attendances. Missed targets are often reported in attention-grabbing stories, which could contribute to a belief that things are worse in the NHS than they are. Interestingly, the younger the respondents, the more likely they were to view decreased public support as an issue, which contrasts with their generally more positive view about the future of the NHS.

The public were broadly right about many aspects of the NHS – including the proportion of staff who work unpaid extra hours each week, health care spend in comparison to other OECD countries and increases in life expectancy.

However, misperceptions are pervasive and addressing them is difficult. We should avoid judging false perceptions as ‘ignorance’. Our perceptions are a complex product of our beliefs and theories, and the things we have seen and heard – and can often be changed by new information. Understanding why and how our false perceptions about the NHS have arisen is a first step to shifting them.

Part of the solution will be ensuring the relevant facts about health and the NHS are part of the public debate. This sounds simple but these facts need to be communicated in interesting ways to make them relevant to the public. In an era of social media and ‘fake news’, this is perhaps harder than ever. We also need to counter myths and try to stop these from embedding as ‘facts’, as well as encouraging people to step out of social media-induced echo chambers. Countering misperceptions is not a straightforward challenge but it is vital to good decision making.

Further reading

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Misperceptions about NHS risk undermining views of its sustainability

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