Introduction

Trust is believed to be particularly salient to the provision of healthcare because it is characterised by uncertainty and an element of risk regarding the competence and intentions of the practitioner on whom the patient is reliant (Titmuss, 1968; Alaszweski, 2003). The need for interpersonal trust relates to the vulnerability associated with being ill as well as the information asymmetries and unequal relationships that arise from the specialist nature of scientific, medical knowledge. Scientific medicine's expertise, or claims to expertise, appears to be the basic condition for generating trust in this context (Rose-Ackerman, 2001) although the affective component may also have an influence (Hall et al, 2001). In the UK National Health Service (NHS), trust has traditionally played an important part in the relationship between its three key actors: the state, healthcare practitioners, and patients and the public. The post-war consensus was underpinned by trust in the ‘altruistic’ values associated with medical professionalism (Newman, 1998) with the state and patients tending to trust the norms of professional self-regulation and state licensing procedures to ensure that health professionals and healthcare institutions operated in the best interests of patients and citizens. Service users trusted the judgement, knowledge and expertise of health professionals to provide a competent service that met their needs and they trusted the state to ensure equity in the allocation of public goods and services.

These presumed or taken-for-granted trust relationships have, it is claimed, been challenged as a result of the introduction of changes in the organisation and funding of the health service, in the regulation and performance assessment of health professionals, and in public attitudes to healthcare and scientific medicine. This chapter seeks to explore how and why trust relations may be changing, using the NHS in the UK as a case study. It presents a theoretical framework for investigating them in future empirical research.

Definitions of trust

Trust has been characterised as a multi-layered concept primarily consisting of a cognitive element (grounded on rational and instrumental judgements) and an affective dimension (grounded on relationships and affective bonds generated through interaction, empathy and identification with others) (Mayer et al, 1995; Lewicki and Bunker, 1996; Gambetta, 1998; Gilson, 2003).