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There has been a growing demand for analysis of healthcare process as it has become increasingly recognised that patients, professionals and managers tend to value aspects of process as much as healthcare outcomes. The articles in this special section of Policy & Politics aim to consider the methodological and theoretical challenges involved in exploring the questions addressed in process analysis and process evaluation. This introductory article provides an overview of the general questions that need to be explored and how the articles inform these questions. These general questions are organised around the following five analytical themes: theory building and process analysis; interface with policy and practice; epistemiological and methodological rigour and transparency; the analysis of context; and the need for greater external validity and cumulation.

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It has been argued that the health system in India appears to be systematically falling short in achieving equitable improvements in health status, quality of care, and social and financial risk protection. The poor performance of the health system is to a large extent due to the failure of the state regulators and of the professional associations to uphold their mandates, which in turn appears to be related to a broader and more fundamental failure of ‘trust’ in the expert systems that deliver health care and in institutions that are mandated to oversee this ‘entrustment’. This chapter attempts to identify the sources of this erosion of trust by analysing the regulatory and stewardship arrangements of the health system in India

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Chapter One takes a number of the themes raised in the Introduction – especially risk, vulnerability and uncertainty – and develops these in order to come towards a more precise conceptualisation of trust in relation to these other factors. To this end, ‘what trust is not’ is clarified as a means of ascertaining and specifying the nature of trust as applied in the book. Social theories of trust are drawn upon in achieving this, before the difficulties of researching trust in empirical settings are considered. Phenomenological approaches are discussed as a solution. The remainder of the chapter outlines the nature of the empirical study and the logic of the research design behind this.

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Chapter Two further develops the theoretical and conceptual framework introduced in Chapter One, illustrating this in more depth through the qualitative data from interviews with service users and professionals. Sections investigate how these respondents – especially service-users – reconciled broader assumptions regarding the motivations and competencies of actors (based on institutional context, profession and other ideal-types) with more individualised ‘signs’ expressed through face-to-face communication. This chapter thus considers how trust in individuals is possible despite more problematic institutional contexts and related uncertainties and vulnerabilities which emerge from negative past experiences. At the heart of the analysis is the development of understandings of how inter-personal interactions are able to override negative perceptions of the abstract system within the formation of trust.

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Chapter Three tackles some of the tensions alluded to earlier in the book between conceptions of trust as a more or less ‘rational’ form of behaviour. A range of arguments that consider trust as more or less calculative, cognitive and emotional, and conscious and less-than-conscious, are considered in the light of our own findings. Moreover we seek to demonstrate how many of these dualisms that exist within trust research may be overcome. Drawing in particular on the theoretical work of Barbalet and the philosophy of Gray, a number of critiques of overly narrow ‘rational-actor’ conceptualisations of trust are put forward in emphasising the broader rationality of trust and mistrust in overcoming vulnerability in the midst of uncertainty.

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Chapter Four tackles a rather contentious theme that is emerging within the trust literature pertaining to vulnerability, choice and power. Considerations of the extent to which one is able to choose a course of action within a specific situation, and the corresponding relevance of trust (or whether the term ‘trust’ should indeed be applied at all), are explored. This leads to considerations of trust as a forced-option amidst vulnerability and the extent to which this latter factor, especially where it exists in heightened form, may lead to a ‘will to trust’. This apparent willingness may make trust more likely but not inevitable. In this sense it is possible to identify agency even in situations where apparently limited choice exists regarding treatment.

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Chapter Five moves towards considering the organisational and policy dimensions of our study and especially explores the possibilities and difficulties for trusting relationships to develop within a context dominated by frameworks of risk, calculability and accountability. In particular there is a focus upon the experiences of professionals and managers in the varying mental health contexts of our study and the manner by which a culture of audit and risk bears upon different relationship dimensions within the organisation. From here it becomes apparent that the nature of (mis)trust relations which exist within one level of the organisational context have implications for the development and character of relationships elsewhere – and therefore for trust.

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Trusting on the edge: implications for policy Chapter Six draws together a number of the key themes emerging within the book and considers these, and the value of trust, as a principle for policymaking – at local and macro-policy levels. Mental health policy has oscillated over many years between facilitating the meeting of need through a more medicalised focus and recurring preoccupations with proceduralism – not least those around risk. It is argued that mental health services organised around a concept of trust may be more effective in satisfying both these concerns. The potential for trust to replace risk as a dominant organising concept for mental health policy is thus explored alongside factors that would seem to limit such a possibility. A number of broader reflections across the themes of the book are also raised.

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The chapter surveys a range of recent social theorising regarding the nature of vulnerability and uncertainty within late modernity and the pressures faced by individuals and institutions in light of these. Risk and trust are discussed as common ways of responding to vulnerability and uncertainty. The tensions emerging within the management of risk and the potential for trust are explored. Following Williamson, various ‘atmospheres’ of trust are described in setting the wider context of the analysis which follows later in the book.

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This chapter seeks to deconstruct the notion of stress. The discourse of work stress is collapsing under the weight of its own conceptual and methodological contradictions, only to be replaced by a new discourse of wellbeing. Much of the work-stress literature adopts a positivist epidemiological standpoint that sees stress as a response to ‘objective’ job characteristics, such as demands, control or support. As such, it fails to recognise the multi-factorial nature of mental health or the role of subjective appraisal in mediating the stress response, and is therefore unable to explain why individuals in objectively similar jobs report radically different levels of stress, or why the stress epidemic emerged at a time when work was arguably substantially less demanding than in earlier times. Interventions based on the work-stress model have spectacularly failed to reduce the incidence of work stress or the number of working days lost because of it, despite a major campaign by the HSE since 2001. Various attempts to overcome the limitations of the work-stress concept by empirical innovation have not proven successful.

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