1 Do you want to know what public trust in the healthcare system is about

Background Public trust is essential for the well-functioning of healthcare systems. Examples of healthcare activities that are heavily dependent on high levels of public trust are vaccination, organ donation, establishment of national health records or acceptance of measures against pandemics. Despite the frequent use of the term in the public sphere and societal interest to maintain high levels of public trust, we have only a limited understanding of what public trust as a concept actually is. This conceptual uncertainty of public trust in the healthcare system poses problems for health care governance and policy making. Aim We aimed to answer: what is public trust in the healthcare system? Methods We analysed three English NHS case studies: an analysis of online news with readership comments concerning the care.data initiative; a secondary analysis of interviews about participants’ experiences and perceptions of biobanks; and an analysis of public focus groups about perceptions of the 100,000 Genomes Project. Further, we analysed existing conceptual work and trust theory. Results This resulted in a full conceptual framework of public trust in the healthcare system. The framework constitutes of 16 conceptual, nine framing and two effect themes. Public trust builds on information equally relating to past experiences, present perceptions and future expectations. Public trust legitimises the actions of the healthcare system as well as encourages the public to participate in healthcare-related activities. Further, levels of public trust are affected by spill-over effects from high or low levels of public trust in other parts of the government system. Last, many actors inside and outside the healthcare system influence public trust. Conclusion Future research needs to translate this conceptual framework into policy guidelines, as well as to validate the conceptual framework for healthcare systems other than the British NHS.