Patients need to believe in their doctor to get the best care, but how can real trust be built if they are always seen by different GPs? It is time to return to old-fashioned good manners and small practices

Nurses at a hospital in Bath were recently described by a peer as "grubby, drunken, promiscuous, slipshod and lazy". In the same week it was alleged that one in three nurses are violently assaulted at work each year. Subsequently Unison head of nursing Gail Adams declared: "The entire country holds nurses in the highest regard." Obviously this is not true for all.

Clearly how we regard nurses and other health workers has changed. The trust that once characterised the public's relationship with the medical profession has diminished and we are left wondering how to put the genie back into the bottle. Without trust, patients won't come through the door and they won't take the medicine. And yet research has shown that to be trusted by patients all professionals have to do is be seen as competent, responsible, and caring. That is not too much to ask, surely?

To try to answer this, I looked at a study that appeared a few years ago in the British Journal of General Practice concerning public trust in doctors and the combined measles, mumps and rubella vaccine. It examined factors influencing parental decision making at a time when media attention had focused on a possible link with autism.

Risks associated with MMR were minimal and unproven. But great media attention was paid to the issue, which amplified and distorted the debate. Medical practitioners and their colleagues had difficulty putting clear, scientific evidence in front of parents and even then few would accept it.

When researchers looked at what was needed to make the doctor's input a decisive factor in this process, timing, style and presentation were more important than factual accuracy. Without them, truth did not even make the starting line.

The professional's manner was also important. Those with an authoritarian style did not stand a chance, as opposed to those who presented their scientific evidence in a way which connected with the "tangible facts" of parents' lives. Doctors were seen as partial and biased and were no longer trusted.

Loud and clear

It is hard for clinicians to compete with mass media messages. But increasingly public health and primary care providers are going to have to improve their communication and public relations skills if they do not want to be seen as dull and uninformative.

Even in the best clinical practice, there is room for improvement, at least in presentation and communication. Three years on, uptake of the MMR vaccination is still falling short.

We should not fall into the trap of thinking that it is only the bossy doctor whose stock has fallen. Patients and service users generally want to be treated as grown-ups.

When we look at which professions we trust, technical experts - surgeons, civil engineers, test pilots - come out top, with journalists and politicians at the bottom. Technical expertise comes up trumps every time.

However, the more mainstream the subject, the more open the field. Most of the population trusts health information more from local media, while the educated middle classes trust national news and broadsheets. In effect, we trust people we identify with.

After that, we rely on experience. Failing that, we ask: "Do I really need to trust this person?" Clearly in emergencies we may answer this question more quickly than at other times. This forced compliance is essential in extremis but it is not the same as building trust over time. When you enter a hospital as a patient, you have to suspend your disbelief and trust that those involved will help you.

However, if risk is perceived to be distant or diminished, we flex our muscles against authority. When you go to see a GP, there is space to challenge or negotiate the therapeutic relationship, especially if that doctor is different from the one you saw last time and the time before. Being forced to confide the most personal details of your private life to a stranger in eight-minute chunks every time you visit your doctor does not encourage a therapeutic relationship to develop. Indeed, it does the opposite.

This quote from a 17-year-old user of a Birmingham health centre is typical: "I don't like going. You don't know who you are going to see. It is always a different doctor, so you can't build a relationship with them. Even the name on the door is someone else's, so you don't know who's going to be behind the door when you go in."

The discomfort and uncertainty she describes means that for this patient, and thousands like her, the chances of building a trusting relationship with her local doctor are infinitesimal.

The move towards ever larger health centres militates against the development of the trust that is essential to therapeutic relationships. If we know this, why are we planning even larger polyclinics?

A better place

When we talk about the decline of trust there is an inherent assumption that there was once a better time, a happy land when doctors and nurses were kindly and trusted, a friend to the poor, the lame and the blind. Some were, but there were still also those who were arrogant, predatory, cold and downright unpleasant.

Those who fell into the former camp though were characterised by two things that seem to have almost disappeared in the modern NHS: a sense of selfless vocation and good personal manners.

There was once the idea that health professionals believed in the socially progressive ideals of the NHS. We trusted them to heal not only patients but even society itself. Perhaps that was a hopeless ideal, but today there is a growing feeling that doctors have followed dentists in their flight from vocation.

In general there has been a decline in the idea of vocation in public health services. Talking to doctors, pharmacists, opticians and dentists, I am often struck by the sublime contradiction in their role. The public sees them as public servants but they essentially see themselves as small businesses.

Yet, when there is a perceived threat to their status, the roles reverse and a mixture of martyrdom and militancy floods the medical media, while the public views GPs with reported incomes as high as£300,000 a year as greedy and self-serving.

Trust, as part of the therapeutic relationship, is the very heart and soul of the NHS but, according to behavioural scientist David Mechanic, "is now more conditional and negotiated and depends on communication, provision of information and the use of evidence to support decisions."

Perhaps it is the same with physicians as with politicians. We suspend our disbelief in politicians as long as we can buy into the magic. Once the magic has gone, the trust goes too. But what is that magic? For the medic, it is a mixture of expertise and charm. Charm, like expertise, is learned. It consists of kindness and good manners.

I was always told that you can go a long way in life if you have good manners, a firm handshake and a nice smile. Obviously GPs and health professionals need a touch more than that to succeed, but these basics would at least be a start.

But treating patients well - with politeness and consideration - is surely the minimum from which all professional care derives. Listening well, valuing the patient's input, respecting and including them in decision making: all are features of good, well-mannered patient care.

Too often, doctors are described as brusque or rude. If your patients see you as uncaring and ill-mannered, they will find it difficult to trust your competence to cure.

Doctors and health workers need to connect with their patients if they are to rebuild trust. But increasingly doctors live in a world far removed from their patients. So how do they make this connection?

To effect national change we start by acting locally. Let's start by developing smaller, friendlier clinics that allow more sustained relationships. Let's engage patients in the shared venture of personal and public health. Let's remember why we came into the job and talk about our work and our vision. It will take time and may be difficult, but no task is more essential to rebuilding the best patient care.