David Oliver: A matter of trust—doctors, the NHS, patients, and the public

The public still have high levels of trust in doctors as a profession, but we must not take that trust for granted

david_oliver_2015Recently, I was asked to deliver a short talk at a conference whose theme was trust. People from a variety of professional backgrounds and academic disciplines were talking about what trust meant to them. I was asked to give a doctor’s perspective. It gave me some cause and pause for thought. “Trust me, I’m a doctor” is still common parlance and the title of a TV show. While media discussions of medicine still tend to mention the mythical swearing of the Hippocratic Oath.

In the latest Ipsos MORI Veracity Index, only 64% of the population trust the average person on the street to be honest. But when asked which professions they trust most to tell the truth, nurses (94%) and doctors (91%) top the poll. Those professions now also have a regulatory duty of candour—compulsory truth telling.

Trust in the NHS itself still remains high. The most recent British Social Attitudes survey shows that 63% of the public feel very or quite satisfied with the NHS (against an all time high of 70%). And last year Ipsos MORI found that 88% of those polled thought the NHS should be the highest priority as an area of public spending that should be protected. While 88% supported a health service provided by the government and free at the point of delivery with no payments.

Despite all the coverage of pressing problems in NHS funding, staffing, and performance; the independent data and reports to back those media stories; and the personal experiences of people using services, this continuing high public support may have bizarrely allowed politicians not to prioritise healthcare. Although it could backfire soon.

Neither doctors nor sections of the media and public have great trust in the government, ministers, the department of health, and its arm’s length bodies right now. This may be the result of a public perception of what David Lock QC recently identified as a “management culture in the NHS [that] is close to dishonest.” Pressure from national bodies on care providers can make them play down bad news or overpromise on financial targets or performance. Financial projections and control totals, performance targets, and ministerial assertions about funding or workforce have all at points been hatched using partial or spun data. Statistician and writer David Spiegelhalter has set out how healthcare statistics have been used creatively by the government in a culture of spin and half truths. The Full Fact charity provides a great public service by going through such assertions point by point.

In the wake of Dr Hadiza Bawa-Garba’s case and the junior doctors contract dispute, doctors are currently mistrustful of the General Medical Council, Health Education England, NHS Employers, and of government ministers.

Trust is, of course, at the centre of the classical doctor-patient relationship, which is still the bedrock of medical values and practice. I have written before about the key professional responsibility doctors have to never promise to patients or families things that we can’t personally guarantee will happen, and to never make promises on behalf of other clinicians.

We now have equally important roles in fair use of scarce public resources, ensuring that health systems work effectively, and addressing wider population health. Rationing and prioritisation are a fact of life. We must be equally trustworthy and professional in this regard.

I think ongoing high levels of trust in doctors come from a few sources: the highly competitive selection process for medicals schools, the duration and rigour of (serially examined) postgraduate training, and the commitment it requires to make it; the interactions patients and their families have with us; TV documentaries that show the nature of our work and workload, and the skill required to pull it off; the use of scientifically rigorous research evidence to inform practice; and the very nature of the work we have chosen. Doctors who work only for the NHS are demonstrating a commitment to public service. Unlike those working in other health services, we have no perverse financial “fee for service” incentives to overtreat or overinvestigate. I imagine that we must also garner public respect for this.

However, I don’t take trust for granted. As NHS funding and workforce pressures bite, and more stories emerge of a service under pressure, there will be opportunity aplenty for those opposed to the model of universal public provision to brief against it. Gradually, the public may conclude that the current funding and provision model is bust.

As for trust in the profession, there will inevitably be fallout from the recent criminal convictions of doctors, campaigns around alleged patient neglect or avoidable death, and from public inquiries such as the recent Northern Ireland report on the deaths of children from hyponatraemia. In some quarters there’s a feeling that we close ranks or cover up or protect our own when things go wrong. We have to correct this narrative and challenge any behaviours that perpetuate it.

More broadly, we live in an era of democratised access to information and of people taking more control of their own decisions in areas that would have usually required a professional intermediary. We’ve also witnessed the rise of a populist mistrust of the “establishment,” crystalised in Michael Gove’s statement that “people have had enough of experts.”

I, for one though, have not. I rely on their expertise daily, just as our patients rely on us. When I travel on the new Elizabeth Line in London, I will be pleased that it’s been designed by trained structural engineers. When I get on a plane, I trust the pilots. When I take my car to the garage, I put my hands in their expertise. I am all for the move towards more and better partnerships between the public and professionals, a democratisation of information, and a greater focus on supported self care in medicine. But when people are sick and worried, especially in a crisis, most still want to put their trust in a skilled, caring expert.

Too often these days, we have patients and families on the front foot, looking to find fault, to complain or challenge before we have even had a chance to explain or reassure. My plea to the public is this: accept that in general, highly trained professionals know their job, are acting in good faith, and come to work every day to do the best they can. We are not automatons. We are human and fallible and capable of moral distress if the system won’t allow us to give the standard of care we would like to. Trust in us is surely there to be lost, not earned.

David Oliver is a consultant in geriatrics and acute general medicine; a senior visiting fellow at the King’s Fund; and author of The BMJ’s weekly “Acute Perspective” columns, which are all free to access.

Competing interests: None declared.