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People are more likely to trust their doctors and other healthcare professionals than the system of health care. Not surprising, perhaps, but this emphasises the importance of the relationship between patients and doctors and the central role of individual healthcare professionals in rebuilding and maintaining trust in healthcare services in the aftermath publication of details of failures of care. Openness with patients is central to maintaining their trust in their care. And openness and transparency are crucial, too, if everyone, including those who work in health care, is to regain trust in the system of care. A spirit of openness and involvement might help the NHS implement change. Many do not feel involved in national initiatives; perhaps they share the same sense of unease about institutions and systems of care as the public. Those promoting change should increase the effort committed to communicating the rationale for change and take time to listen to the concerns of doctors and managers.


It is claimed that there has been an erosion in public trust in health care and healthcare practitioners in the UK and abroad. But how do the public assess trust in health care? Is the assessment based on criteria associated with the structure, organisation, and financing of the health service or is it more to do with “micro” level issues, such as the quality of healthcare provision, professional expertise, and the doctor–patient relationship? This question is the focus of the statistical analysis presented in the paper by Calnan and Sanford, which explores the specific determinants of public trust in health care. The analysis is based on a recently completed national postal survey of a random sample of people (18+) in England and Wales (n = 1187). The results showed relatively low levels of trust with specific aspects of health care particularly with the organisation and finance, such as concerns about cost cutting and waiting lists. However, the results of statistical analysis suggested that the crucial determinants of public trust were those measuring the extent to which the doctor is patient centred and the perceived level of professional expertise. It confirms how critical the quality of the doctor–patient relationship is to maintaining trust.
 See p 92


Why does an air of scepticism and resistance continue to pervade the NHS modernisation agenda? While some people have embraced recent reforms, the reluctance of key staff, especially doctors, to become involved poses a significant challenge to the spread and sustainability of improvement.

A study undertaken by a research team at the NHS Modernisation Agency explored scepticism and resistance among doctors and managers towards two national improvement programmes. They found that personal reluctance to change, misunderstanding of the programmes’ aims, and a dislike of how they had been promoted all contributed. Improvement leaders often succeeded in persuading sceptics to become involved, but this took time and a tailored approach. Not surprisingly, the support of some new “converts” was fragile and needed ongoing evidence of benefits. Most change leaders viewed opposition as a problem to be overcome; few welcomed it as a positive challenge to the change agenda.
 See p 108


Malpractice claims data provide a patient centred window on medical errors and identify opportunities for improving patient safety in primary care. Phillips and Colleagues studied 49 345 malpractice claims made against primary care physicians in the US between 1985 and 2000, focusing on a subset of 5921 claims that could most clearly be identified as errors. They found that the majority of claims were for errors in outpatient settings, despite a significant presence of primary care physicians in hospitals, and resulted in over 1200 deaths. No medical condition accounted for more than 5% of claims, but over one third were due to diagnostic errors. When medical condition frequency in claims were compared with the same condition frequency in practice, potential priority conditions for improving safety and reducing claims emerged. Medical negligence yields more than 16 000 paid claims in the US and 3500 paid claims in the UK annually and at a cost of nearly $4 billion and £4 million, respectively. Malpractice data represent real costs to people and countries and should continue to be systematically analysed to improve the quality of health care. Improving the review processes that discern negligence, determine root causes, and identify contributing, system related factors could enhance their value for this purpose.
 See p 121


Making medical practitioners “more accountable” for what they do seems to be self-evidently a laudable aim. The UK government has gone further than any other in trying to institutionalise accountability, introducing a regulatory regime based upon inspection, measurement, and rule adherence. In this paper we discuss the distinction between confidence and trust, and argue that this regime concentrates on confidence at the expense of trust, and carries with it dangers. In seeking to find an alternative, we discuss the nature of accountability, including the multiple audiences to whom individuals and institutions must be accountable and the ability of those involved to apply sanctions if the “account” rendered is unsatisfactory. Openness as a basis for accountability and a possible route to rebuilding trust in healthcare systems is discussed.
 See p 130

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