Public Values and Public Trust:
Responses to Welfare State Reform

Abstract

The current reform programme in the UK welfare state appears to improve cost-efficiency and responsiveness in many areas, but runs the risk of generating further problems.  This paper argues that the justification for the new directions in policy rest ultimately on a particular understanding of agency.  The limitations of this account explain why proponents of the reforms tend not to recognise or pay adequate attention to problems of legitimacy and public trust.  Evidence from a new survey is used to demonstrate this in the context of the reform of the National Health Service.

Keywords

Rational action, Trust, Welfare State, NHS, Reform, New Public Management

Responses to Reform

The established form of the UK welfare state faces challenges from a range of economic, social and political developments.  These are extensively discussed elsewhere (for example, Pierson, 2001, Huber and Stephens, 2001, Ellison and Castles, 2006) and we do not review then here, other than to note that many policy-makers believe these pressures require new policies to make public services more cost-efficient and more responsive to increasingly diverse users (see Prime Minister’s Strategy Unit 2006 for a  summary).  The main approach to achieve this has involved the combination of targets, regulation and consumer choice in quasi-markets often referred to as New Public Management (Flynn, 2007), plus increased investment in specific areas.  

Taken together, public service reforms have achieved a great deal, as improvements in many of the key indicators show (Treasury 2007 3-5).  It is not possible to provide a full assessment of the impact of the new policies here.  Many independent commentators are largely positive.  Hills and Stewart conclude ‘in some of the most important areas, it is fair to say both that the tide has turned, and that policy has contributed to turning that tide’ (2005, 346).  Toynbee and Walker give a generally favourable verdict: ‘By 2007, Britain was a richer and fairer society than in 1997.  It was healthier, safer and in many respects better governed’ (2005, 327).  ‘Including adjustments for quality change and for increasing value of health, NHS productivity is
estimated to have risen on average by between 0.9 and 1.6 per cent per year over the ..
1999 to 2004 period’, (Lee 2006).  The King’s Fund Independent Audit of the NHS 1997-2005 concludes ‘the results…are very positive….has there been a step-change? If step change means a change of gear with more and better services, then yes, there has’ (King’s Fund, 2005).

However, these improvements do not seem to be accompanied by enhanced public optimism about the future of the public sector. IPSOS-MORI surveys show that expectations remain low (Figure 1).  For public services as a whole, more people believe that standards will deteriorate than think they will improve throughout the last six years.  For health care the overall trend  is downwards and for the highest ranked service, education, roughly flat.  Only between five and ten percent more people anticipate improvement than deterioration.  For police, transport and environmental services pessimists outnumber optimists for most of the period and there is no upward trend (Ipsos-Mori, 2007).

FIGURE 1 ABOUT HERE

These developments raise the question of why public services that affect large numbers of people and appear to be delivering better provision in many areas are not seen more favourably.  Many factors are relevant to perceptions of public policy, from individual experience to party political propaganda and media campaigning (for example, the repeated references to the NHS as a ‘dead duck’ in Sun newspaper leaders, Sun 2006a, b, c).  However, individuals are best understood not simply as passive recipients of the pronouncements of media and astute politicians, but as playing an active role in interpreting, accepting, rejecting and responding to the messages they receive (Eldridge, Kitzinger and Williams, 1997; Petts, Horlick-Jones and Murdock, 2001).  Considerations that may be framing public interpretation of and response to welfare reform are thus of interest.

Much of the current reform agenda is concerned to change the way professionals and managers in public services behave, and to encourage service-users to act more effectively and responsibly in their own interest.  The reforms rest at bottom on a particular conception of agency, which, we argue is limited.  We briefly review theories of agency and their relevance to social policy, and then discuss the survey material.

Agency and Public Policy

A large literature may be summarised by distinguishing three main approaches: instrumental, expressive and normative (for a clear summary, see Hargreaves-Heap et al, 1992 ch1).  Instrumental accounts understand agency in terms of the rational deliberative choice of means to achieve particular ends, the model of ‘homo oeconomicus’.  Since the logic is instrumental, the theory does not address the ends directly but takes them as given, as grist to the mill of reason. Expressive approaches interpret action as essentially communicative, in the context of interactions with other social actors, the sociology of the ‘action frame of reference’.  Normative accounts consider agency primarily in relation to the accepted rules of behaviour in a society, the sociology of functionalism and order.

All three accounts carry weight.  They are validated by introspection and in experience.  We know that we and others sometimes do things because we think it is reasonable to believe the course of action will advance our goals.  We also act to communicate values or stake a claim to an identity as a particular kind of person, and sometimes in relation to social conventions and rules.  Much recent work has been concerned to provide accounts that link the different aspects of agency

Instrumental rational action

The independent rational actor model has become dominant across modern economics and influential in political science and other fields (Jaeger et al, 2001, 20-29).  It analyses agency instrumentally, as based on independent individual choice pursued to achieve the values held by the chooser which are not themselves the immediate concern of the theory.   A number of additional approaches qualify this, pointing to the practical and contextual restrictions of human reason in terms of constraints on deliberative ability (Simon, 1978) and effort (Todd and Gigerenzer, 2003), of the limitations of the ‘mental models’ we may user (Atman et al, 1994), or of the shortcomings of common cognitive heuristics (Kahneman et al 1982).

Proponents of this approach typically understand the diversity of values that serve as goals for people’s actions as psychological ‘brute facts’.  This gives rise to (well-recognised) limitations in giving adequate accounts of expressive and normative aspects of social action, where considerations outside the individual appear to be structuring behaviour.  More recent developments seek to address this by providing explanations of how the interactions of rational choosers should give rise to the emergence of shared norms.  As one commentator remarks ‘ the future of rational choice lies in the analysis of norms and institutions’ (Cook and Levi 1990, 1).  One problem is that most of these analyses only give an account of the development of one specific norms (most frequently, reciprocity) under particular circumstances, not of overall normative structures.  Examples are accounts of the emergence of reciprocity in games played between rational individuals (Axelrod 1981 and others), in the management of public goods under particular governance arrangements (Ostrom and Walker, 2002) or in a range of interactions provided that a particular mix of psychological characteristics exists in the population (Fehr and Gächter 2000).

Normative and expressive action

Other approaches, located chiefly in sociology and also influencing political science and social psychology, have started out from the role of social norms (Hargreaves-Heap et al, 1992, 17-20).  Norms have been understood, for example, as elements of a social system (Parsons 1949), as  embedded in social action (Polanyi 1944), or as contributing to the habitus that forms the context of everyday life (Bourdieu 1990). 

While normative approaches provide strong accounts of the regularity and coherence of society and of groups within it, they faces difficulties in accounting for individual instrumental or expressive actions which run counter to established normative frameworks, a problem often discussed in relation to functionalism (Holmwood, 2005).  One response is to argue that the relationship between normative structures and deliberative and expressive action is dialectic.  Thus Giddens understands society as a ‘skilled accomplishment’ of active human subjects, as both the medium in which individual action takes place and as a framework which shapes action (1993, 4).   Human beings produce society, but they do so as historically located actors, and not under conditions of their own choosing.  Another approach distinguishes different co-existing rationalities appropriate to different spheres of life.  Weber identifies cultural, traditional, emotional and deliberative rationalities (1978, 130).  Habermas analyzes the interplay between technical/instrumental and normative rationalities in modernity (1987).  Luhmann bases the various rationalities of different social sub-systems in communication (1995).  The problem then becomes providing accounts of the development of different rationalities and of their interaction between the various domains.

All the approaches very briefly reviewed above recognise that a range of rationalities is encountered in social life and address the issue of developing an inclusive analysis.  Corresponding debates in social policy reach back to the 1830s (Offer, 2006) but the starting point for much discussion is Titmuss’ concern for the opportunities to express particular normative values embodied in voluntary blood donorship (1970, 13).  This focuses on the role of social arrangements in reinforcing particular moral relationships.  The interaction between instrumental and normative and expressive rationalities is particularly salient in the context of current reforms, for two reasons:

First much social provision inhabits both instrumental and normative frameworks.  Social services deploy resources according to priorities to achieve particular ends. In many areas the value of provision derives both from the quantity of resources available and also from the quality of the contact with the service provider.  Both the instrumental logic that influences judgements of access to resources and the normative and expressive logics that influence the experience of service use are relevant to how people perceive and respond to provision in areas like health and social care and education and thus to their satisfaction and to their behaviour.

Secondly and more broadly, social provision addresses the risks and uncertainties that people face in everyday life.  A number of writers argue that, although living standards have certainly risen, changes in family patterns, in labour markets and in expectations mean that life is experienced as more uncertain (see Denny, 2007, chs 1 and 4 for a review).  This brings issues of the overall legitimacy of and the strength of public trust in welfare institutions to the fore. 

Legitimacy is concerned with the extent to which the service is seen as fair, as operated according to principles which are morally acceptable. Issues of legitimacy and public policy have been extensively discussed (for a recent review, see Mau and Veghte, 2007).  Here we focus on the contribution of legitimacy to public trust.

A substantial literature on trust exists and we will not provide a full discussion here (se Seligman, 2000, Moellering, 2006 for overviews). Trust in the institutions of social provision relates to expectations about actions in particular settings, in this context about how services like the NHS will deal with one.  Thus the discussion of individual instrumental and more normative and expressive accounts of trust corresponds to the earlier review of different approaches to agency.  One perspective fits trust within an instrumental rational model of agency (Hardin, 2002; Gambetta, 1988; Dasgupta, 1988).  People act with he intention of advancing their interests.  A trustor can predict a trustee’s actions with more or less success on his basis.  As a result I can guess whether your actions are likely to follow the pattern that suits my interests or as Hardin puts it to ‘encapsulate’ them (2002, 6).  One outcome of this logic is an approach which aligns the interests of actors in order to generate stronger trust on a rational basis without taking account of normative or expressive considerations.  This is precisely what the choice and competitive market approach seeks to do.  The reform agenda based on that approach should then lead to stronger trust in public services.

An alternative perspective argues that people behave in ways that express particular values or to follow normative rules, as well as to promote their own identified interests, and that they expect similar considerations to affect others.   This means that value commitments and value-context are important factors in relation to institutional trust (Sztompka 1998, Moellering 2006).     Rothstein argues that it is not only individual interests and their alignment that matter, but also the extent to which the whole social setting is conducive to promoting trust.  He produces evidence from studies of trust in others and in social institutions and government to argue that social trust is more likely to develop when provision embodies a normative framework of commitment to universalism and equality rather than self-interest (see also Calnan and Rowe, 2005).  Similarly a long-standing tradition of empirical work in social psychology identifies among the bases for social trust value commitments to caring for the interests of others and to integrity alongside the practical ability to deliver the goods that suit the trustor’s interests (Cvetovich and Earle 1997, Metlay 1999, Hovland and Kelley, 1953).  From this perspective, public service reforms need to take into account the normative assumptions implicit in the new policies as well as the impact of those policies on the interests of relevant actors in order to assess their effect on public trust in welfare institutions.

The Reform Strategy

Both normative and expressive and instrumental rational approaches to action are included in social policy debates.  Relevant behaviour takes place in the context of norms and involves deliberative individual choices at the same time.  Approaches to social policy need to develop ways of analyzing both aspects.  However it is an instrumental rational logic that is at the centre of current public service reform.  The recent discussion paper from the Prime Minister’s Strategy Unit (2006) provides a clear overview of the strategy.  The reform agenda stresses the regulation of public sector staff and the empowerment of users as individual consumers.  It focuses on instrumental rationality and gives a limited role to expressive and normative approaches:
 
‘Increased spending on key public services [has been].. accompanied by a considerably sharpened top down performance management regime ..targets, regulation and performance assessment/inspection. These top-down approaches have increasingly been complemented by horizontal pressures (of competition and contestability), bottom up pressures (of user choice and voice) and measures to build the capacity and capability of public services..’(PMSU, 2006, 21).

The objective is a dynamic ‘self-improving’ system in which the pressures from all these sources tell in a benign direction.  The fourth area of capacity and capability-building rests to some extent on shaping agency through reformed and more flexible pay schemes, bargaining structures and greater flexibility in work, but is primarily concerned with organisational reform, management and leadership and will not be addressed here.  

The importance of an individual model of agency is apparent in the pattern of reform and in the diagnosis of possible problems.  In all three areas the individuals concerned are assumed to be motivated by individualised instrumental motives and directly responsive to positive and negative incentives.  From the top-down perspective, the actions of managers and service providers can be constrained to advance cost-efficiency and responsiveness while maintaining quality by the positive and negative incentives of a system of targets, regulation and inspection, with appropriate sanctions.
Competitive pressures are seen as automatically rewarding those who provide what service-users as consumers want and do so cost-effectively, provided cream-skimming is prevented and funding follows service-users.  Choice and voice offer a further stimulus to the operation of competition and to allowing users to express their wants.  The logic follows models developed by social scientists who apply an individual, rational and instrumental model of agency to the social policy context (Enthoven 2002, Preker and Harding, 2002, Dixit, 2002).

TABLE 2 ABOUT HERE

The table above summarises the key aspects of the approach to reform using the examples of health care and education.  The third column includes examples of the particular directions in policy and the fourth the key principles underlying them.  In relation to the top-down approaches involving central target-setting, regulation, inspection and intervention, targets are typically set through Public Service Agreements associated with the Comprehensive Spending Review, and filtered down to services through more detailed targets and strategies (CSR 2007).  More recently the number of overall targets has been reduced and attempts made to establish targets that cut across different departments of government.  The objective is to avoid the problem of demoralising service providers whose autonomy and initiative is restricted by close targets (Hoggett, 2001, Hoggett et al, 2006); to avoid the issue that precise targets in particular fields may construct a perverse incentive-structure and direct attention away from important issues that are not subject to targets (see Bevan and Hood, 2006a and b), and to ensure that top-down approaches do not undermine opportunities for networking and co-ordination between agencies (PMSU 2006, 59; Frey, 2000).   The paper argues that the evidence for demoralisation is limited and that the move away from top-down approaches will resolve this issue, as it will mitigate the others. 

Current directions in policy seek to stress the horizontal approaches more powerfully and this involves competition and choice (Le Grand 2007, ch 2).   The key issues in this area are that the service must be reorganised into separate agencies and that funding must follow service-users.   Examples are the system of open enrolment and budget-holding schools, financed mainly on the basis of pupil numbers, and the development of Trust Hospitals and other services in the NHS, where fund-holding, commissioning and now ‘choose and book’ schemes allow users or their proxies to make choices.  Prices are set for each procedure on a national basis.

The objectives are to construct incentives for cost-efficiency and responsiveness, since the schools and health trusts must attract users for their services to gain resources and must educate and treat them within budget to remain viable.  The problems identified are to do with cream-skimming, since schools or hospitals may actively discriminate in favour of particular prestigious, low cost or attractive users; with achieving a level playing field in the market-place for all suppliers and users; and with ensuring that an adequate range of suppliers exist for the market to function.  Solutions include preventing suppliers refusing particular users, increasing payment for some more costly groups, such as pupils with learning difficulties, and subsidising new market entrants such as Independent Sector Treatment Centres.

Choice is also a central aspect of the market and quasi-market system.  Here the key problems are to do with level of information and the support for weaker groups in putting choices into practice.  The greater public availability of performance data, league tables and inspection reports, the extension of services like free school transport and the Hospital Travel Costs Scheme and the re-introduction of EMAs are all seen as facilitating choice.  Issues of voice are given relatively little attention in the document although developments like parent governors, annual school meetings and the greater use of consumer satisfaction surveys are mentioned.

The document identifies a number of problems, but pays little attention to some other issues discussed in the literature, such as the problems in achieving level playing fields in quasi-markets (Propper et al, 2006, 554), the difficulties in attracting high-calibre staff to more onerous managerial positions (Hoggett et al 2006; Finlayson, 2002), in addressing persistent education inequalities (Taylor, 2007) or in ensuring that new providers deliver value for money (Taylor 2007, House of Commons Health Committee 2006).

Across all three areas, the impact of changes at the level of values is discussed only in relation to demoralisation of staff.  Here the evidence is seen as equivocal and a matter for leadership and incentives.  The interaction of the new policies with normative frameworks among the broader public and thus with issues of legitimacy and public trust is not considered.  We argue that a fuller account of agency would direct attention to these issues.

The Survey: Popular Understanding of Health Service Reform

Theoretical accounts of agency and of institutional trust include instrumental and normative and expressive rationalities.  The current reform agenda rests mainly on instrumental approaches.  Our research examines the question of how people’s perceptions of public sector reform relate to their values and the normative principles they associate with public services.  The NHS is chosen for study because it is a highly valued service often taken to symbolise the central features of the UK welfare state; it is substantially affected by the factors identified by government, particularly demographic shifts, the decline in informal care, labour market shifts and the pressures on public spending; the reform agenda is well-advanced, highly salient and the subject of extensive public discussion; and it is at the heart of many of the public debates about welfare reform (Baggott, 2007).

In order to investigate people’s understanding of and responses to NHS reforms we carried out forty-eight individual qualitative interviews in the first half of 2007.  The sample was designed to cover a range of population groups.  It contained equal numbers of routine working class and professional managerial workers, of women and men and of young adults, under 30, without family responsibility, families with children and people over the age of 55 without children.  Interviewees were recruited from three geographical areas: a metropolitan area, a provincial town and a small village.  We used a common interview schedule, covering ideas about the NHS, values associated with it, perceptions of the current reforms, and particularly of spending, choice, competition, regulation and targets, and responses to the reform agenda.  The interviews were recorded and analysed to identify common themes across the whole sample and among the different socio-demographic groups within it, and to reflect discourse about the health service.  Here we focus on NHS values and issues of legitimacy and public trust and set the interview findings in the context of data from the British Social Attitude survey.

The Findings: NHS Values and the Reforms

The NHS as an institution carries a clear identity, expressed by all our respondents with striking unanimity.  The service is seen as a central feature of the welfare state, as the second and third quotations below emphasize.  The normative framework of the health service incorporates two main themes, universality and individual care.  Perhaps more than any other institution in the UK it bridges the divide between social justice, which is typically understood as formal and rule-bound, and care, which is committed and individual.  The following comments bring together the idea of fairness as availability to all and care for people’s individual needs.

Values are that it is fair and free. People make contributions but not everyone uses it in the same way. The idea is to make a level playing field where it doesn’t matter if they have contributed for one year or 10 years  they have access to the same level of care. (Patrick, D, Family)

NHS is essential. If we didn’t have that we would have to have everybody sign up for some sort of private treatment … and I don’t think that is necessarily fair. Don’t think this country would be as good a country as it is without the NHS, we are very reliant on the NHS and I think it has the potential to be a very good and caring organisation. (Jones, C1, post-family)

Absolutely, its kind of the cornerstone of the welfare state I think isn’t it. If we didn’t have the NHS I think a lot of other things would have to change. (Jemima, C1, post-family)

The NHS symbolizes that we a caring bunch and we do want to help others. We do believe there should be a state system. There are rich and poor, there is every class, but this way, we are all the same. This might be the only time there is a classless society (Adrian, C1, pre-family).

Most of those we interviewed did not have a coherent overall grasp of the reform agenda as combining top-down, horizontal and bottom-up elements to enhance cost-efficiency and responsiveness in the way that policy-makers understand it.   They were, however, familiar with key aspects of the new approach such as targets and market competition involving greater choice for service users.  While there was some support for the introduction of targets and use of markets as providing an incentive system to address quality issues, this was only evident among a minority of the sample.  Twice as many working class as middle class and younger as against older respondents fell into this group.  National surveys conducted by both British Social Attitudes and IPSOS-MORI show a similar pattern of stronger working class interest in choice (Le Grand, 2007, 51-4).

Most of the people we interviewed expressed concerns about the new regime.  The 13 out of the 48 respondents who argued that targets have some value qualified their views:

You need to have targets, but my concern is that people are seen as statistics rather than patients…because healthcare should be what it says, caring for people’s health, not treating them as statistics (Enzio, C2, pre-family).

[Targets do] a good thing by providing an incentive. It will improve people’s treatment and quality of life ultimately. But if you can’t hit targets, you might lose out. But there has to be more staff to deal with extra patients, otherwise the customer might be disappointed by rushed service. ‘Target plus service’ is what matters (Richard, C2, pre-family).

Even among these respondents, concern was expressed about the extent to which targets damage the core values of care and individualised commitment, encouraging the treatment of people ‘as statistics’ as the first interviewee above puts it.  Another respondent was antagonistic to the reforms on similar grounds:

It is too money-oriented.  It feels like there is no humanity left in the NHS..there is not human compassion, it is just you are a piece or meat of a pound sign, or a number.. (Zenna, D, pre-family).

Similarly there was some minority support (expressed by seven out of the 48 interviewed) for the directed incentives involved in markets, but again this was typically qualified:

So, I can see good and bad points. Just can’t see it actually being able to work. What is going to happen to the less popular hospital? Is it going to close down? And the popular place can’t cope with demand so queues get bigger. Do they get more money for treating more people? Is this how they are paid nowadays? … So one will go downhill and the other will get better. Can see the logic but not sure it will work.  (Adrian, C1, pre-family)

It would improve a lot of hospitals although some would lag behind and would go into the background and maybe not be used and be wasting money. It is a good idea because…it would improve the motivation to improve. It would improve their effectiveness and use of money (Sammy, C2, pre-family). 

Patient choice only attracted the support of nine:

We should get the same standard of treatment wherever you go. So that doesn’t appeal to me. … you know it shouldn’t be this hospital is better than that hospital, it should just be a hospital. It should be consistent service wherever you go…(Enzio, C2, pre-family).

I don’t agree that you should be given a choice - everywhere should be the same standard give or take personality differences but the budget should be the same and the waiting list should be the same  (Ramona, D, family)

The new agenda of NHS reform is only weakly supported among those we interviewed.  The reasons why the use of targets and competitive choice was seen as of limited value among the sample are twofold.  First, from a practical and instrumental perspective, the approach was seen as beside the point.  NHS users want good quality treatment available to them locally and do not greatly value empowerment or individually personalised provision as such.  The new arrangements are often seen as a waste of resources.  This corresponds to national attitude survey findings.  For example, attitude survey evidence shows that while there is weak support for choice, it is much less marked than concerns about quality and access (Appleby and Alvarez-Rossette, 2005, 132).  This was summed up in one representative comment on the introduction of ‘choose and book’, the new scheme which offers all those needing elective treatment the choice of at least four institutions:

It is perhaps giving something to people that they don’t really need or don’t really want and the bureaucracy that surrounds the whole thing is money that is being wasted. It could just be spent directly on healthcare (Luis, E, family).

Secondly, from a normative perspective, the new more consumerist agenda contradicts the core NHS values of universalism and fairness, as well as commitment to care:

You can’t change the NHS into a market place, it is not morally right. People are going to be even more sceptical. [Why?] It is not morally right to have the NHS as people here have been used to having it for the last 60 years, it has been there from cradle to grave, now your particular hospital in your particular area has to compete on figures in case you might need it, it is just not right. (Sheryl, E, post-family)

No, they have got to think this through. Think about the people and the whole system and what it was set up for. They have completely forgotten the value of the NHS which is for the people, the local people. (Ronald, B, post-family)

These responses do not immediately address the logic underlying the reform agenda.  If it is the case that the imperatives of competition exert a benign influence, enhancing cost-efficiency and responsiveness, as the PMSU document argues (2006) the developments will have an instrumental value, whether service-users recognise this immediately or not.  However, if the established NHS values play an important normative role in enlisting public support for the service, then policies that are seen to damage them may undermine public support regardless of their effect in practice.  In any case there is evidence of concern about the reforms, both on the instrumental grounds that they are not seen to address the issue of good-quality local service, valued highly by respondents, and on the normative grounds that they run counter to the moral framework associated with the NHS and valued equally highly.

The Findings: Legitimacy and Public Trust

The main theme in the comments of most of those we interviewed is the conflict between the universality and commitment to caring of the NHS, on the one hand, and the pursuit of targets, cost-efficiency and competition, on the other.  It is this opposition between values seen as essential to the service and an impersonal dehumanising finance- and target-driven agenda that underlies much of the dissatisfaction and disquiet, summed up by the respondent who complained about being treated ‘like a pound sign’.  Both older and younger and middle and working class interviewees made similar points:

And all the problems with management and the sort of structure of it and I think it is not about health anymore, it is about numbers. It is not about caring, it is not about health (Susanne, C1, post-family).

These hospitals are being run by managing directors and the thing is it hasn’t made people feel any better or feel any more comfortable. All they want to do is get seen to and a bit of respect, a bit of dignity, a clean hospital and seen quick and…they put targets out and I haven’t noticed I feel happier when I use the hospitals and stuff (Phineas, C1, pre-family).

The NHS used to have values - putting the patient first, proper nursing, but now it seems to be paper pushing, reports on reports that kind of thing (Ronald, D, post-family).

Respondents locate NHS values directly in the behaviour of professional nursing and medical staff.  The majority of those we interviewed were dissatisfied with the service, but felt strongly that those delivering it embodied the core values associated with it and also highly valued by the users.  The font-line staff are typically seen as trapped between their normative commitments and the instrumental requirement to meet targets and enhance the competitive performance of their hospital or clinic.

They [staff) know they haven’t got the funding and work all hours to fill three jobs…Doctors are frustrated because they haven’t got theatres or nurses to do operations as much as they would like. Also not as many ward nurses so not as much one to one patient care. Not having equipment must be frustrating (Chantel, C1, family).

Staff are just doing their job, although there is maybe not enough money or too much pressure so they can’t do their job properly. Their personal values might not mean a thing because there is not enough facilities for them to do their job properly (Martin, C1, pre-family).

The gap between the professional staff motivated by a normative commitment to patient care and patient interests and managers who were seen as responding to an instrumental agenda of targets and regulation, as remote from service users and often of poor quality is a key element in the way many people across different groups among those interviewed expressed their response to NHS reform.  It is the latter group who symbolise the new managerial approach who are the focus of mistrust.
 
I trust the actual practitioners in the NHS, but the management: big question mark.  [Why do you distinguish between the two?]  Because they are no longer the same. In the old days there used to be a matron and the likes of matrons, but now you have got people who are paid extortionate sums of money for running it and certainly in this area they are not doing very well and therefore, frankly, should be out.  (Ronald, B, post-family)

They have got to make themselves more open and allow them to make their point of view and the point of view is listened to…I mean sometimes you see the heads of these trusts on the TV and quite frankly I want to wring their blasted necks because they are sitting at the top of the tree and telling you how wonderful they are … they have got to tell the truth, involve the public in their areas far more, make themselves more open and then the members of the public will trust them a lot more. They call themselves a trust, they need to be trusted. (Gina, C1, post-family)

These issues reflect evidence in national surveys of a division between perceptions of commitment and care and of level of resources and technical quality of provision and facilities (Appleby and Alvarez-Rossette, 2005). Picker Institute studies show that over the period 2002-7 ‘care has improved significantly in some important respects…but.. the service as a whole is still far from patient-centred’ (Picker, 2007, 2).  We have argued that trust in this context is influenced both by rational judgements about the interests and motives of suppliers and by normative perceptions of the values and commitments expressed in the way the service is organised and the implicit assumptions about how people should be treated.  The former fits within the instrumental framework and is likely to be influenced by track-record and capacity to deliver service of a high technical quality.  The latter is more a question of the values embedded in the framework of provision and expressed in encounters with staff.  Many of those interviewed felt that the NHS was being side-tracked from its core values and that less important issues were being prioritised over the basic goal of ‘patient-centred care’:

Obviously they have these government-driven stats that they have to adhere to as well, which maybe stops them giving patient-driven care. You know if they have to make these targets or they don’t get any funding  … then maybe they lose sight of what is important (Shulamith, B, family).

Priorities are quicker turn around time, quicker treatment, getting through the waiting list and through the door. Patient’s interests rank quite low. It’s all about waiting times and you feel like you are being rushed in and out the door cos all emphasis is on time (Jane, B, family).

It is all sort of minimalist and you are getting half a service basically … there is still that little question mark at the back of your mind. It is just quite scary really…there is a feeling of distrust there. Are people who are supposed to be helping you actually doing all they can or is there something that they could be doing but they won’t be doing because of money…especially for people with long term illnesses…(Zenna, D, pre-family).

A key overall theme across the interviews is that the instrumental concerns of the reforms conflict with NHS values.  Although it is now better funded, the service is abandoning its established normative principle of respect for the needs of patients and for their interests as people.  Perceptions of the impact of the new managerialist approach, often expressed in an opposition between managers and front-line staff, make a strong contribution to this.  The outcome is a weakening of public trust. 

Conclusions

We argued earlier that the new agenda of public sector reform is based on a particular approach to agency that applies an instrumental model of independent rational action to service providers and users.  This approach pays less attention to the expressive and normative aspects of behaviour which play a central role in theories of legitimacy and public trust.

The general public place considerable emphasis on the values associated with the health service, which include both the universality and fairness associated with the welfare state and the caring commitment of staff to the needs of users.  Agency in the NHS is seen as expressive of particular values.  While the reforms may serve the goal of improving the delivery of the service, there are strong public concerns about their impact on health service values.  The instrumental analytic framework focuses on the rational assessment of priorities and does not address the issues of the values contained in the reform programme.

Front-line staff are seen as retaining their commitment to core NHS values.  However, many of the members of the public we interviewed believe that the reform programme obstructs the ability of staff to provide the service as they would wish.  The conflict for the staff is seen to arise because they remain committed to the traditional NHS values of care and patient-centredness, while the reforms focus simply on the cost-efficient achievement of outcomes set by managers who are seen to have little awareness of their concerns.  The problem from the respondents’ point of view is that the value-context of the NHS is narrowed to an instrumentality of competitive success or achieving targets, ignoring the interests of patients as human beings. 

This contradiction between reform and the values embodied in the service is particularly relevant to public trust.  A crucial division in theoretical accounts lies between the individualism that sees trust purely in terms of rational judgements about the instrumentality of the trustee and its alignment with the interests of the trustor, and approaches that also include the normative commitments of the trustee and the extent to which they embody and express overarching values with which the trustor is sympathetic.  

From this perspective, NHS reform faces two problems.  First, as outlined above, the instrumental motivation assumed by the programme damages its capacity to serve the normative aspects of public trust, so that confidence in the service for many users is likely to be damaged.  The second problem concerns the choice and quasi-market agenda.  Advocates argue that one of its chief virtues is the capacity to align the incentives of providers with the wants of individual users through competitive pressures.  From an instrumental individualist perspective this should strengthen trust and public confidence.  In practice, users do not seem to value choice particularly highly and regard the competitive mechanism with disquiet.  They see the new approach as damaging the ability of the service to meet their needs, because it undermines the highly-prized normative framework of the service.  In short the more government pursues a reform agenda to improve provision based on an instrumental notion of agency, the more it risks undermining popular support by eroding the normative and expressive aspects of the way people understand their own and others motives and behaviour.  

The experience of the NHS is a salient example of a dilemma in welfare state reform.  There are excellent reasons for reforms that emphasize cost-efficiency and responsiveness to users.  However the predominant approach to pursuing these ends damages the legitimacy of and public trust in services.  This may erode public support, with the result that policies entered into in order to tackle the difficulties government and many commentators recognize may solve one problem at the cost of creating another. 

References

Atman, C., Bostrom, A, Fischoff, B. and Morgan, M. (1994) ‘Designing risk communications and correcting mental models of hazardous processes’, Risk Analysis, 14, 5, 779-87.
Appleby, J. and Alvarez-Rossete (2005) ‘Public responses to NHS reform’, Park A. et al. British Social Attitudes, Sage, London
Axelrod, R. (1981) ‘The Evolution of Cooperation’, Science, 211(4489):1390-6
Baggott, R (2007) Understanding Health Care, Policy Press, Bristol.
Bevan, G and Hood, C. (2006a) ‘Have targets improved performance in the English NHS?’, BMJ, 332, 419-22. 
Bevan, G and Hood, C.. (2006b) ‘What’s measured is what matters’, Public Administration, 84, 3, 517-38.
Blair, T. (1998) The Third Way, Fabian Society.
Bourdieu, P., 1990. The Logic of Practice, Polity Press, Cambridge.
Calnan, M. and Rowe, R. (2005) Trust Relations in the NHS, SCARR Trust Conference, London, 12.12.05.
Cook, K and Levi, M (1990) The Limits of Rationality, University of Chicago Press.
Cvetkovich, G. and Earle, T. (1997) ‘Culture, cosmopolitanism and risk management’, Risk Analysis, 17, 1, 55.
Dasgupta , P. (1988) Trust as a commodity’ in Gambetta op cit.
Deacon, A. and Williams, F. (2004) ‘Care values and the future of society’, Social Policy and Society, 3, 4, 385-90.
Dixit, A. (2002) ‘ Incentives and organisations in the public sector’, Journal of Human Resources, 37, 696-727.
Eldridge, J, Kitzinger, J., and Williams, K (1997) The Mass Media and Power in Modern Britain, Oxford University Press.
Ellison, N. and Castles, F. (2006) The Welfare State Reader, Polity Press, Cambridge.
Enthoven, A. (2002) Introducing Market Forces into Health Care, Nuffield Trust, London.
Fehr, E. and Gächter, S. (2000) ‘Fairness and retaliation: the economics of reciprocity’, J. Ec. Persp. 14, 3, 159-181.
Finch, J. (1989) Family Obligations and Social Change, Polity, Cambridge.
Finlayson, B. (2002)  Counting the Smiles, Kings Fund
Flynn, N. (2007) Public Sector Management, Sage, London.
Frey, B. (2000) ‘Motivation and Human Behaviour’, Risk, Trust and Welfare, P. Taylor-Gooby, ed, Macmillan.
Gambetta, D. (1988) Trust, Oxford University Press.
Giddens, A. (1993) New Rules of Sociological Method, Polity Press, Cambridge.
Habermas, J. (1987) The Theory of Communicative Action, tr. McCarthy,  Polity, Cambridge
Hardin, R (2002) Trust and Trustworthiness, Russell Sage, NY.
Hargreaves-Heap, S.. Hollis, M., Lyons, B., Sugden, R. and Weale, A. (1992) Choice, Blackwell, Oxford.
Health Committee (2006) press release 24.7.06
Hoggett, P. (2001) ‘Agency, rationality and social policy’, Journal of Social Policy, 30, 1, 37-56.
Hoggett, P., Mayo, M. and Miller, C. (2006) ‘Private passions, the public good and public service reform’, Social Policy and Administration, 40, 7, 758-73.
Holmwood, J., (2005) ‘Functionalism and its Critics’ in Harrington, A., (ed) Modern Social Theory, Oxford University Press, Oxford, 87-109
Hovland, C., Janis, I. and Kelley, H. (1953) Communication and Persuasion, Yale UP, New Haven.
Huber, E and Stephens, J (2001) Development and Crisis of the Welfare State, Chicago UP, Chicago.
Ipsos Mori (2007) Government Delivery Index     http://www.ipsos-mori.com/political/gdi.shtml consulted 9.11.07
Jaeger, C., Renn, O., Rosa, E. And Webler, T. (2001) Risk, Uncertainty and Rational Action,  Earthscan, London.
Kahneman, D., Slovic, P. and Tversky A (eds, 1982) Judgement under Uncertainty: Heuristics and Biases, Cambridge University Press, Cambridge.
King’s Fund (2005, modified 2007) An Independent Audit of the NHS under New Labour 1997-2005, Briefing Paper 23.
Le Grand, J and Bartlett, W (1993) Quasi-Markets and Social Policy, Macmillan, Basingstoke.
Le Grand, J. (2003) Motivation, Choice and Public Policy, Oxford UP, Oxford.
Le Grand, J. (2007)  The Other Invisible Hand, Princeton, NJ.
Lee, P (2006) Public Service Productivity: Health, ONS, February, http://www.statistics.gov.uk/articles/nojournal/PublicServiceProductivityHealth(27_2_06).pdf [accessed 19 November 2007]

Luhmann, N. (1979) Trust and Power, John Wiley, New York.
Luhmann, N. (1995) Social Systems Stanford University Press, Stanford, CA
Mau, S. and Veghte, B (2007) Social Justice, Legitimacy and the Welfare State, Ashgate.
Metlay, D. (1999). ‘Institutional trust and confidence’ in G. T. Cvetkovich,  and R. Löfstedt (eds.), Social Trust and the Management of Risk, London: Earthscan. 
Moellering, G. (2006) Trust, Elsevier.
Offer, J. (2006) ‘social theory and agency in social policy since 1830’, Journal of Social Policy, 35, 2, 283-302.
Ostrom, E.  and Walker, J. (editors, 2002) Trust and Reciprocity, Russell Sage Foundation
Petts, J, Horlick-Jones, T. and Murdock, G. (2001) Social Amplification of Risk, HSE Books, Sudbury.
Picker (2007) Is the NHS Becoming More Patient-Centred?, Picker Institute, London.
Pierson, P (2001) The New Politics of the Welfare State, Oxford UP, Oxford.
Preker, A. and Harding, A. (2002) Innovations in Health Service Delivery, World Bank, Washington, DC.
Prime Minister’s Strategy Unit (PMSU) (2006) The UK Government’s Approach to Public Sector Reform, PMSU, Whitehall.
Propper, C, Wilson, D and Burgess, S (2006) ‘Extending choice in English health care’, Journal of Social Policy, 35, 4, 537-558.
Seligman, H. (2000) The Problem of Trust, Princeton UP, Princeton.
Simon, H. (1978) ‘Rationality as process and as product of thought’, American Economic Review, 68, 1-16.
Sun (2006a) Wasted Decade, 12 October.
Sun (2006b) Our NHS and the Truth Which Dare Not Speak its Name, 14 April.
Sun (2006c) MRSA, 24 February.
Sztompka, P. (1998) Trust, Cambridge UP, Cambridge.
Talbot-Smith, A. and Pollock, A. (2006) The New NHS: A Guide, Routledge, London.
Taylor J, 2007, 'The impact of the specialist schools programme on exam results', Lancaster University Management School Working Paper
Taylor-Gooby, P. (2006) ‘New approaches to expert and institutional trust’, Jnl Risk Research, 9, 1, 79-95.
Titmuss, R. (1970), The Gift Relationship: From Human Blood to Social Policy Allen and Unwin, London
Todd, P., and Gigerenzer G. (2003) ‘Bounding rationality to the world’, Journal of Economic Psychology 24 (2003) 143–165.
Toynbee, P. and Walker, D. (2005) For Better or Worse?, Bloomsbury Press, London.
Treasury (2007) Comprehensive Spending Review: Meeting the Aspirations of the British People, Cm 7227, HMSO.
Weber, M. (1978) Economy and Society, University of California Press, Berkeley.
Polanyi, K. (1944) The Great Transformation. Beacon Press, Boston.