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ARTICLE IN PRESSG ModelEAP-3190; No. of Pages 9
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Contents lists available at ScienceDirect
Health Policy
journa l h om epa ge: www.elsev ier .com/ locate /hea l thpol
he acceptability of care delegation in skill-mix:he salience of trust
homas Anthony Dyer ∗, Janine Owens1, Peter Glenn Robinson2
chool of Clinical Dentistry, University of Sheffield, Claremont Crescent, Sheffield, South Yorkshire S10 2TA, United Kingdom
a r t i c l e i n f o
rticle history:eceived 27 November 2013eceived in revised form 14 February 2014ccepted 15 February 2014
eywords:kill-mixcceptabilityrust
a b s t r a c t
The aim of this research was to explore the acceptability of care delegation in skill-mix, usingthe views and experiences of patients and parents of children treated by dental therapists asa case study. A purposive sample of 15 adults whose care, or that of their children, had beendelegated to dental therapists in English dental practices was interviewed using narrativeand ethnographic techniques (July 2011 – May 2012). Experiences were overwhelminglypositive with the need for trust in clinicians and the health system emerging as a keyfactor in its acceptability. Perceptions of general and dental health services ranged fromthem being a collectivist public service to a more consumerist marketised service, with theformer seemingly associated with notions of dentistry as a trusted system working for thesocial good. Interpersonal trust appeared built, sustained (and undermined) by the affectivebehaviour, perceived competence, and continuity of care with clinicians providing care, andcontributed to trust in the system. It also appeared to compensate for gaps in knowledge
needed for patient decision-making. Overall, where trust existed, delegation of care wasacceptable. An increasingly marketised health system, and emphasis on the patient as aconsumer, may challenge trust and acceptability of delegation, and undermine the notionof patient-centred health care.© 2014 Elsevier Ireland Ltd. All rights reserved.
. Introduction
With health systems under increasing pressure to con-ain costs whilst maintaining access to care, the need todopt a team approach has been emphasised [1–3]. Fifteenrganisation for Economic Cooperation and Development
Please cite this article in press as: Dyer TA, et al. The acceptabiHealth Policy (2014), http://dx.doi.org/10.1016/j.healthpol.201
OECD] countries have recent policy changes encouraging wider use of skill-mix. Common drivers for such shifts inolicy include skills shortages, cost containment, quality
∗ Corresponding author. Tel.: +44 07917610796.E-mail addresses: [email protected] (T.A. Dyer),
[email protected] (J. Owens), [email protected]. Robinson).
1 Tel.: +44 0114 271 7891.2 Tel.: +44 0114 271 7892.
http://dx.doi.org/10.1016/j.healthpol.2014.02.013168-8510/© 2014 Elsevier Ireland Ltd. All rights reserved.
improvement, changes in need and demand, technologicalinnovation and changes in legislation and regulation [1,3].These factors have influenced UK policy with additionalimpetus provided by the desire for the National HealthService (NHS) to be primary care-led [4–9].
In the UK, skill-mix in dentistry has gained prominenceover the last two decades. Influential reports [10,11] andsubsequent legislative change [12] have led to greater inte-gration of a class of dental worker called dental therapists.Using their full scope of practice [13], dental therapistscould provide treatment at 70% of all appointments, repre-senting 60% of clinical time in UK primary dental care [14]and are predicted to have an increased role in NHS dentistry
lity of care delegation in skill-mix: The salience of trust.4.02.013
[15,16]. Four aspects of skill-mix in health care have beendefined: substitution, delegation, enhancement and inno-vation [17,18]. Predominantly, dentists have delegated careto dental therapist within a dental team, however recent
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Table 1Characteristics of participants.
Gender Number (n) Median age (years) Mean age (years) Range Working (n) Retired (n)
54
48.75
Male 7 56
Female 8 48
policy to allow direct access to dental therapists means thatthey may be increasingly used in substitution for dentistsin the future [19].
One common concern is that increasing skill-mix mayaffect the quality of care [20]. Quality in health care isa complex and multidimensional concept, with the effi-ciency, effectiveness and acceptability of services being keyfactors [21,22]. Existing data on efficiency and effective-ness suggest that such concerns about skill-mix in generalhealth care [23,24] and dentistry [25,26] maybe unfounded,although less is known about its acceptability [23–26].
Assessments of the acceptability of services shouldconsider social acceptability (or legitimacy), and the expe-riential views of service users, commonly measured usingpatient satisfaction questionnaires [22]. Our studies onthe social acceptability of delegation and substitution ofdentists with dental therapists identified low levels ofawareness or experience. Acceptability of dental therapistsundertaking some procedures was high, whilst more inva-sive procedures and those involving children were lessso [27,28]. Greater satisfaction has been reported frompatients in general health care [23,30] and dentistry [25,29]where role substitution or care delegation has been expe-rienced, although the reasons for these differences remainelusive [23,25,29,30]. However, there are theoretical andmethodological difficulties in assessing patient satisfac-tion. For example, assessing satisfaction using quantitativemethods may omit factors important to patients andother subjective views [31,32]. Qualitative exploration ofpatients’ lives, views, and experiences, can complementquantitative findings [32,33] and be a precursor to quan-titative research that measures patient experience [34].
Therefore, the aim of this research was to explore theacceptability of skill-mix and care delegation using theviews and experiences of patients and parents of childrentreated by dental therapists as a case study.
2. Method
A purposive sample of 15 adult patients was inter-viewed in South Yorkshire, England between July 2011 andMay 2012. Participants were patients at six dental practiceswho had experienced care delegation to a dental therapistwho had then provided treatment. Four of these partici-pants had children who had also been treated (Table 1). Allpatients paid for their treatment and were from a mix ofsocioeconomic backgrounds. For reasons of feasibility andpracticality, children (under 16 years) were excluded.
A multistage process recruited dental practices that pro-vided a mix of NHS and private dental care to patients
Please cite this article in press as: Dyer TA, et al. The acceptabiHealth Policy (2014), http://dx.doi.org/10.1016/j.healthpol.201
from a range of socio-economic, ethnic and cultural back-grounds, which were assumed to have the potential toinfluence views and experiences. Eight practices employingdental therapists were invited to participate, four agreed.
53 5 237 7 1
Two further practices, which had recently employed thera-pists, were suggested by participating practices also agreed.Each practice was visited by the lead researcher (TD), theaims of the study were described and questions aboutthe research answered. The importance of ensuring thatpatient participation was voluntary was emphasised.
The practices then invited patients to take part in thestudy. Interested patients were given an information sheetdescribing the study’s background and aims. Once theyhad consented, patients were contacted by telephone andfurther information provided. Once informed consent wasgained, data were collected at a venue of participants’choosing and convenience.
Narrative interviews and participant observations wereused to collect data. Although questions were looselyframed around a topic guide, interviews were largelyunstructured, allowing participants freedom in relayingaccounts of experiences of care. Areas of inquiry includedparticipants’ experiences and perceptions of general healthas well as dental services. The researcher intervened as lit-tle as possible; using active listening to invite additionalstorytelling [35,36], which enabled probing to encour-age expansion on emergent issues [37]. The researchersummarised the interviews with participants and providedan outline interpretation to clarify and verify intendedmeanings. Field notes were taken before, during, and afterinterviews to inform interpretation of the analysis. Forexample, researcher’s feelings, anything unusual that mayhave happened during the interviews, hesitations, facialexpressions, and body language which reflected partici-pants’ emotions and were not represented by speech alonewould be recorded [36].
All interviews were audiorecorded and transcribed bythe lead researcher. A synopsis of the interview and inter-pretation were given to each participant to check forinconsistencies and confirm interpretations and so thatmeaning could be negotiated [35,38,39]; so-called memberchecking. In all cases, the interpretation was consistent withparticipants’ intended meaning and a co-understandingwas established [40].
Transcripts were read at least four times to identify theunderlying narratives [41]. A narrative thematic experi-ence analysis was then undertaken [42,43]. Rather thancoding small segments, this approach preserves sequencesof data to keep stories intact for interpretation. The aim isnot merely to inductively identify stable themes and con-cepts to theorise across cases, but to take a case-centredapproach and to seek to contextualise them [44]. Nonethe-less, generalisable concepts still emerge from the storiesof individuals [42,44]. Each transcript was analysed and
lity of care delegation in skill-mix: The salience of trust.4.02.013
vignettes constructed to provide accounts of participants’personal characteristics and their views and experiencesof having care delegated to a dental therapist. Transcriptswere also analysed line-by-line to seek narrative themes.
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here they emerged, intact narratives were then allocatednder each theme on an electronic database. This processas repeated for each interview. Sampling continued until
he depth and breadth of the data captured were sufficiento allow a richness and depth of analysis that met the aim ofhe study and when emergent themes became repetitious45]. All participants were anonymised and pseudonymsre used in the presentation of the data.
Ethical approval was provided by the South Yorkshireesearch Ethic Committee (REC reference: 11/YH/0004)nd Research Governance approval was provided by theealth communities in which the study was undertaken.
. Results
Overall the data revealed that participants held posi-ive views of having their care, or the care of their children,elegated to dental therapists. The acceptability of theirxperiences appeared to be dependent on the trust the par-icipant had in the NHS and other health-related authoritiesn one hand (described here collectively as the health sys-em), and trust in their individual dentists and their teamrom interpersonal interaction on the other (Fig. 1).
.1. Trust in the health system
Participants’ perceptions of the nature of health ser-ices in general and dental services in particular, variedetween and within individuals, depending on the context
n which services were being discussed. Perceptions rangedrom a public service perspective with “traditional” collec-ivist views of dental services. In such cases confidence inhe NHS arose from familiarity with an organisation whoseim was believed to be for social good. At the other endf the spectrum, more consumerist views were related toower levels of trust in the health system as a whole. Suchonsumerist perspectives tended to emphasise the patienthoice, costs and convenience of treatment provided. Thisange of perceptions influenced views on the rationale forsing skill-mix.
Dennis, a builder, saw the NHS as a force for good anderceived the rationale for skill-mix centred on its ability to
ncrease access to care and use resources more efficiently:
“Well, if I’m reading the newspapers correctly, we’re inshort supply of dentists and presumably we’ve got toreplace them with something and in the meantime trainup therapists, to see if we can move up their skills levelsup to the point where they can cover more of the dentist’swork.” (Dennis)
onversely, consumerist perspectives centred on moreynical views that centred on skill-mix’s potential at a sys-em level to cut costs:
“I should say that it’s down to money really. It usually is.
Please cite this article in press as: Dyer TA, et al. The acceptabiHealth Policy (2014), http://dx.doi.org/10.1016/j.healthpol.201
It certainly was in my line of work. Even if something isa good idea for another reason, but happens to cost less,it’s usually the fact that it costs less that becomes the mostimportant thing.” (Margaret)
PRESS xxx (2014) xxx–xxx 3
3.2. Loss of trust in the system and its remedy
Many participants reported bad experiences in theirchildhood that had resulted in a lack of trust in dentistryand reluctance or failure to attend. David, a builder andfather of two children, had a pragmatic view of health care.His early experiences of dentistry were largely for symptomrelief:
“[. . .] I got sent to this other place and had teeth ripped out,you know wi’ gas. I think I went a couple of times, yeah, sohad about ten teeth taken out, something like that. It wereterrible - nobody said owt, you know, the smell of gas andair stuff, yeah.” (David)
Later experiences changed his views, enabling regularattendance despite some residual anxiety:
“Like I say, it were mainly the attitude of all the people, youknow, the staff that were different. They talk to you, theyseem like, like they want to know how you’re doing andthat. (Pause) It’s hard to remember though what it werelike though, you know, exactly, when I were a kid cos itwere so long ago and I didn’t go much, but it’s much better,yeah.” (David)
Trust in the system of dentistry appeared to be influencedby interpersonal experiences. Lucia, a mother and teacher,had a trusting relationship with her dentist, but her firstexperience of dental care in the UK resulted in her beingdisillusioned with UK dentistry:
“[. . .] the first experience I had here it was ‘ok, open yourmouth for half an hour or longer than that’ – no chat orexplanation [. . .] my mouth was open for so long that Icouldn’t shut it afterwards and I had a dislocated jaw, itdidn’t hurt or anything, but it was a horrendous experienceand from that experience I was just really concerned aboutgoing to the dentist, you know, in England.” (Lucia)
Loss of trust in the system for Lucia was remedied by posi-tive experiences, related to interpersonal interaction and asense of being cared for:
“To me it is the relationship you have with the dentist. Youdeserve some time apart from the treatment, you need tofeel at ease with the dentist or doctor [. . .] you need to feelsafe and trust them.” (Lucia)
3.3. Trust, regulation of skill-mix and training
Despite high levels of trust reported in their practicesand teams, some participants had been initially unawarethat they had not been treated by a dentist. Others believedthat they were being treated by a hygienist (another typeof dental auxiliary with more restricted permitted duties).When asked how he felt when he had been treated by a den-tal therapist, Peter, a retired Armed Forces Officer, trusted
lity of care delegation in skill-mix: The salience of trust.4.02.013
in the system to regulate appropriately:
“[. . .] don’t see a problem with it as long as the officialbodies are happy with their level of training – then I don’tsee personally why I should have any issues as I am trusting
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ust and
Fig. 1. Factors impacting on trin the fact that they have received the correct training.”(Peter)
Despite recent bad experiences of NHS dental care, Jenny,a mum and care worker, held very positive views of thehealth service as a whole, particularly its public servicenature and implicitly supported its founding principles. Herbelief in professional and NHS regulation meant that shewas not concerned about the delegation of her care or thatof her child:
“[. . .] they wouldn’t put anybody there who couldn’t do thejob properly I’d hope. I don’t know really, it’s hard to think,but now when I think about it I just assumed she were justa dentist. You do put your trust in people don’t you whenthey work in a place like that, in the NHS, like in a doctorsas well? [. . .] I just assumed that they wouldn’t send mychild or me to someone that weren’t capable of doing that,so they must be trained, obviously.” (Jenny)
3.4. Trust and consumerist perspectives
Increasing skill-mix use elicited conflicting perspec-tives. On one hand, some felt that access to clinicians ofvarying levels of qualification provided opportunities forchoice:
“[. . .] you will have to have two price levels; one for thetherapist and one for the dentist, you are paying morebecause the dentist is a fully trained man, experienced man,
Please cite this article in press as: Dyer TA, et al. The acceptabiHealth Policy (2014), http://dx.doi.org/10.1016/j.healthpol.201
he would oversee everything but perhaps you would expectto pay less for the hygienist (dental therapist) because theyare not the same level, which some might like, you know,the option.” (Peter)
the acceptability of skill-mix.
Peter was self-employed and had been in the Military.He demonstrated a need to trust the dentist to compensatefor gaps in his knowledge of dental therapists’ training andremit and questioned anyone’s ability to act as an informedconsumer:
“Also, if you trust your dentist, you would assume that theywould only refer you to somewhere that they are happywith too. That’s the important thing for me – at somepoint you have to trust the professional – I don’t have thetime or the knowledge to question otherwise. . .Who has?”(Peter)
Dissonant views were also held by Chrissie who combinedher role as a wife and mother of two children with runninga business. She frequently visited the US, and identifiedwith its more meritocratic society. Her consumerist stancereflected her relatively distrusting disposition towardsdentistry:
“I think you ought to be given the choice of whether yougo to the dentist or the hygienist (dental therapist) becausethey’ll be plenty of people that have not got a fear and trustanyone and they’d be quite happy to go to the hygienist(dental therapist) and have it done if it means they get aquicker appointment.” (Chrissie)
However, she did not extend the importance of choiceto others who she felt did not deserve it:
“Because if they don’t tell them they’re not a dentist [. . .],
lity of care delegation in skill-mix: The salience of trust.4.02.013
especially if it’s in the NHS and a vast majority peopledon’t pay for it, then what does it matter? If they (the den-tal therapists) know what they’re doing, don’t tell them.”(Chrissie)
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.5. Trust from interpersonal interaction
Two key inter-related themes emerged from the datahat contributed to trust and the acceptability of delegat-ng care. The first was the affective behaviour of the dentaleam, and the second was experiences of care, delegationnd continuity of care.
.6. Trust, affective behaviour of the dentist and dentaleam
Affective behaviour refers to the dentists’ and dentaleams’ approach to communication. For example, positiveffective behaviour would include social interaction/talk,greement, building rapport, reassurance, and facilitation.ll participants had been regular attenders at their currentractice for a number of years. Positive perceptions of den-istry were described, based on the affective behaviour ofhe dental team:
“When I went to this dentist it was different world, youknow all I can remember was rubber and chloroform. WhenI got there, there were people who were interested in whatwas going on, they talked me through the treatments theywere going to give me, they told me exactly what they goingto do step-by-step, they kept checking I was okay, that Iwas happy with everything, I found it very reassuring.”(Peter)
thers had experienced other providers which made themppreciate their own dental team:
“[. . .] I had to go to an emergency dentist [. . .] when I hadan abscess or whatever wi’ me’ wisdom tooth, I think itwere. That were crap compared with ours – they [the team]never spoke to me or owt, but she [the dentist] could hardlyspeak English, don’t know where she were from, but sheweren’t nowhere as good as my dentist. All she did were likewrite me for some antibiotics (pause) don’t think she reallylooked in me’ mouth or asked what the problem were, like,which were a bit weird [. . .] I know it sounds bad sayingthis, but honest to God, she weren’t good. I wouldn’t wanther doing a filling or owt, honestly.” (Ben)
Terms used to indicate positive affective behaviourncluded friendliness, openness, interested, good bedside
anner, reassuring and having time to address partici-ants’ concerns.
The trust that affective behaviour engendered resultedn some unquestioningly accepting delegation of their careo a dental therapist, despite having little or no knowledgef their training or qualifications. However, in some caseshis lack of communication resulted in dissatisfaction. Gary,
self-employed plumber, had changed to his current den-ist having been unhappy with his previous practice wheree had seen different dentists who “sent” him to see theygienist for treatment, which he suspected was for theenefit of the practice rather than for his health improve-
Please cite this article in press as: Dyer TA, et al. The acceptabiHealth Policy (2014), http://dx.doi.org/10.1016/j.healthpol.201
ent:
“Well I just thought they didn’t explain anything that theywere doing or how they were going to do it [. . .] It’s difficult,I know, they’ve got a job to do and they’ve got to get on with
PRESS xxx (2014) xxx–xxx 5
it and do it, but just for the sake of two or three minutes,explaining how they were going to do it would have beena lot better. It would have put my mind at ease a lot more.”(Gary)
Trust that developed through interaction with their den-tist could compensate for gaps in awareness of trainingand permitted duties of dental therapists and facilitatedthe delegation of care. When Mary, a health care profes-sional, was referred to the therapist, she was unaware oftheir training and qualification:
“But I didn’t have a problem with it. In the end you’re atthe dentist and just have to get on and trust the dentist andthose looking after you, don’t you?” (Mary)
In the absence of knowledge, some participants with highregard and trust in their dentist seemed to erroneouslybelieve that dental therapists were specialists trained incertain aspects of care:
“No, he just refers them straight through (to the dentaltherapist) cos I think she’s the one that deals with the kidsmore when they’re having fillings and things. I don’t thinkthe dentists do that so much and think she’s like specialisedin treating children (pause) I think that’s right.” (Linda)
3.7. Trust, experience, delegation and continuing care
Experience of delegated care was invariably positive,with the affective behaviour of the dental therapists being akey factor, coupled with participants’ perceptions of theirclinical competence. Edith attended irregularly when shewas younger, which she linked to a number of bad expe-riences. She would have preferred to continue to see herdentist with whom she had developed trust, but agreed tohave her care delegated on his recommendation:
“[. . .] it hadn’t entered my head about what qualificationsthey have - I’ve had loads of treatment which has all beengreat so it’s not an issue now. I suppose it might have beenlooking back and I might have been more interested if thecurrent hygienist (dental therapist) left to go somewhereelse. That might be a worry.” (Edith)
For many, the perception of competence was more impor-tant than any particular qualification, which they may ormay not have been able to interpret anyway:
“[. . .] if somebody is doing a good job, you’re not botheredwho they are, it’s not qualifications, it’s ‘can they do thejob?’ You can have a string of qualifications and can berubbish [. . .] you might be qualified as a dentist but youmight cause a patient a lot of suffering because of yourmanner, but you might be qualified therapist, but you’vegot that manner that puts your patients at ease.” (Ernest)
Fear of a break in the continuity of care with a dentist was abarrier to seeing the dental therapist for some. Linda’s will-ingness to attend depended on the trust in her dentist who
lity of care delegation in skill-mix: The salience of trust.4.02.013
would continue to oversee care, but she was still concernedabout seeing a different clinician:
“Oh my god! What she gonna do? I was right worried ‘cos itwere like just another person that might treat me and I only
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just got enough bravery to go to the dentist and were onlyjust seeing them, so I were really worried about, I didn’treally want to go.” (Linda)
However, the desire for continuity of care now extended tothe dental therapist once she had been treated by her:
“[. . .] ‘cos I know what she does, I know what she’s like andshe knows me. When you get somebody different you’relike ‘are they gonna hurt me, are they gonna do somethingdifferent?” (Linda)
Ben had always been treated by one dental therapist. Hehad always been happy to attend but was unhappy aboutbeing treated elsewhere:
“God, you’re making me think, ‘cos I’ve only ever been tothe same people, you know, dentists [. . .] no I wouldn’t liketo (see another therapist) because you hear about all thesestories from me’ dad, like, and other people, and they havea nightmare.” (Ben)
4. Discussion
To our knowledge, this is the first study to explore viewsand experiences of adult patients and parents of childrenwho had had their care delegated within a health care team.Overall, participants reported positive experiences of treat-ment for themselves and their children, which is perhaps tobe expected given that all attended regularly. Nonethelessthese findings complement and are consistent with exist-ing quantitative patient satisfaction data in general anddental health care. They also corroborate reports that highlevels of patient satisfaction reported in surveys can alsomask areas of concern [31,32,46–48].
The key theme to emerge from the data was the salienceof trust. Its unsolicited emergence has been reported beforefrom studies of patients’ experience and is a discrete con-cept from patient satisfaction: “trust is a forward lookingand reflects an attitude to a new or on-going relationship,whereas satisfaction tends to be based on past experienceand refers to assessment of provider performance” [49].Trust has also been identified as a key factor in publicacceptability of pharmacist-led medical services [50].
Two main theoretical perspectives on trust in healthcare arise from Giddens [51,52] and Luhmann [53,54]. Bothrecognise two forms of trust operating at a system level(which Luhmann describes as “institutional” and Giddensas “faceless”) and at an interpersonal level or what Gid-dens describes as “facework”. Both theorists propose thatinterpersonal trust is negotiated between individuals andis a learned personal trait. It can be built, sustained ordamaged in face-to-face encounters and is more likely tobe increased with longer relationships [55]. Giddens sees“access points” to the system where “facework” commit-ments occur where the demeanour (or affective behaviour)of the agent (e.g. a clinician) influence trust in that system.Their views on the “system” are also similar; although Luh-
Please cite this article in press as: Dyer TA, et al. The acceptabiHealth Policy (2014), http://dx.doi.org/10.1016/j.healthpol.201
mann’s “system” incorporates social, political and judicialsystems as well as health care.
There are also differences. Giddens sees the need totrust in society arising from increased risk, self-reflection
PRESS xxx (2014) xxx–xxx
and willingness to challenge experts in late modernity.Trust is needed because choices are made with partialknowledge or ignorance; if there is full knowledge, there isno need to trust. Giddens’ “faceless” commitment reflectsthe perceived legitimacy, technical competence and abil-ity of the system and he argues that trust in the systemis sustained through “facework” commitment, i.e. trust ina clinician is required to have trust in the system as awhole [51,52]. Luhmann sees trust as “glue” holding societytogether, reducing complexity and the need to constantlyto make decisions for ourselves. He argues that as systemcomplexity has increased in late modernity there has beena concomitant increased need to trust. Luhmann’s theoryrests on relationships: trust is theorised as a medium ofinteraction between social systems and individuals. Trustbetween systems and an individual is seen as multidimen-sional, with trust in one system being influenced by othersocial systems and individuals. The corollary is also thecase, where trust in an individual (e.g. a clinician) is con-tingent on trust in social systems, so Luhmann sees trust asboth an outcome and response to increasing complexity inlate modern society [53,54].
The perception of the nature of dental services wasfound to be important in our earlier study of adults whohad not experienced delegation of their care. Collectivist,public service views were associated with more supportfor delegation than more consumerist perspectives [28].These data suggest a more consumerist stance tends tobe less supportive of skill-mix and perhaps less trustingof services overall. A similar finding has been reportedwhen care traditionally provided by GPs is to be dele-gated to pharmacists in a commercial community setting[50].
The notion of the patient consumer has arisen wherehealth care policy has adopted a free market model andpatients have been referred to as customers. Our find-ings are consistent with Gidden’s concept of the individualreflecting entrepreneurially for self-benefit and where theunquestioning acceptance of medicine as the sole sourceof expertise is challenged [56]. Ironically, such a stanceincreases the need to trust, if patients become aware oftheir lack of knowledge. However, our data also support thetension for patients who wish to exercise informed choiceon the one hand, yet wish to take a more passive role as a“receiver” of services in which they trust health care pro-fessionals in the absence of full knowledge, on the other[57].
Consumerist perspectives are manifest in participantsseeing increased use of skill-mix as an opportunity forfinancial gain or cost-saving rather than a more efficientuse of resources. Some also saw skill-mix’s potential toincrease patient choice, with opportunities to choose thehealth care worker with a shorter waiting time or at lowercost. Conversely, more collectivist views were linked toa more unquestioning acceptance of the use of skill-mix,assuming it was through necessity to manage workload andto trust the dentist delegating care. Interestingly, although
lity of care delegation in skill-mix: The salience of trust.4.02.013
more collectivist views tended to see no need for a dentistto diagnose disease and prescribe treatment, a team hierar-chy was seen as important with reassurance by the dentistoverseeing treatment.
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The system was widely trusted to adequately regu-ate and train health care workers to operate in a teampproach. Despite many participants’ bad experiences ofare, they remained willing to trust the system as a whole,eemingly supporting Luhmann’s, rather than Gidden’s,ess linear theory. However, those that had bad experi-nces of care had since had positive experiences whichppeared to alter perceptions and engender trust overall49,51–54,58].
Interpersonal trust facilitated the acceptance of del-gation of care, with the quality of clinician–patientnteraction, being the key factor. Two aspects of cliniciannd service characteristics appear important in developingnd sustaining trust; moral integrity (i.e. patients’ percep-ions of honesty, transparency and confidentiality); andersonal doctoring (i.e. power sharing in decision-making,umility, respect, compassion, competence, continuity andealism) [59]. One way to improve affective behaviour isor clinicians to take a holistic, patient-centred approachorking towards mutual understanding and avoidance of
oercion [60,61].Participants used trust in their dentists to compensate
or gaps in their knowledge of dental therapists’ educa-ion, training and remit. Experiences of treatment providedy dental therapists, whether that be for themselves orhat of their children, appeared to reinforce trust in theirental practice, supporting Luhmann’s notion of trust as
multidimensional and multidirectional phenomenon;ositive experiences of technical competence and interper-onal interaction complemented existing trust in a system53,54,62].
Given this salience, patients’ trust in clinicians shouldot be underestimated or abused. For these participants,rust meant they accepted delegation of care to a clinicianbout whom they knew little. Clearly this has implica-ions for ethical practice [58], particularly the imperativef valid consent in team working [63,64]. The degree tohich patients can be fully informed is questionable and so
rust may always be needed, even within shared decision-aking. Information inequalities are inevitable and are not
ecessarily the cause of dissatisfaction or poor quality care65,66]. Indeed, it is argued, public perception of the legiti-
acy and quality of services is dependent on the existencef trust [22,67].
Clinical governance was designed to re-build trust in UKealth care [68,69]. Ironically, it has had little or no effectn trust in the system as a whole, and trust in health careanagers remains very low. Conversely trust in clinicians
emains high [49]. It has been argued that policies to estab-ish a health care market increase the number of serviceroviders, undermines continuity of care and increaseseprofessionalisation. The net result of these changes ishat trust is undermined [49,59] and the legitimacy of ser-ices compromised [67]. There is evidence that there haseen a reduction in the quality of the NHS and patients’ per-eptions of the service appear to have been undermined,hereas satisfaction with their individual experiences of
Please cite this article in press as: Dyer TA, et al. The acceptabiHealth Policy (2014), http://dx.doi.org/10.1016/j.healthpol.201
are remain high [70]. It appears that the negative percep-ions of proposed changes to the NHS and the Governmentave contributed to this fall of trust overall, and mightave been influenced by the negative views of powerful
PRESS xxx (2014) xxx–xxx 7
professional organisations and some sections of the media[71].
5. Reflexivity
Statistical generalisations cannot be inferred fromqualitative research but conceptual generalisations can.Consequently the key themes identified as emerging fromthe data are likely to be present amongst patients inother practices and services, although their prevalenceis unknown. The overwhelmingly positive experiencesreported here, maybe partly a consequence of the recruit-ment process. Dental practice teams approached patientsto participate, and were asked to include those who sub-sequently declined to see a therapist again after an initialvisit. Unfortunately only one such patient agreed to par-ticipate; all others had attended regularly for a number ofyears. Research ethics and the study protocol did not permitpursuit of those declining involvement.
A second concern was the similarity of participat-ing practices. As the 2006 NHS dental contract does notencourage skill-mix, those employing it are likely to beatypical. There was a sense that participating dentistsand practices had a particularly patient-centred approach.Nonetheless, qualitative methods were able to identifyareas for improvement in the process of delegation, espe-cially in communicating its rationale and the training andremit of dental therapists. Finally there was concern aboutthe power imbalance between the researcher (who was adentist) and participants and any resulting response bias.Although it would be naïve to suggest that these factorswere totally accounted for, they were mitigated as muchas possible by modifying language and avoidance of dentalterminology. Notwithstanding these concerns, the researchand report meets NICE methodological criteria for qualita-tive research [67].
6. Conclusion
This study identified positive views and experiences ofthe delegation of care in services using a team approach,even when treatment involved minor surgical interven-tions and for children. This acceptability appeared relianton trust in clinicians and the system as a whole, with affec-tive behaviour, perceptions of competence and continuityof care being of importance. Trust appeared to compensatefor any lack of knowledge about the training and remit ofteam workers providing care.
Although trust is needed in health care, there is a “dark-side” to trust as it can be abused and lost. An increasinglymarketised health system, and focus on the patient as aconsumer, may challenge trust and the acceptability of del-egation and the notion of patient-centred health care.
lity of care delegation in skill-mix: The salience of trust.4.02.013
Conflicts of interest
None declared.
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Acknowledgement
The research was supported by a grant provided by theBritish Society of General Dental Surgery.
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