Institutional Trust and NHS Reform: Final Report

Institutional Trust and Healthcare Reform

Final Report

Summary

This project examines public attitudes to recent NHS reforms in the UK, paying particular attention to the impact of quasi-market and management-by-target policies on public satisfaction and public trust. It is essential to understand how the public views current reforms and in particular whether the new policies damage trust. Reforms are necessary in view of the pressures on the service. However, if the reform programme diminished public trust it may undermine the political sustainability of state health care. The research is based on in depth discursive interviews with 48 people, review of the literature and secondary analysis of national attitude surveys.

The NHS faces a number of difficult challenges:

• Demand on the service is rising, mainly due to population ageing.

• Cost-pressures are rising, mainly due to the development of new technologies and therapies and to some extent to a real increase in staff costs.

• Patients and citizens are more challenging and assertive and demand more responsive provision.

• Despite a number of innovations and increases in spending, productivity is sluggish.

The current government has pursued policies of developing quasi-markets in health care within a strict framework of targets in order to meet these challenges. The reforms in the health service are of particular interest because they correspond to reform processes across the welfare state, and because the NHS is widely seen as the flagship of state welfare in the UK. Our research shows

• Public understanding of the reform programme is limited.

• Most people see the reforms as at best irrelevant and at worst damaging.

• The reforms are seen to prioritise the interests of a remote and uncaring management over professional care staff who are concerned with patients’ interests (the iconography of the ‘bean-counter’ versus the ‘matron’).

• The outcome is that real achievements do not receive the attention they merit and that there is widespread public disquiet about the reform programme.

This analysis is set within a theoretical account of trust, which contrasts a rational actor approach to trust (based on judgement that someone will act in your interests) with a sociological account (based on judgement that someone shares your values and has your interests at heart). The problem is that the reforms highlight the former and pay little attention to building the latter aspect of trust.

The research leads to recommendations for:

• Greater public engagement in local health initiatives through public meetings, user councils and similar activities, to establish a stronger sense of management in the interest of the community rather than ,management to achieve competitive success in a quasi-market.

• Recruitment of patient ‘ambassadors’: lay people with experience of the service who would take the leading in consulting in local areas about NHS developments policies and priorities