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Title: Trust in health care: An agenda for future research Author: epglc Last modified by: p.f.taylor-gooby Created Date: 11/9/2004 11:22:19 AM Document presentation ... – PowerPoint PPT presentation

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Title: TRUST RELATIONS IN THE


1
TRUST RELATIONS IN THE NEW NHS THEORETICAL
AND METHODOLOGICAL CHALLENGES
  • Michael Calnan and Rosemary Rowe

Taking Stock of Trust E.S.R.C ConferenceLondon
School of Economics12th December 2005
MRC HSRC Department of Social Medicine University
of Bristol http//www.hsrc.ac.uk/Current_research/
research_projects/public_trust.htm
2
Context
  • Trust, risk and uncertainty in the provision of
    health care
  • Trust relationships challenged by changes
  • in organisation of NHS
  • in regulation/performance of health professionals
  • in public attitudes to health care

3
Aims
  • To explore how and why trust relations in the NHS
    may be changing
  • To develop a theoretical framework
  • To consider methodological implications
  • To describe current research

4
What is Trust? Definitions
Trust relationships are characterised by one
party, the trustor, having positive expectations
regarding both the competence of the other party
(competence trust), the trustee, and that they
will work in their best interests (intentional
trust).
  • Characteristics of trust specific to health care
    context
  • Stronger affective component (vulnerability)
  • Altruism working in best interests of patient
    (honesty, confidentiality, caring and showing
    respect)
  • Competence (social and technical)

5
Framing trust relationships in health care
6
Does it matter?
  • Important as health care characterised by
    uncertainty?
  • Important for patients assessment of quality of
    care?
  • Indirect influence on health outcomes through
    adherence and direct therapeutic effect?
  • Important in its own right for organisation ie
    like social capital?
  • Benefits to the organisation eg job satisfaction?

7
The costs or dangers of trust
  • Abuse of trust with vulnerable patients
    particularly those with limited resources
  • Easier to trust if powerful and wealthy
  • Tension between development of trust and patient
    empowerment?

8
Research into Trust by Country
9
Focus of Study
10
Perspective of Interest
11
Why are trust relations changing?
  • Influence of wider social structure on trust
    relations
  • New context for trust relations in NHS

12
Drivers of change
  • Top down policy initiatives, e.g. performance
    management
  • Wider social and cultural change, e.g. decline in
    deference to authority
  • Negative media coverage of medical scandals

13
Changing trust relations in the new NHS
policy initiatives
  • Trust and Performance Management
  • Trust and Patient Choice
  • Trust and Patient Participation in disease
    management

14
How are trust relations changing?
  • High trust in professional self-regulation.
  • Patients trust clinical recommendations for
    treatment.
  • Patients passive trust in GP to determine access
    to specialist services.
  • Greater regulation and monitoring that is low in
    trust.
  • Greater patient self-care requires clinical
    trust.
  • Patients expected to actively choose where to go
    for specialist care.

15
The distribution of trust and state control in
various models of governance


High Trust

Professional model




(accountability implicit)





Stakeholder model


Bureaucratic model

Low
High


(accountability explicit)




State







Control








Control




Market model



New Public




(choice)




Management model



Low Trust

16
Levels of trust
  • Levels of patient trust in specific clinicians
    appear to be high
  • Lower public trust in clinicians and health care
    systems
  • Lack of prospective studies monitoring changes in
    overall levels of trust
  • Lack of studies into nature of trust relations

17
Trust in health services staff putting interests
of patients above convenience of organisations
18
Public trust in health care Netherlands present
and future
Source Van der Schee et al (2005), Nivel. Utrecht
19
Levels of Trust with specific aspects of health
care
20
Levels of Trust with specific aspects of health
care (cont)
21
Specific determinants of overall rating of
trust/confidence top six
22
Specific determinants of overall rating of
trust/confidence bottom six
23
New forms of trust relations
  • Shift from affect to more cognition based
  • Greater interdependence in trust relations
  • The role of information in trust creation
  • The importance of institutional trust
  • More informed but conditional trust

24
Framework
25
Methodological implications (1)
  • How do you recognise conditional trust?

Low trust
High trust
 
Conditional trust
26

Attitudes that reflect felt trust
27
Methodological implications (2)
  • Can current instruments identify conditional
    trust behaviour?

28
(No Transcript)
29
Methodological implication (3)
  • If institutional and interpersonal trust interact
    how do we examine this?

30
Embodied and Informed TrustPatients beliefs
and behaviour
  • If trust is more embodied you would expect
  • Patients have a more passive, deferent role
  • Information is valued for the respect it shows
    rather than its content
  • Advice/recommendations are accepted
    unquestioningly
  • Trust relates to family/personal experience
    of doctor
  • There is an association between the level of
    direct contact and level of trust
  • There is minimal checking or monitoring with
    managers and clinicians being given considerable
    autonomy in decision-making
  • Rules are unwritten, informal and processes are
    not prescriptive
  • There is an assumption that the other party is
    well-intentioned towards you
  • A clinicians altruism is unquestioned
  • Willingness to take risks is based on the
    reputation of the organisation or individual
  • If trust is more informed you would expect the
    following beliefs and behaviours
  • Information is used to calculate whether trust is
    warranted
  • Careful monitoring, supervision and checking
    (possibly covert)
  • Patients want to play a more equal role in
    decision-making
  • Patients expect doctors to trust their
    ability/competence to self-manage
  • Patients may be more questioning of treatment
    recommendations
  • They may express greater suspicion and scepticism
    about others intentions

31
Peer and earned trust clinicians beliefs and
behaviours
  • If trust is peer you might expect the
    following
  • An individual clinicians authority and
    reputation are based on their position in the
    medical hierarchy, personal networks and word of
    mouth recommendation.
  • Senior clinicians views and decisions are
    unquestioned.
  • Clinical freedom is unquestioned
  • Performance is self-regulated, individually
    assessed and not publicly reported
  • Complex patients are only seen by senior doctors
  • Successful relations between clinicians are
    based on conforming to traditional roles
  • Trust is generally higher between clinicians of
    the same profession and specialism
  • If trust is earned you might expect the
    following beliefs and behaviours
  • An individual clinicians authority and
    reputation are based on their proven skills and
    competence, and being up-to-date with medical
    technology
  • Clinical freedom may be limited and trust gained
    by following agreed protocols and an ability to
    work well in a team
  • Careful performance monitoring against targets
  • Both complex and easy patients may be seen by
    junior clinicians on the basis that they are
    following agreed protocols
  • Successful relations between clinicians are
    based on mutual respect for their different
    skills
  • Trust may be higher between clinicians who have
    experience of working together, irrespective of
    their profession or specialism
  • Communication skills and providing information
    are important in building trust.
  • Junior clinicians may question the views of their
    seniors.

32
Status and performance trust managers beliefs
and behaviours
  • If trust is based on status you might expect
    the following beliefs and behaviours
  •  A clinicians authority relates to their
    position and role within the hospital/organisation
  • Rules are unwritten and there is minimal
    monitoring of clinical activity
  • Trust is one way clinicians have little need to
    trust managers whereas managers have to trust
    clinicians
  • In decision-making managers act as
    administrators, trusting strategic decisions re
    service development to clinicians.
  • Managers are not involved in monitoring or
    checking clinical activity.
  • If trust is more based on performance you might
    expect the following
  • A clinicians authority relates to their ability
    to meet targets as well as their position within
    the organisation
  • Trust is likely to be higher in those clinicians
    who have some managerial role
  • A willingness to provide information on clinical
    activity and to engage with managerial agendas
    creates trust
  • In successful clinician-manager relations trust
    is important because it reduces the need for
    checking and monitoring
  • Trust is two-way clinicians need to work with
    managers to secure resources and to develop
    services
  • In decision-making managers work with clinicians
    to make strategic decisions about services
  • An evidence-based approach to clinical practice
    using guidelines and protocols encourages trust

33
Examining trust relations in different
organisational and clinical settings
Current empirical research
  1. To compare and contrast trust relations between
    patients, clinicians and managers in two
    different clinical and organisational settings
  2. To explore the most appropriate methods for
    examining trust relations in the NHS

34
Design
Comparative Case Study (Ethnography)
Case Study 1
Case Study 2
Diabetes (Type 2)
Elective hip surgery
Chronic
Acute
Mutual Trust
Dependence (uncertainty)
Self Management
Choice
Primary Care
Hospital Care
35
Conclusions
  • New forms of trust relations may be emerging in
    the NHS
  • Implications for methods
  • Need to examine in empirical research
  • Are trust relations in healthcare any different
    to those in other welfare and public sector
    services?
  • http//www.hsrc.ac.uk/Current_research/research_pr
    ojects/public_trust.htm

36
Future Direction of Trust research in health and
health care
Roundtable Discussion
37
Agenda for future research
Roundtable discussion
  • What are the direct therapeutic benefits of trust
    relations?
  • What levels of trust contribute to positive
    health outcomes and effective health care
    delivery?
  • What is the relationship between public/patient
    assessments of institutions and local providers?
  • What is the relationship between trust and
    performance in health care?

38
Agenda for future research (cont)
  • What is the relationship between trust,
    empowerment and choice in health care?
  • What are the characteristics and nature of trust
    relationships between providers and between
    providers and managers?
  • Do different types of health care systems
    generate different trust relationships?
  • How do trust relations contribute to implementing
    changes in service delivery?

39
Agenda for future research (cont)
  • In what contexts are trust levels more or less
    important and are different relationships of
    trust found in different treatment settings?
  • 10. How does trust in health care compare with
    levels of trust in other services/institutions?
  • How is the concept of conditional trust
    operationalised?
  • What is the relationship between felt and
    enacted trust?
  • http//www.hsrc.ac.uk/Current_research/research_pr
    ojects/public_trust.htm
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