TRUST RELATIONS IN THE ‘NEW’ NHS: THEORETICAL AND METHODOLOGICAL CHALLENGES

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. Providers/practitioners Trust (organisational) Managers/commissioners/regulators Trust (interpersonal) Trust (institutional) Public/patients/carers 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. 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. How are trust relations changing?

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. Relationship Trustor Trustee Context Type of Trust Affect based Cogniti-on based Reputation based on status Reputation based on performance Traditional clinician –patient X X Paternalistic medicine Embodi-ed trust Traditional Clinician-clinician X X Autonomous self-regulation Peer trust Traditional clinician-manager X X Prof autonomy/ expertise Status trust New NHS clinician-patient X X X X Expert patient Informed trust New NHS Clinician-clinician X X Shared care Earned trust New NHS Clinician-manager X X Clinical governance Perfor-mance trust Framework

25. Methodological implications (1) • How do you recognise ‘conditional’ trust? Low trust High trust Conditional trust

26. High Trust Low Trust Belief that others will not harm us Belief that others might harm us Low levels of anxiety, suspicion and scepticism High levels of anxiety, suspicion and scepticism Limits to knowledge are ok Limits to knowledge are not ok Lack of control is ok Lack of control is a problem Draw comfort from relations Anxious about relations Attitudes that reflect felt trust

27. Methodological implications (2) • Can current instruments identify conditional trust behaviour?

28. High Trust Behaviour Low Trust Behaviour Minimal checking Constant monitoring Informal, unwritten rules Detailed and prescriptive regulations Significant professional autonomy Intense supervision and little delegation of authority Willingness to take risks Risk averse Willingness to divulge information Information is withheld Passive, deferent role Questioning, possibly sceptical role Advice is accepted unquestioningly Request for a 2nd opinion or alternative source of treatment

29. Methodological implication (3) • If institutional and interpersonal trust interact how do we examine this?

30. Embodied and Informed Trust:Patient’s 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 clinician’s altruism is unquestioned • Willingness to take risks is based on the reputation of the organisation or individual If trust is more informedyou 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 other’s intentions • Willingness to take risks is based on careful weighing up of the situation

31. Peer and ‘earned’ trust: clinicians’ beliefs and behaviours If trust is ‘peer’ you might expect the following: • An individual clinician’s 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 clinician’s 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 clinician’s 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 clinician’s 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. Current empirical research ‘Examining trust relations in different organisational and clinical settings’ • 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

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_projects/public_trust.htm

36. ‘Future Direction of Trust research in health and health care Roundtable Discussion

37. Roundtable discussion Agenda for future research • 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_projects/public_trust.htm