What do cancer patients want from the NHS? What can the NHS afford? Laura Thomas Ipsos MORI Social Research Institute 23 February 2012

A thought experiment £750k per patient Extends life by a month £10k per patient Extends life by 10 years Consider two new treatments... What’s acceptable to the public? What’s the tipping point? How will this change over coming years?

Services more explicitly rationed … and social media mean people can organise Public hit in their own pockets Union unrest – can’t rely on staff as advocates

So why is this important?  Context for QALYs very different now to a few years ago  The new context likely to shape what the public see as “acceptable spending”  NHS needs to be ready for what is likely to become an increasingly vocal debate  Producers need to be sensitive to the public opinion constraints on the NHS

So where will public priorities land?

6 Some slides from a few years back % Q10Which of the following statements best reflects your thinking about the NHS? Base: English adults age 16+ (c.1,000 per wave) The NHS is crucial to British society and we must do everything to maintain it The NHS was a great project but we probably can’t maintain it in its current form Don’t know

7 Base: British public, 18+ (1,001) January 2006 But by everything, they mean... Agree Disagree Don’t know There should always be limits on what is spent on the NHS… unlimited spending... 31% strongly disagree

8 The NHS should provide all drugs and treatments no matter what they cost Base: British public, 18+ (1,001) January 2006 and little concern about value for money…… The NHS should provide the most effective drugs and treatments no matter what they cost The NHS should provide the most effective drugs and treatments provided they represent good value for money 72% expect NHS to provide drugs no matter what they cost no matter what they cost treatments no matter what they cost

Before deliberation the most effective drugs & treatments no matter what they cost Don't know all drugs and treatments no matter what they cost the most effective drugs and treatments provided good value for money After a day’s deliberation … which are deeply entrenched Base: British public, 18+ (90) Birmingham NHS should provide: 78% “no matter what costs” 62% “no matter what costs” Q. “Which of the following do you agree with the most?

But around election, some signs of shift

Recognising the limits to public services... “I’ve got a particular beef about dental care, you see people who totally abuse that, that feed their kids nothing but sweets … and it’s really hard to get an NHS dentist now.” Focus group participant, London, April 2010

12 Not a blank cheque “George Best being given a new liver – that to me, repeatedly doing damage to themselves, it makes me feel quite angry actually … there’s huge waiting lists for other people that have serious health problems that aren’t their fault and people like George Best are running the gauntlet again.” Focus group participant, London, April 2010

Making judgements about “good” and “bad” NHS spending “The NHS will give out things like boob jobs and gastric bands, so why won’t they give my son a chance at happiness?” Metro, 5 th July 2010

Base: 1,646 British adults 15+, th April 2010 Source: Ipsos MORI Health Insight Unit/Personal Responsibility (CAPIbus questions) The NHS should give less priority to people who do not take care of their health It is the job of the NHS to keep people healthy It is the individual’s responsibility to keep themselves healthy The NHS should be there to take care of people regardless of why they are ill Base: 1,646 British adults 15+, th April 2010 Source: Ipsos MORI Health Insight Unit/Personal Responsibility (CAPIbus questions) But it’s not clear where this trend will net out

What’s more certain: challenging times ahead

“There is a tsunami of anger heading towards the NHS which will overwhelm people paddling in their canoes acting as if nothing is happening” Sir Robert Francis QC

Base: 1,003 British adults 18+, 17 th – 19 th June 2011 % Worse% Better Standards of treatment for patients in the NHS The service provided by GPs or family doctors How efficiently the NHS spends public money Source: Reuters/Ipsos MORI Is he right? Thinking about the NHS and from what you know or have heard, do you think the following will get better or worse over the next 12 months or will they stay the same? The length of time patients have to wait before receiving treatment % Stay the same% Don’t know

Do you recognise the headlines? Mortality lottery in NHS Guardian, 15 Jan 2001 Cancer victim forced to buy her own drugs Daily Mail, 4 April 2001 Care hit by staff shortages, say nurses Guardian, 18 Sept 2001 Huge differences in the number of doctors per bed at hospitals dramatically affect a patient's chances of survival, according to a study. Daily Mail, 15 Dec 2001 Cash crisis is crippling us, say hospitals Daily Mail, 21 Feb 2001 NHS reforms look tarnished BBC, 4 May 2001 NHS rationing on way, say doctors BMA says extra resources not enough to meet demand Observer, 7 Feb 2001

So will public concerns peak again? NHS Crime/ Law & Order Race/ immi- gration Economy Source: Ipsos MORI Issues Index What do you see as the most/other important issues facing Britain today? Unemployment Base: representative sample of c.1,000 British adults age 18+ each month, interviewed face-to-face in home

So...  A possible shift away from “NHS should fund everything”... ... Towards willing to make judgements about what NHS spending is acceptable  Public don’t currently have appetite for withholding treatments  But we can anticipate public anger – will that:  Change their views on what’s acceptable?  Make them more vocal in expressing that?

What about the wider context?

A pretty clear story... society is becoming less compassionate Source: British Social Attitudes Survey 2010 The state has a duty to provide a decent standard of living for the unemployed 1985 Now Government should redistribute wealth to help the poor 1994 Now

...and fewer support extending services Tax cut/reduce services Things left as are Don’t know Tax increase/extend services People have different views about whether it is more important to reduce taxes or keep up government spending. How about you? Which of these statements comes closest to your own view? Source: Ipsos MORI Base: c.1,000 British Adults % Taxes should be cut, even if it means some reduction in government services, such as health, education and welfare % Don't know % Things should be left as they are % Government services such as health, education and welfare should be extended, even if it means some increases in taxes 46% 33% 18% 2%

Source: Reuters/Ipsos MORI Political Monitor Base: c. 1,000 British adults each month Agree Disagree There is a real need to cut spending on public services in order to pay off the very high national debt we now have Or is it so clear? Second thoughts…?

From what you know, do you think the government has on the whole made the right decisions or the wrong decisions about where spending cuts should be made? More now think the government is making the wrong decisions on spending cuts Source: Reuters/Ipsos MORI Political Monitor Base: 817 British adults 18+, 20 th October 2010 Right decisions Wrong decisions Don’t know Right decisions Wrong decisions Don’t know October 2010 March 2011 Base: 1,000 British adults 18+, 11th - 13th March 2011

So back to our thought experiment...

A thought experiment £750k per patient Extends life by a month £10k per patient Extends life by 10 years Consider two new treatments... What’s acceptable to the public? What’s the tipping point? How will this change over coming years?

Unclear where the public will land on this?  Unprecedented times – and views still evolving  Discord between what people think in theory and in practice  Likely to be public anger – but where will it focus  Govt for cuts?  NHS – for not spending enough?  NHS – for spending too much? BUT...  Views will form – which will shape the tipping point: what spending people see as acceptable  Commissioners need to be sensitive to emerging public priorities

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