Features: March 21st, 2003

Delivery, Delivery, Delivery – What Do The Citizens Think?

By Brian Gosschalk

Chief Executive MORI

Reproduced by permission of the Public Management and Policy Association.

The public values, and fears for its services. Public services consistently head the public’s concerns when asked what are the most important issues facing the country with, for example, the National Health Service the most frequently named single issue in all but six monthly surveys in the first five years of the present Labour government. In surveys, the general image of public services seems to be that they are worthy and often important, and staffed by dedicated public servants who struggle against poor management, bureaucracy and above all inadequate funding.

Attitudes influenced by media

Despite the public’s concern, rating for public satisfaction with many services are reasonably high. They can, however, fluctuate substantially under pressure of media coverage or when forced to the front of the political agenda. In January 2001, during the build-up to a general election in which opposition attacks on the standard of public service played a significant role, satisfaction with the NHS fell to 46% with 44% dissatisfied. In the same survey other services fared even worse: only 38% said they were satisfied with standards in education, the same proportion who felt dissatisfied; 43% were satisfied with the way their area was policed but 50% dissatisfied. The following year, satisfaction with ‘railways in Britain’, the service hit by the most public series of crises, fell as low as 10% satisfied with 65% of the general public and 77% of rail users dissatisfied. (By way of comparison, in 1991 half of all rail users, 51% said they were satisfied with British Rail and only 31% dissatisfied.)

Even at its November 2001 ‘high’ of 60%, satisfaction with the NHS is lower than it might be. This is not, it seems, a direct result of experience of its performance. In surveys, satisfaction with medical staff is invariably much higher then satisfaction with the overall NHS. For example in February 2002, 91% of those surveyed said they were satisfied with the way doctors do their job, 94% were satisfied with nurses and 85% with dentists. Satisfaction scores when those who have recently been treated in the NHS (or have had family members treated) are asked to rate their own experiences are also usually good.

Under pressure, under-funded, bureaucratic

The public seems to derive an overall view of the NHS, perhaps from its portrayal in the media and its perceived use as a football in political debate, that is more pessimistic than their own experience and levels of satisfaction – might warrant. A MORI survey of adults in England in April-May 2000 asked respondents to pick three words or phrases which best described the NHS much the most frequently selected were ‘under pressure’ (58%) and ‘under-funded’ (57%), with no other description picked by even 30% of the sample. Only 23% characterized the NHS as ‘slow’. Further, only 14% picked ‘high quality health care’.

This pattern is reflected in the more general image of public services as a whole. In September 2001, two-thirds of the public considered them ‘under-funded’ (68%) and 41% picked ‘bureaucratic’. The third most frequently chosen description, the choice of 30%, was ‘hardworking’. Just as revealing are the descriptions at the bottom of the list: only 5% think public services are ‘open’, 7% ‘honest’ and, perhaps worst of all, only 8% feel that ‘good value for money’ is a description which applies. This seems a long way of from the ‘world class’ public services the Government aspires to.

The 2002 Budget, with its tax increases specifically to fund investment in the NHS, had some positive effect in persuading the public that the government will succeed in improving public services over the next few years. Nevertheless, fewer than half the public expect improvement in any of the main public services, and in the case of public transport more expect deterioration than improvement.

Increased taxation only one solution

The public’s preferred solution to the perceived ills of the public services, is, of course, greatly increased funding. Indeed the majority often express themselves wiling to pay higher taxes to achieve this. MORI polls during the last parliament found between three-fifths and three-quarters of the public supporting tax increases.

Other polls emphasize that the public does not always equate increased taxation with increased spending and that the pubic needs to be assured that the money is well spent and that the there is no other source of appropriate funding. In November 2001, ICM found that 54% of the public said they would be willing to pay more in income tax to ‘fund the recovery of the national Health Service’, but 82% thought that ‘the government should consider options other than raising income tax to improve the NHS’. A MORI poll in 2000, which explicitly set out possible options found funding from the national lottery, was the most popular means of raising NHS funding. The same poll found that considerably more people favoured the diversion of funds to the NHS from other areas of government expenditure than increased taxation.

Delivery more important than process

It is in this context that the question of the acceptability to the public of PFI, and other potential private sector involvement in public services, needs to be considered. In the field of public services, as with many other areas of the governmental sphere, delivery is much more important to the public than process. Achieving effective services is overwhelmingly more important to them than who provides those services. In a September 2001 MORI survey only 22% of respondents defined public services as being managed by central or local government and 10% that the staff should be employed by central or local government. Only 12% specified that the service should be non-profit making. More important was that the services were available for everybody to use (40%) and ones that are important for the whole community (38%).

In the same survey 68% agreed with the statement ‘If a private sector company can provide public services more efficiently than central government or local councils, it should be allowed to do so’.

Yet this does not mean that, all things being equal, the public would not prefer public services to be provided by the public sector. An August 2001 survey found a majority saying that some key service – notably schools and health – should be provided entirely or mostly by public sector companies. Probably this attitude feeds at least partly on a fear that partial privatization will be a precursor of diminished, perhaps eventually disappearing, services.

But assuming that universal public services survive, it will probably continue to be the effectiveness of the delivery rather than the identity of the deliverer that determines public satisfaction. Certainly, if things go badly, public sector providers will be convenient scapegoats, though governments will not escape blame either (In January 2002, 46% of those dissatisfied with the state of the railways, blamed the previous Conservative government, which privatized them, 35% blamed Railtrack and 32% the Train Operating Companies; the present Labour government, which merely failed to re-nationalize them, was blamed by 26%)

Communication – key to delivery

Since it is perception rather than reality that determines public reaction, one crucial aspect of delivery is good communication. MORI’s surveys have persistently found, in all fields, a strong correlation between familiarity with an institution and favourability towards it.

In general terms it is the commercial or private sector service providers (including the privatized industries and the still public – but commercially – minded BBC) who have best exploited the relationship, achieving good communications and high satisfaction, whereas government departments and agencies, as well as local councils, tend to do poorly in both areas. Ease of communication (such as availability of staff in evenings or at weekends) and quick response to enquiries are also frequently mentioned in surveys asking the public how services can best be improved. Speed of services is especially vital in emergencies and it is noticeable that in 2000 the People’s Panel name emergency services – GPs, hospitals, police, fire and ambulance well ahead of education and transport in their list of priorities.

Yet it is the ‘routine’ services, having more frequent contact with the public, that have the best opportunity to improve their image through more frequent and effective communication. Good delivery, of course, is the aim and no doubt the greater funding for which the public calls would help. But communicating any success is also important. A health service where 91% are satisfied with the doctors yet only 60% with the service is missing something somewhere. If the public services could convince more than 5% of the public that they are ‘open’, 7% that they are ‘honest’ and 8% good value for money’, it would be an important start.