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This thing called trust: putting patient care first

Lynn Young
Community Health Adviser for the RCN

I seem to be talking a lot about trust these days, maybe boring a number of folk along the way, but during these days of endless measurement, nurses need to think about how we can best protect the public's safety.
Provocation has come my way via this year's Reith Lecture, given by Baroness Onora O'Neill,(1) and the recent A-level chaos. In many people's view it was bound to happen and brought little surprise to those of us who are uncomfortable with the present obsession with counting, measuring, assessing, league tables and performance - and, by the way, look out for foundation status. As Suzanne Moore states in her recent article in the New Statesman:
"Just repeat after me: what is the logical conclusion of obsessive testing, league tables, overexamination? Cheating, fiddling, tweaking."(2)
She was referring to the world of education, but there are similar patterns emerging in healthcare, and nurses need to find ways to prevent themselves feeling diminished from being over and aggressively performance managed.
The Commission for Audit and Health Improvement will soon have new inspectorate powers, GPs are to undertake regular appraisals, star ratings will be inflicted on PCTs as well as hospitals, and talks on the regulation of nonprofessional support staff continue. None of these is bad, but taking all into account the culture of healthcare could shift from one of liberalism and trust to one that smells of control, counting and excessive regulation.
Sir Ian Kennedy had much to say about the culture of the NHS in his report published as a result of the Bristol Inquiry. He talks about the dangers to both patients and staff that arise from tribalism between different disciplines (nurses can be so skilled at this!), a protective club culture, poor leadership, and the lack of teamwork, effective communication, self-criticism and integrity.
Baroness O'Neill's view is that too many rules can damage good people who need to be free to create with imagination, knowledge and invaluable experience. Perhaps we should talk more about responsibility than the more hard-nosed notion of accountability?
The call for organisations to be transparent has resulted in an overwhelming amount of information being made available to the public - but how much of this informs the public on the level of kindness and compassion they can expect at their local hospital or general practice?
We need to limit the need and/or desire to deceive and take positive action to encourage people to admit their mistakes. Sharing of experiences, high-level peer support, and honesty and trust will benefit patients more than tight controls, punishment and punitive systems.
Nurses should share their drive and efforts to implement Essence of Care with other disciplines - it is too important to keep within the nursing domain.(3) All healthcare organisations should underpin their clinical governance framework with the "Essence" principles - benchmarking, self-criticism and reflection. Patients also wish to be involved in their care, they want a decent environment in which they receive their care, and they need carers who are so well supported that it is easy for them to act with humanity, compassion and kindness.
I was unable to hear this year's Reith Lecture, "A Question of Trust", presented by Onora O'Neill, but I  managed to get hold of the written version. It is to be strongly recommended, as when we consider how we can improve patient care we also need to debate "Trust versus Regulation".


  1. O'Neill O. A question of trust. The BBC Reith Lectures 2002. Cambridge: Cambridge University Press; 2002.
  2. Moore S. New Statesman 30 Sept 2002. p. 17.
  3. Chief Nursing Officer Department of Health. Essence of care London: Department of Health; 2001.