The Civilizing process of trust: Developing quality mechanisms which are local, professional-led and thus legitimate

'Quality' and 'performance' have become defining concepts for policymakers and health-care systems alike. Yet whilst these principles are of fundamental importance, their practical implementation and assurance are far from straightforward. This commentary analyses the difficulties faced in enhancing quality and performance in the English NHS. Many recent initiatives have been driven through incentives and external auditing of the professionals providing health care on the frontline. Drawing on recent literature and research findings, we argue that this checking-based 'audit culture' is fundamentally flawed in driving quality and performance. Many targets and measures are too crude to reflect important aspects affecting patient outcomes and therefore these frameworks lack legitimacy amongst professionals. An alternative, trust-based model is proposed - one more capable of acknowledging the meaning, complexity and specificities inherent to professional work. Quality mechanisms developed locally by professionals are able to produce the legitimacy crucial for their effectiveness. It is argued that the normative obligation of approaches based on conditional trust is a more compelling incentive towards good practice than targets and sanctions. This governance by 'the social' is able to motivate a more holistically enlightened and consistent reflexivity towards practice, though it is only able to flourish in the absence of purposive-rational systems. © 2011 Blackwell Publishing Ltd.