Rowe Rosemary, Calnan Michael
MRC HSRC, Department of Social Medicine, University of Bristol, Bristol, UK.
J Health Organ Manag. 2006;20(5):376-96. doi: 10.1108/14777260610701777.
This paper seeks to address how and why trust relations in the NHS may be changing and presents a theoretical framework for exploring them in future empirical research.
DESIGN/METHODOLOGY/APPROACH: This paper provides a conceptual analysis. It proposes that public and patient trust in health care in the U.K. appears to be shaped by a variety of factors. From a macro perspective, any changes in levels of public trust in health care institutions appear to derive partly from top-down policy initiatives that have altered the way in which health services are organised and partly from broader social and cultural processes. A variety of policy initiatives, including the introduction of clinical governance and the resulting use of performance management to scrutinise and change clinical activity, increasing patient choice and involvement in decision-making regarding their care, are examined for how they have changed the context for trust relations within the NHS.
It is argued that these policy initiatives have produced a new context for trust relations within the NHS, shifting the inter-dependence and distribution of power between patients, clinicians, and mangers and changing their vulnerability to each other and to health care institutions. The paper presents a theoretical framework based on current policy discourses which illustrates how new forms of trust relations may be emerging in this new context of health care delivery, reflecting a change in motivations for trust from affect based to cognition based trust as patients, clinicians and managers become more active partners in trust relations. The framework suggests that trust relations in all three types of relationship in the "new" modernised NHS might, in general, be particularly characterised by an emphasis on communication, providing information and the use of "evidence" to support decisions in a reciprocal, negotiated alliance.
ORIGINALITY/VALUE: The paper examines the drivers for change in trust in health care relations in the U.K. and develops a theoretical framework for the emergence of new trust relations that can be subsequently explored through empirical research.
本文旨在探讨英国国民医疗服务体系（NHS）中信任关系如何以及为何发生变化，并提出一个理论框架，以便在未来的实证研究中对其进行探究。
设计/方法/途径：本文进行了概念分析。研究认为，英国公众和患者对医疗保健的信任似乎受到多种因素的影响。从宏观角度来看，公众对医疗机构信任水平的任何变化似乎部分源于自上而下的政策举措，这些举措改变了医疗服务的组织方式，部分源于更广泛的社会和文化进程。本文考察了一系列政策举措，包括引入临床治理以及由此产生的使用绩效管理来审查和改变临床活动、增加患者选择以及让患者参与有关其护理的决策，探究它们如何改变了NHS内部信任关系的背景。
研究认为，这些政策举措为NHS内部的信任关系营造了新的背景，改变了患者、临床医生和管理人员之间的相互依存关系和权力分配，也改变了他们彼此之间以及对医疗机构的脆弱性。本文基于当前的政策论述提出了一个理论框架，该框架说明了在这种新的医疗服务提供背景下可能正在出现的新型信任关系形式，反映出随着患者、临床医生和管理人员在信任关系中成为更积极的伙伴，信任动机从基于情感的信任转变为基于认知的信任。该框架表明，在“新的”现代化NHS中，所有三种类型关系中的信任关系总体上可能特别强调在相互协商的联盟中进行沟通、提供信息以及使用“证据”来支持决策。
原创性/价值：本文研究了英国医疗保健关系中信任变化的驱动因素，并为新型信任关系的出现构建了一个理论框架，后续可通过实证研究对其进行探索。
