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inter-country comparisons of trust rela-tions in health care, it is important toidentify countries that show particulardevelopments that are relevant from atheoretical point of view. One couldthink of variations in institutional guar-antees, such as patient charters, in theintroduction of patient choice in socialhealth insurance systems, and in con-tracting arrangements.

References

1 Rowe R, Calnan M. Trust relations in health

care: the new agenda. Eur J Pub Health

2006;16:46.

2 Freidson E.Doctoring together: A study of

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the division of expert labor. Chicago: University

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Peter P. Groenewegen

NIVELNetherlands Institute for Health Ser-

vices Research, P.O. Box 1568, 3500 BN

Utrecht, The Netherlands

Correspondence:Peter P. Groenewegen PhD,

NIVELNetherlands Institute for Health Ser-

vices Research, P.O. Box 1568, 3500 BN

Utrecht, The Netherlands,

e-mail: [email protected]

doi:10.1093/eurpub/ckl003. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Trust relations in health carethe new agenda

Introduction

Trust has traditionally been considered acornerstone of effective doctorpatientrelationships. The need for interpersonaltrust relates to the vulnerability asso-

ciated with being ill, the informationasymmetries arising from the specialistnature of medical knowledge, and theuncertainty and element of risk regardingthe competence and intentions of thepractitioner on whom the patient isdependent. Without trust patients maywell not access services at all, let alonedisclose all medically relevant informa-tion. Trust is also important at an insti-tutional level, as trust in particularhospitals, insurers and health care sys-tems may affect patient support for anduse of services and thus their economic

and political viability. However, in ourso-called post-traditional order1 is truststill necessary? The days of doctor knowsbest when patients blindly trusted in anddeferred to medical expertize are fastbecoming a distant memory in industria-lized societies where the consumer isdubbed king and where the expertpatient expects to play an active partin decision-making regarding their treat-ment. Might lower levels of trust, or infact distrust, be merited in light of medi-cal errors, drug side effects, and the slowadoption of evidence-based medical

innovations and clinical guidelines? Inthis paper we set out how and whytrust relations in the healthcare context

are changing, arguing that although trustmay now be more conditional it is stillvitally important for both health careproviders and institutions.

How have trustrelations changed?

Trust relationships are characterized byone party, the trustor, having positiveexpectations regarding both the compe-tence of the other party, the trustee, andthat they will work in their best interests.2

In the context of healthcare there havebeen changes to both interpersonaltrust relations and to institutional trustrelations.

Traditionally,patients haveplacedhighlevels of trust in health care professionals.Such interpersonal trust relations have

been typified by a type of blind,embodiedtrust that developed as a result of apatients knowledge of and relationshipwith their personal physician. Institu-tional trust in health care practitionersin general, health care organizations andsystems have also tended to be high. Thismay well have been the effect of patientshigh level of interpersonal trust in theirdoctor, and also have been due to clini-cians professional status, and the rela-tively recent provision of health care as astate guaranteed welfare right. However,we would argue that these relationships

have been fundamentally altered bychanges in the organizational structureof medical care and the culture of health

care delivery which have been promptedby wider social change. Public attitudestowards professionals and their authorityas medical experts are changing, reflectinga more general decline in deference toauthority and trust in experts and institu-

tions, together with increasing reliance onpersonal judgments of risk.3 The days ofblind trust in a doctor who knows besthave been consigned to history. Thesebroader social and cultural processesthat have encouraged change in interper-sonal trust relations have also stimulatedchangesininstitutionaltrust.Beliefsaboutthe limits of medical expertize togetherwith concerns about the effectiveness ofprofessional regulatory systems to ensurehigh standardsof clinical care, highlightedby the media coverage of medical errorsand examples of medical incompetence,

have eroded trust in health care organiza-tions, in the medical professions in gen-eral, and in health systems as a whole.Levels of public trust in individual clini-cians may remain high but levels of trustand confidence in managers is consider-ably lower, a UK study4 found that


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governments and the medical professionsand raises the question of whether trust isstill relevant and necessary to theprovision of medical care in the 21stcentury.

Is trust still necessary?We would argue that trust is still essentialto health care encounters, even if patientstoday no longer rely exclusively on theirfamily doctor as an entry point to care.Trust encourages use of services, facili-tates disclosure of important medicalinformation and has an indirect influenceon health outcomes through patientsatisfaction, adherence and continuityof provider.5 Although trust is highly cor-related with patient satisfaction6 it is con-ceptually distinct. Trust is forwardlooking and reflects a commitment to

an ongoing relationship whereas satisfac-tion tends to be based on past experienceand refers to assessment of performance.As an indicator of future behaviour highlevels of institutional trust are still veryimportant. Now that patients are able toparticipate in decisions as to where, whenand how they are treated poses consider-able challenges for health systems. Thosesystems which have used GP gatekeepersto control referrals to specialist care inorder to contain costs may find thatthey can no longer do so in the light ofpatients preferences for a particular hos-

pital or consultant. Efforts to restrictpatient choice are likely to be stronglyresisted as witnessed by the failure ofthe medecin referent scheme in Francewhich sought to reduce choice of physi-cian. However, trust may offer a solutionto these problems by limiting patientsdesire to shop around or seek a secondor third opinion as it engenders loyalty.Institutional trust is also important toorganizations in promoting efficiency,team working and job satisfaction andmay bring benefits to health systems asa source of social capital, reducing trans-

action costs due to lower monitoring andsurveillance and the general enhance-ment of efficiency.7 It may also offer poli-tical capital in sustaining support forpublicly funded services. However, whilstpublic and patient trust is still importantit can no longer be taken for granted. Wewould suggest that new forms of trustrelations are emerging now, in whichtrust has to be actively negotiated andnurtured.

New forms of trust

The shifttowards more informed patientswilling to participate in decision-makingwe would argue has produced greaterinter-dependence between patient andclinician. This has not removed the

need for trust in clinical encounters,rather trust is now more conditionaland negotiated and depends on the com-munication, provision of information,and the use of evidence to support deci-sions. This is particularly important inthe management of many chronic dis-eases such as diabetes where successdepends at least as much on changesthat the patient can make, requiring apartnership between patient and healthcare practitioner. The realization ofsuch newforms of trust of course requiresgreater communicative competence onthe part of clinicians. The ways inwhich clinicians interact with serviceusers have to change, providing informa-tion and supporting their participation indecision-making requires greater com-munication skills and may result inlonger or more consultations. It also

depends on patients willingness and abil-ity to adopt a more active stance, andwhether they have access to the resources(finance, time, and energy) to do this.

Just as interpersonal trust is more con-ditional so is institutional trust. Ratherthan assuming that high standards ofcare will be provided, the public increas-ingly requires information that this is thecase. In countries like the UK where pub-lic trust in the health system is believed tobe in decline the political response hasbeen to seek to use performance manage-ment as a mechanism for rebuilding pub-

lic trust. Rather than relying ontraditional processes of professionalself-regulation to ensure high standardsof competence and conduct, govern-ments are increasingly turning to externalagencies to regulate, monitor, and pub-licly report on the quality of care. The useof health technology assessment agenciesin standard setting to encourage the pro-vision of care that is clinically and costeffective, and of external regulators suchas the Healthcare Commission in the UKto assess quality of services, act to providevisible reassurance that services are being

monitored and that standards of care canbe relied upon. The public reportingof anorganizations results (in terms of meet-ing targets such as waiting times, patientsatisfaction, and clinical outcomes) alsoin theory enables patients to make aninformed choice about where to seektreatment.

Such public disclosure of performanceis designed to rebuild public confidencein health care organizations but ironicallythis very mechanism further underminestrust. Clinicians distrust managersefforts to meet centrally determined tar-

gets, fearing that it will reduce their auto-nomy and ability to prioritise treatmentaccording to patient need. Patients aresceptical about the reality of performancefigures in light of evidence of mangers

gaming the system to meet targets.Indeed, we would argue that low levelsof trust are implicit in performancemanagement approaches to governancewith their increased monitoring andsurveillance of professional behaviourinevitably causing a decline in trustwithin organizations and between healthservices.

How can trust benurtured?

Given that trust remains important, howcan new forms of trust relations be devel-oped and sustained? There is consider-able evidence as to what factorsencourage patient trust in clinicians:the clinicians technical competence,respect for patient views, informationsharing, and their confidence in patientsability to manage their illness.8 Patientparticipation per se does not necessarilyresult in higher trust, rather it is asso-ciated with value congruence regardingparticipation, patient involvement pro-duced higher trust where patients wantedto participate.9 In contrast, evidence as towhat builds institutional trust is sparse,with trust relations between providersand between providers and managers aparticularly neglected area. Hall et alUS survey of HMO members10 foundthat system trust could help the develop-ment of interpersonal trust, where there

was no prior knowledge of the clinician,but it is not known how interpersonaltrust affects institutional trust. Medicalerrors and cost containment are asso-ciated with distrust of health care sys-tems, whereas relationship buildingwith the local community is regardedas an important trust building mechan-ism. However, little research has beenconducted to identify how differentmodes of governance affect institutionaltrust.

The focus of trust relationships may ofcourse differ according to the model of

health care delivery; in market based sys-tems such as the US patient trust may bemore important to secure loyalty to par-ticular providers whereas in tax-financedsystems which are organized by nationalor regional agencies public trust may bemore necessary. However, as health sys-tems converge and increasingly sharecommon challenges including: providingadequate patient choice; managing amixed economy of provision; and moreexplicit rationing, then both interper-sonal and institutional trust will continueto be important for all health systems.

In conclusion, we would argue thatclinicians and managers need to addressand respond to the changing nature oftrust relations in health care. The benefitsof trust demonstrate the value to be

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gained from ensuring that both interper-sonal and institutional trust are devel-oped, sustained, and where necessaryrebuilt. Trust is still fundamental to theclinicianpatient relationship but as thatrelationship has changed so has thenature of trust. Trust is now conditionaland has to be negotiated but, whilst clin-icians may have to earn patients trust,there is good evidence as to what isrequired to build and sustain such inter-personal trust. The lack of knowledgeabout how institutional trust can bedeveloped indicates the need for research,ideally through inter-country compar-isons to identify whether such trust variesby health system and how it can be gen-erated. The cost of failing to recognize theimportance of trust and to address thechanging nature of trust relations couldbe substantial: economically, politically,

and most important of all, in terms ofhealth outcomes.

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Rosemary Rowe

Michael Calnan

MRC HSRC, Department of Social Medicine,

University of Bristol, Canynge Hall, White-

ladies Road, Bristol BS8 2PR, UK

Correspondence: Rosemary Rowe. e-mail:

[email protected], tel: +44 117

9287223doi:10.1093/eurpub/ckl004

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