Continuity, trust and cooperation: a game theory perspective on the GP-patient interaction

There is evidence that personal continuity is associated with positive processes and outcomes, although much of the previous work has lacked a theoretical framework. This thesis aims to explore, and develop a model of, the relationship between continuity, trust and cooperation in primary care, based on existing principles from game theory. Hypotheses generated from a game theory perspective were tested through a questionnaire survey of 279 patients. A secondary qualitative analysis of two data sets – interviews with patients and GPs – was also carried out to explore experiences of trust and cooperation in primary care. The survey findings indicated that a history of positive interactions between a patient and a GP, and expectation of future interactions, were associated with higher trust, as was interpersonal care. Trust was found to be weakly associated with self-reported adherence to treatment. The analysis of patient interviews found that patients described relatively high levels of initial trust. Repeated interactions allowed initial trust in the GP to be validated, and allowed the patient to build their own reputation as cooperative. Over time, experience of consulting the same GP could lead to a reduction of uncertainty, and a move to a more stable, affective basis for trust. This was associated with increased willingness to disclose information, and to accept treatment or advice. Analysis of GP interviews explored GP views of patient trust, and identified mechanisms inherent in repeated interactions that could promote quality of care. The findings from the qualitative and quantitative work are drawn together in order to develop a model of trust and cooperation in primary care, informed by game theory principles. This thesis highlights the reciprocal and interdependent nature of the health professional-patient relationship, and the value of repeated interactions in promoting mutual trust and cooperation. The implications of this for policy are discussed.