Hello and welcome to BJGP Interviews.

I'm Nada Khan and I'm one of the Associate editors of the Journal.

Thanks for joining us here to listen to this podcast today.

In today's episode, we're speaking to Professor Richard Baker, Emeritus professor at the University of Leicester.

We're here to talk about the paper that he and his colleagues have recently published here in the bjjp.

The paper is titled Factors Influencing Confidence and Trust in Healthcare A Cross Sectional Study of English General Practices.

So, hi, Richard, thanks for joining me here today and it's nice to see you again.

Just before we talk about this paper, I wonder if you could just talk to me about trust and why you think it's important in general practice interactions.

Well, it's difficult to have a consultation with a patient if they don't trust you.

I mean, it's just very basic, a very basic level, very simple level.

But there's lots of evidence as well that trust is important.

People who trust you are more likely to follow your advice.

They're more likely to take the medication.

They're more likely therefore, to come back and see you again, more likely to use services appropriately in the future.

And there's some evidence that the outcomes are better if there's trust there.

Trust obviously should be earned.

You can't take it for granted, you've got to be trustable.

But it's obviously very important for clinical practice and essentially always has been, hasn't it, really?

Going back to the.

The Greek doctors, trust was important then, just as it is now.

And you mentioned about different outcomes.

So what sort of outcomes do we know could be associated with trust?

Just use of services is one example.

So you can get people who, if they don't trust who they see, they go and see someone else and again, and so they overuse services and that waste resources.

On the other hand, you may get people who just won't come, so they'll delay presenting with the problems because they don't trust the provider to get it right.

Then they risk of poor outcomes as a consequence of that.

So it's a whole mixture of things.

So what were you trying to do in the study?

So you wanted to look at trust and how it impacted on patient outcomes, or was it more about sort of the predictors and associations with trust, isn't it?

Yes, I think we were conscious that general practice has gone through a lot of change.

The big changes came about during the pandemic as to how general practice is delivered, how people have their appointments and things have sort of Reverted a bit to how they were, but only partially in terms of who you get to see face to face, appointment and so on.

And we were asking the question, well, what has been the consequence of this?

Should we be thinking about confidence and trust in association with these changes?

I mean, the changes may have been absolutely essential because we just don't have the capacity in general practice to do everything that we would like to do for an increasingly multi morbid population.

But what are the consequences?

How do we need to respond?

How do we need to respond?

Questions I guess for follow on from Is there a link between confidence and trust and these changes in general practice changes?

I think when we looked at this, we've sort of grouped them, we sort of imagined that there are two models of general practice which the relationships based care and the transactional model.

Of course there aren't two models, it's all mixed up.

But to simplify it, you call it two different things.

And we've tried to categorize or explain what relationship based care might be, which has typified by high context continuity, face to face appointments with someone, you know, usually a gp, to get generalist medical care.

And then the transactional model where you, you have a problem, you, you phone up or email or whatever it might be online and you get allocated or triaged to a particular professional who deals with that particular problem and then off you go on to something else.

And, and it could be face to face, it could be over the phone, it could be all sorts of different health professionals.

So there's two different ways, it's all mixed up.

And every practice offices offers these two approaches in different degrees.

It's just.

So this arbitrary division that we've described and we're sort of interested in how we look at that, how is competent trust linked to that?

This was a study looking at the general practice patient survey, which includes a question about whether patients felt that they had confidence and trust in their healthcare professionals.

And.

And then as we were discussing, you looked at some of the factors that might influence this trust.

But I wonder if you could talk us through the findings.

So in this survey, how many respondents felt that they trusted their healthcare professionals?

This was, we were interested and the question was, did you have complete confidence in trust in the professional scene at your last appointment?

And around about the figure was 64, 65% on average across all the practices.

So this was all general practices, but the vast majority of 99% or something of all general practices in England, 6200 practices were roughly in the study.

And this was 20, 23, 24 year.

It was a simple cross sectional study for reasons the data weren't available for a longitudinal study, unfortunately.

But so there are inevitably limitations on that.

But I suppose, yes, you would say two thirds had full confidence in trust and others had partial confidence trust and others had absolutely no competence and trust in the professional they had last seen.

Now, this relates to all types of health professionals seen, so it would include gps, but it would include the nurse you saw, the physiotherapist or the pharmacist or whatever.

It would be the general practice based pharmacist, the people in the primary care team who, who consult with them see patients.

And you talked earlier about these two different models of care, the relationship based model and the transactional model.

And you know, you described that some of this might be a bit more mixed in practice, but did you find any associations between those different ways of working and how trust was or how much patients trusted their interactions with their last healthcare professional?

There's a tendency among the findings for relationship based care to be associated with higher levels of competence and trust, relationship based care being typified by higher levels of continuity, more face to face appointments, more appointments with gps.

And of those three things, continuity is perhaps the most powerful association and then points with GPS the next most powerful.

And face to face being the third or least powerful element of that three.

When you put all three together, I think it becomes quite a powerful message really saying patients do by and large tend to be more trusting, have more confidence in relationship based care.

But that doesn't mean to say there are patients who don't want transactional care and have trust and confidence in it, they get it and when they want it.

So it's not a simple either or.

The picture at the moment appears to be there are probably more patients who want relationship based care than are able to get it.

And I wanted to touch here more on continuity of care and it's an area of research that you've worked in for a while and there have been previous studies.

I know Chris Salisbury's team in Bristol did some work around healthcare professionals and trust and continuity.

What are your thoughts about this based the results that you've pulled out from this survey as well?

Well, it just reinforces my perception of continuity being preferred by patients.

Some of the first studies I did way back in the 1980s, 90s, I wasn't investigating continuity, but I was investigating what patients thought about their care and continuity just stood out.

It just, it almost, almost slapped me around the face.

Come on.

Notice this.

And it was, it was as a became a to say, look, we need to take this seriously and try and provide what patients want.

They prefer, by and large, not all patients, but most patients, especially when they've got a more complex or worrying problem, want to see someone they developed a relationship with, a relationship of trust where they know, where they can understand what the person is telling them.

Because if you've seen somebody once and they've got you right that time, then you're going to go back and see them again, aren't you?

It's just sort of obvious really, but the continuity has actually, since the 80s and 90s, it's really just steadily declined and that's a sort of frustration as to why that's happened.

And keep on providing more evidence about the value of continuity from the patient's perspective, from outcomes perspective, from health professionals perspective.

This is just another example of one of those studies I'm totally expecting.

In this study we were to find that continuity was a predictor of confidence and trust.

What we were looking at was a face to face appointments a predictor as well.

And is seeing a GP a predictor as well?

And yes, they were.

They're all linked parts of relationship based care.

And yes, the story of the last two or three decades has been a gradual decline in relationship based care, which I think is a shame.

And there is this almost tension between this idea of relationship based care currently and quicker access, more transactional ways of working and fewer appointments between a patient and a GP in practice with an increasing multidisciplinary team.

So in some ways it seems like a frustrating system, not just for patients, but for GPs as well.

Really?

Yeah, absolutely, I'm sure it is.

Yeah, absolutely.

It must be.

Well, it's obvious we all know it's very, very difficult working in practice at the moment, juggling so many things at once.

It's really difficult.

And the changes that have come about in terms of proportion of appointments with gps proportion that were face to face, it's almost, it's essential, it's necessary to enable the service to continue, isn't it?

So it's not a deliberate policy of gps to reduce relationship based care.

It's something that had to be done in the face of.

I don't know quite where the policies came from, but it feels to me as though there'd been a failure to respond to what we knew was going to happen.

An aging population, greater demand for healthcare.

We should have got our, rolled our sleeves up and planned to deal with that well in advance.

Maybe the NHS workforce plan will start to put right some of those things in the next few years.

We'll have to see.

Any other key findings that you want to mention from this paper?

I think the other one that I picked up on is patients have greater confidence in trust when they report that their needs were met at their last consultation.

I think that was another finding using information from the general practice of patient survey data, and I think that was quite an interesting one in ways.

It's sort of not unexpected.

People who write theories about trust, patient trust in the health professional talk about patients assessment of competence, and it seems to me that's perhaps linked to that.

So I think that's another thing that it might be worthwhile just thinking about and knowing more about.

And I've sort of written that down as that'd be interesting to do a longitudinal study of that or something maybe in the future to try and get.

Further into that and just moving on to think about how we could apply the finding of the findings of this study more widely.

Do you have any ideas about how practices could try to increase trust in their patient population?

Do you have any ideas for GPs or people working in general practice or policy?

I certainly, from a general practitioner's practice point of view, I would say look at the GPPS data and understand what's happening locally, what's happening for our practice, how are we doing?

I think these are really goldmines of information and you follow it over a few years, years and you start to see trends and what have you.

I think that's really a starting point and every practice is going to be different.

It's not.

There's not a. I don't think there's a blanket thing general practice must do xyz, it's just not that simple.

But understanding your own situation and thinking about how we're doing, some practices will be doing fine and don't need to really worry too much.

And some might feel, well, we could perhaps do a little bit better.

Maybe we need to when the opportunity presents, or we need to tweak things so we can bump up continuity a little bit.

Or maybe we're in the situation of, you know, thinking about our staffing needs for the next year or two.

How do we.

How do we make sure we've got the right staff in place that are going to help confidence and trust or those.

Those sorts of questions, I think, are probably things that questions that practices can ask.

It's not going to produce an instant solution, but a little bit tweaking things a little bit each year.

Moving in the right direction is better than either standing still or going backwards.

And that's really what I would encourage.

But I mean, it's very difficult for practices, given this current resourcing situation, to dramatically change things.

But over time, we hope the message gets through to policymakers that they do start to, I mean, I want to say invest in general practice, but.

And I think that's actually true.

But I want to make it simpler for policy makers because things are not necessarily easy for them either, are they really?

They've got so many different demands and so we have to present solutions to the problems they're facing.

And I think, yes, it is a little bit of resource improvement as well as everything else.

And again, a tweaking a bit over time.

In a few years time we could make a difference.

It's taken 20, 30 years to get to this low in terms of continuity and relationship based care.

Let's accept that it's going to take quite a few years to get back up to where we'd like to be.

But it's making that the first step is always the important one.

Keep making steps after that.

And as you mentioned, it's important to note that the general practice patient survey does have this longitudinal data over time, so it is a helpful tool for practices to go back and look at the data over time.

And it's obviously publicly available as well for practices to go and look at.

Yeah, yes, I think, I think is a.

We're very fortunate.

We have public data.

We use the data from the NHS appointment, general practice appointments data sets as well in this study and that's got lots of material in as well.

And there are other sources of data as well about general practice that we can draw on.

We didn't look at.

Well, we didn't use any quaff variables in this particular project because they weren't helpful to us in this particular project.

But there's lots of data and.

I.

Think that's really, really good that the NHS is collecting, using these data, making them publicly available.

I think that's something to celebrate, I think.

Well, it's been great hearing about this research, Richard, and it sounds like it's given you lots of ideas for projects in the future as well.

So we'll look forward to hearing about those as well.

But I just wanted to say thanks very much for taking the time to talk about it today.

Okay.

No, thank you very much.

It's.

It's great to talk to you and.

Thank you all very much for your time here and for listening to this BJGP podcast.

Richard's original research article can be found on bjgp.org and the show notes and podcast audio are@bjjplife.com thanks again for your time today and by.