To increase public satisfaction in the NHS, we need a new conversation about how to improve it

As satisfaction with the NHS reaches a new low, we should embrace the power of citizens and society to restore public confidence, argue these authors

The recent British Social Attitudes Survey found that less than a quarter (24%) of the 3374 respondents sampled in England, Wales, and Scotland were satisfied with the NHS—the lowest in the 41 year history of the survey.1 Since 2020, there has been an unprecedented drop of 29% in overall satisfaction. More than half of respondents (52%) say that they are dissatisfied in the latest survey data. The results for social care are even worse with 57% dissatisfied and only 13% satisfied. These results are not a surprise as people continue to face long waits to receive care2 and staff shortages persist,3 with very real consequences. The public narrative is that of a “broken system” that is failing to meet patient needs. If we want to increase public satisfaction in the NHS, we must improve the NHS and change our relationship with it.

Public satisfaction may be low, but the spirit of the NHS seems to be alive and well. There continues to be strong support for the founding principles of the NHS: free of charge when you need it (supported by 91% of respondents), primarily funded through taxation (82%), and available to everyone (82%).1 Almost half of respondents (48%) supported raising taxes to increase funding for the NHS.

Even with this public support, simply spending more is unlikely to be enough to improve the service. The cost of the NHS has risen from 27% of daily public spending to 44% since the turn of the century,4 crowding out funding on education, housing, transport, and the environment, which are key drivers of health outcomes. Sajid Javid, a former chancellor of the exchequer and health secretary, says that the NHS is unsustainable in its present form.4 Wes Streeting, the Labour shadow health secretary, has said that “if the NHS doesn’t change, it will die” and that a Labour government would not provide further funding without major reform.5

What could that major reform look like? Improved digital technology and greater use of artificial intelligence,6 management and infrastructure cost saving,7 and judicious use of the private sector8 might help but are unlikely to produce the major reform that is needed to improve the NHS and increase public satisfaction. And, almost unnoticed by the public or politicians, the NHS in England is legally committed to reach carbon net zero by 2045, a commitment that will itself require major change.910

More radical thinking is needed. Javid has called for a royal commission, and the Lancet,11The BMJ,12 and the Times13 have had commissions on the NHS and its future. But these are made up mostly of people within the health system. Given the public support for the principles of the NHS, perhaps more radical ideas for improving the NHS can come from outside.

We can’t spell out an answer fully here, but we set out three possible starting points.

First, we must consider how to create the right conditions for a changed relationship with the public, in which they have greater say over how the NHS is run. Sherry Arnstein, a special assistant in the US Department of Health and Human Services, published a highly influential eight step ladder of public participation with citizen control at the top, non-participation (manipulation) at the bottom, and tokenism (placation, consultation, and informing) in the middle.14 Only citizen control, power delegation, and partnership lead to real participation in healthcare. These principles can help reduce inherent power imbalances between professionals with the knowledge to treat and patients with the need for treatment and can give society and its citizens more active control over the NHS, rather than being passive recipients of healthcare.

A second source of ideas that could guide us to a better NHS and increased public satisfaction comes from the Lancet Commission on the Value of Death. It proposes a set of five principles to move from death as a medicalised experience to one that belongs to families and communities, with health professionals as supporters rather than leaders.15 These principles can usefully be applied to aspects of healthcare and include: a focus on social determinants of health (understanding population health and tackling health inequity), seeing healthcare as a relational and spiritual process rather than simply a physiological event (humanising care), valuing networks of care (including families and communities), making everyday conversations and stories about healthcare more common (including how to make improvements to the NHS), and valuing what patients and carers can offer.

Finally, the designer Hilary Cottam describes practical ideas for transforming the NHS and social care in her book about the welfare state.16 She argues that the NHS needs a “pivot,” which means a new vision, a different solution, and a new business model. We often look to doctors, other health professionals, and the NHS to solve problems that cannot be solved by drugs, operations, and even simple advice.17 To avoid dependency we need to look elsewhere for help—to ourselves, our family and friends, our communities, and civil society. We need to build capabilities outside the NHS, in communities and people.

Money and health professionals will always be limited resources, but citizens, communities, relationships, and capabilities are abundant and intrinsic. If we are going to restore society’s confidence in the NHS, then we should draw on the power of society to improve it.


  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: the Point of Care Foundation is a charity that works to humanise care. RS was the unpaid co-chair of the Lancet Commission on the Value of Death and is the unpaid chair of the UK Health Alliance on Climate Change and Patients Know Best, a company that seeks to empower patients by putting them in charge of all their health and social care records. He is not paid as the chair but has equity in the company. He also has shares in the UnitedHealth Group, which through its division, Optum, works with the NHS, and has a pension from the BMA, which has its own interest in the NHS. Further details of The BMJ’s policy on financial interests is here:

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