The COVID-19 pandemic has already had major consequences for people's perceptions and expectations of health and social care services. Workforce shortages were the single biggest challenge in health and social care before the pandemic, and the last 2 years have left staff overstretched and exhausted. Responding to COVID-19 has caused disruption, delays and increased demands on services, resulting in large volumes of unmet need and delayed care, including the longest waiting list for hospital care since current records began.

But how might public attitudes continue to change? And what might this mean for policymakers working to plot a course out of the pandemic, learn from the response so far and repair the social and economic damage caused by the virus? This long read examines key findings from a new survey of public perceptions of health and social care, the first from a new 2-year partnership between the Health Foundation and Ipsos.

At the time of our survey (in late November 2021), managing the rapid spread of the Omicron variant of COVID-19 left little space for the government or the devolved administrations in Wales, Scotland and Northern Ireland to contemplate much else. But now (in February 2022), despite the continuing pressures on the NHS, ministerial attentions are doubtless returning to longer term policy priorities.

As health and social care are devolved responsibilities, each of the four countries of the UK has different priorities. In England, Omicron interrupted work to develop and implement several major new policies for health and social care. The UK Health Security Agency (replacing Public Health England) had been fully operational for only 55 days when the first UK cases of Omicron were identified. The ink was barely dry on the adult social care reform white paper, with further white papers expected on levelling up, health disparities and integrating health and social care. Legislation to enact the biggest shake-up of NHS structures for a decade was in Parliament. And a ‘build back better’ plan committed the government to protecting people against catastrophic social care costs and bringing down NHS waiting times, funded by a new Health and Social Care Levy modelled on National Insurance.

Weeks after announcing these tax rises, the 2021 Spending Review confirmed a substantial increase in health spending, with day-to-day spend in 2024/25 to be 13% higher in real terms than in 2021/22. Will people see the benefits of this package of investment and reform – in improvements in local health and social care services and ultimately in better health and wellbeing? Fundamentally, this is the critical test now facing the government – as acknowledged by Rishi Sunak as he unveiled the government’s Autumn Budget just before our polling began:

But if the government does deliver, will people actually feel a difference? And if they do, will that progress be attributed to government policy? The difficulty involved with measuring success, as framed by the Chancellor, may not have been fully appreciated at the time. From 2000 to 2012, regular research into public perceptions of health and social care services consistently reported a ‘perceptions gap’. This was a reference to a reliable pattern of people being most positive about their local NHS and social care services, less positive about services across England as a whole, and least positive about the government’s policies for those services.

Will things be different in 2022? To shed light on these and a host of other issues, we have partnered with Ipsos to deliver a programme of research into public perceptions of health and social care over the next 2 years. Every 6 months, we will poll a representative sample of the UK public using the UK KnowledgePanel – Ipsos’ random probability online panel – building on our previous work on this topic.

Our first survey was conducted between 25 November and 1 December 2021, with a total of 2,102 responses from people aged 16 and older across the UK. Fieldwork started shortly before the first UK cases of the Omicron variant were identified, but was completed before Boris Johnson’s announcement of new COVID-19 restrictions in England on 8 December 2021. While this may have been too early to fully reflect views about the prospects of another major surge in COVID-19, it may be a timely reflection of the public mood as ministers were setting out plans for recovery and reform.

Comparisons to historical data should be considered indicative and therefore interpreted carefully. For example, some have used a different method, a different geographical sample (for example, Great Britain instead of the UK) or slightly different age ranges. Where previous surveys differ from the current polling, this is noted in the text.

In this long read we highlight key findings from the first survey, including those related to the current performance of health and social care overall, priorities and expectations for the future, and public views on the Health and Social Care Levy. The full survey results can be found in the downloadable slide deck.

No part of the UK’s health and social care system has been untouched by COVID-19. Protecting the NHS from being overwhelmed during the pandemic has consistently been at the heart of the government’s response, albeit without defining what this means. Previous polls and other evidence suggested the public were more optimistic and less critical of the NHS at the beginning of the pandemic, but expectations began returning to normal as the pandemic progressed. As the response to COVID-19 continues to stretch NHS and social care services, understanding how public expectations are changing is particularly important.

Standards of care over the last 12 months

Compared with previous surveys, the public is now more pessimistic about what has happened to the standard of care. More than half (57%) think the general standard of care provided by the NHS got worse in the last 12 months, compared with 32% in March 2021, 23% in May 2020 and 38% in November 2019. Those with experience of using the NHS during this time are similarly pessimistic.

To understand what may be driving expectations, our survey also asks about aspects of NHS performance that are particularly important to the public. People are most likely to think the pressure on NHS staff (85%), waiting times for routine services (84%) and access to GP services (77%) have got worse over the last 12 months. People are least likely to think the standard of care at their GP practice (56%) and local hospital (37%) have deteriorated, but very few (6%) believe standards in either have improved. People living in the most deprived parts of the country are more likely to think quality of care has deteriorated at their GP practice (65%) and local hospital (45%). This echoes previous analysis showing those living in the most deprived parts of England have poorer access to, and experiences of, general practice and routine hospital care.

The public is even more pessimistic about what has happened in social care over the last 12 months. More than two-thirds (69%) think the general standard of social care has got worse, while only 4% think it has improved (Figure 1). People in some older age groups are more likely to think standards have deteriorated, including 77% of those aged 55–64 and 78% of those aged 75 years or older. This is a considerable shift from May 2020, when 41% thought the general standard of social care had got worse and 10% thought it had improved. This may partly be a reflection of growing public awareness of how the pandemic has impacted adult social care and the gaps in the government’s response, as well as frustration with the continuing restrictions on visiting care homes.

Our survey happened before the Omicron variant took hold in the UK, but NHS and social care services had already been severely affected by the pandemic. With the waiting list for elective care reaching 6 million in England alone, many people are experiencing significant disruption to health and care services.

Less than half of the those surveyed (42%) agree that their local NHS is providing them with a good service while around a third (31%) disagree. Thinking about the NHS nationally, less than half (44%) agree a good service is being provided and around a third (32%) disagree.

This appears to be a notable deterioration when compared with previous research, although changes in methodology and there being no measures between 2016 and 2021 mean comparisons with historic data are only indicative. The ‘perceptions gap’ between local and national services (whereby local services are typically viewed more positively than national services) also appears to have disappeared (Figure 2).

With the public clearly seeing the need to improve NHS services, what issues do people feel are most pressing? The top three priorities cited are addressing the pressure on or workload of NHS staff (37%), increasing the number of staff in the NHS (36%) and improving waiting times for routine services such as diagnostic tests or operations (35%). A total of eight areas were selected as a priority by at least one in five people (Figure 3) – only just excluding COVID-19 vaccination, with the focus on delivering the booster campaign coming after our survey was completed.

Supporting and expanding the workforce are among the public’s top priorities for the NHS. Yet the government has repeatedly failed to produce a comprehensive workforce strategy for the health service in England. Ministers and MPs have even rejected a widely supported amendment to the Health and Care Bill that would require government to publish independent projections of workforce supply and demand to support better workforce planning. The gap between public desire to see the workforce prioritised and the lack of action currently being taken to address workforce challenges should set alarm bells ringing in Whitehall.

The prominence of elective care among the public’s priorities is understandable given the scale of the NHS backlog. The government has clearly anticipated the need to address waiting times and has committed to doing so, backed by extra funding, although also acknowledging that waiting lists are expected to lengthen before they reduce. People may have some tolerance for longer waiting times but, as the waiting list continues to set new records, those waiting for treatment may look beyond the NHS. Overall, we found only a minority of people currently or are likely to pay for private health care with only 13% already paying and 23% very or fairly likely to do so. However, being able to access care and treatment more quickly is the major attraction for most (83%) of those who already pay or are likely to pay. Should this increase in the future, it may indicate growing frustrations with delays and a warning to government that progress is not being made quickly enough.

When developing the policy agenda for the NHS, the government and devolved administrations will need to be alert to the significant differences in priorities among different groups. People aged 55 and older are slightly more likely to view ‘making it easier to get face-to-face GP appointments’ a priority (33%, compared with 27% overall), while those in the most deprived areas prioritise ‘making it easier to get GP appointments’ (29% versus 22% overall). People living in Scotland are more likely to prioritise ‘improving mental health services’ (31% versus 22% overall), as are younger people (aged 16 to 34) across the UK (33%, compared with 22% overall). People from ethnic minority backgrounds appear to give greater priority to health care standards – 20% cite ‘improving the standard of care in hospitals’ as a priority (versus 9% of those from white ethnic backgrounds), while 19% think ‘improving the standard of care in GP practices’ should be a priority (versus 11% of those from white ethnic backgrounds).

The government and devolved administrations face a significant challenge in meeting public expectations around plans for the NHS and social care. Despite government claims to have prioritised the NHS throughout the pandemic, and setting out plans for major reforms, our survey found that only a minority think their policies are the right ones (Figure 4). Just over one in ten people (12%) agree that the government has the right policies for the NHS and more than half (62%) disagree. People in Scotland and Wales are significantly more likely to agree that the devolved governments have the right policies for the NHS (32% and 23% respectively, versus 9% for England).

For context, when this question was put to the English public in a series of surveys between 2003 and 2016, the proportion who agreed that the government had the right policies for the NHS ranged between 22% and 37% (Figure 2). While previous findings are not directly comparable with our survey due to differences in the methodology, the stark decline could indicate a shift in public confidence in the government’s handling of the NHS in England.

Confidence in national policies for social care across all four UK countries is even lower, with no statistically significant differences between them. The public is not so sure that social care has been fixed, with only 8% agreeing the government has the right policies for social care.

While confidence in the government’s policies is low, the public mood does not support a wholesale shift to a fundamentally different model of health care system – backing for the core principles of the NHS remains broadly unchanged. The vast majority think that the NHS should be free at the point of delivery (89%), provide a comprehensive service available to everyone (88%), and should be funded primarily through taxation (85%). This should give pause for thought to anyone advocating for more radical changes to our health care system.

The government is planning to fund its biggest ambitions for health and social care through a new Health and Social Care Levy, essentially a UK-wide tax based on National Insurance. From 2022/23 to 2024/25, the levy is expected to generate an average of £12 billion per year across the UK. This is a considerable amount of money, even if the anticipated £10 billion boost to health and care spending in England still falls short of estimates of what is needed.

People will certainly notice the difference in their pay packets – not least because the government plans to advertise where the extra money is going. From April 2023, ‘Health and Social Care Levy’ will be listed on payslips alongside deductions for income tax and National Insurance. New legislation, passed towards the end of 2021, requires the proceeds to be spent on the costs of health and social care in England, Wales, Scotland and Northern Ireland. In the meantime, the rate of National Insurance will temporarily increase by 1.25 percentage points from April 2022, with tax on dividend income from shares increasing by the same amount.

The notion of earmarking an increase in National Insurance to fund extra health spending is not without precedent. Almost exactly 20 years ago, under the political cover of a landmark independent review of the demands on the NHS, Gordon Brown – then Chancellor of the Exchequer – announced a 1% increase in National Insurance to fund major new financial settlements for health and social care. At the time, the decision to invest more in public services by increasing taxes went with the grain of public opinion and was remarkably popular. With ministers clearly hoping for a similar reception, our polling offers some good news but a few notes of caution too.

The main positive for government is that, at the time of asking, most people (58%) support the Health and Social Care Levy, with only one in five (22%) opposed. Support is particularly high among people intending to vote Conservative – 75% support the decision, with only 13% opposed (Figure 5). Achieving this level of support arguably represents a small but important political victory for the government. Raising taxes to spend more on public services is not exactly traditional Conservative party policy, and doing so unambiguously breaks the 2019 election manifesto commitment not to raise income tax, National Insurance or VAT.

Less positive for government is that support for increasing taxes is weaker among some of the groups expected to pay the most towards the new tax. The Institute for Fiscal Studies expects most of the burden of paying the new tax to fall on people of working age. While the government has changed the law to apply the levy to those working beyond state pension age, older households will still only contribute a small amount of the revenue. Support for the levy is highest among people aged 55–64 (67%), 65–74 (77%) and 75 or older (76%), and lowest among those aged 25–34 (41%).

Equally, a government that won a majority in 2019 by turning the ‘red wall’ blue may be disappointed that increased spending on the NHS and social care has not found more favour among people intending to vote Labour. Just over half of Labour voters (55%) support the new tax, but one in four (24%) are opposed. And after rumblings of discontent about tax rises from within the cabinet, amid concerns about a cost of living crisis, the continued enthusiasm of Conservative voters cannot be taken for granted.

This is an important moment in time to monitor public perceptions of health and social care performance and policy. Health and social care services remain under immense pressure from the pandemic and face a long, difficult road to recovery. Meanwhile, the government is progressing wide-ranging reforms, alongside a new funding announcement and plans for a Health and Social Care Levy.

Our polling shows that the unprecedented challenges faced by health and social care are reflected in negative public perceptions of the current state of services. More than half (57%) think that the standards of NHS care have deteriorated over the past year, while more than two-thirds think the standard of social care has got worse (69%). Less than half believe the NHS is currently providing a good service nationally (44%) or locally (42%). People living in the most deprived parts of the country are more likely to think the quality of care has deteriorated at their GP practice and hospital, and are less optimistic about the prospects of care quality improving in the year ahead.

Supporting and expanding the workforce are among the public’s top priorities for the NHS. In light of this, the continued absence of a comprehensive workforce strategy in England is a glaring omission in the government’s plans. Different groups have different perceptions of what the top priorities for the NHS should be, but addressing the significant workforce challenges in health and social care will support progress towards all of the public’s top priorities over the medium term.

Public confidence in the government’s handling of the NHS appears to be very low for England: just 9% of those living in England agree that government has the right policies for the NHS, even as it progresses with a major programme of NHS reforms. The picture is different in Scotland and Wales, where people are significantly more likely to agree that their government has the right policies for the NHS (32% and 23% respectively). The decision to increase taxes to spend more on the NHS and social care has majority support across the UK, but in the context of a cost-of-living crisis the government will need to keep making the case for the new tax – especially among those who will be paying the most towards it.

The public mood around the state of health and social care seems to be particularly bleak at this moment – especially in England – but our previous polling throughout the pandemic has shown how quickly public views can shift. Every 6 months we will continue to monitor and report on how public perceptions are evolving in these areas and others.