Health services across the UK are in crisis. In 2022, 347,707 patients in England spent more than 12 hours on trolleys in A&E waiting for hospital beds – this is more than four times as many as in the previous 10 years combined. 2023 is unlikely to bring much respite, between workforce shortages, industrial action, budget pressures and, in England, further delays to planned social care reforms. In the year the NHS celebrates its 75th anniversary, there is growing debate on both sides of the political spectrum about the future of the health service and whether fundamental reform is needed.

But how does the public view the state of the health service? After political turmoil in Westminster, do people think the government has the policies to set the NHS on the right course? With the health service under so much strain, do people remain committed to its founding principles?

This long read presents our analysis of findings from the third wave of our programme of public perceptions research with Ipsos that tracks the public’s views on health and social care in the UK every 6 months. Our survey was conducted via Ipsos’ UK KnowledgePanel between 24 and 30 November 2022, with 2,063 people aged 16 and older across the UK (see box on methods).

Full survey results and further details about the methodology and the UK KnowledgePanel can be found in the downloadable slide deck.

The health service had been under severe pressures for some time in the run up to our survey – inundated GP practices, ambulances queuing outside A&E departments and gridlocked hospitals had all become familiar. Although the first strikes by nurses and paramedics had not taken place by the time of our survey, the unions had already voted for historic industrial action. The fieldwork was completed shortly before the prolonged cold snap and spike in influenza admissions in December 2022 that further stretched NHS capacity.

People are negative about how the health service is performing. Only a third (33%) think the NHS is providing a good service nationally – a notable decline from May 2022 and November 2021 (43% and 44%, respectively) (Figure 1). Nearly half disagree (47%), marking the first time in this series of polling that views are more negative than positive.

People are less negative about the performance of their local health services, albeit only slightly. 37% think their local NHS is not performing well, up from 33% in May 2022, while 40% think the NHS is providing a good service locally – similar to May 2022 and November 2021.

The public now appears more pessimistic about what the near future holds for the health service than at any point since at least May 2017 (Figure 2), although comparisons with surveys before 2021 are only indicative. More than half (63%) think the general standard of care provided by the NHS has deteriorated over the past 12 months, while 27% think it has stayed about the same and only 7% think things have improved. People who have used the NHS in the past 12 months are more pessimistic than those who have not (64% versus 53%). Compared with the rest of the UK, people living in Wales are more likely to think standards of care have deteriorated (74%). While our previous survey in May 2022 found tentative signs of public expectations becoming slightly less negative, more people now think standards have deteriorated.

The public is most likely to think the pressure on or workload of NHS staff (81%), waiting times for routine services (78%), waiting times in A&E (75%) and the wellbeing of NHS staff (75%) have deteriorated in the past 12 months. Compared with May 2022, more people now think A&E waiting times and NHS staff wellbeing have become worse, up from 69% and 70% respectively.

People are less likely to think the quality of NHS care has deteriorated. 42% think standards of care at their local hospital deteriorated over the last year, though this is higher than in May 2022 (36%) and November 2021 (37%). 47% think standards of care at their local GP practice have deteriorated and 65% think access to GP services has deteriorated over the past 12 months – similar to the previous survey.

The public is similarly pessimistic when looking ahead to the next 12 months. More than half (62%) think the standard of care provided by the NHS will deteriorate, while 27% expect it to remain the same and 9% expect it to improve (Figure 3). This is considerably more negative than in May 2022 or November 2021, when 39% and 43% respectively expected the general standard of care to decline. Again, the public appears to be more pessimistic about what the near future holds for the health service than at any time since May 2017 – though comparisons with surveys done before 2021 are only indicative. Within the UK, people in Northern Ireland and Wales are the most pessimistic: 73% and 71% respectively expect standards to deteriorate. Those who have used NHS services within the past year are also more pessimistic than those who have not used them (63% versus 52%).

The public expects the year ahead to bring further deterioration on all the measures in our expectations tracker. People are most likely to think the pressure on or workload of NHS staff (74%), waiting times for A&E (69%), waiting times for routine services (68%) and the wellbeing of NHS staff (67%) will decline over the coming 12 months. The public is least negative about the quality of NHS care, but just under half think standards of care in local GP practices (43%) and local hospitals (48%) will fall – only 8% and 6% respectively think standards will improve.

Across the UK, there is limited confidence in national governments to steer health services in the right direction. Only 10% agree that their national government has the right policies for the NHS and 70% disagree. In England, only 3% of people intending to vote Labour, and 24% of people intending to vote Conservative, think the government has the right policies in place.

Public confidence in the government’s approach to the health service is even lower in England than in the other UK nations. Just 8% of people in England agree the UK government has the right policies for the NHS and 73% disagree. People in Scotland (28%) and Wales (19%) have the most confidence in the policies of their respective governments, although a majority in both countries still disagree (52% and 50% respectively).

While differences in methods mean comparisons with surveys before November 2021 are only indicative, public perceptions of NHS performance and government policies appear to be at the lowest level in nearly 20 years (Figure 1).

The current crisis has fuelled calls for fundamental reform of the health system by some media commentators and politicians. Ideas floated include extending user charges (for instance, charging for GP appointments) or a wholesale switch to a system of social health insurance. With people so pessimistic about the current state of the health service, has the public’s attachment to the principles the institution was founded on started to falter?

Our polling series shows that support for the founding principles of the health service remains as rock solid as ever (Figure 4). The public overwhelmingly believes that the three core principles of the NHS should continue to apply today – being free at the point of delivery (90%), providing a comprehensive service (89%) and being funded through taxation (84%). This is similar to previous surveys. While support is stronger among people intending to vote Labour than among those intending to vote Conservative, each of these principles commands majority support right across the party-political spectrum.

Nevertheless, the pressures on services and calls for radical change may be fuelling uncertainty about the future. People are less sure whether there will be a health service based on these principles in 5 years’ time. 63% think the NHS will continue to be primarily funded through taxation, 59% think it will still be free at the point of delivery and 55% think it will provide a comprehensive service. Those who work in the NHS, or have friends or family who do, are more likely to think all three of these principles will not apply in 5 years.

Despite near universal support for the founding principles of the health service the public do not view the NHS through rose-tinted glasses. A substantial number of people think the NHS is inefficient. 53% think the health service often wastes money, while only 33% believe it generally does not and just 4% think money is almost never wasted. This appears broadly unchanged from 2017 and 2014, although differences in the samples and methods mean results are not directly comparable.

People are agnostic about whether NHS-funded treatment should be provided by NHS hospitals or by other types of provider. If given a choice of where to receive hospital treatment funded by the NHS, around half (49%) would choose an NHS service. Making up the other half, 31% would not have a preference, 15% would prefer a private service and 3% a non-profit service.

However, amid concerns that people who need a routine operation may feel their only option is to pay for private treatment, our survey has not detected an increase in the use of private health care over the last year. 13% of the public say they have private health insurance or use private health care – unchanged from May 2022 and November 2021. Around one in five (22%) think they are likely to pay for private health care in the future, but this is not substantially different to May 2022 (25%) and November 2021 (23%).

Our May 2022 survey found the public wanted to maintain the NHS and were prepared to back the higher taxes needed to fund it. With living standards squeezed by high inflation and shrinking real-terms pay, has the public’s support for greater investment in the health service faded?

In the Autumn Statement, delivered shortly before our survey, the government announced extra spending for the NHS. If ministers hoped this would assure the public that the health service has ‘the funding it needs’, they didn’t succeed: 82% think the NHS needs an increase in funding. Support for increasing NHS funding is found across the political spectrum, including most people intending to vote Conservative (63%) and the overwhelming majority of Labour voters (94%). Only 15% of the public think the health service does not need further funding and should operate within its current budget, down from 22% in our last survey.

People are divided on how the government should fund any increase in NHS spending, as with previous surveys, but support appears to have shifted towards increasing taxes and away from cutting spending on other services. While no single option for raising funding commands a majority, the most preferred (with 36% support) is an additional tax earmarked specifically for the NHS – similar to the Health and Social Care Levy introduced by chancellor Rishi Sunak in April 2022 and scrapped by the Sunak government in November the same year. The only other options preferred by at least 20% of the public are increasing national insurance (25%) and increasing income tax (25%). Compared to May 2022, there is less support for increasing spending by cutting other services (19%) and increasing inheritance tax (17%) – down from 25% and 23% respectively.

With all of the pressures on government spending, we asked the public: should taxes increase or other public services be cut to maintain the health service or should the NHS live within its means by doing less?

53% of the public would most like to see taxes increase to maintain the current level of care and services provided by the health service, while 10% would prefer cuts to other services such as education or welfare (Figure 5). Only 6% are willing to see the current level of care and services reduced to avoid the need for higher taxes or cuts elsewhere.

We provided some context to this survey question, noting that many experts argue that it is becoming more expensive to fund the NHS because of increasing costs of treatments, an ageing population and several other factors. This means that even to maintain the current level of care and services provided for free by the NHS, spending on the NHS would have to increase. ​With that in mind, we asked which option the public would most like to see.

The public’s top three priorities for the NHS are addressing the pressure on or workload of NHS staff (40%), increasing the number of staff in the NHS (39%) and improving waiting times for routine services such as diagnostic tests or operations (35%) (Figure 6). This is broadly in line with views in May 2022 and November 2021, though more people now think supporting and expanding the workforce should be a priority. The most notable change is the increase in people who think improving waiting times in A&E should be a priority (31%), a significant increase from May 2022 (25%) and November 2021 (20%).

The public is negative about the current state of the health service. Expectations for the future are even worse, with a majority pessimistic about prospects for the year ahead. With just 8% of people in England convinced the UK government has the right approach to the NHS, our latest survey should ring alarm bells for the Sunak government.

The prime minister has made cutting waiting lists one of his top five political priorities. A plan for recovering urgent and emergency care services has recently been published, with further plans for general practice and the NHS workforce promised in the coming months. It remains to be seen whether these will be enough to address short-term pressures – let alone to deliver the improvements that might convince people that the government has the right approach.

With an election on the horizon, both main parties have so far preferred to talk about reforming the health service rather than increasing investment – suggesting the NHS needs a ‘fundamental rethink’ or to ‘reform or die’. But this kind of rhetoric is at odds with the views of the public. Politicians should not mistake the public’s appetite for improvement as enthusiasm for fundamentally changing the NHS model. Public support for the founding principles of the NHS remains solid across the political spectrum.

Instead, our polling suggests that a policy agenda focused on tackling the underlying problems facing the health service – such as expanding the workforce and improving access to care – would align with the public’s priorities. Making this happen will require a mix of policy change and investment, and most people accept the need to increase taxes to invest in the NHS despite the economic turmoil of recent months. Tackling the public’s pessimism about the NHS by giving them reasons to hope for improvement will be essential for any political party serious about governing in the next parliament.