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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.

This paper provides a conceptual analysis. It proposes that public and patient trust in health care in the UK 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.

The paper examines the drivers for change in trust in health care relations in the UK and develops a theoretical framework for the emergence of new trust relations that can be subsequently explored through empirical research.

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.

The suggestions are summarised under four broad themes.

At an international workshop on trust organised by the UK 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.

Considers trust relations in health care from patient, clinical, organisational and policy perspectives.

The aim of this paper is to provide a rationale for examining trust in health care.

Conducts a review of the literature of trust relations in health care that highlighted that most empirical research has addressed threats to patient‐provider relationships and trust in health care systems from the patient's perspective, but studies in the organisational literature suggests that trust relations in the workforce, between providers and between providers and managers, may also influence patient‐provider relationships and levels of trust.

Suggests that trust is not primarily dispositional or an individual attribute or psychological state, but is constructed from a set of inter‐personal behaviors or from a shared identity. These behaviors are underpinned by sets of institutional rules, laws and customs.

This introductory paper has presented some evidence from an international, comparative study but there is the need for further, more detailed investigation into why trust relations may vary in different health care systems.

This introductory paper provides a rationale for examining trust in health care and a context for the different elements of trust.

This paper considers some implications of recent developments relating to patient safety for understandings of trust in health care contexts.

Conceptual analysis focusing on patients' trust in health care providers and health care providers' trust in patients.

Growing awareness of the scale of the problem of iatrogenic harm has prompted concerns that patients' trust in health care providers may be threatened and/or become inappropriate or dysfunctional. In principle, however, patients' trust may be both well placed and compatible with current understandings of safety problems and efforts to address these. Contemporary understandings of patient safety suggest that, to be deemed trustworthy, health care providers should make vigorous efforts to improve patient safety, be honest about safety issues, enable patients to contribute effectively to their own safety, and provide appropriate care and support after safety incidents. Patients who trust health care providers need not be ignorant of patient safety problems and may be vigilant in the course of their care. Iatrogenic harms do not necessarily reflect breeches of trust (not all such harms are yet preventable), and patients who are harmed might in some circumstances appropriately forgive and resume trusting. Health care providers may feel vulnerable to patients in several respects. From their perspective, trustworthy patients will act competently to optimise the outcomes of their health care efforts and to preserve health care providers' good reputations where those are justified. Providers' trust in patients may strengthen patients' trust in them and facilitate safety improvement work.

Shows how, in principle, trust can be compatible with current understandings of patient safety issues and may enhance efforts to improve patient safety.

If public trust in health care is to be used as a performance indicator for health care systems, its measurement has to be sensitive to changes in the health care system. For this purpose, this study has monitored public trust in health care in The Netherlands over an eight‐year period, from 1997 to 2004. The study expected to find a decrease in public trust, with a low point in 2002.

Since 1997, public trust in health care was measured through postal questionnaires to the “health care consumer panel”. This panel consists of approximately 1,500 households and forms a representative sample of the Dutch population.

Trust in health care and trust in hospitals did not show any significant trend. Trust in medical specialists displayed an upward trend. Trust in future health care, trust in five out of six dimensions of health care and trust in general practitioners actually did show a decrease. However, only for trust in macro level policies and trust in professional expertise this trend continued. For the remaining trust objects, after 1999 or 2000, an upward trend set in.

No support was found for our overall assumption. Explanations for the fact that trust did increase after 1999 or 2000 are difficult to find. On the basis of these findings the study questions whether the measure of public trust is sensitive enough to provide information on the performance of the health care system.

The aim of this research is to study public trust in health care on its abilities to be used as a performance indicator for health care systems.

This paper evaluates the non‐healthcare organisational literature on conceptualisations of trust. The aim of the paper is to review this diverse literature, and to reflect on the potential insights it might offer healthcare researchers, policy makers and managers.

A number of the key concepts that contribute to contrasting definitions of trust in the organisational literature are identified.

The paper highlights the heterogeneity of trust as an organisational concept. Aspects of trust that relate more specifically to non‐healthcare settings are shown to have some potential relevance for healthcare. Five aspects of trust, considered to have particular significance to the changing face of the NHS, appear to offer scope for further exploration in healthcare settings.

The NHS continues to face changes to its organisational structures, both planned and unplanned. Healthcare providers will need to be alert to intra‐ and inter‐organisational relationships, of which trust issues will form an inevitable part. Whilst it might be argued that the lessons offered by conceptualisations of trust within wider organisational settings have limitations, the paper demonstrates sufficient areas of overlap to encourage cross‐fertilisation of ideas.

The paper draws together previous research on a topic of increasing relevance to healthcare researchers, which has exercised management researchers for at least three decades. The paper acts as a guide to future research and practice.

This article explores issues of trust in narratives of interpreted consultations in primary health care.

The paper is based on empirical data from a qualitative study of accounts of interpreted consultations in UK primary care, undertaken in three north London boroughs. In a total of 69 individual interviews and two focus groups, narratives of interpreted consultations were sought from 18 service users, 17 professional interpreters, nine family member interpreters, 13 general practitioners, 15 nurses, eight receptionists, and three practice managers. The study collected and analysed these using a grounded theory approach and taking the story as the main unit of analysis. It applies a theoretical model that draws on three key concepts: Greener's taxonomy of trust based on the different “faces” of power in medical consultations; Weber's notion of bureaucratic vs traditional social roles; and Habermas' distinction between communicative and strategic action.

Trust was a prominent theme in almost all the narratives. The triadic nature of interpreted consultations creates six linked trust relationships (patient‐interpreter, patient‐clinician, interpreter‐patient, interpreter‐clinician, clinician‐patient and clinician‐interpreter). Three different types of trust are evident in these different relationships – voluntary trust (based on either kinship‐like bonds and continuity of the interpersonal relationship over time, or on confidence in the institution and professional role that the individual represents), coercive trust (where one person effectively has no choice but to trust the other, as when a health problem requires expert knowledge that the patient does not have and cannot get) and hegemonic trust (where a person's propensity to trust, and awareness of alternatives, is shaped and constrained by the system so that people trust without knowing there is an alternative). These different types of trust had important implications for the nature of communication in the consultation and on patients' subsequent action.

The methodological and analytic approach, potentially, has wider applications in the study of other trust relationships in health and social care.

Quality in the interpreted consultation cannot be judged purely in terms of accuracy of translation. The critical importance of voluntary trust for open and effective communication, and the dependence of the latter on a positive interpersonal relationship and continuity of care, should be acknowledged in the design and funding of interpreting services and in the training of both clinicians, interpreters and administrative staff.

This is the first study in which interpreted consultations have been analysed from a perspective of critical sociology with a particular focus on trust and power relations.

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.

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.

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.

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.

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.

This article reviews research in the USA bearing on trust in physicians and medical institutions.

This article provides a conceptual analysis, and general review of the literature.

Empirical research of medical trust is burgeoning in the USA, and a fairly clear conceptual model of interpersonal physician trust has emerged. However, most studies focus on individual patients and their physicians, due to the highly individualistic attitudes that prevail in the USA. Lacking are studies of more social dimensions of trust in broader medical institutions. A conceptual model of trust is presented to help draw these relevant distinctions, and to review the US literature. Also presented are the full set of trust scales, developed at Wake Forest University, which follow this conceptual model. These conceptual categories may differ, however, in other languages and cultures.

The considerable body of research in the USA on patients' trust in individual physicians should help inform and focus international efforts to study social trust in medical institutions.