Is the NHS, as the current English Health Secretary has repeatedly claimed, broken? Writing in the BMJ, GP Helen Salisbury described the assessment as a “relief after what felt like years of toxic positivity”. Last week, new Ipsos polling prompted claims that there is a “crisis of public trust” around the NHS, and that people are avoiding accident and emergency departments as a result. Data from the British Social Attitudes Survey paints an apparently contradictory picture: satisfaction with how the NHS is lower than at any point since the survey began in 1983, yet stated commitment to the founding principles of the NHS remains resiliently high. There is little evidence so far of public appetite for fundamental reform of the NHS.

Public debates about healthcare include a complex, sometimes explosive, cocktail of different positionalities. Views on healthcare relate to fundamental socio-political attitudes about responsibility, solidarity, and care; who gets what, when, and how. However, they also stem from our profoundly personal, even intimate, experiences of receiving healthcare. When healthcare fails, the repercussions are societal, yet they are also individually terrifying, with consequences ranging from ‘snatched from the jaws of death’ miracle stories, to life-changing disabilities, and even death.

This complex mixture of the personal and the political was starkly evident in our new analysis of patient views of the UK’s creaking healthcare system, published in the Journal of European Public Policy. We analysed critical reviews of emergency care posted online on the Care Opinion website which not only described a healthcare experience, but explicitly made reference to ‘the NHS’ within the review shared. While the overwhelmingly majority of stories shared on Care Opinion are predominantly positive and even grateful, we focused on a subset which share stories of care going wrong. The litany of sometimes harrowing tales of long waits without food or water, rudeness from over-stretched staff and confusing, poorly coordinated care may not surprise anyone with recent experience of emergency departments in the UK. But what might be surprising, is that not a single story in our analysis went on to reject the NHS wholesale. Far from ‘toxic positivity’, patients and their carers expressed deep sadness and anger about the state of healthcare, while actively expressing support for it. This was accomplished through what we identify as justificatory repertoires: recurring phrasing and juxtapositions which either sought to explain the failure (often by referring to mismanagement and underfunding); to mitigate it with explicit descriptions of what was still good in their experience; and to contrast their own legitimate and appropriate service use with an implied ‘bad’ patient, who used emergency health services carelessly and excessively.

Taken together, the emotional atmospheres of the stories in our analysis were profoundly affecting. Patient narratives, such as those publicly available on the Care Opinion platform, offer us new opportunities to understand the interconnections between answers which are kept artificially separate in survey data. And, while unacceptable failures of care are indeed a sign of a ‘broken’ healthcare system, our analysis sheds light on how public commitment to a system predicated on care for all, free at the point of use and paid for by taxation, nonetheless remains intact.  This duality doesn’t lend itself to snappy headlines. But, as debates about NHS reform gather pace, it is vital that both dimensions of public opinion are understood and taken seriously.  

This article was originally posted on Taylor & Francis website.

First published: 3 March 2025

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