What if support for the populist right is shaped not only by culture or the economy, but by something as concrete as losing a local doctor’s practice? This paper finds that GP closures can change both service satisfaction and political support.

The rise of populist right parties is well studied, but relatively little attention has been given to how public service performance influences voter support. Because public services are often the primary means through which citizens interact with the state, declining public services can create grievances that increase the appeal of populist right parties.

Focusing on England’s National Health Service, the study combines administrative data on local health facility closures with panel data on public preferences and voting intentions. Using a staggered difference-in-differences design, closures reduce satisfaction with public services and increase support for populist right parties.

These effects are moderated by migrant registrations at local health practices, highlighting the interaction between public service performance and immigration concerns in fueling populist right support. The rise of the populist right across established democracies is one of the most significant political developments in recent decades.

A substantial body of literature has emerged to explain the growing electoral appeal of these parties. Some scholars argue that this trend represents a backlash against globalization, where losers of economic dislocation mobilize against status loss and economic insecurity by supporting the populist right.

Other accounts argue that the popularity of the populist right is primarily a backlash against pervasive long-term cultural change. While both economic and cultural explanations offer persuasive accounts of the populist right’s appeal, less attention has been paid to citizens’ direct experiences with the state.

This matters because anti-establishment rhetoric is at the core of the populist right’s messaging, framing the political system as being in constant crisis due to a corrupt elite selling out the virtuous people. Public service provision is one of the most common and direct ways in which people interact with and learn about the state.

In advanced industrial economies, citizens expect high-quality public services in infrastructure, education, and healthcare, but aging populations and sluggish economic growth have placed considerable strain on provision. Recent studies suggest that austerity-induced cuts and reduced access to public services diminish political trust, decrease turnout, and fuel support for far right and nationalist politics.

Direct experience with declining public services creates grievances with the political establishment and increases the appeal of populist right parties. The core argument is that waning public service performance is a key factor in explaining why certain voters turn to the populist right.

The social contract assumes that citizens accept obligations, such as paying taxes and obeying the law, in exchange for a benevolent government that delivers public goods, including public safety, infrastructure, education, and healthcare. If the political establishment is perceived to have failed in upholding its side of this bargain, some citizens may be more inclined to support populist political forces that rally against the corrupt elite.

The effects of declining public services are conditioned by cultural factors, especially when public service decline is linked with cultural grievances about immigration. The populist right uses ethno-nationalist rhetoric when framing broader policy debates, including public service decline.

This rhetoric presents grievances about the state as evidence of a failure by the establishment to protect deserving natives from undeserving migrants. In the context of public service decline, the populist right tends to pin the blame directly on the over-utilization of such services by immigrants.

The expected effects of service decline on support for these parties are stronger in areas experiencing increasing inflows of foreign immigrants, where this framing resonates and appears more credible to voters. The study focuses on Britain’s National Health Service, which for many Brits represents the embodiment of the state’s duty to care for its people.

Public satisfaction with the NHS is at its lowest level in three decades, and one reason is the decline in local doctors known as general practitioners, or GPs. Since 2013, nearly one thousand seven hundred GP practices have closed, accounting for more than twenty-five percent of all public GP practices in England.

This is an apposite case because most citizens access NHS services through their GP, public health is a core state-delivered service, and closures reflect structural pressures such as rising demand, staff shortages, and an aging population. The study considers the universe of GP practice closures in England between 2013 and 2023, using administrative data directly from the NHS.

Because practices began to close at different times starting in 2013, the study adopts a staggered difference-in-differences design using spatial and temporal variation to causally identify average effects on attitudes and party choice. The first analysis examines patient experiences measured through GP Patient Surveys, showing that closures result in decreased satisfaction and more negative experiences making appointments.

Two separate large-scale annual panel datasets are then used to demonstrate that direct exposure to a GP practice closure increases support for the populist right. Figure Two maps the universe of NHS GP practice closures in England between twenty thirteen and twenty twenty-three, using NHS Digital data.

Each red point marks a separate practice that closed, revealing closures distributed across the country, with especially dense clusters visible around major urban areas such as London and parts of northern England. This matters because it establishes the geographic reach of the disruption before the authors examine how closures affect individuals and political behaviour.

The additional analyses examine how the effects of practice closures are conditioned by deprivation, unemployment, and immigration. Descriptive evidence comes from communication by UK Independence Party and Reform UK on YouTube and in official press releases, where both parties consistently blamed immigration as a driver of declining NHS services.

The effects of practice closures are conditioned by higher levels of local immigration and migrant GP practice registrations, suggesting that populist right messaging is more resonant where demographic change is more visible. The findings provide robust causal evidence of the influence of public service decline on support for the populist right, while also demonstrating that increased immigration serves as an important moderating factor.

The populist right’s framing of natives in direct competition with foreign migrants over vital public services can broaden electoral appeal among voters who connect public service decline with increased immigration in their local communities. This advances understanding of how demographic change and public service deprivation combine to motivate support for the populist right.

Public service delivery is one of the primary ways citizens interact with and evaluate whether the state is providing for them and is responsive to their needs. Even citizens who lack political interest and sophistication can learn about failures in public service delivery through direct experience, especially with public healthcare.

A decline in public service delivery is likely to generate dissatisfaction and grievances about the functioning of the state. People’s willingness to pay taxes and respect for the law hinges on perceptions of whether political elites are upholding their side of the social contract and investing in communities through service provision.

If this reciprocal obligation is seen to be broken and the state does not deliver core public services, citizens can be expected to withdraw their support. One way dissatisfied citizens can express their discontent is by casting a ballot for populist parties that espouse anti-establishment rhetoric and rally against the corrupt elite in favor of the virtuous people.

A steep decline in core public services leads to grievances about the state’s ability to provide for citizens, validating the populist sentiment that the political establishment cannot deliver on its side of the bargain. Any direct experience with a decline in the delivery of public services in a local area is therefore likely to increase the appeal of populist parties for affected voters.

Populist parties on the right tend to frame policy debates in ethno-nationalist terms as a competition between natives and non-natives. This rhetoric is likely to resonate with voters who associate strains on public services with rising immigration and perceive migrants as consuming more public resources than they contribute through taxes.

Citizens attribute public service decline to government policy, underfunding, or structural pressures, and the argument does not dismiss these explanations. Grievances about declining services become politically consequential when they are articulated through specific political narratives.

The populist right is distinctive in linking dissatisfaction with service provision to immigration, portraying migrants as a drain on resources and elites as complicit in neglecting ordinary people. The study tests these expectations by examining the closure of GP practices as a case of core public service delivery in the United Kingdom.

The first expectation is that exposure to GP practice closures generates grievances by reducing satisfaction with public healthcare provision. The second expectation is that exposure increases support for the populist right.

The third expectation is that the effects are more pronounced in local areas experiencing rising levels of immigration. A key aspect of NHS public service decline and associated public dissatisfaction relates to the closure of GP practices. Since 2013, over three thousand facilities providing NHS services have closed or merged, including nearly one thousand seven hundred GP practices.

The GP or family physician is the primary means through which citizens access the NHS, treats minor illnesses, and acts as the gatekeeper for more specialized medical care. As of early 2024, over sixty-three million people in England were registered as patients at a GP practice, so closure is likely to have a significant impact on the public’s experience of the NHS.

The consequences of GP practice closures are examined by assembling data from multiple sources. Patient experiences are studied using the GP Patient Survey, an annual, or in some cases bi-annual, survey fielded by NHS England and Ipsos MORI.

The surveys target a random sample of each practice’s registered patients who are over sixteen. Ipsos MORI weights the surveys to reflect the demographic characteristics of the local population according to the United Kingdom Census.

These surveys provide a data source for understanding patient experiences over time for every GP practice in the country. The effects of GP practice closures are identified using temporal and spatial variation in a staggered difference-in-differences design. The design compares changes in behavior after a closure in one location with changes at the same time in a place that has not yet experienced a closure.

The primary identifying assumption is that, without a closure, areas that experienced closures and areas that did not would follow parallel trends. Event study plots with controls such as immigration, deprivation, and unemployment assess pre-trend differences between treated and control units.

The estimator is used for two complementary analyses. The first uses annual cross-sectional data aggregated at the GP practice level to study how local closures affect patient satisfaction. The second uses individual-level panel data to examine effects on political attitudes and voting intentions.

In both cases, the analysis exploits the staggered timing of GP practice closures across space and time to identify causal effects. The first step is that GP practice closures create grievances among affected patients, tested through self-reported experiences. A closure may affect not only patients of the closed practice but also patients in nearby practices forced to absorb new patients.

Area practices are therefore expected to experience an increase in new patient registrations, reducing patient experiences and satisfaction. The specification captures this clogging effect by defining as treated practices sharing the same Census MSOA as practices that have closed. MSOAs are census output areas containing approximately five thousand to ten thousand individuals.

Figure 4 suggests that the closure of a GP practice creates a decline in patient experiences. The estimates suggest a one to two percentage-point increase in reports of negative experiences making an appointment over the following years.

A closure is followed by a one to two percentage-point decrease in patients reporting positive overall experiences at area practices. For both outcomes, the effects appear almost immediately after a closure and remain detectable for at least five years. In the post-closure region to the right of the dashed line, the red circles sit above zero while the black diamonds sit below it at each displayed year.

Their error bars generally remain on their respective sides of the zero line, showing a sustained separation from the pre-closure estimates clustered around zero. The USOC panel is used to examine the effects of GP practice closures on intention to vote for the populist right.

Before treatment, the event study demonstrates support for the parallel trends assumption. Following a closure, voters become more likely to report intention to vote for a populist right party. Vote intention gradually increases, with estimates peaking at about two point five percentage points approximately three to four years after a closure.

In the post-closure region to the right of the dashed vertical line, the red point estimates sit above the horizontal zero line, while the earlier estimates cluster around it. The vertical confidence intervals are widest at later event times, especially around year four, showing greater uncertainty even as the estimates remain positive.

Results from the USOC and BES data suggest that the closure of GP practices increases support for the populist right among affected voters. The effects are nearly immediate and persistent across both data sources, lasting for at least four to five years.

The results are consistent in magnitude and duration across two independent data samples, suggesting that the effects are robust and not specific to one sample. The effects are relatively small, amounting to an increase of about two to four percentage points in intention to vote for the populist right.

Immigration, and specifically new migrant GP practice registrations, are the most important moderators of closure effects on voting intention for the populist right. In areas with the highest levels of immigration and migrant GP practice registrations, closure effects are much greater than in areas where immigration is lower.

Unemployment appears to have some explanatory power, but it does not meet traditional thresholds for statistical significance, while immigration and migrant GP practice registrations do. The closure effects are magnified in areas with higher levels of international migration and new migrant GP registrations.

The positive interaction with local immigration appears only for the populist right; for Labour, the Conservatives, the Liberal Democrats, and the Green Party, the interaction is either absent or negative. Look especially at the two bottom panels: the fitted black lines rise from left to right, and the red estimates at the high moderator level sit visibly above those at the low level.

By contrast, the employment-rate panel slopes downward, while the deprivation panel remains close to flat, with broad uncertainty bands around the estimates. Public service decline is an important driver of grievances and, in turn, support for the populist right.

When the state falls short in upholding its obligations to the public, voters may be swayed by the anti-establishment rhetoric of populist right parties pointing to the failings of a political elite disconnected from ordinary people. When shortcomings in public service delivery are combined with concerns about heightened competition with undeserving immigrants, voters are more likely to punish establishment parties by supporting the populist right.

The paper’s central finding is that GP practice closures reduce satisfaction and increase support for the populist right, especially where immigration and migrant registrations are higher. That links everyday public-service decline to broader political backlash.