Trust relations in health care: an agenda for future research

PURPOSE: The aim of this paper is to draw together suggestions for future research from the papers and from the discussion that took place at the workshop. DESIGN/METHODOLOGY/APPROACH: The suggestions are summarised under four broad themes. FINDINGS: At an international workshop on trust organised by the U.K. MRC Health Services Research Collaboration there was broad agreement that trust was still a salient issue in diverse health care contexts. The workshop proceedings identified a number of important questions for empirical research and several key conceptual, theoretical and methodological questions relating to trust that need to be addressed in support of or alongside this. The collection of papers in this volume starts to address some of these questions. ORIGINALITY/VALUE: Considers trust relations in health care from patient, clinical, organisational and policy perspectives.     

Trust in health care: theoretical perspectives and research needs

PURPOSE: This paper presents some key theoretical issues about trust, and seeks to demonstrate their relevance to understanding of, and research on, health systems. Although drawing particularly on empirical evidence from low- and middle-income countries (LMICs), the paper aims to stimulate thinking across country settings. DESIGN/METHODOLOGY/APPROACH: Drawing both on conceptual literature and relevant empirical research from LMICs, the paper presents an argument about the role of trust within key health system relationships and identifies future research needs. FINDINGS: Theoretical perspectives on four questions are first discussed: what is trust and can it be constructed? Why does it matter to health systems? On what is it based? What are the dangers of trust? The relevance of these theoretical perspectives is then considered in relation to: understanding the nature of health systems; issues of equity and justice in health care; and policy and managerial priorities. The identified research needs are investigation of: the role of trusting workplace relationships as a source of non-financial incentives; the influence of trust over the operation of different forms of citizen-health system engagement; approaches to training trustworthy public managers; and the institutional developments required to sustain trustworthy behaviour within health systems. PRACTICAL IMPLICATIONS: The policy and management actions needed to strengthen health systems within LMICs, and elsewhere, include: recruitment of health workers that have the attitudes and capacity for moral understanding and motivation; training curriculae that develop such motivation; and developing the institutions (e.g., communication and decision-making practices, payment mechanisms) that can sustain trusting relationships across a health system. It is also important to recognise that distrust in some relationships may act to guard against the abuse of power. ORIGINALITY/VALUE: Although the notion of trust has become of increasing importance in health policy debates in high-income countries, it has received less attention in the context of LMICs. The papers adds to the very limited literature on trust in LMIC health systems and also opens new lines of thinking for those working in high income countries--particularly around the role of health systems in generating wider social value.     

Trust is the prescription for hospital/physician relations under health care reform

Hospitals are reacting to health care reform by forming collaborative physician/hospital organizations and other ventures. The success of these new partnerships depends on what shape the reformed system takes and establishing trust between all players.     

Mentoring: a framework for developing health disparities researchers

Health disparities have been conceptualized as being the result of a confluence of factors: environmental, social, biological, economic, and cultural to name a few. Given the increasingly deleterious impact of health disparities on the lives of all Americans, new research methodological research approaches are needed to adequately understand and address the component parts of health disparities. To effectively address health disparities, an increased focus is needed on implementing transdisciplinary approaches to health disparities research. One approach is to focus on mentoring young investigators and students. This article discusses the centrality of mentoring in developing young health disparities researchers. An overview of health disparities research and researchers, and a summary of the different aspects of mentoring are provided. In addition, a case study of the implementation of a transdisciplinary mentoring framework at a higher education institution is presented.     

A framework for developing evaluation capacity in health care settings.

The purpose of this paper is to provide a framework for developing an effective evaluation practice within health care settings. Three features are reviewed; capacity building, the application of evaluation to program activities and the utilization of evaluation recommendations. First, the organizational elements required to establish effective evaluation practice are reviewed emphasizing that an organization's capacity for evaluation develops over time and in stages. Second, a comprehensive evaluation framework is presented which demonstrates how evaluation practice can be applied to all aspects of a program's life cycle, thus promoting the scope of evidence-based decision making within an organization. Finally, factors which influence the adoption of evaluation recommendations by decision makers are reviewed accompanied by strategies to promote the utilization of evaluation recommendations in organization decision making.     

Primary care education for the new NHS: a discussion paper

CONTEXT: The White Paper, The New NHS: Modern, Dependable, once again heralds change and new expectations of primary care in the UK. OBJECTIVES: This discussion paper aims to encourage reflection on the implications for primary care teams of current governmental strategy, and to address the pivotal role which education can play in equipping practitioners for their roles. KEY AREAS: The paper examines the opportunities and threats for primary care in the new NHS developments, the strengths and weaknesses of the role that education currently plays in primary care, and how recent innovations might be used to give a more holistic approach to the needs of practitioners. The challenges for clinical governance of lay engagement and ethical decision making are seen as two crucial outcomes for an educational strategy which must be practice-led, and must interface individual practitioner education with the needs of the team and the community as a whole. I draw on a range of policy documents and educational literature to alert the reader to the different choices which can be made when thinking about appropriate educational models and methods; and offer a detailed structure for a practical educational strategy that may effectively unite theory and practice. The key elements are a three-tier link between practices, primary care groups, and district-level resources for all educational and training activity, and the aim of continuing multiprofessional development which will underpin the new NHS.     

A new policy framework for health care markets

The frustration with health care markets recorded in the paper by Len Nichols and colleagues reflects the general, and accurate, perception that these markets typically do not work well. But markets respond to the framework of rules and tax incentives in which they must operate, and in health care this framework works against efficiency. The sensible response is not to reject market-based approaches in health care as inherently ineffective in achieving efficiency and cost control. Nor is it to add yet another layer of rules and government micromanagement. It is instead to fix the framework so that markets will foster efficiency.     

Training for health care in developing countries: the work of the Tropical Health and Education Trust

The Tropical Health and Education Trust (THET) was established to strengthen medical education and training for health care in developing countries. The Trust responds to requests from training institutions with a wide range of activities and programmes. Projects to meet specific needs are planned in outline with the Deans or Directors of institutions, as a basis for a long-term link with a similar institution in the United Kingdom. These links are now the preferred method for meeting requests to develop skills, strengthen services and promote staff development. However, funding is always necessary for their support. THET has promoted students' community-based training by enabling students in a team-training programme in Ethiopia to make interventions in primary health care. A prize for the best students' community, clinical or laboratory projects in six African countries encourages enquiry by the students, promotes independent learning, and relates academic work to problems in health care. Work with Ministries of Health includes a continuing medical education programme for rural medical officers in Uganda, courses in basic and life-saving surgery for Ethiopian health and medical officers, and a programme to update the skills of laboratory technologists in rural hospitals in Ghana. The range of projects that THET supports is wide because the needs, defined by those who are working in, and responsible for, training in the health service are diverse.     

Strategic marketing in the NHS: Kwik-health NHS Trust

Unlike managers in most service organizations, hospital managers do not have significant control over the shape or cost of the service product or the manner of its delivery. Hence, the crucial issue for hospital management to address is how to develop the marketing of a service the control of which is divorced from those with the strategic market perspective. While the internal management of hospital care in NHS is in its infancy, initial developments such as clinical directorates point the way forward in creating a market orientation within provider units. Ultimately, it must be considered what degree of influence over clinical decisions affecting hospital services is realistic, ethical and desirable for strategic marketing and business services. Arguably there is a case for the adoption of some middle ground, with both sides moving from their present positions but perhaps with the clinicians moving furthest.     

Public participation in regional health policy: a theoretical framework

How best to involve the public in local health policy development and decision-making is an ongoing challenge for health systems. In the current literature on this topic, there is discussion of the lack of rigorous evaluations upon which to draw generalizable conclusions about what public participation methods work best and for what kinds of outcomes. We believe that for evaluation research on public participation to build generalizable claims, some consistency in theoretical framework is needed. A major objective of the research reported on here was to develop such a theoretical framework for understanding public participation in the context of regionalized health governance. The overall research design followed the grounded theory tradition, and included five case studies of public participation initiatives in an urban regional health authority in Canada, as well as a postal survey of community organizations. This particular article describes the theoretical framework developed, with an emphasis on explaining the following major components of the framework: public participation initiatives as a process; policy making processes with a health region; social context as symbolic and political institutions; policy communities; and health of the population as the ultimate outcome of public participation. We believe that this framework is a good beginning to making more explicit the factors that may be considered when evaluating both the processes and outcomes of public participation in health policy development.     

Sustainability of health care: a framework for analysis

This paper introduces a conceptual framework which can be used to study the sustainability of health services in developing countries. A health service is considered sustainable when operated by an organizational system with the long-term ability to mobilize and allocate sufficient resources for activities that meet individual or public health needs. The framework includes three clusters: (1) contextual factors, which outline the task and general environment of the services; (2) an activity profile, which describes the services delivered and the activities carried out to deliver them; and (3) organizational capacity, which shows the carrying ability (capability) of the organization in broad terms. In this framework, health care provision is seen as an open system model where five main factors determine how inputs are converted to outputs, linking them through feedback loops. These factors are aims, technology, structure, culture and process. The framework has proven useful in analyzing factors critical to sustainability, and in describing structures and processes both in basic public services and in private not-for-profit services. It should also be tested on more complex systems, such as national health care.     

Towards a psycho-social theoretical framework for sexual health promotion

Numerous interventions have been designed to promote safer sexual behaviour amongst young people. However, relatively few have proved effective, which is, at least partially, due to the lack of development of theoretically based programmes. An understanding of the origins and control of sexual behaviour can be derived from basic social science research. Unless this is applied to the design of behaviour-change programmes they are unlikely to target the most important determinants of young people's sexual behaviour and are, therefore, unlikely to be effective. This paper outlines some of the key theoretical insights which have been drawn upon in the development of a new sex education programme currently being tested in Scottish schools. The theoretical basis is intentionally eclectic, combining social psychological cognitive models with sociological interpretations, since we are not concerned to advance any particular theory but to find which are most useful in promoting sexual health. First, the social influences on sexual behaviour are considered, and then the way in which these translate into individual perceptions and beliefs. Finally, the paper attempts to develop a theoretical understanding of sexual interaction and the social contexts of sexual behaviour.     

The new NHS framework for handling performance concerns

There have recently been important changes in the procedures for handling performance issues among medical and dental employees. The author explains the background, explores the practicalities, and discusses the challenges and unresolved issues for medical managers.     

Determinants of health policy impact: a theoretical framework for policy analysis

Summary This paper addresses the role of policy and evidence in health promotion. The concept of von Wrights logic of events is introduced and applied to health policy impact analysis.According to von Wright (1976), human action can be explained by a restricted number of determinants: wants, abilities, duties, and opportunities. The dynamics of action result from changes in opportunities (logic of events). Applied to the policymaking process, the present model explains personal wants as subordinated to political goals. Abilities of individual policy makers are part of organisational resources. Also, personal duties are subordinated to institutional obligations. Opportunities are mainly related to political context and public support. The present analysis suggests that policy determinants such as concrete goals, sufficient resources and public support may be crucial for achieving an intended behaviour change on the population level, while other policy determinants, e.g., personal commitment and organisational capacities, may especially relate to the policy implementation process. The paper concludes by indicating ways in which future research using this theoretical framework might contribute to health promotion practice for improved health outcomes across populations.     

Reproductive health and health sector reform in developing countries: establishing a framework for dialogue

It is not clear how policy-making in the field of reproductive health relates to changes associated with programmes for the reform of the health sector in developing countries. There has been little communication between these two areas, yet policy on reproductive health has to be implemented in the context of structural change. This paper examines factors that limit dialogue between the two areas and proposes the following framework for encouraging it: the identification of policy groups and the development of bases for collaborative links between them; the introduction of a common understanding around relevant policy contexts; reaching agreement on compatible aims relating to reproductive health and health sector change; developing causal links between policy content in reproductive health and health sector change as a basis for evidence-based policy-making; and strengthening policy-making structures, systems, skills, and values.