A question of trust

I’m pretty sure that the words funding, access, productivity and transformation would figure large in a word cloud representing current conversations among people working in and with the UK’s health and care systems. The nature of the challenges in each of these areas are well understood, but scalable and sustainable solutions are less clear. It’s hardly surprising that this vacuum is filled from above by the most seductive of responses – increased managerialism. 

The Nuffield Trust Annual Summit provides an opportunity for senior stakeholders to briefly step away from their day-to-day work and perhaps consider new terms to add to their word cloud. This year’s Summit proposes trust as a word that has the potential to add both challenge and insight.

We say we want more trust. We lament its decline. We invoke it when things go wrong but we are often less clear about what it actually requires – and what it demands of us.

A bit of (practical) theory

The philosopher Onora O'Neill has long argued that the problem is not simply that trust is falling, but that we talk about trust when we should be talking about trustworthiness. Trust, she reminds us, is not an unconditional good. What matters is whether institutions and professionals are demonstrably worthy of being trusted, that they are competent, honest and reliable, and whether the systems around them help or hinder those qualities.

Crucially, O’Neill also challenges the assumption that more checking automatically produces more trust. In fact, excessive auditing, performance management and box-ticking can erode the very professionalism they are meant to assure. When accountability becomes synonymous with surveillance, intrinsic motivation is damaged.

That argument feels uncomfortably relevant.

Failure to trust can generate untrustworthy behaviours

We are operating in a low-trust environment – in society and in public services – where confidence in institutions is brittle. Public debate is increasingly polarised and social media accelerates outrage and misinformation. And within the health and care system itself, there is a persistent gravitational pull towards managerialism: more data requests, more oversight, more reporting, more assurance frameworks.

Both NHS England and the Department of Health and Social Care are under intense pressure to demonstrate grip. Ministers want certainty, the Treasury wants numbers and the public wants guarantees. The result is a system that can default to checking rather than trusting.

Of course scrutiny matters. Public money demands accountability and patients want transparency. But there is a balance to be struck between intelligent assurance and institutionalised suspicion. If we squeeze out discretion and relational leadership in the name of control, we are likely to end up with performative and gaming behaviours but not necessarily commitment.

The Summit agenda

This tension between trusting and checking sits at the heart of the agenda for this year’s Summit.

There will be a session on trust in information that will explore mis- and disinformation, from blatant falsehood such as conspiracy theories about vaccines, to influencer-led health advice on social media, to selective presentation of evidence and the less-subtle polarisation of debates about complex issues.

There’s a session on what it means to lead in times of sustained pressure and constrained resources. Many leaders are required to make decisions that sit uneasily with their own values such as closing services or delaying investment. The moral distress and even moral injury which may result are real for people navigating difficult trade-offs in a low-trust environment.

A session on the work of the Independent Commission into Adult Social Care will inevitably raise long-standing challenges about fairness and funding. Reform will require not only technical solutions but a renewed social contract, and that, at its core, is about trust.

Participants will hear from a Dutch activist who took the unusual step of moving into a care home in order to better understand institutionalised models of care for older people. He will be asking us to reconsider what trust looks like at the level of human relationships between residents and staff, patients and professionals, and communities and services. 

Finally, participants will examine the shift from hospital to home – a policy ambition which might be constrained by the realities of a housing crisis. Delivering more care at home assumes that homes are safe and suitable, and for many they are not. Trust in policy depends on whether it is grounded in practicalities. Promising care closer to home without addressing the conditions of housing and community support may result in trust being eroded further.

The Summit covers a lot of ground. But a single thread runs through it – how we create trustworthy institutions, how we balance scrutiny with respect for professional judgement, how we might address mistrust and how institutions might better trust the public.

So, an exciting agenda offering hope for the future. Whether you join in person or follow the live-stream on our website, I hope you enjoy the Summit and pick up new ideas and renewed energy to develop them.

Professor Martin Marshall CBE is the Chair of the Nuffield Trust.

The Nuffield Trust Summit takes place on Thursday and Friday this week (March 5-6). You can register to watch the live-streamed sessions. More information about the event can be found here.