The salience and meaning of trust has been the focus of the analysis of social theorists for some time now, and scholars such as Simmel, Goffman and Giddens have recognised it is a key element in the way society is glued together. Yet in some contexts such as health care it is believed to be even more important because of the risks, uncertainties and vulnerabilities which are inherent in its provision not just for patients but also for clinicians. For example, Richard Titmuss (Reference Titmuss, Oakley and Barker2004) suggested that there are various limits (he identified at least thirteen) to the idea of consumerism (voice, choice and exit by patients) in relation to health care and these were all associated with uncertainty and unpredictability. However, despite this recognition that trust and trust relations may be fundamental in the provision of health care trust, it still remains an elusive concept which is difficult to define as well as operationalise. Trust, as with similar nebulous concepts such as dignity, is easier to analyse when it is under threat or lost. Hence much of the recent academic, policy and popular discourse on trust in the context of health care has focused on the decline in or breakdown of trust in medicine and health care institutions and the implications of this so-called ‘problem’ of decline.

This problematising of ‘trust’ is one context in which trust relations are discussed in this book, although it adopts a much broader approach by following a multidisciplinary perspective, drawing mainly on sociological, psychological and philosophical approaches to understanding trust relations in the context of health care. The bringing together of these disciplinary perspectives is one of the strengths of this book, as trust had been of interest to many disciplines such as philosophy and ethics, not least because of the obvious moral connotations associated with trustworthiness. The structure of the book is organised around three modes of analysis which the authors see ‘as an original contribution to debates on trust in healthcare [as it] is an attempt to triangulate all three modes of analysis’ (p. 181). These modes of analysis include perspectives on trust from popular, practitioner and different disciplinary viewpoints; levels of trust which involve trusts in oneself, interpersonal and social levels of trust (trust in others) and trust in systems and institutions and, finally, the neglected but important depth and relational proximity of trust. Following this framework, there are separate chapters on interpersonal, social and systemic aspects of trust interspersed with chapters on ethics and trust, including one on psycho-social and psycho-ethical aspects of trust. The penultimate chapter provides an analysis of three different types of case studies usefully classified into medical scandals, medical controversies and routine breakdowns in order to ‘cross reference’ to the previous more academic discussions. The final chapter provides an overview of the approach, concluding with a discussion of the political considerations about trust in health care.

This book is an ambitious attempt to provide an analysis of the complex and multi-layered concept of trust and trust relations which is accessible to a broad audience; this style is helped with each chapter finishing with a boxed summary of the key points, and at the end of the book there is a glossary of the key concepts. So does it succeed? In many ways it does in that it contains a wealth of material some of which was novel, at least to this reviewer, and brings together a number of contrasting perspectives in one volume. One level which has tended to have been neglected in previous analyses (Calnan and Rowe, Reference Calnan and Rowe2008) is self-trust or intra-personal trust, which Pilgrim and colleagues refer to as ‘confidence in ourselves’. This concept may be important for patients given the current emphasis in health policy on patient self care and management, and particularly in the context where identity is under threat and confidence in social competence can be undermined, such as with some mental health problems. This book quite rightly also considers trust from the often-neglected point of view of clinicians. Much of the focus in previous work is on the vulnerabilities of patients, yet clinicians may also feel vulnerable, leading to defensive and inappropriate practice. Self-trust may be particularly salient for less-experienced clinicians who have clinical discretion but who feel vulnerable as they may not have the confidence in their own competence, will be less willing to take risks and will follow protocol and rely on tests which may lead to a lack of personalised care which may have consequences for patient trust. Certainly, in the prevailing organisational context in the English NHS, with its emphasis on performance management, auditing, accountability and risk management, there is a low trust culture (and blame culture where mistakes are not acceptable or admissible), which may compromise clinical practice.

The book confines itself mainly to examining trust relations in the NHS, although drawing on evidence from other countries might have thrown further light on questions that relate to trust in systems. Evidence from countries such as Australia, which have a more mixed, pluralistic system of health care, suggests that a form of trust (symbolic trust) is crucial to the publics’ decisions to subscribe to private health insurance (Natalier and Willis, Reference Natalier and Willis2008). This leads on to the thorny but fundamental question of the relationship between the different levels of trust relations and if and how system level trust relations might shape interpersonal relations or vice versa. This reviewer is still to find a clear framework with explicit explanations or pathways provided for a possible link between the different levels, and this book does not provide much further insight into this despite the triangulation of the different modes of analysis.

This book has a lot to commend it not least that it shows the complexity and diversity of the approaches and arguments about trust and trust relations, the incompatibility of some of the different perspectives and that there is no single and predominant account of the nature of trust relations in health care.