We have divided this section of the paper into two main parts. We provide both the results, and a discussion of them, in relation to extending the theory of trust and further understanding the nature and extent of trust in public in public and private hospitals in Australia. Firstly, we provide our analysis of the trust considerations from interviews with public patients and then we go on to explore the trust considerations from interviews with private patients. We acknowledge that we have constructed a binary categorisation of public patient /private patient to describe our participants which does not do full justice to the reality of using hospital services – ‘private patients’ often had experiences in both public and private hospitals (although predominantly the latter) although ‘public patients’ tended to only have heard about private hospitals rather than been treated as a patient in one.
Trust considerations in public hospitals
Blind faith in experts
A common theme expressed by public patients was having no choice in which doctors they consulted, but also not necessarily seeing this in negative terms. Public patients, without exception, talked about the knowledge and expertise of doctors and their own relative lack of knowledge, which for them set up an innate trust, or at least faith, in the doctors. For example Darlene said
“Trust…, for me it means that the people that are giving you advice that- could ultimately determine your life or death potentially, sensing, and it is just a sense, it’s not based on anything other than a sense, sensing that you are in good hands, that the outcome may not go well but at least everybody’s doing everything they possibly can to give you the best level of care and the best chance. So for me the pivotal moment of that was when I was told I would need to go into emergency surgery which would require a general anaesthetic that under the circumstances may not be ideal but that was the only option and that sense of ‘oh crap things aren’t going particularly well here’. We’re getting down to minutes now, not hours but I just had this sense of ‘well, you know what, I can’t physically change the outcome myself. I’m in good hands. I just have to trust that this is going to go okay’. And had that sense from the staff as well, that I was in the best hands. It’s intangible to describe really I guess” (female, 38, public).
This extended quote highlights a number of the key issues in this section of the paper. This participant talked about the uncertainties and intangibles involved in trust (“it is just a sense”), the vulnerabilities patients face when in medical emergencies (“ultimately determine your life or death potentially”), the lack of choice one has during these circumstances (“I just have to trust”), but also a pragmatic acceptance of the situation (“I can’t physically change the outcome myself. I’m in good hands”) and a sense of optimism that she was in “the best hands”.
Similar to previous research , it was difficult for participants to differentiate between ‘trust in doctors’ and ‘trust in the hospitals’, since the doctor was the flesh-and-blood representative of the hospital. Indeed, Giddens’  notion of the ‘access point’ articulates this, whereby individuals invest (dis)trust in the system (i.e. hospital) through their inter-personal interactions with the representatives of the system (i.e. doctors or other staff).
Lillian simply said, “As for hospitals, we really go in with blind faith” (female, 72, public), whereas another participant specifically linked the asymmetry in doctor-patient knowledge to his faith in doctors, “Well I’m not trained medically so I’m taking a lot of what they say on faith” (male, 47, public). This ‘acceptance’ of asymmetric knowledge and expertise is reminiscent of Parsons’ ideas about the sick-role [43, 78]. However, the unreflexive part of ‘blind faith’ sits in contradistinction with Luhmann’s theory of trust , which presupposes that trust is built on experience and familiarity. On this experiential basis, a decision is made, amongst a variety of decisions that ‘could’ have been made, to trust a particular doctor. However, in the context of public hospitals, participants seem to trust ‘doctors in general’ and then in specific circumstances, transfer this trust to individual doctors who they rely on for care and treatment. This ‘dependence’ has been found in other contexts of health care [2, 30, 63]. Whilst there has been a movement around ‘patient expertise’, patient-centred care and ‘shared decision making’ [79–81], there have also been questions around whether choice ‘really’ exists for vulnerable, marginalised and/or low income groups [29, 82, 83].
In addition to the numerous statements about ‘blind faith’, there was the added temporal dimension mentioned by participants. The sheer urgency of being taken into an emergency department meant that actively seeking information on which to base trust, whether a public or private patient, become impossible. In this context, patients had little option other than to ‘go with the flow’, as outlined by Jodie:
“Yes because you’ve got faith in the hospital trauma or emergency department and the time, you don’t have time to Google them or whatever so you just have to trust them. They’d have to be highly skilled to be in that environment. I know things go wrong and people get ramped and they’ve got to sit in the ambulance and stuff but I think they’re really very skilled in that department” (female, 39, public).
Jodie made an assumption that the staff were ‘highly skilled’ and used this as the basis of trust, even when ‘things go wrong’. A number of public patients made comparisons with hospitals in the past or in resource-poor countries or the US, stating how ‘fortunate’ they are to even have a publicly funded system. The following quote illustrates this point, stating that they lived in a metropolitan area where they actually have hospitals, in comparison to being in a ‘desert’, and they used this comparison to justify and rationalise their ‘blind trust’. Interestingly, Colin also talked about health care professionals being ‘in charge’ of him and being ‘in their hands’, symbolising a shifting of responsibilities:
“We’re in their hands aren’t we really because we’re in a system where – you know, we’re not lying out in the desert and we don’t have to come up with a tourniquet and bite on a piece of wood, do we? We’re in their hands and they’re medicating us. Generally yes, I trust the people that are in charge of me” (male, 48, public).
An over-riding theme from public patients was their acknowledgement of the various ‘problems’ associated with public hospitals, and the publicly funded healthcare system in general. There was a mix of personal experiences and exposure to negative media reporting, predominantly about long waiting lists and ramping (patients remaining in ambulances outside emergency departments, sometimes for long periods of time, until beds become free in the emergency department). The following quote from Michael describes a participant’s pragmatic acceptance (i.e. recognise the problem as intractable) of the ‘failures’ in the publicly funded health system and their unwillingness to criticise or challenge it:
“I’m a realist and as long as you have human beings in anything something’s going to fail sometime because that’s human nature. You are going to get the mistakes…. you just pray that it’s not you or one of your relatives or whatever else. No, it’s a good system. It’s a faulted system but it’s a system that we’ve got and it’s a system that I’d be happy with” (male, 51, public).
This quote, and a number of others in the analysis, shows the knowledge of the health system and its failings, but also a recognition that humans in the system (e.g. doctor, nurses) are trying to do their best. There was a palpable sense with all public patients of both respect and sympathy for healthcare professionals working in public hospitals, which led them to fervently defend the public system. Michael also had a sense of hope when he said he would “pray it’s not one of my relatives that are in the hospital when the mistake is made”. For this and other participants, the base-level trust seems to be in the medical/hospital system, which may relate to a trust in hospital bureaucracy, doctor registration, medical training, quality and safety systems or medical research and drug discovery. For Giddens , the hospital would be conceptualised as the ‘access point’ within which trust is won or lost, although Giddens recognises the durable trust in ‘systems’ and the more fallible trust in ‘individuals’, “although everyone is aware that the real repository of trust is in the abstract system, rather than the individuals who in specific contexts “represent” it, access points carry a reminder that it is flesh-and-blood people (who are potentially fallible) who are its operators” (p. 85).
For a number of the public patients, pragmatic acceptance was not just for ‘non-urgent’ elective care, but carried over into their experiences of emergency care. Linked to both ‘blind faith’ and a lack of choice, participants talked about the fact that they ‘had’ to trust the hospital staff. Darlene’s recollection of her experience of emergency surgery in a public hospital is an example of both accepting the relative chaos of emergency departments and investing trust when there is arguably no choice. Prior to the previous quote from Darlene where she talked about ‘just trusting’, she had been talking about the reasons she was rushed into hospital and the ‘chaos’ of the system when she arrived, which highlight the perceived lack of choice but to ‘just trust’:
“Yes. I did have a few moments in that process going ‘oh oh’ – I remember one of the staff commenting to me ‘you seem remarkably calm’ and I just remember saying to her ‘well, I don’t know what other choice I have at this point to be honest. I could flap and be in quite a mess but that’s not going to serve any of us well at this point so it is what it is and let’s get on with it’ really” (female, 38, public).
Another public patient, Emma, used to pay for PHI, but is no longer able to afford it. She talked about the benefits of private hospitals over public hospitals, and would certainly prefer to have PHI again. However, now that she ‘has’ to use the public hospitals, she exhibits a form of pragmatic acceptance:
“So many people like myself that just can’t afford private cover that they need to use the public system. I guess there’s not much you can do really because there’s just getting more and more people, isn’t there, now that use the system? …..You can’t get it right for everyone, it’s just not possible, we’re human” (female, 44, public).
The following public patient, Christina, talked about a variety of negative experiences in emergency department, but despite these negative experiences, tried to rationalise the situation and still talked about having trust:
“Well in the XXXX [name of hospital] I was actually told by the person treating mum, she was so flat out that had no time to do the obs …. and I have no medical …I haven’t got any medical training…. It was not ethical…but it’s only because they were stretched to the max and you could understand the pressure…” (female, 85, public).
Public patients were uncomfortable being seen to complain about or criticise public hospitals, and when they made seemingly negative comments in interviews, they countered these with excuses or justifications. All of the public patients in our study ‘justified’ potentially negative elements of public hospitals through what we argue is sustained optimism (i.e. the individual doctors are still trying to do their best under difficult circumstances), for example:
“Okay, they might be overflowing with people but if it was a serious thing they would eventually get round to you. Fortunately I’m not out in the country areas and it’s a different scenario there. I’m in a city so – yeah” (male, 75, public).
Another participant talked about the media stories of ‘ramping’ (treating patients in ambulances outside hospitals because the emergency departments are full), which could be seen in very negative terms. However, this participant recognised the problems inherent with this practice and assumed that the paramedics would just take him to another hospital and he would trust their judgement and the care at the un-named hospital he would be taken to:
“XXX [hospital name], yeah, not this one, or the - you know, you hear the stories about all the ambulances banked up down here so they might send me to somewhere else, you see, and I’d say well good on them because they’ve got me where they could quickest and I would accept whatever treatment was available” (male, 64, public).
In this respect public patients seek ways to maintain their trust, possibly because they have no fall-back position (i.e. in the free, allopathic medical system). If public patients were to distrust, they may force themselves into an uneasy state of existential anxiety , not knowing where to turn or which knowledges to privilege – an apparently generalised state in late modernity known as both ‘era of insecurity’  and ‘culture of anxiety’ , neither of which might be regarded as salutogenic  or eudemonic states. We argue that in such circumstances, trust is sustained through optimism. With respect to public hospitals, if optimism was removed, then patients may simply be left with complaint and negative feelings, potentially leading to distrust. However, distrust may be too unsettling in public hospitals because there are little if no alternatives for health care. The sustained optimism therefore becomes a necessary strategy whereby mistakes or lack of funding are viewed through the lens of optimism.
Jeff had repeated negative issues while in a public hospital, but kept qualifying/justifying the problems he experienced while in hospital. He was a ‘private patient’, but his condition was dealt with in a public hospital. He expressed being let down by the system post-surgery, being forgotten about, and being left to fend for himself. He notes how “packed out” the hospital was and talked about his internal struggle to justify both the competency and yet inadequacy of the system that let him down: “I think we are very lucky to have this system and that we’ve got it at all…they were just so busy and I do understand…there was nothing they could do and it was just going to be one of those things” (male, 64, private). He mentioned repeatedly how busy and chaotic the hospital was and that he did not know what was happening to him or his care, but accepted that it was just ‘how it is’: “it just seemed like it was unorganised and chaotic and busy and all of those things at once…you’re just bombarded with people walking in, walking out…it was just a blur”. As soon as he commented on the difficulties incurred, he went on to defend the doctors and nurses working in the hospital: “you do very much become part of the system there. I think it’s very much that and you can understand why, because there is so many patients, after being in there and seeing the patients that come through, I do have a lot of sympathy for them…and the nurses were fantastic”. Interestingly, he did criticise the PHI company whose ‘red tape’ made it difficult to claim from. He is bearing a certain amount of guilt for still costing the system money due to his delayed recovery: ‘I’m costing the public system. I’m costing everyone.’
Trust considerations in private hospitals
In non-emergency health scenarios, a division between public and private participants interpretations/consideration of trust appears: For the private patients, the central foci related to a choice of hospital and physician/surgeon. Private patients had a number of explanations for their trust in private hospitals, relative to public hospitals. Choice is a concept not really up for offer in public hospitals:
“I think the private system, for me it gives me flexibility to be sceptical and to make choices amongst who does the work, that’s probably the advantage. In the public system I think you take what you’re given” (male, 47, private)
Choice and reputation
Keith made a link between patients being able to choose their doctor in private hospitals and the doctors themselves needing to develop and sustain a positive reputation, an informal league table, with the winners having more patients and thus more income:
“.. some of the doctors in the public system are not up to scratch, but they wouldn’t last in the private system…if you get a bad reputation you won’t get people referred to you because the old boys’ club, you’d call it, or the group, you’d be a reject really quick if you were no good. That said I’ve seen a couple of guys in private practice – not treating me fortunately – but who have been a bit less than ideal. Then again that’s the reason I wouldn’t go to see them even though I was asked if I’d be referred to them because I did know that they were unsuitable” (male, 56, private)
By implication, Keith’s remark about specific doctors being “a bit less than ideal” and “unsuitable” suggests the capacity and ability to criticise the performance of doctors in private hospitals, and ultimately to choose a different doctor. This sense of choice was not seen as possible in public hospitals, whereby any criticism tended to be both accepted and excused, thereby retaining the status quo of trust.
A number of private patients talked about the importance of reputation for doctors in private hospitals, often talked about as ‘pressure to perform’. Reputation of surgeons was also an important determinant of trust in the UK when ‘choice’ was brought into the English NHS . This perceived competition within and across private hospitals was perceived to improve the quality of care and made the choice of doctor easier through reputational trust. However, the corollary was that the lack of competition in and between public hospitals does not force doctors to constantly assess and improve their quality vis a vis their peers or ‘customers’:
I guess me personally, yeah, I’d probably always go for a private setting for any kind of surgery. Yeah so I must, part of me….the private doctors, they’re so dependent on their reputation so if they are really bad then it affects their livelihood whereas in public maybe there’s not that pressure on them. They’re not as well known. When you turn up, you get who you get. (female, 39, private)
Contrary to patients in public hospitals who felt unable to criticise their doctors, Julie felt able to criticise her care while being treated as a public patient (with a work cover injury) within a private hospital. Implicit within her belief is also that she can complain in private hospitals whereas as a public patient she cannot:
“I would rather go to xx public hospital than xx private hospital again…I mean Dr X doesn’t know any of that because I never told him. I think he’d be horrified if he knew the way I was treated that morning…If I’d been a private patient and it would have come out of my pocket I would have really said something” (female, 56, public)
George paid for PHI and was both reserved and sceptical about how doctors could help him. Although he said he did not distrust the medical profession, he was certainly cautious and sought alternative therapies rather than consult doctors. He described trust as an objective criterion of a doctor’s abilities, and was something that can and should, in his view, be assessed by patients and demonstrated by doctors. In this way, George talked about something akin to ‘earned trust’, as opposed to less reflexive concepts such as blind or assumed trust. He talked about making a decision whether or not to ‘submit’ himself to the doctor’s recommendations, suggesting an active engagement and possibly an internal struggle with considering whether or not to trust a doctor and follow their advice:
‘Well I’ve seen doctors that to my mind, they just don’t really have the experience or the depth of understanding to understand the problems that I’ve got….. but I need to have someone who understands where I’m coming from before I can have the level of confidence in them to submit to their direction on this…I want these people to really demonstrate to me they understood what was going on with it and that they knew how to fix it before I’d submit to it(male, 47, private).
Personal responsibility resulting from their choice
There is a concept amongst some private patients that they have to take responsibility for their own health and their own decisions, a form of shared care and patient centred-care. Luhmann  argued that trust means choosing one action (consent to surgery) in preference to another (have a second opinion or choose a different doctor), in spite of the possibility of being disappointed by the actions of the trusted person . The following quote from Randall shows a want to take on responsibility for deciding which doctors to consult, and in so doing, to also take on the blame if their trust was misplaced. Luhmann  argued for the importance of this form of ‘self-trust’, and also for the internal attribution of blame and self-doubt:
“It’s not so much the full trust I just think it’d be silly – yeah, I guess it’d be silly to just place your full trust in someone else when it’s your health. My health is my responsibility. It’s my responsibility to seek out a GP if I’m sick and if I don’t then it’s my own fault. If I go to a GP and just take their word for it and it’s wrong, well, it’s not their fault, it’s my fault because I didn’t do my own homework. They’re not perfect” (male, 35, private).
Natasha had PHI and suffered a traumatic loss which left her with, “a huge loss of trust in the system” (female, 50, private). On the basis of this loss of trust, she took-on more responsibility for her own health care as a result of her bad experiences in the system “I can’t trust anyone to be doing the right thing because they didn’t in the past so it’s got to be up to me”. When confronted with a major health issue, Natasha found a way back into the system by, “taking control… it’s up to me…I knew I had to be prepared and steer the ship in going back into the health system”. This interview was interesting as she created a way to cope with a system she had completely lost trust in. Her strategies involved working out the best way to develop a relationship with the individuals in the system in order to get the information she required in order to make an informed decision. Instead of ‘blindly’ trusting the system, this participant had developed a format of critical, conditional trust [51, 88] in order for her to extend her control over her care and manage her vulnerability.