Can consumer choice replace trust in the National Health Service in England? Towards developing an affective psychosocial conception of trust in health care

In risk we trust? Making decisions about knee replacement

Risk communication is a key legal and ethical component of shared decision-making. Decisions about total knee replacement, a common surgery, must contend with the fact that a minority of cases result in unintended outcomes, some of which have devastating effects. To understand how risks are communicated during decision-making, we audio-recorded and analysed 62 consultations between surgeons and patients. Various communication methods were evident, including listing risks without elaboration, discussing them in a conversational manner, abrogating discussion of risk, or using decision-tools. Discussion of risks was often brief in nature, and risk communication was sometimes curtailed or deferred by both patients and surgeons. Risks could also be observed to play a part in reinforcing policy norms of the doctor-patient relationship that highlighted patient responsibility. Nevertheless, patients and surgeons in the observed consultations appeared more interested in developing trusting relationships than in discussing risks. Because patients had sometimes experienced considerable deterioration in their knee function before their consultation, were in pain and struggled with mobility, the realities of clinical practice clashed with the policy norms of choice and patient responsibility. Rather, decisions could appear coerced by the disease process rather than being clear-cut examples of self-determination. While policy norms putatively use risk disclosure to frame communication between patients and clinicians as a transaction between customer and technician, the lack of conformity to these norms in the consultations may indicate resistance to this framing. A greater emphasis on determining positive roles for trust and care would help policy to present a nuanced understanding of decision-making. Risk communication could be seen as a factor in the formation of trusting relationships, improving its role in decision-making processes while recognising its inherent tensions with practice.

Caring for care: Online feedback in the context of public healthcare services

People increasingly provide feedback about healthcare services online. These practices have been lauded for enhancing patient power, choice and control, encouraging greater transparency and accountability, and contributing to healthcare service improvement. Online feedback has also been critiqued for being unrepresentative, spreading inaccurate information, undermining care relations, and jeopardising professional autonomy. Through a thematic analysis of 37 qualitative interviews, this paper explores the relationship between online feedback and care improvement as articulated by healthcare service users (patients and family members) who provided feedback across different online platforms and social media in the UK. Online feedback was framed by interviewees as, ideally, a public and, in many cases, anonymous 'conversation' between service users and healthcare providers. These 'conversations' were thought of not merely as having the potential to bring about tangible improvements to healthcare, but as in themselves constituting an improvement in care. Vital to this was the premise that providing feedback was an enactment of care - care for other patients, certainly, but also care for healthcare as such and even for healthcare professionals. Ultimately, feedback was understood as an enactment of care for the National Health Service (NHS), as symbolically encompassing all of the above. Putting these findings in dialogue with STS scholarship on care, we argue that, in this context, the provision of online feedback can be understood as a form of care that is, simultaneously, both directed at healthcare (in the round, including patients, professionals, services, organisations, and, of course, health itself) and part of healthcare. We conceptualise this as 'caring for care'. This conceptualization moves beyond dominant framings of online feedback in terms of 'choice' and 'voice'. It embeds online feedback within pre-existing healthcare systems, relations and moral commitments, foregrounds the mutuality of care relations, and draws attention to the affective labour of feedback practices.

'So just to go through the options…': patient choice in the telephone delivery of the NHS Improving Access to Psychological Therapies services

This article considers patient choice in mental healthcare services, specifically the ways that choice is enabled or constrained in patient-practitioner spoken interaction. Using the method of conversation analysis (CA), we examine the language used by practitioners when presenting treatment delivery options to patients entering the NHS Improving Access to Psychological Therapies (IAPT) service. Analysis of 66 recordings of telephone-delivered IAPT assessment sessions revealed three patterns through which choice of treatment delivery mode was presented to patients: presenting a single delivery mode; incrementally presenting alternative delivery modes, in response to patient resistance; and parallel presentation of multiple delivery mode options. We show that a distinction should be made between (i) a choice to accept or reject the offer of a single option and (ii) a choice that is a selection from a range of options. We show that the three patterns identified are ordered in terms of patient-centredness and shared decision-making. Our findings contribute to sociological work on healthcare interactions that has identified variability in, and variable consequences for, the ways that patients and practitioners negotiate choice and shared decision-making. Findings are discussed in relation to tensions between the political ideology of patient choice and practical service delivery constraints.

Couldn’t care less? A psychosocial analysis of contemporary cancer care policy as a case of borderline welfare

This article engages with recent shifts in public healthcare policy in Norway through a psychosocial analysis of contemporary cancer care, which evokes the hope of cure and reparation in the psychosocial imaginary. With increasing incidence and prevalence, cancer is a persistent challenge for public health services. Policy makers therefore emphasise that resources must be prioritised while ensuring good-quality care for vulnerable citizens. In 2015, Norway implemented integrated patient pathways as national guidelines to standardise clinical assessment and medical treatment for patients with a suspected cancer diagnosis. In a text analysis of ‘the integrated breast cancer pathway’ as a framework for practice, we found the concept and practice of care absent. There were sparse descriptions of the relational responsibilities of health professionals, beyond informing and communicating. From a psychosocial care understanding, we problematise how the emphasis on information delivery presupposes a universally autonomous, competent, resilient and rational patient, rather than a particular human being with complex thoughts, feelings, needs and vulnerabilities in the face of a life-threatening illness. We refer to wider issues effected by neoliberal governance, which may profoundly impact on the relationship between professionals and patients. We raise the concern that integrated cancer care is a case of borderline welfare, characterised by a fear of feelings associated with mutual vulnerabilities and dependencies. We identify values and ethical pressures at stake in an emerging careless policy in Norwegian welfare, in light of the government’s stated ambition to become an international role model for good patient trajectories.

Why We Must Talk About Institutional Corruption to Understand Wrongdoing in the Health Sector Comment on "We Need to Talk About Corruption in Health Systems"

While various forms of corruption are common in many health systems around the world, defining wrongdoing in terms of legality and the use of public office for private gain obstructs our understanding of its nature and intractability. To address this, I suggest, we must not only break the silence about the extent of wrongdoing in the health sector, but also talk differently about corruption in general, and corruption in healthcare specifically. I propose adopting the notion of institutional corruption (IC) developed by Thompson and Lessig, as divergence from the original purpose of the institution, which may not be illegal but may nevertheless cause harm to people who depend on it by creating perverse dependencies and compelling individuals to act against its core purpose. Such work is much needed to provide in-depth accounts of how external political and legislative pressures enable corruption in healthcare systems. I also argue for bringing together insights from various research domains and levels of analysis to capture why and how corruption becomes systemic, deeply embedded, and intractable.

Low institutional trust in health insurers in Dutch health care

A central element of the 2006 health insurance reform in the Netherlands is strategic purchasing by health insurers. After a brief elaboration of the concept of trust this article discusses the trust of insured in the new purchasing role of health insurers. There are various indications of a trust problem or credible commitment problem in Dutch health care. Insured say to trust their own health insurer (specific trust) but also say to have little trust in the behaviour of health insurers in general(institutional trust). The article briefly explores four models to explain the trust problem: the lack-of information model, the anticompetition model, the pro-profession model and the political communication model. A critical analysis demonstrates that the 'objective ground' for low institutional trust is rather questionable. Low trust seems to be based more on perceptions than on the insurers' objective purchasing behaviour. The article ends with a discussion on some potential strategies to address the trust problem. Low institutional trust may be something insurers have to live with.

Whistleblower Subjectivities: Organization and Passionate Attachment

What is the nature of whistleblower subjectivity? In this article, we depart from current scholarly depictions of this figure as a fearless truth-teller who is fully independent of the organization. We argue for a new framing that sees the self-construction of the whistleblower as infused with passionate attachments to organizational and professional norms, even after one experiences severe reprisals. We base our claims on recently gathered empirical data and draw on Judith Butler to theorize how, contrary to existing understandings, passionate attachments to one’s organization and profession shape whistleblower subjectivity, rather than conscious risk-taking, or autonomous self-reinvention. Our second contribution is to highlight the importance of practical and material supports for this vital figure in society; until now the whistleblower has been idealized as an extraordinary hero rather than a real human in need of assistance. Overall, we propose a new theorization of the whistleblower involving passionate investments in the organization or profession that has cast one out.

Fostering trust in healthcare: Participants' experiences, views, and concerns about the 100,000 genomes project

In this paper, we present findings from a project involving 20 patients with rare diseases, or parents thereof, participating in the 100,000 genomes project (100 kG P). We explored their experiences of, and views about, the project, including why they took part, and their hopes and concerns about the future of genomic medicine. Patients who attended genetic clinics for testing were offered the opportunity to undergo the more extensive whole genome sequencing (WGS) if they agreed to take part in the 100 kG P. Once people had agreed, a specific additional appointment was organised for them. Taking part in the project therefore involved additional travel and appointments ('clinical labour'). We found that interviewees' decisions to participate in 100 kG P were based on interpersonal and institutional trust in the NHS, and on an investment in improving care for the future. Interviewees relied upon receiving good ongoing NHS care for managing their own or their child's rare disease, but they worried about what their relationships with NHS healthcare professionals would be like in future. A few participants worried about whether Genomics England's biorepository would remain protected and an asset of the NHS. To honour and foster participants' trust - which may easily be lost - and their clinical labour, we therefore recommend ongoing public engagement and consultation about how genomics is being integrated more widely across specialties (especially given current funding and staffing constraints in the NHS) within the newly formed NHS Genomic Medicine Service.

How Do Women View Risk-Based Mammography Screening? A Qualitative Study

BACKGROUND

Decades of persuasive messages have reinforced the importance of traditional screening mammography at regular intervals. A potential new paradigm, risk-based screening, adjusts mammography frequency based on a woman's estimated breast cancer risk in order to maximize mortality reduction while minimizing false positives and overdiagnosis. Women's views of risk-based screening are unknown.

OBJECTIVE

To explore women's views and personal acceptability of a potential risk-based mammography screening paradigm.

DESIGN

Four semi-structured focus group discussions about screening mammography and surveys before provision of information about risk-based screening. We analyzed coded focus group transcripts using a mixed deductive (content analysis) and inductive (grounded theory) approach.

PARTICIPANTS

Convenience sample of 29 women (40-74 years old) with no personal history of breast cancer recruited by print and online media in New Hampshire and Vermont.

RESULTS

Twenty-seven out of 29 women reported having undergone mammography screening. All participants were white and most were highly educated. Some women accepted the idea that early cancer detection with traditional screening was beneficial-although many also reported hearing inconsistent recommendations from clinicians and mixed messages from media reports about mammography. Some women were familiar with a risk-based screening paradigm (primarily related to cervical cancer, n = 8) and thought matching screening mammography frequency to personal risk made sense (n = 8). Personal acceptability of risk-based screening was mixed. Some believed risk-based screening could reduce the harms of false positives and overdiagnosis (n = 7). Others thought screening less often might result in missing a dangerous diagnosis (n = 14). Many (n = 18) expressed concerns about the feasibility of risk-based screening and questioned whether breast cancer risk estimates could be accurate. Some suspected that risk-based mammography was motivated by a desire to save money (n = 6).

CONCLUSION

Some women thought risk-based screening made sense. Willingness to abandon traditional screening for the new paradigm was mixed. Broad acceptability of risk-based screening will require clearer communication about its rationale and feasibility and consistent messages from the health care team.

Performing Values Practices and Grassroots Organizing: The Case of Solidarity Economy Initiatives in Greece

This article discusses solidarity economy initiatives as instances of grassroots organizing, and explores how ‘values practices’ are performed collectively during times of crisis. In focusing on how power, discourse and subjectivities are negotiated in the everyday practices of grassroots exchange networks (GENs) in crisis-stricken Greece, the study unveils and discusses three performances of values practices, namely mobilization of values, re-articulation of social relations, and sustainable living. Based on these findings, and informed by theoretical analyses of performativity, we propose a framework for studying the production and reproduction of values in the context of GENs, and the role of values in organizing alternatives.

Accessing support and empowerment online: The experiences of individuals with diabetes

CONTEXT

The use of the internet for health information by those with long-term conditions is growing. It has been argued that this represents a form of empowerment by patients, as it enables them to control the content and flow of the information available to them. To explore this, the use of online discussion groups by those with diabetes was examined.

METHOD

Semi-structured interviews were conducted with 21 participants with type 1 and 2 diabetes and analysed using thematic analysis. Participants were recruited via online and offline routes, namely discussion boards, newsletters, and research networks related to diabetes.

RESULTS

By drawing on the advice, information, and support shared online, participants were empowered to position themselves as active participants in their own health care and to further engage with health-care professionals.

CONCLUSION

The findings indicate that forums can play a valuable role in aiding and motivating individuals in the daily management diabetes and highlight how this support is used to complement formal health services. However, more work needs to be carried out to determine to explore when and under what circumstances online support may be particularly beneficial to those with long-term conditions.

Thinking critically about affect in organization studies: Why it matters

Affect holds the promise of destabilizing and unsettling us, as organizational subjects, into new states of being. It can shed light on many aspects of work and organization, with implications both within and beyond organization studies. Affect theory holds the potential to generate exciting new insights for the study of organizations, theoretically, methodologically and politically. This Special Issue seeks to explore these potential trajectories. We are pleased to present five contributions that develop such ideas, drawing on a wide variety of approaches, and invoking new perspectives on the organizations we study and inhabit. As this Special Issue demonstrates, the world of work offers an exciting landscape for studying the ‘pulsing refrains of affect’ that accompany our lived experiences.

"You get to know the people and whether they're talking sense or not": Negotiating trust on health-related forums

The internet is increasingly being used as a source of health advice and information by individuals with long term conditions (LTCs). Specifically, online forums allow people to interact with others with similar conditions. However, it is not clear how online health information is assessed by those with LTCs. This study aims to address this gap by exploring how individuals with contested and uncontested LTCs utilise internet forums. Semi-structured interviews were conducted with 20 participants with ME/CFS and 21 participants with type 1 and 2 diabetes and analysed using thematic analysis. Participants were recruited via online and offline routes, namely forums, email lists, newsletters, and face-to-face support groups. The findings indicate that the use of online forums was a complex and nuanced process and was influenced by a number of individual and illness-specific factors. Participants trusted those with similar experiences and perspectives as themselves, while also valuing conventional biomedical information and advice. By accessing support online, forum users were able to draw on a personalised form of support based on the lived experiences of their peers. However, the role of digital literacy in developing and maintaining online relationships must be acknowledged.

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The use of online forums by individuals with LTCs is a complex and nuanced process.

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Participants trust those with similar experiences and perspectives as themselves.

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Users can access a personalised form of support based on the experiences of peers.

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Role of digital literacy in developing online relationships must be acknowledged.

Advice, authority and autonomy in shared decision-making in antenatal screening: the importance of context

Shared decision-making (SDM) has been widely advocated across many branches of healthcare, yet there is considerable debate over both its practical application and how it should be examined or assessed. More recent discussions of SDM have highlighted the important of context, both internal and external to the consultation, with a recognition that decisions cannot be understood in isolation. This paper uses conversation analysis (CA) to examine how decision-making is enacted in the context of antenatal screening consultations in Hong Kong. Building on previous CA work (Collins et al. , Toerien et al. 2013), we show that, whilst previously identified formats are used here to present the need for a decision, the overriding basis professionals suggest for actually making a decision in this context is the level of worry or concern a pregnant woman holds about potential foetal abnormality. Professionals take an unknowing 'epistemic stance' (Heritage ) towards this worry, and hence step back from involvement in decision-making. We argue that this is linked to the non-directive ethos that prevails in antenatal screening services, and suggest that more research is needed to understand how the enactment of SDM is affected by wider professional contexts and parameters.

Sensemaking and the co-production of safety: a qualitative study of primary medical care patients

This study explores the ways in which patients make sense of 'safety' in the context of primary medical care. Drawing on qualitative interviews with primary care patients, we reveal patients' conceptualisation of safety as fluid, contingent, multi-dimensional, and negotiated. Participant accounts drew attention to a largely invisible and inaccessible (but taken for granted) architecture of safety, the importance of psycho-social as well as physical dimensions and the interactions between them, informal strategies for negotiating safety, and the moral dimension of safety. Participants reported being proactive in taking action to protect themselves from potential harm. The somewhat routinised and predictable nature of the primary medical care consultation, which is very different from 'one off' inpatient spells, meant that patients were not passive recipients of care. Instead they had a stock of accumulated knowledge and experience to inform their actions. In addition to highlighting the differences and similarities between hospital and primary care settings, the study suggests that a broad conceptualisation of patient safety is required, which encompasses the safety concerns of patients in primary care settings.

A structuration framework for bridging the macro-micro divide in health-care governance

BACKGROUND

Extant studies demonstrate that macro (hierarchical) and micro (relational) governance initiatives in health-care settings continue to be developed in isolation rather than interactively. Government-driven hierarchical governance endeavours that guide health-care reforms and medical practice are disconnected from micro-level physician-patient interactions being unable to account for patient preferences in the macro-level policymaking.

METHOD/OBJECTIVE

We undertake a review of the recent literature to couch our argument for a unified governance framework for bridging the macro-micro divide in medical contexts. Adopting an interdisciplinary approach to health-care delivery, we maintain that the (strong) structuration theory provides a fruitful opportunity for narrowing the gap between hierarchical and relational governance.

DISCUSSION

Emphasizing the coexistence of institutional structures and human agency, the (strong) structuration theory elucidates how macro and micro governance devices shape each other's structure via mutually reinforcing cycles of influence. Micro-level encounters between patients and physicians give rise to social structures that constitute the constraining and enabling forces through which macro-level health-care infrastructures are altered and reproduced over time. Permitting to illustrate how patients' agency can effectively emerge from complex networks of clinical trajectories, the advanced structuration framework for macro-micro governance integration avoids the extremes of paternalism and autonomy through a balanced consideration of professional judgement and patient preferences.

CONCLUSION/IMPLICATIONS

The macro-micro integration of governance efforts is a critical issue in both high-income states, where medical institutions attempt to deploy substantial realignment efforts, and developing nations, which are lagging behind due to leadership weaknesses and lower levels of governmental investment. A key priority for regulators is the identification of relevant systems to support this holistic governance by providing clinicians with needed resources for focusing on patient advocacy and installing enabling mechanisms for incorporating patients' inputs in health-care reforms and policymaking.

Why and how is compassion necessary to provide good quality healthcare?

Recent disclosures of failures of care in the National Health Service (NHS) in England have led to debates about compassion deficits disallowing health professionals to provide high quality responsive care. While the link between high quality care and compassion is often taken for granted, it is less obvious how compassion - often originating in the individual's emotional response - can become a moral sentiment and lead to developing a system of norms and values underpinning ethics of care. In this editorial, I argue why and how compassion might become a foundation of ethics guiding health professionals and a basis for ethics of care in health service organisations. I conclude by discussing a recent case of prominent healthcare failure in the NHS to highlight the relationship between compassion as an aspect of professional ethics on the one hand, and values and norms that institutions and specific policies promote on the other hand.

A Theory of Imagination for Organization Studies Using the Work of Cornelius Castoriadis

At a time when organizations are asked to imagine themselves anew in order to survive, organizational treatments of ‘imagination’ lack engagement with its profound political and generative nature. To address this gap, the paper draws on the works of Cornelius Castoriadis (1922–1997) and proposes a politically situated theory of imagination for organization studies. We build on Castoriadis’s core ideas of representation, signification and affect to develop a radical proposition: imagination is ‘where it all begins’, an inexhaustible psychosocial force driving organizations and organizing, and setting the institutionalization process in motion. To illustrate the great potential contributions of this proposition for organization studies, we discuss how three key persisting dualisms in organizational thinking, those between ‘representational’ and ‘non-representational’ inquiry, ‘body’ and ‘mind’, and between the ‘private’ and ‘public’, begin to dissolve when considered under our suggested framework. We then draw some important implications of Castoriadian imagination for charting alternative futures at times of economic and social crises, and identify some directions for future research.