Summary

This project examines public attitudes to recent NHS reforms in the UK, paying particular attention to the impact of quasi-market and management-by-target policies on public satisfaction and public trust.  It is essential to understand how the public views current reforms and in particular whether the new policies damage trust.  Reforms are necessary in view of the pressures on the service.  However, if the reform programme diminished public trust it may undermine the political sustainability of state health care.  The research is based on in depth discursive interviews with 48 people, review of the literature and secondary analysis of national attitude surveys.

The NHS faces a number of difficult challenges:

•	Demand on the service is rising, mainly due to population ageing.

•	Cost-pressures are rising, mainly due to the development of new technologies and therapies and to some extent to a real increase in staff costs.

•	Patients and citizens are more challenging and assertive and demand more responsive provision.

•	Despite a number of innovations and increases in spending, productivity is sluggish.

The current government has pursued policies of developing quasi-markets in health care within a strict framework of targets in order to meet these challenges.  The reforms in the health service are of particular interest because they correspond to reform processes across the welfare state, and because the NHS is widely seen as the flagship of state welfare in the UK.  Our research shows 

•	Public understanding of the reform programme is limited.

•	Most people see the reforms as at best irrelevant and at worst damaging.

•	The reforms are seen to prioritise the interests of a remote and uncaring management over professional care staff who are concerned with patients’ interests (the iconography of the ‘bean-counter’ versus the ‘matron’).

•	The outcome is that real achievements do not receive the attention they merit and that there is widespread public disquiet about the reform programme.

This analysis is set within a theoretical account of trust, which contrasts a rational actor approach to trust (based on judgement that someone will act in your interests) with a sociological account (based on judgement that someone shares your values and has your interests at heart).  The problem is that the reforms highlight the former and pay little attention to building the latter aspect of trust.

The research leads to recommendations for:

•	Greater public engagement in local health initiatives through public meetings, user councils and similar activities, to establish a stronger sense of management in the interest of the community rather than ,management to achieve competitive success in a quasi-market.

•	Recruitment of patient ‘ambassadors’: lay people with experience of the service who would take the leading in consulting in local areas about NHS developments policies and priorities.

Background

The reform programme is discussed in greater detail in the early sections of the attached paper: New Labour and Reform of the English NHS: user views and attitudes.  The theoretical framework underlying the analysis of public attitudes is described in the early sections of the second paper Public Values and Public Trust.  We will list the key features here.

Reforms

 The NHS reforms involve four main processes:

•	The break-up of a large centralised state bureaucracy with the introduction of much greater budgetary autonomy for individual primary trusts and hospitals or groups of hospitals;

•	A shift in control of patient care budgets from the secondary to the primary sector so that purchasers and providers of services are strictly separated.  The primary sector then purchases care from clinics and hospitals, who now face the incentives of a competitive market.  In some areas shifting budgetary control further to the service-user is under consideration; and 

•	The establishing of mechanisms to establish targets, to provide quality control and give overall direction to the services; and

•	Better information for both managers and users of the service on health care and health needs and the range and quality of provision, to empower consumers and ensure that choices in the new quasi-market are appropriate.

Current policy initiatives are concerned to reduce the importance of targets and develop greater market freedom for service users and providers.  These reforms have taken place in the context of large increases in spending but little gain in productivity.

Values and Trust

Trust is understood in two main ways:

As confidence that a person or institution will act in a particular way grounded in understanding of their interests, their competence and resources and the information available to them.  This may be termed ‘rational trust’;

As confidence that a person or institution will act in a particular way grounded in understanding of their values and sympathies.  This may be termed ‘normative trust’.

Both currents are important in the literature and most approaches to trust combine them, while some interpret trust purely in rational terms (mainly in economics and decision theory) and some purely in normative terms (mainly in sociology and social anthropology).  A further development is the interpretation of trust in social psychology in terms of ‘affect’, an emotional disposition towards something.  This operates in away similar to social values.

The relevance of this debate is that the NHS reform programme tends to understand relationships in terms of the rational deliberative choices on individuals within a market or faced by strong incentives to meet strict targets.  However, a strong tradition in the NHS (and elsewhere in the welfare state) understands trust as strongly influenced by caring relationship, respect for the interests of others and humane values.  The risk is that the reforms will damage this aspect of trust and reduce public confidence in the NHS.  

Objectives

The initial objectives of the project were:

1.  To explore the basis of trust in the NHS as a public service, and of the parts played by rational deliberation and by values and affect in generating such trust.

2.  To investigate public perceptions of current reforms and of their impact on services, and the relation between understanding of the current reform agenda and trust in the NHS.

3.  To contribute to understanding of the sustainability of market-based public policy reforms in services such as the NHS.

These research objectives translated into a set of practical themes for the interview topic guide:

•	Exploring the perceptions of what the NHS stands for, the relationship people have to it, what its problems are, how its performance could be improved, how it should be funded and meanings of patient care.

•	Examining the extent to which people trust (or otherwise) the NHS, the dynamics of their (mis)trust, factors that influence their (mis)trust.

•	Discussing understandings and perceptions of aspects of market reform (competition, private sector involvement, performance targets, patient choice) and how their impact on the NHS and its users.

The interviews successfully elicited useful data in relation to these objectives.  We found respondents eager to discuss their feelings and values with regard to the NHS, its problems and the meanings attached to patient care in general and within the service (Objective 1). These were often discussed in light of personal experiences or experiences of family or friends as well as the social values attached to the NHS as part of the welfare state.  We were able to conceptualise a distinct value orientation that most respondents adhered to and contrast that with the more instrumental orientation of the market reform agenda.  We also succeeded in investigating public perceptions of reform and the relationship to trust in the NHS (Objective 2) as well as how sustainable such policies are in terms of public support (Objective 3).  However, such discussions were usually prefaced by an explanation from the interviewer about the logic and arguments for reform. Most respondents had little understanding of the reforms as a coherent quasi-market programme and tended to understand them in terms of specific aspects: greater power for managers; the choice system; more spending on the health service.  
 
Methods

The research sought to develop understanding of public attitudes and values in relation to NHS reform.  These issues were approached qualitatively to enable the researchers to explore and analyse the structure and relationships between social meanings.   

Forty-eight individual qualitative interviews were carried out with adults evenly divided by gender and social class – routine working class (C2DE’s) and professional or managerial (ABC1’s) chief wage earner households and divided by three different life stages: young adults without family responsibility (18-30), families with children (31-55) and people over the age of 55 without children. We also divided the sample into three distinct localities – a metropolitan area, a provincial town and small village.   The sample frame took account of the main dimensions of NHS usage and trust – life stage (older people and those with young children have greater contact, and trust in general appears higher in older people, possibly associated with deference to authority and to professionals); gender (women generally have higher trust than men); and social class (scepticism and critical trust is typically associated with more middle class groups ).

Quotations were obtained from three commercial field research organisations and one was contracted to recruit the appropriate sample of participants in our three localities and to organise interview times and locations. The interviews were conducted by the same researcher throughout the project to ensure consistency in interview style and technique.  Some address supplied did not give a satisfactory range of middle class respondents.  This was rectified.

A semi-structured interview schedule was designed, piloted with 4 volunteers then used as a topic guide in the 48 interviews conducted with members of the public (see Appendix). The schedule explored a range of relevant themes regarding the NHS beginning with general questions about respondents’ normative values about healthcare, welfare provision and public spending. It then moved on to probe views on specific experiences of the NHS and to discuss aspects of market reforms such as patient choice, target regimes and competitive pressures. Each interview was taped using a digital recorder, with additional paper notes made by the interviewer. Each respondent was offered a cash gift of £25 for their time and participation.

After completing the interviews, each recording was labelled and transcribed to create 48 individual files. Prior to exploring the dataset, a provisional coding framework was constructed to enable the systematic retrieval and categorizing of data. Each interview file was formatted and imported into computer software programme Nvivo to improve the retrieval process. The coding framework was then used to create ‘nodes’ of comparable data drawn from each interview. This process allowed the responses of participants to be grouped and analysed efficiently. Organising the dataset in this way also allowed for other pertinent codes to emerge from the transcripts in a ‘grounded’ way resulting in a continual revision of the initial coding framework and enhancing the analysis process.  

The thematic node structure enabled us to compare the responses of participants and formulate arguments based on the patterns present in these responses. We began by controlling for particular social characteristics – social class, gender, age initially – and explored the relationship of that characteristic to values and feelings in particular areas. We then examined the concepts of ‘trust’ and ‘NHS values’ and compared responses to various aspects of NHS reform.  These included performance targets, the development of markets, the increased role of the private sector and greater patient choice. The results of this analysis were then written up under appropriate headings and formed the basis of two papers submitted to peer-review journals. One paper was a largely descriptive exposition of the research and the findings in relation to market reform.  The other addressed the complex value orientations inherent in public attitudes and feelings about the NHS and contrasted them with those implicit in the rational actor approach underlying the market reforms.

Once the analysis of the individual interviews was completed, we organised a further focus group to discuss some of the findings. We invited members of local NHS public involvement forums to participate in the group discussion. The purpose of this was to explore how those more informed members of the public responded to the findings of our research. We chose five volunteers, all of whom were involved in a variety of NHS public forums and paid them a cash gift of £30 for their time and participation. A suitable topic guide was constructed to enable the moderation of a productive group interview. The discussion was moderated by the PI and researcher and lasted approximately ninety minutes. It began by inviting – in a similar vein to the individual interviews - the views of the participants on aspects of market reform. It then continued by inviting participants to think about and respond to the findings of our research. This provided a valuable discussion and enhanced our subsequent analysis of the dataset.

Results

Key findings:

Attitudes towards the NHS
• The majority support the ‘traditional’ NHS values of universal access, free at the point of use, run by the state
• Some believe this model is outdated in the modern world and cannot meet everyone’s needs satisfactorily given the extra pressures on from medical advances and an ageing population 
• However, there is no desire to see the NHS dismantled; widespread pride in the NHS.  It is considered better than systems in the USA and other countries
• Nonetheless, a strong sense that the NHS is underperforming and failing to meet public expectations

Problems identified in the NHS
• Operational problems like ‘super-bugs’ and inadequate facilities
• Widespread perception that money is not spent effectively, and that too little goes to patient care
• A strong feeling from many people that the NHS is top-heavy with managers and other bureaucrats
• A sense that a combination of targets and red tape is constraining the ability of frontline staff to provide good patient care: the traditional ‘matron’ is contrasted with the ‘bean-counting manager’

Feelings about the reforms of the NHS 
• Limited awareness and understanding of reforms on the part of most interviewees
• Little support for a market where hospitals and clinics compete for patients within the NHS
• However, support from some of those interviewed for the NHS to be more business-oriented and efficient
• Widespread unease about greater private sector involvement in the NHS; worries about profits being put before patients
• Targets seen as an ineffective or, at worst, damaging way to manage performance
• Mixed reaction to greater patient choice. Some in favour, some against, with the majority in the middle unsure how to handle choice or make informed choices. Many do not perceive choice to be a reality in their area and believe it will overload some hospitals and force some groups to rely on poorer facilities
• No evidence of public support for the current reform approach to the NHS. Indeed, most people think current reforms could damage the NHS further and lessen its ability to deliver care to patients and ensure they are treated with proper respect.

The overall value orientation of the public regarding healthcare emphasizes universality and fairness, and the care and respect of staff for patients.  This contrasts with the instrumentalism that underpins individualised models of behaviour and motivation. It was notable that this instrumentalist logic was viewed by three-quarters of respondents as encroaching upon the ability of staff to maintain the more human elements of healthcare provision.

The two papers submitted with the report summarise findings on 

•	Attitudes to and perceptions of NHS reform: New Labour and Reform of the English NHS: user views and attitudes and

•	NHS values and trust in the service: Public Values and Public Trust.  

Activities

We have:

•	Presented a paper to the annual UK Social Policy Association conference in July 2007 entitled “Institutional trust, public perceptions and NHS reform”.

•	The research is included in broader papers presented by the PI on the topics of risk, values and welfare reform. These included a keynote plenary paper given at the UK Social Policy Association conference and a paper presented to the ESRC SCARR Network’s Risk and Rationalities conference at the University of Cambridge in March 2007.

•	Issued a press release was published in November 2007 which were reported by Age Concern, Private Health UK, News-Medical.net, Pharmaceutical Marketing, Hospital Healthcare Europe and Healthdemocracy.org.uk and in a discussion on BBC Radio Kent’s morning news programme.

•	Two further refereed journal articles have been produced based on the theoretical issues and secondary analysis included in the research for Social Policy (forthcoming, June 2008) and Administration and European Journal of Social Quality (6,4, 2007).  These are available via the ESRC Society Today Website

Outputs

All material for the conference has been posted on the ESRC Society Today website via the ESRC Information Centre.

The ESRC data archive has accepted the data for deposit and anonymised audio-files have been sent to them.

Impacts

Media attention is listed above.

Future Research Priorities

The research leads in two directions:

•	Further work to explore attitudinal response to NHS reform and to reform in other areas of state welfare.  Such reforms are necessary in the short term to meet current pressures.  However, reforms that damage public trust may undermine the political sustainability of the welfare state in the longer term.

•	Further work to examine methods of mitigating the problems identified above.

Both directions of research might profitably be pursued comparatively to examine responses to different directions in policy.

Ethics  

Full ethics approval and monitoring for this project was sought and gained from the University of Kent’s School of Social Policy, Sociology and Social Research Ethics Committee. The main ethical considerations of the project were being mindful of the potentially sensitive themes which could arise during interviews given the focus on healthcare and experiences of the NHS. We were aware therefore of the need to stress the anonymity that respondents’ would be afforded in future publications. Where personal information was relayed by a participant during an interview, which would allow them to be identified, either details of the story were altered, or such sections were omitted from the analysis, to ensure that they can not be identified. It was undertaken that any data made available to the ESRC data bank would be anonymised and all identification data, location data and material on individual circumstances from which participants might be identified will be changed or removed. The recruitment policies of the research company contracted to enlist participants are line with the Data Protection Act 1998 which ensured the details of each person were further protected. 

The exploitation of research participants was also a key consideration. It was decided that each participant should receive a financial gift as recompense for their time and effort. In addition, participants were given the choice of where and when their interview should take place. Some were happy to be interviewed in their own home, whereas others chose public places like cafes or a friends home. Prior to each interview, participants were informed of the nature and purpose of the research and asked to sign a form acknowledging the receipt of their cash gift. After each interview, participants were asked for their feedback on the topic guide and the interview experience. In addition, each person was asked if they would like to receive a summary of the research findings once analysis had been completed. In December 2007, each participant who provided a viable address was sent a copy of the findings summary and invited to comment on them. 

Appendix:  Interview schedule

1. Knowledge and experience of the NHS (to explore both the extent of familiarity with the NHS and values and satisfaction expressed in relation to the NHS)

Values
-	When you think about the NHS, what does it mean to you?
-	Do you think having a National Health Service is important? Why?
-	What should the core values of the healthcare system be? Do you think the NHS embodies those values?
-	How should healthcare be paid for? Would you support tax rises to provide more money for the NHS?
-	Do you think patients should make a contribution towards the cost of treatment?
-	Should the state be responsible for providing healthcare or just funding it?
-	How does the public view the NHS?
-	Do you think the NHS has any wider role in our society? Should it? What might that role be?
-	Do you feel any sense of loyalty to the NHS?
-	On the whole, what sort of expectations do people have about the quality of treatment they receive from the NHS? And you? Are they met?
-	Are people treated equally by the NHS? Explain.

Satisfaction
-	Have you or your close family used a hospital service recently? GP?
-	(Using an example) Did you / they feel satisfied with the service? Why?
-	How do you think the service could be improved?
-	Would you be satisfied if you had to use this service again? 
-	On the whole, do you think the NHS is improving / getting worse / the same?
-	Does the NHS represent good value for money?
-	What key changes would improve the NHS as a whole?

2. Understanding of reform (exploring knowledge / perception of and values in relation to reform)

-	What reforms have recent governments introduced to the NHS? How is government trying to change the NHS?
-	What do you understand by ‘modernising’ health services? 
-    What do you understand by market reforms within the NHS?
-	What do you think lies behind these changes? Are they beneficial?
-	Does having the NHS run more like a market change the way you feel about it?
-	How do you feel about being seen as a ‘consumer’ of healthcare? Pros / cons?
-	Have you ever used a private health service such as Bupa? How does it compare? If not, under what circumstances would you consider it?
-	If you knew your local hospital or clinic was run by a private company, how would feel about that? What about a charity?
-	What experience do you have of ‘patient choice’ in the NHS? What happened?
-	How do you feel about the concept of patient choice? 
-	What is your opinion on performance targets for NHS services? Such as waiting list targets? Are they useful?
-	Have you noticed any differences in the way patients are viewed / treated by the NHS? If so, what do you think has initiated this change?
-	Do you think that waiting times for treatment have gone down?

3. Exploring general bases of trust

-	When presented with a choice of hospital / clinic / treatment centre, how do you / would you make decisions about where to get treatment?
-	Do you feel more informed about NHS performance than in the past? (Not just media) 
-	Do / would you trust the information that is provided about the NHS? (Waiting list stats, league tables etc) Have you, or would you use such information to make a decision about where to get treatment?
-	Where do you get your information from?
-	Have you ever used NHS Direct? How do you feel about healthcare phone lines and websites?
-	Do you use any alternatives to NHS treatment for your health needs? Why?
-	Why are more people suing the NHS for compensation today than in the past?
-	Would you feel entitled to sue the NHS if errors were made in treatment? Would you have nay reservations?

4. Exploring affective factors

-	How would you define excellent patient care?
-	Can you describe your feelings before an operation / an operation of a close relative?
-	What would / does put you at ease before an operation? 
-	What makes you feel confident your treatment will be successful?
-	How could patients be put at ease before a significant operation?
-	What steps do you take (if any) to feel confident in a doctor or hospital?
-	What makes a good GP? Why? Has this changed over time or with GPs? Why? Would / Does this influence your willingness to make appointments / disclose health problems? Do GPs differ from other doctors?
-	What do think it is like to work for the NHS? Would you enjoy it? Do you think its staff enjoy working for the NHS? 
-	To what extent do you feel cared for when using the NHS?
-	How respected do you feel when using the service? Do you think patients are respected as a whole by the NHS? What makes you feel that way?
-	What would make you feel more cared for / respected?
-	Do you feel medical staff have patients’ interests at heart? If yes, how do they show this? What are their priorities do you think?
-	How safe do you feel when in NHS care? Why?
-	How much faith do you have in what medical staff tell you? Explain.
-	How honest do you think they are?
-	Do you feel you have a voice when it comes to making decisions about relative’s healthcare? How strongly do you feel listened to by staff? 
-	Would you like a greater say in treatment decisions?
-	Do / would you sit on the board of a hospital or health authority if given the opportunity? Do you sit on a patient support group?
-	Should the public be represented on NHS boards? Why?
-	What steps does the NHS take to consult the public about its performance, new drugs, management etc? Does it do enough?
-	Do you feel connected to the NHS as a public institution?
-	Do you think about whether you trust the NHS? Do you trust the NHS?
-	What factors do you think affect your level of trust in the NHS? Has your level of trust changed over time?
-	Do you think the level of public trust in the NHS has changed?
-	What could be done to enhance the public’s trust in the NHS?