Michael Calnan - Trust matters, the case of health care.
My name's Michael Calnan and I'm a Professor of Medical Sociology in the School for Social Policy, Sociology and Social Research here at the University of Kent.
One of the areas of interest that I've been working on for some time now is looking at trust and trust relations in the context of healthcare.
Sociologists have looked at trust for a long time now - coming from different theoretical perspectives. A number of them have highlighted how crucial trust
is both at the macro level, in terms of creating social cohesion in society, and the more micro level, in terms of creating cohesion in relationships between people.
Trust is particularly important in the context of uncertainty. And one particular, and perhaps unique, characteristic of healthcare is that
it's characterised by uncertainty, unpredictability and increasing complexity. Therefore, trust is a kind of useful strategy or device for managing that uncertainty or bridging that
uncertainty. Trust has two different elements which are interrelated: one is a competence trust. From the patient's point of view, in the context
of health care, it's whether your doctor is competent to do a good job. The second element is intentional trust about motives: is your clinician working with
your interests at heart? Or is the doctor - he or she - working in the interests of the organisation? Or, if in the context of, say, a private health
care system...Is the doctor working to enhance their income? So trust is quite important. When we think about the doctor...
when we think about trusting relations, we tend to think about patients trusting clinicians or doctors. But it's more than that because it's not only doctors
trusting patients... Do they trust our testimony? Do they trust us to take our medication? Do they trust our narrative or story? But we're also interested in
trust relations in organisations; trust relations between managers and clinicians. This is important because poor trusting relations between managers and clinicians can actually have a
knock-on effect for the quality of patient care that clinicians can be providing. So if they're dissatisfied
with their working environment that may affect the type of care that you and I, as patients, receive. So for the patient's point of view, or the public's point of view, there's also institutional trust.
Do we trust in the institution of medicine - the medical profession? Do we trust in this country - in England - do we trust the NHS? So we're interested
in public trust in these institutions and there's the thorny issue of the relationship between institutional trust and interpersonal trust.
That is an issue that actually  has raised contested explanations for that. Now, does trust matter? Does trust matter for patients, clinicians and managers?
Well, from a theoretical point of view there's lots of arguments why trust is important but there is empirical
evidence from research at least in the healthcare system that trust is particularly important for patients.It's a marker of quality in terms of their assessment of the quality of care that they can receive.
It actually influences their choice. [There is] great emphasis in the NHS on choice, and trust is quite important in actually
influencing how patients may make decisions - if they can - about the type of care and the type of clinician that
they're going to consult. It's also important in the context of patients: [if there are] trusting relations, they're more likely to consult their clinician; they're
more likely to disclose information to their clinician, and they're more likely to adhere to the advice of the clinician. So there's evidence of that. As for the evidence about whether having a trusting
relationship actually has a long-term effect on health status - the jury's out on that. There aren't many experimental studies that really have explored that
in any detail, so it's difficult to know. But one would assume that there's the indirect effect of the impact of taking medication.We also need to think about... well, trust is important but there's what we call a dark side to trust
and this is associated with blind trust. Blind trust can lead to the abuse of power through exploitation or domination. And it needs, what we...Obviously it's important to have
relatively high trust cultures but that can actually exploit the lack of vigilance and assessment of performance. Cozy relationships may stifle innovation
and foster current practice. So there are some hazards or dangers or risks of trusting relations. So we need to actually think about... trust might be important but
what sort of trusting relations do we want? There's evidence that, in fact, trusting relations are changing - for all sorts of reasons:The rise of the so-called 'consumer' in healthcare -
a much more enlightened patient, much more informed;Greater regulation and monitoring; marketisation: the introduction of market principles even in a publicly financed
health system like the NHS in England. Some say there's a decline in the status and cultural authority of professionals and experts in general.
And also there's a whole range - at least in the early part of this century - of negative portrayals of doctors which are fuelled by the media. So there are drivers for change and there's some
evidence that there is changes in trust relations between patients and doctors. We no longer are looking for blind trust;
we, as patients, tend to adopt a more critical trust. We're looking to adopt a more conditional trust. we are expecting doctors to earn our trust and we're not actually content to accept
a kind of blind and dependent relation that we may have have done in the past. Trust relations also vary by context and, in terms of the changes in nature of trust relations, if
you look at survey data you'll find that actually clinicians are right up there in terms of high trust relations.So in a sense that if you could actually say there's been a decline in trust...
Well... it would be difficult to find strong evidence to say [there's] that decline in trust in medicine...maybe at medical institution [level] there has
been...But on an individual level, for doctors, there are still relatively high levels of trust.At least compared with other professionals and occupations.
But what's happening is that there might not have been a decline in trust but trust relations may have changed. We also should consider the different organisational, and clinical, and cultural settings.
I want to highlight two different elements here: we've done some work on mental health. Now, in a Mental Health setting - for all sorts of reasons, particularly to do with both
competence and intentional trust - there's low levels of trust. It's a culture of low trust in that context. Not least because
of the negative stereotypes and the stigma associated with - still associated with [mental illnesses] - particularly with psychotic illnesses. Yet trusting relations in the context of
mental health are crucial particularly for talk therapy where it's important for both players in the therapy to trust each other if that therapeutic
intervention is to have some impact. But we found lots of... well... a number of examples where trust is important but you also found examples where, despite a
lack of trusting relations, particularly on the side of the patient, there was still some reciprocal relationship between the clinician and the patient.
For example, in one particular case... although the patient rejected the psychotic diagnostic label given by the clinician, they were still willing to
take the prescribed medicine but they used it to manage, what they considered was, an anxiety disorder. So from both sides - from the clinicians
point of view and the patients side - they were both happy with the outcome of that consultation. From the patient's point of view, they were taking the drug but
rejected the diagnosis. From the clinician's point of view, the patient was taking the prescribed drug. But what was interesting, in this
context, was the emphasis in this particular area, of individual responsibility.  So in terms of trusting relations there are areas where trusting
relationships are contested; there are lower levels of trust... but even in those contexts [where there is] the lack of trust,there can be effective reciprocal relations.
Now I've talked about high income countries,health systems in the global north... But what about health systems in low- to middle-income countries, where the infrastructure is not as strong as it is
in high-income countries - at least in their health system. We've done some research in India - some exploratory research. India's got a public... it's a pluralistic system and what we mean by that it's a mixture of public and
private - a much bigger private system. In context of India, we found some evidence that there was very poor
trusting relations between both regulators and doctors. They didn't trust each other; they both thought that they were...they doubted their trust from an
intent point of view. And there were claims of irregular practices, unethical practices and money changing hands for all sorts of different reasons.
The most interesting point about this is that from the patient's point of view, they were very aware of this. They didn't necessarily condone it but they accepted that it is
the way it was, or is. And as long as their doctor was competent, they fully accepted that these other practices were just part of the way the system operated. So in that particular context - different from high-income countries - there may have
been a lack of trust within the system but patients were accepting of that in that cultural context.So finally, what about the evidence of... when trust is lost... about building trust?
Well, there were lots of policies and strategies that had been put forward: better communication, greater transparency, better accountability.. A whole range of policies have been suggested but the jury's outin terms of evidence of effectiveness.
So there needs to be a lot more substantive research exploring the feasibility and effectiveness of these different types of policies.
So thank you for listening.