Public attitudes to the NHS: A love-lament relationship?

Kate Duxbury and James Frayne on how the public really feel about the NHS and what that might mean for the upcoming election.

13 March 2024

With a general election looming, how does the public really feel about the NHS? And how are the main political parties responding? To scratch beneath the surface, Matthew Taylor sits down with Kate Duxbury and James Frayne to explore attitudes towards the health service. Delving into views on access, performance and staff and perceptions on waste, efficiency and spend, they consider where next for the NHS.

Kate is a research director leading health policy research at Ipsos. James Frayne is a founding partner at Public First.

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  • Matthew Taylor

    Hello and welcome to Health on the Line. This week we're talking about the public, we're talking about politics, we're talking about the election.

    And it's a topical issue for everybody, of course, but particularly for us at the Confed, because we've recently published our Confed manifesto. Now, there are lots of manifestos out there, lots of health commissions, many of them with lots and lots of recommendations. I was an advisor to one, the Times Health Commission, but we felt at the Confed it was important to keep it simple and clear and memorable. So our manifesto has these core five asks.

    First, we want politicians to commit to avoiding any top-down structural reform. Previous elections, changes of power have been followed by structural reforms that have consumed a huge amount of time and energy. We don't want that. We think the structure is okay. We want an increase in capital spending. Of course, we want reasonable revenue spending as well, but what we're focusing on in our manifesto is improving capital spending and improving the capital regime so it's easier for trusts and systems to access capital and spend it the ways that they want to. 

    Thirdly to commit to fund and to deliver the NHS Long Term Workforce Plan alongside an equivalent for social care. 

    Fourthly to make progress on this long-standing commitment to try to move resources upstream or leftward, whatever phrase we want to use; more investment in primary in health in community settings, mental health and community settings. 

    And then finally that we have a national strategy for health, recognising the NHS only determines 20 per cent of people's health outcomes that we have a joined up approach to how it is we improve public health and prevention as a whole. So no structural reform, increase capital spending, deliver the long-term workforce plan, shift resources upstream and have a joined up national approach to health. 

    So that's our manifesto, but how do the public feel about the health service? What are going to be their priorities as we move into an election period? Well, to discuss that, I'm joined by, well, I couldn't be joined by two better people really, by Kate Duxbury, who's research director at Ipsos. Kate leads on health policy research at Ipsos, including a focus on public perceptions of the NHS. And James Frayne, who's managing director at Public First, a consultancy specialising in public policy, public opinion and campaign strategy. 

    Now, we at the Confed have commissioned and worked with Ipsos MORI and Public First on some in-depth quantitative and qualitative research about where the public are as we seek to shape the debate in the months to come. So first of all, James, Kate, welcome to Health on the Line. 

    I'm going to start. James, with you, with just a really simple question, which is, you know, different elections, issues can become more or less salient and indeed part of the political battle is agenda setting. So where does the NHS feature in terms of the public's priority concerns in this election year? 

    James Frayne

    So the NHS is almost always a sort of tier one issue for the public. So it's normally sort of either first, second or third and that's where we are at this moment. Some months you'll do a poll and it's absolutely number one. Another poll it will be or just be shaded into second place or something but for the public it's absolutely front and centre of where they want politics to be. I think probably it's not where necessarily most politicians would like to be at this point in time. I think it is difficult for all parties to talk about the NHS in this year. 

    The Conservatives because they've obviously been in power now for sort of 14 years and they are perceived not to have had a great record on it. On the other hand, the Labour Party ordinarily, you might think, would like to put the NHS front and centre of things, but there's not that much money in the coffers. They're very nervous about making great spending commitments. 

    So there is likely to be a bit of tension between politicians and voters at this point where voters want to hear more and more about it. Politicians are thinking, well, we can talk about it, but we'd sooner fight on other issues probably, and we'll see how that plays out. 

    Matthew Taylor

    Yeah, no, that's fascinating, I think, James, because other polling that I've seen suggests that the voters think that we should be putting public spending ahead of tax cuts in terms of priority. But given that that polling, given the polling that I've seen, does show that the public wants to prioritise public investment, are you surprised at all that Labour isn't willing to kind of show a bit more leg in terms of, well that's going to be our priority, public investment? 

    James Frayne

    Well, personally, I'm a bit baffled by Labour's commitment to, what we used to call not so very long ago, ‘balanced budgets’ – in that the sort of public belief in the need for balanced budgets has been completely decimated in the last few years, partly by covid because we found vast amounts of money for furlough and all the other things associated with it. So we had that. But then secondly and thirdly, we had the mass funding of armaments for Ukraine. And we also had the great support for energy bills that we gave to people. And we had those two latter things after we've had the big sort of covid splurge, if you like. 

    And I think people therefore, for the first time, certainly in my sort of political lifetime, if you like, they no longer believe that politicians can't find money for something. They do believe actually genuinely there is a magic money tree. So in the late 2000s, the Conservatives went into the last election on quite a tough austerity balance of budget message, and it resonated with the public. Now, the public, as I say, just think you can find money elsewhere. 

    So if I was Labour personally, I would be bolder on public spending generally, but bolder on the NHS specifically. 

    Matthew Taylor

    So, Kate, I'm interested in your perspective on this and the relationship between the debate about the NHS and the debate about tax and spend. I mean, I'm old enough to remember the 92 election, which people say was won on tax and spend by the Conservatives. Obviously, there was a leadership issues there as well. How do you see this NHS tax and spend nexus working out over the next few months? 

    Kate Duxbury

    So we often see it as a pendulum where it almost swings between people wanting higher taxes so that we can fund public services like the NHS better and then back towards wanting tax cuts. But the picture's been a little bit blurred on that in more recent times, but you're absolutely right people are not looking for tax cuts at all.

    I think the state of where the NHS is in terms of people's experiences, how well they think the NHS is doing, they are willing, or they say they are willing I should say, to put more money forwards in order to fund the NHS. And I know you can't always entirely believe that because what you say in a survey versus what actually happens when it starts hitting your pocket can be two different things. 

    But if you look back to the health and social care levy a couple of years ago, actually more than half of the public supported that being implemented and even once it was implemented and it had started hitting people's pockets, it's still just over half of people supported that levy. 

    So I think really people are behind it because they're worried about the state of the NHS and indeed public services in general at the moment. 

    Matthew Taylor

    So Kate, just pursuing that a bit more. One of the reasons that I got involved, for example, in the Times Health Commission was to kind of try to ensure that big speculative pieces like of work like that didn't get into questioning the kind of foundations of the health service, the core principles of the health service, the idea of care provided on the basis of need free at the point of delivery funded through taxation. But where is the public in relation to those core principles of the NHS? 

    Kate Duxbury

    They're so strongly supportive of the core principles. You can't underestimate that at all. So in the survey work that we've done for you and through that, you can see a really clear majority agree with the founding principles. So 87 per cent think it should provide a comprehensive service available to all. Eighty-seven per cent think it should remain free at the point of delivery. Eighty-three per cent think it should be funded primarily via taxation. 

    I mean, those are really high percentages, but also just the strength of feeling behind that when you do qualitative research with the public. They're still so proud of it as a system. They'll quite often compare it with the American system. It so strongly holds the values that we hold ourselves that people just very strongly subscribe to them. 

    Matthew Taylor

    So, James, in terms of the kind of, you know, deeper kind of qualitative analysis, what Kate describes is powerful. I mean, there's that famous line, isn't there, that the NHS is the closest we've got to a kind of national religion. When you kind of take apart people's commitment to the founding principles of the NHS, commitment that holds up despite what we're going to explore in a minute, what's kind of going on there? Is that a thought through thing? People are aware of the fact that other systems funded differently aren't any better. They're aware of the problems of the American system, or is it at a kind of visceral national level that we feel this is part of our identity? 

    James Frayne 

    I think it's probably both. There is this enormous fear that we can't overstate, which is there is more and more experience, I think, of healthcare systems abroad. It's partly, we're all traveling a lot more than we used to. Flights are cheaper. More people are going on more foreign holidays. They're being more exposed to international healthcare systems. And likewise, the country is becoming more diverse. We've obviously had more immigration into the UK in the last sort of 15 or so years. So people are coming to the UK with experience of their countries of origin and comparing that to the UK. 

    And for the most part, there's a great fear of moving to a different system, an international system. Obviously, America is the one that people raise all the time. But in the qualitive research that we did, we have people talking about, for example, the expense of the Irish system or the two-tier access of the Egyptian system. There is just a lot more knowledge out there now about international systems and therefore fear. 

    Nonetheless, I think as you sort of suggested, I think was Nigel Lawson that said that the NHS was like a religion for the British people. And that really hasn't changed. People are just brought up with this great respect for the people that work in the NHS and a respect for the quality of care when they're able to get it. 

    There are a couple of issues though that we need to always keep in mind when we're talking about their commitment to the principles, which is on some issues whilst people say they are deeply committed to the principles of the NHS, those principles can be slightly bent around a little bit. So for example, people would say everyone should have healthcare free at the point of use. However, often people would say, but the very richest should pay a little bit. 

    Or they might say if you miss an appointment, you should pay or if there are some parts of treatment that shouldn't be provided for at the point of use and therefore people should pay. That's not to sort of say that the commitment isn't strong. It is strong, but it's not as sort of simplistic, naive even, as it might appear on a first look. 

    Kate Duxbury

    Well, I wonder sometimes, James, it's a bit of cognitive dissonance that people believe in it so strongly they overlook the parts that they disagree with. So for example, you know, they love the equality that's within the NHS system and they'll mention that, oh, of course it's not entirely equal because some people pay for private care and then they might get care sooner, but they kind of dismiss that because it doesn't fit with their overarching picture. 

    Matthew Taylor

    Well, Kate, that takes me on neatly to the next question, which is that that commitment to the founding principles of the NHS remains remarkably strong, but that doesn't mean that the public is unaware of the challenges the NHS is facing. So what does your research tell us about what the public is most concerned about in terms of the NHS's performance right now? 

    Kate Duxbury

    So in terms of performance, I'd say access is absolutely top of the list of what they're worried about. So, in many ways, their views of quality are holding up. They're not as good as they were five years ago, but they are holding up to some extent, whereas perceptions of access have just, I mean, collapsed is a strong word, but it fits. 

    So for example, in the research we did for you, we had 65 per cent of the public dissatisfied with waits for routine hospital appointments; 65 per cent dissatisfied with waits for urgent and emergency care; 71 per cent for mental health; and 61 per cent dissatisfied with how easy it is to get a GP appointment. That's when you remove people saying they don't know. But this is the top issue that people will talk about in terms of how their experiences of the NHS have declined in recent years. 

    Matthew Taylor

    And Kate, to what extent is that a reflection of direct personal experience and to what extent is that a reflection of what people read about in the newspapers? And I know how significant that difference is. And when I worked for the Labour government in the early 2000s, we talked about a delivery gap, which was that people would often say, well, my school's not bad, my hospital's not bad, my GP's not bad, but the school system or the health service is collapsing. So there was a gap between their own perceptions and what they've read about. Is that an element of what's going on with our service or is this public concern to satisfaction actually driven by people's own personal experiences? 

    Kate Duxbury

    I think it's more so driven by people's experiences than perhaps it has been in the past. So if you look at the patient experience surveys of what people have actually experienced when they do services rather than what they think is happening, the GP patient survey, for example, has still got amazing statistics on some measures like 91 per cent say their needs were met at their last appointment, people still feel like they're treated with care and concern, et cetera. 

    But then you've got only 54 per cent saying that their overall experience of making an appointment was good. So it's the access part that really pulls down people's experiences of GP practices. And it's similar for the CQC inpatient survey, for example, the quality, the experiences that people have being treated with dignity and respect are still very well rated, but then the access parts are where the falls have been greater.

    Matthew Taylor

    And James, when you put this together, at the heart of this, that the big danger is simply a loss of belief that the NHS is going to be there for you when you need it. So Kate's talked about specific elements of this route access, but reconnecting it to that kind of founding principles point seems to be part of our love for the NHS is the idea that it is there for us when we need it, regardless in a sense of who we are and what our needs are and why it is we're ill.

    Do you think that there's a danger that people's concerns about access to GP access, waiting list and all that, it does undermine this deeper sense that the NHS can be relied on? 

    James Frayne

    It does. I think that's a good way of characterising and it's, whilst I said that I think the Conservative party doesn't really want to talk about the NHS in this election year, the one area where I think they absolutely cannot not talk about it and they know this is around GP access. So we've seen some stuff recently on that from the Prime inister, because I think it came through very strongly in our research as well, where you heard very harsh criticism was around people's ability to get GP appointments. 

    And in the past, you often had a bit of a rural town split on that, where you might have people in more rural areas saying, even a few years ago, they had a family doctor, they've had that doctor for many years, the care was very good, they knew their children, all the rest of it. You might have people in towns talking about it was a bit more difficult to get appointments now there's sort of universal concern and frankly irritation about people's inability to get a GP appointment and certainly in cities more and more people are moving if they have to private GP appointments. 

    We've seen that in the statistics that's very clearly happening but I think people do think that GPs are bit of a special case that needs special attention. Yes, there are other areas of the NHS where people are concerned, but for the most part, people think the NHS is great. We believe in the founding principles, it's still working. However, GP access is really bad. 

    And I think, were I a future Labour Secretary of State, I would be thinking hard about how to deal with GP access on day one, because that's really where the public are. Obviously, a big part of primary care is staffing, a problem which could get worse in the years to come. 

    And that takes me to the question of staff. When a service is underperforming, I guess one danger is that the public start to blame the people who are providing that service. But I think, James, you'll confirm, and I'll come to you then on this, Kate, that actually it's the reverse, that even though people are concerned about what they see in the NHS, they absolutely don't blame the staff. And indeed, they think the biggest problem is not necessarily themselves, that is the public, but the way that staff themselves are treated in a sense, there's a kind of altruistic element to people's concerns about the NHS. They want staff to be better treated. That's right, isn't it, Kate? 

    Kate Duxbury

    It is right. There's definitely an altruistic feeling there. They're so grateful to NHS staff for working hard, for working through the pandemic, and they very strongly believe that they should be treated better than they are at the moment. It's not entirely altruistic, I would say. That's why staff are so important to the public attitudes picture because of how it links into so many different elements of people's experiences. 

    So, for example, access is very strongly linked to staff. So people think access is poor because there aren't enough staff, but they also link it to quality. So if there aren't enough staff and if staff overworked and their morale is low, they feel like their consultations with staff will be more rushed and therefore the quality of care they get will be worse or if people feel very unhappy at work that the quality of care they can provide is worse. 

    So there's definitely an altruistic element to it, but they also think it leads to other outcomes that they're not happy with. So it's important to them to increase the number of staff, but it's also very important, just as important I would say, to look after the staff that are there better. 

    Matthew Taylor

    James, looking at the data, it is It's really kind of heartwarming that the public's concerned, the bond that seems to exist between the public and NHS staff. 

    James Frayne

    Yes, it really is. Absolutely. I mean, it's huge respect for people who work in the NHS, obviously, particularly for nurses. And we're seeing it played out even now with attitudes to the public over the various strikes that we've seen. There's massive public support for nurse strikes for higher pay, which is obviously why the government is particularly look to come to a combination on that. But also I think some sympathy probably has gone down a bit, but as well some sympathy for junior doctors as well. So it really is very, very, very strong. 

    There is one slight caveat to this, which is this sort of concept of quote managers unquote, where there is this feeling, particularly amongst conservative leaning voters that there is this sort of group of managers who are very big and there's too many of them and they're causing waste and they should be more money spent on doctors and nurses. 

    And this comes and goes and it's coming and coming gone over the course of the last 15 or 20 years that people have sort of raised this management question. And it does seem to be having a bit of a moment again, there is this concern that there are too many managers. But again, when you get into the polling of it, most people drastically overstate how many managers there are.

    That when you really understand what the role of managers are, and when it is put to them, for example, that, well, firstly, there isn't that many. And secondly, you need this sort of tier of management in order to take some of the admin bureaucracy over off the frontline staff. There is a great waning of concern on this issue. And I think the NHS therefore should be reasonably robust in defending, quote-unquote, managers over this election period. But coming back to the main point, yes, there's absolutely huge support for staff and I cannot see that changing anytime soon. 

    Matthew Taylor

    So let's just stick on this point, James, which is, let's just say, and I'm sure you're far too ethical and principled for this, but let's just say I come to you from a right-wing think tank and said, look, what I want you to do is to design for me a campaign that's really going to undermine this kind of blinkered public support for the NHS. So you've told me that one of the things you'd be focusing on is alleged proliferation of highly-paid managers.

    Where else would you kind of go for if you were commissioned to have a national campaign to get the public to be more critical of the health service? 

    James Frayne

    I think I would probably firstly recommend that actually you did a campaign on something else and this probably wasn't going to move the needle. But if you put this sort of metaphorical gun to my head, I mean where the vulnerabilities are for the NHS, managers as I've just discussed, that is quite a big concern as well. And that takes you into the broader issue of waste.

    So there is this sense strongly felt but not very specific that the NHS wastes a lot of money. It tends to be, you asked before about whether or not this was from direct experience or whether or not people had sort of read about it or heard about it. I'll put that very much in the latter camp. You know, people don't really have much experience of NHS waste. It's mostly stories that they've heard about, but waste would be another issue. 

    And then one issue that hasn't raised its head, in a big way yet, but I think probably will do in the not too distant future is this idea of sort of woke waste, if you like, that there are parts of the National Health Service which are too politically correct and, you know, too concerned about not upsetting people or all that sort of thing. 

    That is starting to register slightly in the polls. Again, I don’t want to overdo it. This is not a majority opinion, but it's gradually creeping up this idea that, you know, the NHS is wasting money on things about non-gendered language or things like this, which again doesn't irritate the majority, but there's a small minority that does annoy and it's growing slightly. 

    So you could see where the main vulnerabilities lie. One very brief thing I would though raise is not so long ago, voters would often raise the point about immigration and say that immigration was putting lots of pressure on the NHS, it was making access more difficult, et cetera. That has dropped down actually very significantly since covid and it's dropped down since Brexit, where I think people are seeing, well, actually, we really do need staff from wherever we can find them. They are welcome here. 

    I think most people have now pivoted to a great, even greater support for having staff coming from overseas to staff NHS jobs. And that sort of concern about immigration has significantly diminished in recent years.

    Matthew Taylor

    Kate, if you were approached by a writer who sent a think tank with a billionaire backer asking you to devise a campaign, would you give the same advice that James has? 

    Kate Duxbury

    I really would. And if I can pick up a few points around waste and inefficiency as well. I find it really interesting because when you ask in surveys what people's priorities should be, like improving efficiency doesn't come particularly high. It's about halfway down the list. But when you do focus groups with people, they talk an awful lot about waste and inefficiency. And they always have done for as much as long as I've been doing this, they've talked about it. But the feelings behind it, I think, are stronger at the moment in the context of a cost-of-living crisis. 

    And we talked at the beginning a little bit about the balance between increased funding for the NHS versus taxes. And the waste and inefficiency issue is important for that because people aren't going to want to pay more taxes where they feel like too much money is being wasted.

    And it does, a lot of it does come from what people hear and what people read about. So a good example, I think that has exacerbated how people feel about it at the moment is procurement during the pandemic. So things like the nightingales standing empty, things like the stories they've heard about PPE procurement, they have fed into this feeling of inefficiency. 

    But I do also think sometimes people are experiencing what they would consider to be waste when they're using services. So for example, something like being referred to the wrong department and then having to be referred again and start again, or receiving multiple letters about appointments that have different appointment dates on, or getting a letter about an appointment that comes the day after the appointment was meant to be. 

    Those all are direct experiences of what people consider to be an inefficient NHS. So in some ways, the NHS, I think, does have more control over those kinds of elements. 

    Matthew Taylor

    Well, look, that's really helpful from both of you. And of course, we are using these insights to develop resources for our members around, and we're calling it myth busting. So we're producing particular targeted bits of material, but to address some of these kinds of issues around managers and woe and waste. And that's an important part of trying to make sure that we don't end up having a discussion about the NHS, which is negative and which focuses on an issues blown out of proportion. 

    Now I've got two last questions for you. And I'll start Kate with you on this one, which is that in some ways, we could kind of sit back and say, well, this is good. You know, the public supports the NHS. They want to see more money invested. They want to support staff. But there is another element to this, which is also if you were to say to the public what really matters, they'd say waiting lists, they'd say access. 

    They probably talk about the kinds of things that politicians put in the shop windows, retail offers. What they might not talk about are the kinds of things that leaders we work with would themselves say were priorities. They might not spontaneously talk about investing more money in prevention. They might not talk about moving resources upstream out of the acute sector into proportionately, that is, into primary and community services. 

    So, Kate, what does the polling tell us about the willingness of the public to get involved in that kind of deeper conversation about things we might need to do to help the health service be more sustainable in the medium term? 

    Kate Duxbury

    So I think that this is always going to be a challenge for the politicians that people do want to see that improved access. And so as long as that's getting worse, I think it will be hard to engage the public with other conversations. 

    Having said that, from the research I've done, I just think that there's a strong feeling that it would be better to stop people from needing hospital care in the first place. 

    And actually people do have an understanding of some of the challenges facing the NHS in terms of an ageing population who also have more long-term conditions to manage. And people can understand that therefore it's important to have longer-term approaches to protect the NHS for the future and actually reducing demand for hospitals and preventing illnesses in the first place. They do appeal to people.

    It just is very hard for them in the face of access that is worsening. It would be very hard for them to put that ahead of improving what's right in front of their faces at the moment. 

    Matthew Taylor

    Yeah, no, no, interesting. So you've got to kind of stem the bleeding before you can start talking about the kind of underlying condition. 

    James, I'm interested in your perspective on this. And I think back to those relatively few occasions where politicians have really been able to change the way the public think about something. I guess I go back to Tony Blair and tough on crime, tough on the causes of crime as a way of getting people to think not just about punishment but about the underlying factors behind crime, or maybe the way in which David Cameron and George Osborne won an argument about austerity. 

    So for an organisation like us at the Confed, if we were trying to get the public to not just support the health service but support different strategies around areas like prevention and shifting resources upstream, what advice would you give us?

    James Frayne

    I think people have become much more open to discussions about prevention, the public health debate more broadly, so around things like obesity, even now fitness, which is a slightly different question, you know, around developing strength for older age and these sorts of things are starting to filter into the public mind now. And I think 15, 20 years ago, if you'd have talked about the idea of prescribing exercise, people would have thought it a little strange. 

    Now I think that they're much more open to that. So I think I would be probably quite robust on trying to lead the conversation on that. And mental health would be another one as well, I think, which 20 years ago there might have been a bit more of a pull your socks up and get on with it type approach. 

    And I think now increasingly, and again, partly because of how people experienced covid and how they saw their children experience covid, there's much more openness, I think, to slightly alternative routes of treatment and thinking about healthcare more broadly. So I would be pretty confident about trying to lead that conversation.

    Kate Duxbury

    I agree with that, James. And I also just think the public really want a longer term approach to planning and strategy for the NHS. And this is the kind of area that would fit within this about how is it going to be OK in ten years? How will it still be free at the point of access? Well, these are the types of things that might help us to get there. 

    Matthew Taylor

    Really interesting. 

    Now, a final question takes us beyond the election. So one of the things we're doing at the Confed is work with our leaders, which is around, in a sense, trying to get to the point where whoever wins the election, whoever is Secretary of State the day after the election, we don't just go to them and say, bail us out and save us because everything's terrible. 

    But actually what we say is that we do know as NHS leaders some of the things that we need to do to get the NHS onto a position of financial sustainability, improving outcomes. But a lot of this is about a government supporting us to do the work that we need to do within our places and our systems. So you don't need to save us, but you do need to give us some space and support to do what we need to do. 

    Now, I'm interested from both of you, what can we do after the election in terms of the way in which we engage communities if we want to have more productive conversations and avoid, for example, these terrible set piece rows when we try to reconfigure services? 

    James, you first and I'll come on to you then, Kate.

    James Frayne

    I think it is possible to try to engage the public on a sort of frank conversation about firstly, the longer-term pressures that are likely to affect the health service. I'm thinking about things like an aging society, thinking about how illnesses like dementia and Alzheimer's are going to be more of a problem further down the line. 

    It's possible to engage them in a conversation on changing living patterns, the way that cities are growing and these sorts of things and how that will change the nature of healthcare delivery. So I think I would probably try to get into those more serious conversations by trying to have this longer-term conversation and people, you can engage them on these longer-term conversations. 

    You know, they have views on it. They have thought about it. I don't think it's sort of fair to say that the public just want, you know, they just want jam today. They are, you can engage them on this, on this longer term thing. I think when you get into that longer term conversation, you are able to start talking much more about trade-offs. You know, should we be spending money on this or should we be spending more money on that? 

    And I would probably therefore enter that conversation through that sort of long-term pressure route, I think. 

    Matthew Taylor

    And Kate, I know you've done some thinking about kind of the best ways to engage the public, to have a better kind of conversation. How do you think we should be doing that better? 

    Kate Duxbury

    So I think that in some ways you have to try and take some positives from the current situation, which is people are really worried about the future of the NHS. And actually now they do have quite a reasonable understanding of some of the challenges. So I think that can be a base for trying to have this more sort of grown-up discussion with the public. It's definitely not an overnight discussion. 

    Some of the type of work that we will do is sit down with a group of the public and give them some information about what's happening in the NHS and then pose questions to them that we can try and resolve together once they've got information that will help them to make those decisions. So it's really about having a more informed conversation with a group within the public that can help us to look at these really complex, tricky trade-offs. 

    And actually there aren't right or wrong answers to a lot of them. Sometimes it's an ethical decision and it's a decision that should be driven by the public in terms of where we should fall on different decisions, for example about where resources should be invested. 

    Matthew Taylor

    Well Kate, James, it's been fascinating talking to you and it's been great working with you over recent months. 

    My colleagues at the Confed are going up and down the country presenting in depth the work that we've done with you around the public and around some of the debates that are going to develop over the election, how we can influence those. It's been invaluable work. If you want to know more about the Confed's work on the election then do go to our website, reach out to us. 

    But it just remains for me to thank Kate Duxbury, research director at Ipsos and James Frayne, managing director at Public First, for joining me on Health on the Line. Thank you.

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