1、TRUST RELATIONS IN THE NEW NHS: THEORETICAL AND METHODOLOGICAL CHALLENGES,Michael Calnan and Rosemary Rowe,MRC HSRC Department of Social Medicine University of Bristol http:/www.hsrc.ac.uk/Current_research/research_projects/public_trust.htm,Taking Stock of Trust E.S.R.C Conference London School of E
2、conomics 12th December 2005,Context,Trust, risk and uncertainty in the provision of health careTrust relationships challenged by changes: in organisation of NHSin regulation/performance of health professionalsin public attitudes to health care,Aims,To explore how and why trust relations in the NHS m
3、ay be changingTo develop a theoretical frameworkTo consider methodological implicationsTo describe current research,What is Trust?: Definitions,Characteristics of trust specific to health care context: Stronger affective component (vulnerability) Altruism working in best interests of patient (honest
4、y, confidentiality, caring and showing respect) Competence (social and technical),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 inte
5、rests (intentional trust).,Framing trust relationships in health care,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
6、right for organisation ie like social capital?Benefits to the organisation eg job satisfaction?,The costs or dangers of trust,Abuse of trust with vulnerable patients particularly those with limited resourcesEasier to trust if powerful and wealthyTension between development of trust and patient empow
7、erment?,Research into Trust by Country,Focus of Study,Perspective of Interest,Why are trust relations changing?,Influence of wider social structure on trust relationsNew context for trust relations in NHS,Drivers of change,Top down policy initiatives, e.g. performance managementWider social and cult
8、ural change, e.g. decline in deference to authorityNegative media coverage of medical scandals,Changing trust relations in the new NHS: policy initiatives,Trust and Performance ManagementTrust and Patient ChoiceTrust and Patient Participation in disease management,How are trust relations changing?,H
9、igh 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 activ
10、ely choose where to go for specialist care.,High Trust,Professional model,(accountability implicit),Stakeholder model,Bureaucratic model,Low,(accountability explicit),High,State,Control,Control,Market model,New Public,(choice),Management model,Low Trust,The distribution of trust and state control in
11、 various models of governance,Levels of trust,Levels of patient trust in specific clinicians appear to be highLower public trust in clinicians and health care systemsLack of prospective studies monitoring changes in overall levels of trustLack of studies into nature of trust relations,Trust in healt
12、h services staff: putting interests of patients above convenience of organisations,Public trust in health care Netherlands: present and future,Source: Van der Schee et al (2005), Nivel. Utrecht,Levels of Trust with specific aspects of health care,Levels of Trust with specific aspects of health care
13、(cont),Specific determinants of overall rating of trust/confidence top six,Specific determinants of overall rating of trust/confidence bottom six,New forms of trust relations,Shift from affect to more cognition basedGreater interdependence in trust relationsThe role of information in trust creationT
14、he importance of institutional trustMore informed but conditional trust,Framework,Methodological implications (1),How do you recognise conditional trust?,High trust,Low trust,Conditional trust,Attitudes that reflect felt trust,Methodological implications (2),Can current instruments identify conditio
15、nal trust behaviour?,Methodological implication (3),If institutional and interpersonal trust interact how do we examine this?,Embodied and Informed Trust: Patients beliefs and behaviour,If trust is more embodied you would expect: Patients have a more passive, deferent role Information is valued for
16、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 b
17、eing 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 organisat
18、ion or individualIf 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 doct
19、ors 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 Willingness to take risks is based on careful weighing up of the situation,Peer and earned trust: clinicians be
20、liefs 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 i
21、s 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
22、specialismIf 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 pro
23、tocols 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 sk
24、ills 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.,Status and performance trust:
25、 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 clin
26、icians 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 p
27、erformance 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
28、 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
29、clinicians to make strategic decisions about services An evidence-based approach to clinical practice using guidelines and protocols encourages trust,Examining trust relations in different organisational and clinical settings,Current empirical research,To compare and contrast trust relations between
30、 patients, clinicians and managers in two different clinical and organisational settings To explore the most appropriate methods for examining trust relations in the NHS,Design,Comparative Case Study (Ethnography),Case Study 1,Diabetes (Type 2),Chronic,Mutual Trust,Self Management,Primary Care,Case
31、Study 2,Elective hip surgery,Acute,Dependence (uncertainty),Choice,Hospital Care,Conclusions,New forms of trust relations may be emerging in the NHSImplications for methodsNeed to examine in empirical researchAre trust relations in healthcare any different to those in other welfare and public sector
32、 services?http:/www.hsrc.ac.uk/Current_research/research_projects/public_trust.htm,Future Direction of Trust research in health and health care,Roundtable Discussion,Agenda for future research,What are the direct therapeutic benefits of trust relations?What levels of trust contribute to positive hea
33、lth 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?,Roundtable discussion,Agenda for future research (cont),What is the relationship betw
34、een 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 ch
35、anges in service delivery? *,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_projects/public_trust.htm,
