Managing risk: Risk perception, trust and control in a Primary Care Partnership

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Social Science & Medicine 64 (2007) 911–923

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Managing risk: Risk perception, trust and controlin a Primary Care Partnership

Rae Walker�, Penny Bisset, Jenny Adam

La Trobe University Bundoora, Victoria, Australia

Available online 29 November 2006

Abstract

In this article, managers’ perceptions of risk on entering a newly formed primary health care partnership are explored, as

are the mechanisms of trust and control used to manage them. The article reports a qualitative component of a 2-year

National Health and Medical Research Council funded study of trust within the structures of a Primary Care Partnership

(PCP) in Victoria, Australia. Multiple methods of data collection were employed. We found that managers identified risks

at system, partnership and agency levels, and that as trust was built, concern about risks diminished. Trust effectively

facilitated joint action, but it was betrayed on occasions, in which case the informal power of group process was used to

contain the problems. The implications of this study for policy makers are in terms of understanding how perceptions of

risk are constructed, the ways managers use social control to create a safer context in which to locate the trust-based

relationships that facilitate joint action, and the importance of institutional arrangements. Without trust, joint action is

hard to achieve, and without control, it is difficult to prevent breaches of trust from inhibiting joint action.

r 2006 Elsevier Ltd. All rights reserved.

Keywords: Australia; Risk; Trust; Primary health care; Management

Introduction

For two decades governments in Australia havesought to reform publicly provided health servicesystems to address perceived failures such asinefficiency and service gaps (Hancock, 1999,p. 1). In pursuit of these ends, a business-oriented,Victoria state government transformed the publicservice system during the 1990s, from one char-acterised by bureaucracy to one manifesting manyfeatures of a market. In the case of community

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1783.

resses: [email protected] (R. Walker),

e.edu.au (P. Bisset).

health centres and their staff, one type of primaryhealth care agency, the effects, by the late 1990s,were complex.

Community health centre managers and staffoperate in an environment that is partly amarket, partly a bureaucracy and partly a servicenetwork. The environment is market in so far asoutput-based funding [funding is provided forspecified units of service delivered] establishes asystem of product pricing, competition to gainresources, and incentives to deliver services atcompetitive prices.yTraditionally, communityhealth centres have arranged their servicesthrough using network forms of organisationbased on mutual knowledge and trust (Walker,

.

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ARTICLE IN PRESSR. Walker et al. / Social Science & Medicine 64 (2007) 911–923912

1992). These have manifest as collaborativerelationships and systems of cross referral,organisational and peer support. Networksremain an important way of organising relation-ships with community constituencies [less so withagencies that were, or could be, competitor-s].yAmalgamations of centres to reduce costshave created larger and more bureaucraticorganisational structure in which relationshipsare coordinated and controlled by the exercise ofauthority (Lewis & Walker, 1997, p. 50).

The market reforms improved efficiency but wereunable to fill the service gaps and create anintegrated system for service users. Communityhealth centre managers argued that although policy-makers considered service linkages very important,in practice ‘its not actually reflected in what we can

do on the ground’ [emphasis added] (Lewis &Walker, 1997, p. 35).

By the late 1990s, the market model wasperceived, by policymakers, to have failed toprovide improved health services to users (Smith,1999, p. 175). In 2000, a new Victorian stategovernment sought to address these problemsthrough the Primary Care Partnerships (PCPs)Strategy which was to enhance cooperation betweenagencies to improve health service delivery to usersand reduce the burden of ill health in the commu-nity (Department of Human Services, 2000).A PCP:

�
is a voluntary alliance of the primary care serviceproviders in a geographic area; that, � will improve the health and wellbeing of a
community; and,
� will work in a social model of health (Depart-
ment of Human Services, 2000, p. 4).

PCPs were ‘voluntary’ in the sense that there wasno formal compulsion to participate but there weremany compelling incentives for participation. Mem-bership of the PCP was area based and mostincluded 2–3 local governments, 2–3 communityhealth services, diverse smaller primary care agen-cies, and single membership from agencies such as ahospital and district nursing service.

The use of a partnership model to inform servicesystem reform in Victoria reflected similar develop-ments in the United States (Rainey & Busson, 2001,p. 49) and in Britain (Attwood, Pedler, Pritchard, &Wilkinson, 2003; Powell & Glendinning, 2002). The

partnership model, it was argued, would help solvedifficult problems that crossed organisational andprofessional boundaries by facilitating the use of‘integrated (‘seamless’) service planning, management

and delivery’ of services to clients (Hudson & Hardy,2002, p. 51). Following a review of diverse publicsector service partnerships in Britain, Rummeryidentified two defining characteristics: interdepen-dence between agencies in their achievement ofobjectives, and trust between partners ‘to deliver on

jointly held objectives’ (Rummery, 2002, p. 235).The research question underpinning this study

was: How do actors within the primary health andcommunity support system create and maintainrelationships of trust between individuals, andbetween organisations? The focus of the study wason the issue of trust broadly defined. Trust wasviewed as a characteristic of partnerships and acomplex phenomenon that operated at multiplelevels, influenced by the actions of participants andthe systems in which they were embedded.

What follows is a brief discussion of why and howpartnerships have been used in health system reformaround the world, a brief review of the concepts ofrisk, trust and control, discussion of the methodsused in the study and some key findings and theirimplications.

Literature review

In Australia, from the late 1970s to the early1990s, community health services used collaborativestrategies to change the way services were delivered.By the end of this period, the networks of personaland organisational relationships had been welldocumented (Raftery, 1995; Walker, 1992). Thesenetworks never disappeared, and provided a foun-dation for contemporary partnership strategies inprimary health care. The market reforms of the1990s created tensions between cooperation andcompetition in the primary health care sector (Lewis& Walker, 1997).

In a study of a collaborative approach to healthsystem reform in the state of South Australia,participants identified many benefits of the partner-ship-based reforms and five major barriers: uncer-tainty about funding of reform implementation,variable commitment from reform actors, agencyprotection of activities and funding, confidentialityof client information, and, concern about clientexperience of the changes (Baum, Blandford, &Dwyer, 2001, p. 321). Alexander (1995, p. 18)

ARTICLE IN PRESSR. Walker et al. / Social Science & Medicine 64 (2007) 911–923 913

describes these kinds of barriers as ‘potential costs

of coordination’ and categorises them as ‘the

perceived risk of losing or spending scarce resources’and ‘a threat to the organisation’s critical values’.The risks managers perceive in their environ-ment, and in the face of which they must act,are the ground upon which trust relationships arebuilt.

Risk perception

Trust and risk are related in that without riskthere are no grounds for trust (Luhmann, 1988). Inthe sociological literature, risk is defined broadly,for example, as ‘the probability of adversity related

to our own actions, due to our own commitments’(Sztompka, 1999, p. 30). Actions may create risksbut they may or may not be perceived. In themanagement literature, risk is often conceived morenarrowly as vulnerability to opportunistic beha-viour (Davies, 2001, p. 45; Huxham & Vangen,2005).

The ways people view risk can be considered froma social constructionist perspective in which under-standings of risk emerge from social experience andpersonal knowledge. Joffe (2003, p. 60) argues thatfrom this perspective, risk is the result of ‘socio-

cultural, historical and group-specific forces [becom-

ing] sedimented’ in the individual’s knowledge andemotions. ‘Anxiety and trust, rather than ‘cold’information-handling processes, may well play pivotal

roles in the apprehension of risk’ (Joffe, 2003, p. 62).Managers within a service sector acquire, with time,a historical perspective on risk (Taylor-Gooby,2002, p. 110).

Joffe (2003) argues that two key processes,anchoring and objectification, are used to constructthe representations of risks in a particular context.Anchoring is a process in which new events aremoulded to appear continuous with existing ideas(Joffe, 2003, p. 63).

Anchoring is not purely an intrapersonal processof assimilation. Rather, the ideas, images andlanguage shared within groups steer the directionin which members come to terms with theunfamiliar. This makes the alien event imagin-able (Joffe, 2003, p. 63).

In the risks identified by our informants we mightexpect to find reflections of their prior experience ofthe primary health care system.

Objectification refers to the inclusion of emo-tional and political elements in the representationof risk.

In social representation formation, the processtermed objectification works in tandem withanchoring, transforming the abstract links topast ideas that anchoring sets up into concretemental content. Unfamiliar ideas can be madefamiliar by being linked to historically familiarepisodes and/or to the culturally familiar. Whileanchoring involves drawing on shared knowledgefrom the past, objectification involves drawing onthe current experiential world of the particulargroup (Wagner cited in Joffe, 2003, p. 64).

The systemic stresses within the primary healthcare system at the time of the PCP reform processwere likely to influence the risks managers per-ceived. As a consequence of anchoring and objecti-fication, the risks identified in this study reflect thehistory of service development in primary healthcare as well as experiences of the current reformprocess that impacted on core values, individual andgroup identities and interests.

Das and Teng (2001, p. 251) argue that risk inpartnerships is managed using trust and control.Trust, of itself, is insufficient for the long-termmaintenance of relations between organisationsbecause trust, as an expectation of future action,can always be betrayed. Control is the exercise ofpower that may be called upon when expectationsare not fulfilled. Buskens and Raub (2002) arguethat, in continuing social relationship (such as apartnership), participants learn about trust, the riskof betrayal and the possibilities of control. Thislearning occurs within, and is shaped by, theparticular institutional environment. In this study,the interplays between risk, trust and control, in aprimary health care system, are explored.

Trust and risk

Risk is a concept that describes the uncertainty ofthe outcomes of human action in a complex world(Luhmann, 1979). Risks only exist in the context of‘decision and action. They do not exist by themselves.

If you refrain from action you run no risk’(Luhmann, 1988, p. 100). If a course of action ischosen ‘in spite of the possibility of being disap-

pointed by the actions of others, you define the

situation as one of trust’ (Luhmann, 1988, p. 97).Risk and trust are complementary. In a partnership


context, trust creates risk, the magnitude of which isinfluenced by the level of trust (see definition below)and the institutional context of the actors (Zaheer &Harris, 2006). In addition, ‘as trust develops it

becomes a means for dealing with risk’ (Huxham &Vangen, 2005, p. 163).

In this paper, the definition of trust, thatencompasses the diverse views of our informants,is one that emphasises expectations about trusteeactions. Trust is defined as:

The expectation that an actor (1) can be relied onto fulfil obligations, (2) will behave in apredictable manner, (3) will act and negotiatefairly when the possibility for opportunism ispresent (Zaheer, McEvily, & Perrone, 1998,p. 143).

This definition includes a number of usefulconcepts from the trust literature. Reliance onpartners to fulfil obligations captures the experienceof partnership participants in Britain who trustedpartners ‘to deliver on jointly held objectives’(Rummery, 2002, p. 235). Furthermore, expecta-tions that a trustee will fulfil obligations is related tothe concept of competence-based trust (e.g. Barber,1983) and to the concept of ‘fragile trust’ (Ring,1997) which is trust that is limited in scope andsomewhat calculated. Predictability of an organisa-tion’s behaviour is an expression of commitment tothe joint objectives (Hudson & Hardy, 2002, p. 56).In this context, predictability means that there is ahigh probability that actors will behave as antici-pated. The importance of fairness in partnershipnegotiation of benefits is a recurring theme indiscussion of partnership functioning (for exampleHudson & Hardy, 2002, p. 57–59). Expectations offairness and the avoidance of opportunism arerelated to concepts of moral obligations (Barber,1983) and resilient trust (Ring, 1997).

Control and risk

Control is a process of exercising power toregulate the partnership and make it more pre-dictable (Das & Teng, 2001, p. 256). In partnerships,the mechanisms of control are diverse and ‘can be

achieved through governance structures, contractual

specifications, managerial arrangements, and other

more informal mechanisms’ (Das & Teng, 2001,p. 258). Formal control resides in agreed structuresand accountability arrangements (including con-

tracts), informal control in the relationships be-tween the partners.

In the context of partnerships, Huxham andVangen (2005) argue that power cannot be viewedas simply the ability to ensure an actor behaves asrequired by another. In partnerships, power can beexercised for an actor’s own benefit (power over),for mutual benefit (power to) and for altruisticbenefit (power for) (Huxham & Vangen, 2005,p. 175). The purposes for which power is exercisedhave an effect on partnership relationships.

Trust and control

Bachmann et al. (2001) describe the relationshipof trust to control as complementary. At theinterpersonal relationship, level trust and powerare thought to function as alternative ways ofcontrolling a partnership, although with differenteffects. However, when the institutional context of apartnership is considered ‘power often appears as a

precondition rather than an alternative to trust’(Bachmann, 2001, p. 351). When embedded in astrong instititutional context, individuals are con-strained and have fewer options to behave inunpredictable ways. Institutions as ‘multifaceted,durable social structures made up of symbolic

elements, social activities and material resources’(Scott, 2001, p. 49) embody power relationships.The ways risk, trust and control intersect, in thisstudy, reflect the primary health care systemcontext. However, Mollering (2005, p. 284) arguesthat although individuals are embedded in socialstructures that influence their choices by establish-ing the rules of good behaviour and the meaning ofgood and bad action, they remain active, choice-making agents that may never be absolutelypredictable.

Methodology

This research project was an in-depth case studyof one PCP using multiple methods of datacollection. The study was given ethics approval bythe La Trobe University Human Ethics Committee.

In the full study, informants were members of thePCP committees and included CEOs, senior man-agers and service providers. A written questionnairewas completed by each individual to recordpersonal information such as position in theorganisation, profession, and duration of involve-ment. An interview schedule, with open-ended


questions, was used to invite participants to exploretheir experience and views of trust and relatedconcepts. Where possible participating individualswere interviewed twice over the life of the project.The first interview explored: communication struc-tures and processes, the ways trust and distrust wereunderstood, perceptions of risk, characteristics ofpeople and organisations relevant to trust; the waytrust and distrust impacted on the capacity tocollaborate; implicit and explicit rules relating totrust, sanctions when rules were violated; environ-mental influences on trust e.g. competitive arrange-ments. The second interview retained the same formbut was modified to incorporate questions aboutchange since the previous interview. Finally, oncompletion of the interview, each participantcompleted the Trust Evaluation Scale to obtain ameasure of trust (this data is not reported in thispaper). The data reported in this paper is from theinterviews with agency managers participating inthe PCP committee of management, from theMemorandum of Understanding (MOU) betweenthe members of the PCP, and from State level policypapers. Twenty-three interviews with 16 individuals(seven individuals were interviewed twice) wereincluded in the analysis.

Interview data was coded thematically usingcategories established after reviewing the interviewtranscripts (Ezzy, 2002). Two individuals performedthe coding. To ensure consistency both coded, andthen compared their results, on a sample oftranscripts. The major coding categories were thepurpose of the PCP, the concept of trust, individualdimensions of trust, organisational dimensions oftrust, and, the environment in which the PCP waslocated. Each major category contained betweenfive and 13 minor categories e.g. in the individualdimensions of trust major category, subcategoriesincluded the behaviour or attributes of individuals,prior relationships, personal experience of partici-pation in the PCP, general values, effect of trustor lack of it on individuals, personal risks ofparticipation.

The sources of risk, in this study, were classifiedinto system, partnership and agency level factors,the three levels of organisation in the PCP structure.System level factors are those that occur withinthe state health care sector and transcend theparticular PCP, for example funding arrangements.At this level in the primary health care system,agency managers have little control over thedecisions and actions that create risks for them.

Partnership level factors are those that reside inthe particular PCP, for example, accountabilityfor collective funds. At this level, managersnegotiate decisions and actions through the struc-tures and relationships of the PCP. Agency levelfactors are those over which the managers havedirect control, for example, investment of agencyresources.

Findings

Risk perception

In this section, the risks arising from decisionsand actions at the three levels of structure arediscussed.

System level risk

At the system level, managers perceived twosources of risk. First, new arrangements in theprimary health care system could, based on priorexperience, disadvantage an agency, and/or its clientgroup. Participation in the PCP processes wasconsidered one way to ensure the implementationof system level change accommodated the needs oftheir client groups. Active participation reduced theperceived risk. The process of participation, espe-cially the imperative to reach agreement on jointaction, ensured that the interests of participantswere largely accommodated.

Second, changes to the mechanisms by whichpublic sector agencies gained funding created risks.Changes to funding pathways could change powerrelationships between agencies and thence agencyaccess to funds. ‘If they [DHS] start handing money

to the PCP rather than my organisation then over

timey there is potential for my organisation not to

be viable’. In the years immediately prior to thedevelopment of the PCP strategy, the possibility ofreducing transaction costs by directing fundingthrough area-based organisations had been can-vassed. The informant quoted above was expressingconcern that current proposals may be the old onesin new clothing. The new strategy was perceived asanchored in the old. By the second year of theresearch project the funding intentions of DHS hadbeen clarified and the perceived risk diminishedsubstantially.

By the time of the round 2 interviews, partici-pants said that system level risk had declinedsubstantially.


Partnership level risk

At the partnership level, informants identifiedfour sources of risk. First, there was the account-ability for financial and service provision perfor-mance of partners. Within the structures of PCPs,the lead agency that received, managed andaccounted for funds on behalf of the partnershipbore most risk. Financial risks for the lead agencywere reduced by the use of employment contractsconsistent with funding cycles for PCP staff, aMOU that spelt out the responsibilities of the leadagency and the principles by which the PCP wouldoperate, and lead agency openness about finances.Objectification of financial processes reduced therisk perceived.

Some member agencies also considered them-selves at financial risk. The PCP was mandated toprepare a Community Health Plan for the locality.‘Planning decisions are crucial in the transmission of

fundingy it appears PCPs will have a major say in

planning possibly leading to the allocation of funding’.Anchoring the PCP processes within the familiarframework of agency planning and funds allocation,raised anxiety for some informants. However, eachinformant was a member of the group responsiblefor the Community Health Plan and a participant inthe negotiations. Experience reduced the perceptionof risk.

The second area of risk for partner agencies wasthat cooperative work required them to changeinternally. Some informants thought that internalchange had the potential to create conflict, distrustand resistance among the agency staff. However,development of trust enabled partners to considerissues ‘as a cohesive unit in terms of the ultimate

issue, patient care’. The experience (objectification)of trust enabled managers to transcend agency levelanxieties in pursuit of a higher order goal of serviceimprovement.

The third area of perceived partnership level riskwas in the organisational form of the PCP. Themore like a formal organisation, owning its ownfunded projects, the PCP became, the more it wasconsidered a competitor by its members.

The fourth area of risk lay in the dynamicrelationships between partners. A substantial num-ber of relationship issues were thought to impact onrisk. A summary is provided in Table 1 below.

Agency level risk

Managers identified two kinds of risk at theagency level. First, there was the risk of wasting

resources participating in the PCP when they wereneeded for the provision of services.

The risk for our organisationy is the opportu-nity cost.ywe have to be selective about wherewe invest our time and energy to achieve the bestoutcomesy for our consumers.

Investment of agency money was considered highrisk, the investment of staff time in PCP activitiesrelatively low risk. It is unclear why money and timewere valued differently.

There was a persistent issue of agency size andvulnerability. Small agencies tended to see them-selves, and the services they provided to clients, asvulnerable to changes in funding and serviceprovision models. Large agencies were more assuredof continuing survival.

y this is a very large organisationy the orga-nisation is relatively protected at the end of theday if they weren’t to participate.

The large agency experience of power reducedtheir representative’s perception of risk in the PCPprocess.

Trust

Trust and risk were related in the experience ofparticipants. One informant described the relation-ship in the following way.

Well, its like you don’t even think about it [trust]do you, because you don’t need to [in a low riskenvironment]. [However], if you are standing ona plank of wood over a precipice, you’re testingthe strength of the wood, so you are worriedabout how strong the plank is. Because gee, if itdoesn’t hold, you could fall and die, or whatever.If you are standing on a piece of wood just on theground, you don’t even think about it, you arejust standing on a piece of wood.

Low-risk activities were easy and did not requiremuch trust. High-risk activities required more trust.

The purpose and nature of trust

The purpose of trust, it was argued by oneinformant:

facilitates discussion to progress projectsyWhere there is a lack of trust there is ‘‘morenot really substantive conflict, but more effective

ARTICLE IN PRESS

Table 1

Interagency relationships impacting on risk

Factors heightening perceived risk Factors reducing perceived risk

� Partners having negative perceptions of an agency (i.e. poor

agency reputation)

� An agency does not communicate openly on relevant matters

� Competition for funds between PCP members, in partnership

with other agencies

� Inclusion of funder representatives in internal PCP discussions

� Low level of trust in the funder at a political level—but not at

the mission level

� Public statements about pursuing the common good and

private actions about politics and power

� Attempts to collect detailed population and service delivery

data from agencies

� Agency representatives without the authority or power to

make substantial commitments for the agency

� Outstanding interagency and performance issues dealt with

� Shared commitment to cooperation independent of PCP

� Trust in relationships

� Confidence that agency representatives will base decisions on

issues not individuals and will do what they say they will do

� Confidence that agencies will work constructively to resolve

problems

� Positive personal relationships between personnel from the

agencies

R. Walker et al. / Social Science & Medicine 64 (2007) 911–923 917

conflict, where it is more personaly it tends tobe negative. It doesn’t progress things as welly .

The key observation here is that lack of trustinhibits joint action.

Agencies participated in the PCP voluntarily.Joint decisions were made within the committee ofmanagement but they needed to be adopted andimplemented by participating agencies. One infor-mant noted:

My observation is that underlying those state-ments of principle, policy, protocol [agreed bythe committee of management], is actually ameasure of trust because you are only going tosign off on them if you can really trust that [theagreement] is adequate to protect our interest-s.y It [trust] is a very powerful force that hassuch an impact in terms of decisions, actions andoutcomes, but is actually not talked about.

This informant is noting that trust is animportant part of the decision to cooperate. Theother part lies in the content of the agreement.These informants were arguing that trust is animportant foundation for cooperative decisionmaking and joint action, which are the means bywhich service gaps can be overcome and anintegrated health care system created.

Informants were asked to describe what theythought trust was. At the first interview informantsfound this difficult. Responses typically describedtrust as a quality of the relationships betweenindividuals. Trust between organisations, it was

argued, came down to trust between people. Oneinformant said trust:

y is about being able to develop relationshipswhereby you feel comfortable to work with otherpeople on mutual goalsy to realise something.

This informant is reflecting the British experienceof partners acting together on joint initiatives.

Another informant described people who couldbe trusted in the following way.

They say what they mean and they mean whatthey say, and they do and act on the things thatthey said. Also they share information whereverthey can, recognising that there are limitations onthat, and we do recognise that there are limita-tions on that.

For this informant trust is largely about fulfillingobligations but with some pragmatic expressions ofgoodwill.

Individuals were the most frequently identifiedobject of trust.

I am trusting at an individual levely then lookat having faith or trust in the underlying systemsand processes that people have in their variousareas.

Rarely did informants consider trust to be asystemic, or institutional, quality. One informantargued that trust is about building up systems(institutional arrangements) in which doctors find iteasy to refer clients to the manager’s service, thereferrals are appropriate for our agency and do not


disadvantage other clients requiring services, and wedo well by our clients and refer them back. Thisinformant identified characteristics of an integratedservice system.

Some agencies in the PCP had long histories ofjoint work while others had not. Informantsfrequently spoke of the residual effect of priorrelationships and of the importance of increasingfamiliarity in the new ones.

ywhen the PCP first formed a lot of partnerswithin the alliance didn’t know each other verywell at all. They hadn’t been used to dealing witheach other very well, apart from handing outblame for when things went wrong, and probablythey tended to plan in isolation from eachother.y bringing the PCP together will be agood thing because at least people will have abetter understanding of where each partner iscoming from.

Experience of partners was an opportunity tolearn about them and develop a capacity to predicttheir behaviour.

Challenges to trust

When trust-based relationships were establishedwithin the PCP, they were quite resilient. Someviolations of expectations were accepted, by infor-mants, as accidental. For example:

If someone feels they weren’t kept in the loop andwere excluded, I think that is a real detriment totrust. Equally if there is a good standard ofy abaseline level of trust and its just an oversightthen that’s well understood.

It was also recognised that agencies had torespond to their environment.

Sometimes organisations seem to be acting out ofcharacter and untrustworthy because somethingin their environment demands a response andallegiance shift. It can happen to any agency.Needs to be acknowledged when it happens.

In order to assess potential violations of trust, it isimportant to locate the agency’s actions in theircontext. Conceptions of trust within the PCP werefluid and context dependent.

Serious violations of trust were discussed in thecommittee of management, or the perpetrators werechallenged and explanations sought.

A couple of people don’t abide by those [agreed]principles, but there is enough trust to be able totake it up with them. I ring them up and askwhat’s going on.

In addition, members of the committee discussedparticular episodes, offered advice on ways ofmanaging the transgression, and sometimes ar-ranged for individuals with an appropriate relation-ship to the transgressor to take the matter up withher or him. The boundaries of trust and capacitiesfor control were explored to affirm, or re-establish,the terrain in which trust is acceptable in relation tothe risks. Repeated violations of expectationseventually lead to the individual concerned beingviewed more critically, less actively included ingroup activities because of doubts about them‘playing fair’, and eventually marginalised. Giventhat the PCP system brings financial and otherbenefits to participants, marginalisation can becostly to an agency. Appreciation of the way controlprocesses operate in a PCP system is important forparticipants who must function within it, and forpolicy makers who must try to establish theenvironment in which PCPs can function effectively.

Although there was not a lot of discussion aboutinstitutional influences on trust in the PCP therewere occasions when individuals new to particularorganisations were surprised by the ascription of anew role and a new set of expectations about trust-based behaviour. If the organisation had a historyof being uncooperative or difficult the individualwas ascribed a ‘trust status’ related to that history.‘y you become immediately a person not to be

trusted’. The limited discussion of institutionalinfluences within the PCP may be a reflection ofthe enduring and ‘taken-for-granted’ nature ofinstitutional influences.

The groups of like agencies (e.g. local governmentsector) have long-standing relationships outside thePCP and share many interests, and relationships.Occasionally, these interests surface in the PCP.

y you can occasionally see the self-interest peekthrough.y because there is a collegiate relation-ship that has been established people are able tosay: ‘‘Oh, what are you doing, which side are youplaying on today’’? So that gets it over and donewith more quickly.

From the discussion above, it is clear thatchallenges to trust-based relationships were activelymanaged by the members of the management


committee. Control mechanisms were used to eitherbring transgressors back into line, or to marginalisethem and diminish the risk they posed.

Control

Formal control in the PCP

Legal responsibility for funding and employmentof staff was undertaken by the lead agency thatreceived and managed funding from government.The lead agency was accountable to the Departmentof Human Services through a form of contractcalled a Service Agreement, and to the PCP throughthe management committee of the partnership.Initially, the Service Agreement was the only formalcontrol mechanism for the PCP.

PCP member agencies signed a negotiated MOUthat had no legal status. The MOU describedgovernance arrangements including the purpose ofthe PCP, vision, strategic objectives, principles ofoperation and variations to the agreement; and,management of the agreement including the roles,rights and responsibilities of agencies, the role of themanagement committee, decision-making processes,dispute resolution processes, intellectual propertyissues, and risk management. The agreementscontained in the MOU were both stable and opento negotiation.

I don’t think I would treat [the MOU] as a highlyimportant document. I think the commitmentgoes beyond a documenty you know that it isthere if there is not a consensusywe canactually go back to the [agreed process] y itsan evolving partnership that we change as a newrule comes into play. We think we have some-thing down pat and then the whole ball game ischanged because the Department [DHS] has adifferent objective and we just run with that. Torely too heavily on a written set of rules is notrelevant to us, I think.

The policy environment required PCPs to beflexible. In the experience of managers the flexibilitywas enhanced by the use of informal agreementsthat could be readily renegotiated.

Informal control in the PCP

Informal, or social control, uses social interactionas the mechanism to facilitate partners internalisingshared rules and norms, values and beliefs, and toreinforce and reward appropriate behaviour as wellas to sanction the inappropriate.

The social rules, or norms, that formed thefoundation for relationships in this PCP werereadily identifiable and widely, but not universally,shared. They included: competence, commitment,integrity, motivation (that is, ‘there for the rightreasons’), respect, fairness, confidentiality, reliabil-ity, open communication, flexibility, and acting forcommunity benefit.

The social rules provide a safe context withinwhich partners act. One informant, in the context ofa discussion of advice seeking, noted:

I would be more sure of the advice I was gettingif it came from someone I trusted in terms oftheir capability and competence, integrity andconfidentiality, but also in terms of the insightthey would have [into the problematic situation].

Some rules, but not all, were articulated in theMOU. The principles in the MOU assert thatmembers will work collaboratively and coopera-tively to enhance capacities of members and theirservices, communicate openly, treat informationconfidentially, negotiate differences, be open-minded and flexible, act with integrity, shareinformation and act with respect towards others.However, other rules are: ‘‘more informal, they are

unspoken, but when someone breaches them you say,

oh that’s not the way to go about it, building a

processy they are unwritten’’.Adherence to rules was cast in shades of grey.

Around the fairness rule there was an ‘‘unspoken

agreement that everybody was in it for the same sort

of thingywanted to achieve the besty that influ-

enced how naughty people felt they could be and how

much they could get away withyEverybody knew

that you had to be fair.’’ A little bit of naughtinesswas OK ‘‘because everybody knew they had to

protect their turf to a certain degree’’. However, aperson can be naughty ‘‘one too many times’’. Thisinformant is suggesting that the rules are aboutmutual benefit but that some pursuit of self-interestis acceptable, provided it is kept within limits.

The informality, fluidity and nuanced applicationof the rules created opportunities for some membersto exercise influence within the group.

y there are formal communication channels inthe form of minutes and meetings, and agree-ments, resolutions,y but there are also thingsthat mightn’t be said in a meeting but mayactually be followed up afterwards.y So some-thing might come up and I might phone or email


or vice versa, various people will send around,and you know a certain amount of lobbyingtakes place if we’re trying to get a particularresolution and I am not averse to ringing peopleup and getting them on-sidey and sowing a fewseeds prior to the meetingy and so the informalchannels sort of pre-determine the formal chan-nels at the meeting to some extent and informalchannels happen out of it.

For other participants, the same qualities of thepartnership were problematic.

My sense is that a lot of crucial communicationhappens outside the meeting.y It feels as if themanaging group is confronted with proposalsthat have been developed outside and it’s hardertherefore to have a genuine conversation aboutthat, about exploring the pros and cons because aposition has been established before the meeting.And the group [talking outside the meeting] isnot very explicity its probably a mixture ofpeople who are interested, who can be botheredturning up and being involved and you know,sort of personal relationships.

The application of informal rules was seen toempower some participants, for their own benefit,but disempower others. The disempowered wereoften newcomers. Out of powerlessness grew adegree, often unspoken, of distrust. For example, inthe view of one informant agencies from a particularsector were thought to be preparing for when PCPsceased to exist and ‘consequently, they may have

been working outside the [PCP] structure’ to furthertheir long-term interests.

Controlling rule breakers

The most common view, expressed by infor-mants, was that most people tried to abide by thesocial rules. However, when rules were broken,relationships between management committeemembers were central to the control effort. Ifparticipating members of the committee were notoffended by the breach, disciplinary action couldnot occur.

Most of the players stick by the rules but everynow and then (and it seems to be the same one ortwo players primarily) will break the rules.y Itmay be raised in the PCP or an individual mayraise it, you know, in an off the record, over acup of coffee kind of chat.y It’s usually broughtout into the open, and once again there is a fair

bit of advice goes around the group about youknow, I feel like this is becoming an issue howshould I best address it? It seems to work quitewelly

There was tolerance of occasional breaches of therules, but not of repeated breaches. A recurringcomment about a frequent rule breaker was:

It was cumulative. It’s almost like, if you did itonce or twice, other organisations might see youas [remiss], or you could still redeem yourself, butover time you could see the trust [decline]’’.

The individual was sidelined and:

there is a bit more concern about involving thatperson againy trusting the fact that they aregoing to be part [of something] and play fair.

There was agreement, among informants, on themajor strategies used to contain rule-breakers in thePCP. However, there were variations betweenpeople in the ways they responded to rule violations.In one informant’s view people who don’t abide bythe informal rules tend to be avoided. However,pragmatism may take precedence over personalconcern about rule-breaking behaviour. Forexample:

you don’t want your clients denied access totheir servicesy so I sometimes justify to myselfthat I don’t have to be buddy buddies witheverybody.

Discussion

This paper reports on a study of how actors,specifically primary health care agency managers,create and maintain relationships of trust betweenindividuals, and between organisations.

It is widely acknowledged in the literature that thedynamics and experience of interorganisationalrelationships, including those based on trust, arestrongly influenced by their institutional context(Bachmann, 2001; Mollering, 2006; Scott, 2001).With the exception of general practitioners, all theagencies participating in the PCPs were from thepublic sector. The implications of this are two-fold.First, the agencies received most of their fundingdirectly from government and were required tocomply with conditions inserted, by government, intheir funding contracts. Second, the agency man-agers clearly identified client welfare as the domi-nant shared value in the primary health care system.


Together, these issues differentiate the public systemfrom a private one. The bulk of the research into thedevelopment and maintenance of trust betweenorganisations has been undertaken in the privatesector which is embedded in a very differentinstitutional context. Although many qualities oftrust-based relationships are common to public andprivate sectors, there are also important differences,for example, the unifying value of client welfareversus profit, and the risks experienced in workingwith government (Joffe, 2003). This study is unusualin that it explores, in detail, trust-relevant issues in apublic primary health care system.

When this study was designed, trust was an issuefrequently identified by managers as an unexploredelement of partnership work. What has emerged is acomplex, negotiated, set of trust-based relation-ships. Within the group of managers, some weremore committed to joint objectives than others(Hudson & Hardy, 2002; Rummery, 2002), somewere more calculative and others more goodwillfocussed, and some considered trust a moralobligation (Barber, 1983). For most managers, trustwas a quality of relationships between individuals,for others it was also a quality of systems androutines. Although trust is primarily about meetingcommitments, predictability and goodwill these arenot absolutes (Zaheer et al., 1998). It is possible tosometimes be self-serving (a little bit naughty) andto act in unpredictable ways when the policyenvironment requires it. This dynamism is consis-tent with the findings of Mollering (2006) in hisstudy of private sector buyers and suppliers, but thecore values and environmental pressures are quitedifferent.

The issue of control as a necessary companion totrust in interorganisational relationships emergedvery strongly in this study (Bachmann et al., 2001;Das & Teng, 2001). Managers were aware of therisks inherent in system change and in the inter-dependencies of partnership work (Bachmann et al.,2001). Their overwhelming preference for informalcontrol mechanisms, to deal with challenges totrust, enabled flexibility, but at the same timealienated some group members, especially new-comers who had not yet become fully integratedinto the group processes. The dependence oninformal control also highlighted the leadershiprole of the management committee chair in estab-lishing shared rules, fair processes and managing theconversations about breaches of understandingsand agreements.

Institutional arrangements forming the environ-ment of participating organisations have an im-portant influence on the possibilities for trustrelationships (see for example Mollering, 2006).The tendency of managers to view trust inindividualistic terms, to the exclusion of the institu-tional, raises some important questions. For exam-ple, has the period of almost constant systemicchange undermined the trust of managers ingovernment and other organisations? Alternatively,are the institutional arrangements so ‘takenfor granted’ by government and agency managersthat they are invisible? Do managers seetheir decisions and actions as creating patterns thatmay be a foundation for trust and thence thecapacity to manage risk and enhance systemintegration? Where the policy goal is to establishsystematic links between agencies that are able toroutinely meet the service needs of clients thesequestions are important for decision-makers tounderstand.

Conclusion

The PCP strategy initially created perceptions ofsubstantial risks for participating agencies and theirmanagers. Perceived risks were logical assessmentsof the potential impacts of the PCP strategy, if theywere viewed within their historical and politicalcontext.

The focus on risk, and the relationship betweentrust and control that diminished the risks asso-ciated with the primary health care reform process,was important to the managers participating in thisPCP. Within the primary health care sector, it iswidely recognised that trust lubricates joint action.However, the importance of appropriate controlmechanisms, and the form they take, are not widelyunderstood. This study has opened up the issue ofrisk, trust and control, defined some key issues, andestablished some parameters within which they canbe understood in the primary health care context.Many questions remain to be explored. Forexample, how can we articulate the relationshipsbetween trust in individuals and trust in institu-tional patterns of belief, value and behaviour? Whatstrategies for trust-related institution building, atagency and partnership levels, most effectivelybridge service gaps, and what strategies at govern-ment level support this effectively?

Policy makers operating in the context of agovernment bureaucracy often have insufficient


insight into the substantial differences between theircontext and that of the agencies working in thecommunity providing services. An appreciation, bypolicy makers, of historically grounded risk, andstrategies for using that understanding to enhanceparticipation in the reform process would makeimplementation less difficult. The insights into theprimary health care system emerging from thisstudy go some way towards providing a rationalefor government to develop network managementtechniques, better suited to the agency level context,for the implementation of cooperation-based re-forms such this. It also provides a rationale fordevelopment of appropriate leadership capacity inthe partnerships able to effectively manage thesocial control processes and maintain focus on theoutcomes sought.

Acknowledgements

This research was funded by the National Healthand Medical Research Council of Australia. Anearlier version of this paper was presented at theEuropean Institute of Advanced Studies in Manage-ment Workshop on Trust Within and BetweenOrganisations. We wish to acknowledge the threeanonymous reviewers attention to detail and in-sightful suggestions.

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Documents

Managing risk: Risk perception, trust and control in a Primary Care Partnership