Title: TRUST RELATIONS IN THE
1TRUST 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
2Context
- 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
3Aims
- 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
4What 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)
5Framing trust relationships in health care
6Does 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?
7The 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?
8Research into Trust by Country
9Focus of Study
10Perspective of Interest
11Why are trust relations changing?
- Influence of wider social structure on trust
relations - New context for trust relations in NHS
12Drivers 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
13Changing trust relations in the new NHS
policy initiatives
- Trust and Performance Management
- Trust and Patient Choice
- Trust and Patient Participation in disease
management
14How 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.
15The 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
16Levels 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
17Trust in health services staff putting interests
of patients above convenience of organisations
18Public trust in health care Netherlands present
and future
Source Van der Schee et al (2005), Nivel. Utrecht
19Levels of Trust with specific aspects of health
care
20Levels of Trust with specific aspects of health
care (cont)
21Specific determinants of overall rating of
trust/confidence top six
22Specific determinants of overall rating of
trust/confidence bottom six
23New 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
24Framework
25Methodological implications (1)
- How do you recognise conditional trust?
-
Low trust
High trust
Conditional trust
26Attitudes that reflect felt trust
27Methodological implications (2)
- Can current instruments identify conditional
trust behaviour?
28(No Transcript)
29Methodological implication (3)
- If institutional and interpersonal trust interact
how do we examine this?
30Embodied 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
31Peer 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.
32Status 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
33Examining trust relations in different
organisational and clinical settings
Current empirical research
- To compare and contrast trust relations between
patients, clinicians and managers in two
different clinical and organisational settings - To explore the most appropriate methods for
examining trust relations in the NHS
34Design
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
35Conclusions
- 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
36Future Direction of Trust research in health and
health care
Roundtable Discussion
37Agenda 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?
38Agenda 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?
39Agenda 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