Image: Sunset @ Punta Umbría (Huelva), Spain from CrashSunRay2013's Flickr Photostream

When we went to talk to British ex-pats who’d retired to Spain, it was not surprising to find them enjoying the ‘good life’. Sun, sea and the ready community of other British retirees all made Mallorca or the Costa Blanca a more attractive retirement prospect than the damp houses, heating bills and social isolation they’d left behind.  What was more surprising in our study was their wholehearted faith in the Spanish health care system. Typically people prefer familiar surroundings when ill – so why did ex-pat pensioners trust local hospitals and doctors more than the NHS? One reason was their high exposure to negative stories about the NHS in English language media, yet few recent personal encounters with the NHS. This raises crucial questions about what fosters trust in health care provision.

This preference for Spanish health care over returning to the UK for treatment was rather unexpected. We had assumed that, as the pensioners got older and needed more health care, they would face problems. Few had learnt enough Spanish to sustain communication with a doctor; few had much understanding of how the Spanish health system worked; few had much faith in what they called the ‘mañana’ culture of the Spanish public sector in general.

However, they overwhelmingly reported high trust in the Spanish health service:

“I go to the new hospital … it’s the best hospital in Europe … it’s beautiful, it’s clean, it’s airy, it plays music in the corridors. Can’t fault the medical care out here, the attention you get is marvellous, it’s one thing they really have cracked”

When asked directly, most said they would prefer to see a doctor or have an operation in Spain than in the UK. These ex-pats’ accounts of why they would choose Spain had some clues about not just why Spanish health care was so highly trusted, but also on a key question for the public sector: what fosters trust in health care more generally?

Perhaps British pensioners were simply reflecting on an objectively better health care system – Spain does punch above its weight in terms of health gain for the amount spent. However, for the older people in our study, trust did not seem to arise from direct experiences of better outcomes. Even when things had gone badly wrong – long waits for treatment, misdiagnosis, or, in one extreme case, the wrong eye being operated on – people repeatedly told us that they would trust Spanish health services over British ones. Poor clinical outcomes did not seem to dent their faith.

Two factors seemed to explain relatively low trust in the UK system compared with high trust in the Spanish system. For a community who largely read English language press and watched UK television, one was the seemingly unending succession of stories in some newspapers, especially those widely read by the ex-pat community, on the ‘failings’ of the NHS in England:

“There are people in the UK who have had problems being on the National Health and it is such a waiting list, they have died while they were waiting. It’s been on television many times, hasn’t it?”

They had little recent experience of the NHS to bolster their trust through personal encounters – and evidence suggests that it is personal experience with hospitals, doctors and clinics that fosters trust.

Second, their direct experiences of care in Spain were characterised by warmth at the personal level, and efficiency at the institutional level.   Together, these features seemed to capture what a trustworthy system looked like.

As older citizens, our interviewees talked about the respect and care they had from all staff they encountered: doctors, nurses, receptionists, and cleaners were all described as physically demonstrating care through touch, and treating them with genuine empathy. This compared unfavourably to the UK, where they felt older people were marginalised in health care, and treated as ‘numbers’ not people.  Alongside this warmth were very visible indicators of efficiency at the level of the institution. A key one was high levels of cleanliness observed in hospitals:

“You could eat off the toilet floor. It’s spotless, absolutely A1. If I had to give 100, out of 100, I would give them 110% … The place is like a clinic”

To describe a hospital as ‘like a clinic’ suggests something of what makes patients trust a health care facility: If it looks like a hospital, smells like a hospital, it is, it seems, undoubtedly a proper hospital. In the UK where, increasingly, publicly available ratings are used to inform the public about hygiene, clinical outcomes and risk, trust is, paradoxically, eroded. We are reassured by seeing a clean floor; we are not reassured by more information about cleanliness.

The study was done before the recent economic crisis really hit Spain, and in some areas there were sparkling new hospitals, with state-of-the-art facilities. However, it does suggest that more attention to the interpersonal aspects of health care, and less obsession with monitoring and audit, might do more for trust in the NHS.

About the authors: Judy Green is a sociologist at LSHTM, on twitter @judegreen. Helena Legido-Quigley is an Associate Professor at the Saw Swee Hock School of Public Health, National University of Singapore. She has conducted research on the impact of austerity measures on health and healthcare, and migrant populations. Her latest research focuses on health system reform in South East Asia. She can be found on Twitter @legidoquigley.   Martin McKee is Professor of European Public Health at the London School of Hygiene and Tropical Medicine. He has published widely on European health policy. He can be found on twitter at @martinmckee.