Scottish Social Attitudes Survey 2013: core module - attitudes to Government, the economy, health and social care services, and social capital in Scotland

4 Views About The Health Service And Care For The Elderly

4.1 This chapter summarises:

• Trends in satisfaction with the National Health Service (NHS)
• Trends in whether people think that compared with the government, the private sector or the voluntary sector provide the most cost effective or the best quality services
• How views vary on whether the private or voluntary sectors provide the best quality health and social care services
• Trends in who people in Scotland think should pay for care for the elderly.

4.2 In 2012 the Health and Social Care Act introduced a radical restructuring of the NHS in England which was implemented in April 2013. There have, however, been no similar attempts to restructure the NHS in Scotland. NHS spending in Scotland has been protected, as it has been across the UK, although in real terms the budget has still reduced in Scotland. In Scotland the key policy focus has been on integrating health and social care services, requiring joint working and combined budgets for the NHS and local authorities. As part of the move towards more integrated services, the 'Reshaping Care for Older People Programme^[24]' was introduced in 2011 and supported by the introduction of a Change Fund^[25], which had a budget of £80m in 2012/13. As the older population is likely to increase in Scotland by around two thirds in the next twenty years, the Reshaping Care for Older People Programme aims to improve services by focusing more on prevention and anticipatory care.

4.3 The Christie Commission report (2011), and more recently the review undertaken by the UK Carnegie Trust (Wallace, 2013) have focused on the importance of diversifying service provision and actively involving service users in the development of services (rather than simply regarding them as passive recipients of services). One key policy that reflects this move towards so-called 'co-production' is the introduction of self-directed support. The national strategy for self-directed support was launched in November 2010 and the Social Care (self-directed support) (Scotland) Act was passed in 2013. The Act gives people more choice and control over how their support is provided and how their 'individual budget' is spent. This strategy requires there to be a range of different service providers available, in order to meet the different care needs of individuals, and consumers are supported to explore care options in both the voluntary and private sectors.

Satisfaction with the National Health Service

4.4 As discussed in previous chapters the Scottish Social Attitudes (SSA) survey has tracked changing attitudes during the recession in a way which enables the impact of the cuts in public spending introduced from 2010 onwards to be examined. Although the health budget in Scotland has been protected, the increases in cash terms have not kept pace with inflation. Indeed, the Scottish Government has set annual savings targets for the NHS. In 2012/13 the NHS made savings of £270 million, equivalent to three per cent of the budget (Audit Scotland, 2013).

4.5 On the first occasion (1999) when SSA asked how satisfied people in Scotland are with the NHS, the proportion saying they were either very or quite satisfied was 55%. This decreased to 40% in 2005 but has been steadily increasing ever since (Figure 4.1). In 2013, 61% of people in Scotland were either very or quite satisfied with the NHS compared with around a quarter of people (26%) who said they were either quite or very dissatisfied.

Figure 4.1: Satisfaction with the way the NHS runs nowadays in Scotland (2005-2007, 2011, 2013)

Base: All respondents.

Sample size: See Annex A, Table A.21.

4.6 The British Social Attitudes survey has asked people across the UK how satisfied they are with the NHS since 1983. The findings from BSA from 2001 onwards show a steady increase in levels of satisfaction from 2001 up until 2010: 44% said they were very or quite satisfied in 2004 compared with 70% in 2010. However, in 2011 there was a sharp decline of 12 percentage points in satisfaction with the NHS across Britain with 58% of people being either very or quite satisfied with the NHS. The results in 2012 showed a small, but not statistically significant increase to 60%, and this figure remained at 60% in 2013. It is difficult to directly compare trends over time from BSA and SSA, as SSA does not have a complete time series, so the overall upward trend in satisfaction in Scotland from 2005 to 2013 may mask fluctuations that might have existed in between individual years. However, comparing data from the years that both SSA and BSA asked people how satisfied they are with the NHS shows that in 2005 people across the UK were more satisfied than people in Scotland with the NHS: 48% were either very or quite satisfied compared with 40% in Scotland. In 2007 and 2011, SSA and BSA recorded identical levels of satisfaction, whilst the figures in 2013 were almost the same (61% for SSA and 60% for BSA).

4.7 The BSA 30th report (Park et al, 2013) reviewed the relationship between satisfaction with the NHS, public expenditure, and performance. The report concluded that there had been no consistent pattern between satisfaction and NHS expenditure over the last 30 years in the UK. However, the report does suggest that the increase in satisfaction levels in the UK since 2001 may be due to the effects of extra funding which has enabled improvements in performance in some key areas (including the reduction in waiting times). The reduction in satisfaction levels in the UK since 2011 may be due in part to concerns about the organisational reforms in the English NHS following the introduction of the Health and Social Care Act in 2012.

Figure 4.2: Satisfaction with the way the NHS runs nowadays in UK (BSA, 1999-2013)

Base: All respondents.

Sample size: See Annex A, Table A.22.

Views on private and voluntary sector organisations providing care for the elderly

4.8 The role of both the private and voluntary sectors in providing care services has been increasing in recent years and is likely to expand further. The Christie Commission (2011) recommended the use of a diverse range of service providers. Moreover, the introduction of self-directed support means individuals are now able to purchase services directly from both the voluntary and private sectors. It should be noted, however, that the move to a more diverse social care market has not been uncontentious. Previous research has shown that people can have quite negative views about the involvement of private sector organisations providing care services (Curtice & Heath, 2009).

4.9 In 2007 and 2010, SSA included questions on whether people support or oppose 'private companies or businesses' and 'charities or 'not for profit' organisations' providing personal care for older people. In 2010 over twice as many people supported charities or 'not for profit' organisations providing personal care for older people than supported private companies providing this care: 74% compared with 35%. Between 2007 and 2010, there was a substantial increase in the proportion of people supporting charities providing these services, from 44% in 2007 to 74% in 2010. There was a much smaller increase in relation to support for private companies over the same time period, from 28% in 2007 to 35% in 2010.

4.10 In 2011 more detailed questions were included in SSA that explored people's views on i) the cost effectiveness and ii) the quality of services for older people who need regular help. The questions first asked people how they rate the cost effectiveness and quality of services provided by private companies compared with services provided by the government. The survey then asked similar questions comparing services provided by charities as compared with services provided by government. These questions were repeated in 2013 and the findings are shown in Table 4.1 below.

4.11 In 2013, whichever comparison was tested (private companies versus government or charities versus government) people in Scotland did not distinguish between these two aspects (cost effectiveness and quality) in their answers. That is, the proportion choosing who provides the most cost effective service was virtually identical to the proportion choosing who provides the best quality service. See table 4.1. In what follows we therefore focus on people's perception of quality alone.

4.12 People did have different views towards private companies compared with charities providing care services. In 2013, when comparing government with private companies, many more people thought government would probably/definitely provide better quality services (59%) compared with 32% who thought private companies would. The findings were more balanced when respondents compared charities with government. In this case, 48% felt charities would probably/definitely provide better quality services compared with 43% who thought government would.

Table 4.1: Attitudes to who provides the most cost effective and best quality services for older people who need regular help (2013)

	Private companies vs. Government		Charities vs. Government
	Most cost effective	Best quality	Most cost effective	Best quality
	%	%	%	%
Definitely government	22	22	15	15
Probably government	37	37	28	29
Probably private companies/charities	28	27	41	40
Definitely private companies /charities	4	5	8	8
Neither/same/don't know	9	9	8	9
Sample size	1497	1497	1497	1497

4.13 There have been no significant changes in the responses to these questions since 2011. There is an indication that between 2011 and 2013 there was a small drop in the proportion who thought charities probably provided more cost effective services than government (46% in 2011 compared with 41%^[26] in 2013), but in all other respects the patterns and associations were similar.

4.14 SSA 2013 included questions on people's views about private companies or charities running NHS hospitals. The findings show more support for charities running NHS hospitals, rather than private companies. However, even for charities, the proposal attracted fairly limited support. The proportion supporting the involvement of these other organisations in running NHS hospitals was 29% for charities and just 14% for private companies. This question was also asked in 2007, when a similar proportion of people supported the involvement of charities (27%). However, there has been a slight reduction between 2007 and 2013 in the proportion supporting private sector involvement from 17% in 2007 to 14% in 2013.

Who thinks that private companies provide the best quality care for the elderly?

4.15 The SSA 2011 report (Ormston & Reid, 2012) explored how attitudes differed between groups in relation to thinking that private companies rather than government should provide care for the elderly. The report concluded that those who thought that private companies would provide the best quality care were more likely to be: younger, qualified to Higher level compared with all other levels of education, working in the private sector, and more right wing in their political beliefs.

4.16 The patterns were similar in 2013 in relation to age, education and sector of employment (see Table 4.2). In particular:

• younger people were more likely to think that private companies would provide the best quality services compared with older people: 57% of 18-29 year olds compared with 23% of those over 65
• those with Highers, compared with those with both lower and higher education levels, were more likely to think that private companies would provide the best quality care
• people working in the private sector were more likely to think that the private sector would provide the best quality services compared with people working in either the public sector or those who were self-employed.

4.17 By contrast, a different pattern was found in relation to how left or right wing people were in 2011 and 2013. In 2011, people who were more left wing were less likely to believe that private companies provided the best quality services: 25% of people who were on the left of the political spectrum compared with 36% of people who were on the right. In 2013, people who were politically left or right wing did not have significantly different views on whether private companies, rather than the government, would provide the best quality services.

4.18 People's attitudes to whether private companies or government provided the best quality services were also explored in relation to their assessment of their own health. There were (marginally) significant differences by self-rated health^[27], with people rating their health either 'very bad' or 'bad' less likely to say that private companies provided the best quality care compared with all other groups.

Table 4.2: Attitudes to who provides the best quality services for older people who need regular help by demographic factors, self-rated health and political attitudes (2013)

% private companies/ charities definitely/ probably provide better quality services	Private companies vs. government		Charities / 'not for profit' vs. government
	2011	2013	2011	2013
	%	%	%	%
All	33	32	54	48
Gender[28]
Men	29	34	51	48
Women	36	30	58	48
Age
18-29	54	57	65	50
30-39	37	38	57	59
40-64	25	23	53	47
65+	26	23	45	39
Annual household income[29]
Up to £14,300	38	30	50	39
Over £14,300 to £26,000	32	27	53	48
Over £26,000 to £44,200	31	38	54	56
Over £44,200	32	33	65	57
Highest educational qualification
Degree/Higher Education	30	33	57	51
Highers/A-levels	42	38	57	57
Standard Grades/GCSEs	34	34	58	50
No recognised qualification	26	22	43	33
Self-rated health[30]
Very good	34	33	59	49
Good	34	35	53	51
Fair	31	30	53	44
Bad or very bad	23	21	41	39
Occupational sector[31]
Private sector	36	38	57	52
Public sector/ Charity	27	22	57	43
Self-employed	25	28	51	47
Position on political left-right scale
Left	25	30	51	50
Centre	37	34	57	46
Right	36	36	56	52

See Annex A, Table A.23 for sample sizes.

Who thinks that charities provide the best quality care for the elderly?

4.19 In 2011 the groups who had a more positive view of charities providing the best quality care for the elderly compared with government were women, younger people, those on higher incomes and those with any level of educational qualification compared with those with none (see Table 4.2 above). This was similar to the groups who had a more positive view of private companies. However, attitudes to charities are less divided on political factors than attitudes to private companies, as there were no significant differences by occupational sector or how left or right wing people were politically.

4.20 In 2013 there were again significant differences in attitudes by age, income and education levels. However, whether people worked in the private or public/voluntary sector was significantly related to attitudes to charities in 2013 and gender was no longer significant. Younger people were more likely to say that charities would provide better quality services than government compared with older people: 50% of those aged 18 to 29 compared with 39% of those over 65 years old.

4.21 In 2013 people with incomes over £44,200 were more likely to say that charities provided the best quality services (57%) compared with those in the lowest income category (39%). And people with no formal qualifications were less likely than all other groups to think that charities would provide better quality care than the government. Surprisingly it was people working in the private sector who were the most likely to think that charities would provide the best quality care services for the elderly. This may be because this group have the most negative attitudes towards government providing care services and therefore prefer any alternative provider.

4.22 In relation to both private companies and charities providing care services the most negative views were held by those who were more likely to be receiving care now or in the near future. It is too early to say whether this is a cohort effect and as the younger people get older their attitudes will become less positive about private companies and charities providing care for the elderly.

Views on who should pay for care for the elderly and how these views vary among different groups

4.23 In 2007, 2011 and 2013 the survey included a question about who should pay for the care of older people who need regular help with looking after themselves. The three possible responses were:

• The government should pay, no matter how much money the person has
• The person should pay, no matter how much money he/she has
• Who pays should depend on how much money the person has

4.24 Figure 4.3 shows that in 2007 over half of people in Scotland, 55%, thought that the government should pay, no matter how much money the person has; 42% thought it should depend on how much money someone has and only 2% thought that the person should pay regardless. There has been a decline in the proportion believing that the government should pay, regardless of how much money the person has of 10 percentage points between 2007 and 2013, when 45% of people believed this. This has been accompanied by an increase from 42% in 2007 to 51% in 2013 in the proportion of those believing that who pays should be related to how much money the person has. It is worth noting that the most recent change from 2011 to 2013 was statistically significant.

Figure 4.3: Attitudes to who should pay for personal care for older people (2007, 2011, 2013)

Base: All respondents.

Sample size: 2007 = 1,508; 2011 = 1,197; 2013=1,497

4.25 In 2011 significant differences in attitudes on this issue were found in relation to age, education levels and how politically left or right wing people are. In 2013 we explored the relationship between age, gender, education levels, income, self-reported health, newspaper readership and how left or right wing people are. Significant differences in attitudes to who should pay for personal care were found only in relation to education levels and newspaper readership. Those with Standard grades or with no formal qualifications were more likely to say that the government should pay for care no matter how much money the person has compared with those with Highers or degree level education. 49% of those with no formal qualifications compared with 36% of those educated to degree level. Those who read broadsheets, compared with those who read tabloids or no paper at all were less likely to have said that the government should pay for care regardless: 37% of broadsheet readers compared with 51% of tabloid readers.