Trust and Welfare State Reform: the example of the NHS

This article discusses the impact of New Public Management on public trust in welfare state institutions, using the example of NHS reform. Discussion of trust in public institutions across political science, psychology and sociology indicates that it is based on both rational/objective considerations (competence and capacity to deliver the service) and affectual/subjective factors (shared values, belief that the trustee shares the trustor's interests). The New Public Management foregrounds individual responsibility and incentives for both suppliers and users of services, in the NHS example in quasi-markets, management by target and patient choice. These accord with an individualized market rational-actor model rather than with affective considerations. Analysis of attitude survey data on the NHS confirms that rational/objective and affectual/subjective factors contribute to public trust in this field. However, a comparison between perceptions in England, where the internal market has been vigorously pursued, and Scotland, where the purchaser/provider split was discarded after devolution, indicate that the market does not offer a royal road to perceptions of superior quality in the objective factors. Conversely, the more market-centred system can make progress in relation to the more subjective affectual factors.