Risk, Trust and Health

Abstract

This editorial reflects on the relationship between risk and trust in health and health care. It examines how and why trust is a key component in the health care system of risk management, why there is a crisis of trust and the ways in which the trust relationship is being reconfigured in the UK's NHS and how this is likely to effect the management of knowledge and risk.

Keywords:

• risk
• trust
• health
• health care

As Dibben and Lean point out in this issue, risk and trust are interconnected concepts. Trust can be defined as “confident expectations about another's motives with respect to oneself in situations entailing risk” (Boon and Holmes cited in Dibben and Lean, this issue) As Giddens points out, trust is a way of managing the risk generated by ignorance and uncertainty (1991: p. 244). Trust is particularly important in health care given the uncertainties and major consequences of failing to manage risk.

One mechanism for allocating resources in modern society is the market. In perfect markets the behaviour of producers and consumers is aligned through pricing. McGuire, Henderson and Mooney describe this process in the following way:

‘in the traditional market allocation process the activities of producers are co-ordinated with each other and with the demands of consumers by means of information conveyed by market signals … Prices, by conveying relevant signals on both demand and supply, act as a simple mechanism for the resolution of an immensely complex allocation problem’ (McGuire, Henderson and Mooney, 1988: pp. 182 – 3).

Where there is a restriction in or assymmetry of information then the market will fail to create an optimal allocation of resources. Hood and his colleagues argue that market failures created either by the high costs of obtaining information on risk or by the high costs of opting-out of risk are a rational justification for and basis of state intervention to regulate specific health risks (Hood, Rothstein, Spackman et al., 1999). While regulation may be an effective response to environmental health risks, the delivery of health care is associated with fateful risks that often require the immediate use of expert knowledge. One way of managing risk in such circumstances is to rely on agents with appropriate knowledge, who make decisions on behalf of the consumer given ‘the potentially high costs associated with the actual process of decision-making and those associated with making the wrong decision (i.e. anxiety costs)’ (McGuire, Henderson and Mooney, 1988, p. 186). This approach underpins both state health care systems, such as the UK's NHS, and insurance systems in Europe and the USA. In such contexts the relationship has to be based on trust, i.e. the patient or consumer of health care has to trust that the agent, doctor, nurse or other professional, has the right knowledge and will apply it in his or her interest.

In the UK recent medical disasters have led to a review of the role of agents and in particular to the principles of self-regulation which underpin and have in the past privileged the agent/consumer relationship. The disaster in paediatric heart surgery at Bristol Infirmary in the early 1990s was a defining event and has led to a major restructuring of trust relationships in the health care system through clinical governance. The independent inquiry into the disaster identified a major failure of self regulation with the development of a ‘club culture’ amongst senior professionals which meant that criticism and evidence of poor quality decision making and preventable harm was disregarded. There was a breach of trust as people in the service ‘failed to work together effectively for the interests of their patients’ (Learning from Bristol, 2001, synopsis paras 3 and 8). In particular surgeons failed to communicate accurate information on the level of risk which babies undergoing surgery were being exposed to so that parents felt that their consent was being falsely obtained (Alaszewski 2002).

The government's response to the Bristol and other health care disasters has been to modernise the NHS creating ‘a new delivery system for the NHS’. This system is intended to create a ‘high trust’ NHS ‘glued together by a bond of trust between staff and patients’ (NHS National Plan, 2000, Cm 4818-I, paras 6.1 and 6.5). In this system professional self-regulation is subordinated to the overarching regulatory system of clinical governance to ensure public confidence in ‘the standard and conduct of health professionals’ (NHS Executive, 1999; pp. 2 – 3). The aim of the new system is to ‘restore the trust that society and patients historically had in medicine’ (Lugon and Secker-Walker 1999; p. 1). Central to the new system is the effective management of risk and the reduction of the harm caused by errors made by professionals. For example the initial specification of the new ‘high trust’ health care organisations stated that they would ensure that:

	clinical risk reduction programmes of a high standard are in place
	adverse events are detected, and openly investigated; and the lessons learned promptly applied
	lessons for clinical practice are systematically learned from complaints made by patients
	problems of poor clinical performance are recognised at an early stage and dealt with to prevent harm to patients (DoH, 1997: p. 47)

It is important to note that in the UK concerns about declining public and service user trust are not restricted to the NHS but permeate the public sector. For example the House of Lords Science and Select Committee identified a crisis in trust relating to modern science which had been produced by the BSE scandal and by rapid advances in areas such as biotechnology and IT (House of Lords 2000). Similarly the Government's Cabinet Office review of the ways in which the Government could improve its management of risk and uncertainty noted that while levels of trust in the State in the UK appeared to be higher than in other Western democracies there had been a worrying drop in trust over a relatively short time period. In 1983 54% of respondents indicated they trusted Parliament and 46% trusted the civil service while in 1996 only 10% trusted Parliament and 14% the Civil Service (Cabinet Office 2002). In his Foreword to the report the UK's Prime Minister, Tony Blair, placed risk management at the heart of government business:

‘Risk management—getting the right balance between innovation and change on the one hand, and the avoidance of shocks and crises on the other—is now central to the good business of government’ (Cabinet Office 2002: p. 2).

The main recommendation of the review is that ‘Handling risk should be firmly embedded in the government's policy making, planning and delivery’ (Cabinet Office 2002: p. 105).

The modernization of the National Health Services is having a major impact on the ways in which risk is managed. Some of these changes are explicitly designed to identify and manage risk. For example the Department of Health has designed a new national system for learning from adverse events and near misses in the NHS (Department of Health 2001). However some of the changes are less evident and perhaps more fundamental. Flynn (2002) has pointed out that the implementation of clinical governance involves a major shift in the type and use of knowledge in health care. When professionals assess and treat individuals they utilize skills based on knowledge. However they can use different types of knowledge. Knowledge can be developed through explicit or systematic procedures or built up by trial and error from experience. The process of developing and storing the knowledge can be collective or individual (Lam 2000). In the Bristol disaster key professionals and decision-makers were relying on knowledge developed through experience of individuals (tacit or embodied knowledge) and knowledge embedded in shared institutional custom and practice. Clinical governance is designed to prevent a repetition of the Bristol disaster by ensuring clinical decisions are based on encoded knowledge, i.e. knowledge systematically and collectively developed and codified into clinical guidelines and the development of regulatory mechanisms to ensure professionals use this knowledge. While such knowledge is designed to replace both embodied and embedded knowledge, it will also replace ‘embrained’ which is based on the professionals use of cognitive and conceptual skills to solve specific problems. Flynn summarises the process in the following way:

Medicine combines aspects of both ‘embrained’ and ‘embodied’ knowledge, and… current schemes of clinical governance represent a drive to transform medicine into ‘encoded knowledge’ (especially through the promulgation of Clinical Guidelines by NICE…) (Flynn 2002: p. 168)

This shift has major implications for the ways in which knowledge is constructed and used in the NHS. While the NHS is a large impersonal system there has been considerable emphasis on the personalized relationship between patient and doctor as the key nexus between the service and the public and as the locus of trust. A major review of the NHS described the relationship in the following way:

While doctors are properly deferred to as experts on the technical aspects of medicine, options, when they exist should be carefully explained and wherever feasible the choice of treatment left to the patients and his relatives (Royal Commission on the National Health Service 1979: p. 11).

Such deference to and blind trust in experts has been replaced with mechanisms for monitoring and regulating the quality of professional decisions with a shift to a more critical and audit based approach using and publishing a range of performance indicators and measures. Users are to be provided with evidence that they can use to judge the performance of services and to base their judgement about where and when to seek treatment. This was evident in the National Plan for the NHS which was published in 2000 and which proposed that all NHS organisations would be annually and publicly ranked through a traffic light system as green, yellow and red (DoH 2000, para 6.26). This ranking system has been adopted but uses a more technical star rating rather than a traffic light system. The development of an audit culture represents a shift in key components of NHS/Public relationship from doctor/patient trust relationship grounded in face-to-face contact to a more generalised and abstract relationship with health care agencies mediated through the provision of information and ranking system designed to provide the public with ‘reassurance that the NHS is adopting high standards’ (DoH 2000, para 1.21). In the UK, NHS Direct provides the model for a risk-minimisation impersonal system (DoH 2000, paras1.9 and 1.11). It is a 24-h telephone advice service in which nurses use knowledge encoded within computerized decision support software to advice callers about self-care and use of other services. One of the few studies to explore the ways in which NHS Direct actually works drew attention to the difficulties that nurses have in building trust and rapport with callers and identified a number of strategies which nurses used including initiating and personalizing calls, displaying sensitivity to the callers environment and explaining the rationality of activities when, for example, asking questions (Pettinari and Jessopp 2001).

Several articles in this issue provide important insight into the nature and importance of trust in health and health care. Dibben and Lean's article emphasise the continuing importance of personal relationships and face-work in building and sustaining trust. Within the context of managing chronic disease, specialists have the opportunity to develop a relationship with their patients and Dibben and Lean identify a range of tactics by which specialists seek to promote trust. While it may be difficult to establish a close relationship of trust based on mutual personal knowledge and understanding, it is possible to develop a more transient but fruitful relationship which Dibben and Lean refer to as swift trust. One implication of Dibben and Lean's analysis is that evidence-based systems based on audit information are unlikely to play much role in the development of personalised trust relationship and produce the same benefits, improved patient compliance and outcomes.

While trust continues to play a crucial role in the effective provision of health care, it is also central to the effective communication of risk knowledge and the effective use of that knowledge. As the Cabinet Office's review of government's capability to handle risk notes increased public trust in government is not only an important end in itself in democratic societies but also a means to an end especially in public health. The more willing the public are to trust the government, the more willing they will be to accept and act on the risk information which the government provides (Cabinet Office 2002).

In their article in this issue, Frewer and Miles explore the factors which influence the ways in which individuals respond to information about health risks, especially those associated with food. They argue that while individuals are influenced by the nature of specific arguments they are also influenced by the social context, for example the perceived relevance of the information and the extent to which they trust the source of the information. They note that expert sources of information are more trusted than government sources while industry sources are the least trusted possibly reflecting the perception that these sources are protecting important interests. Frewer and Miles argue that trust is particularly important when lack of time or information or the perceived threat of a hazard complicates decision making.

The article by Hobson-West explores why the current campaigns to persuade parents to choose the MMR vaccine by reassuring them about its safety and the dangers of not vaccinating their children has not been more persuasive with target audiences. She shows that this campaign is based on three assumptions that:

	parents make decisions through a comparison of individual risk;
	parental concern about vaccination is due to a miscalculation of risk;
	policy of providing more risk statistics is the best response to the controversy.

This approach to the communication of health risk assumes that the target audience is made up of individuals who rationally review evidence to identify and choose the best course of action, i.e. the one which will maximize health benefit. There is little evidence that these approaches have made a major impact, despite the investment in health promotion and public health, targeted in particular at ‘at-risk’ groups: e.g. drug taking amongst young adults.

Duff examines drug campaigns in Australia in his article. He argues that young adults reject messages that do not accord with their experiences, for example that all illicit drug use is dangerous and leads to addiction. He argues that if government communication is to have any effect it must take into account and be grounded in the current perceptions and strategies used by young people to manage the risks associated with drug taking. Otherwise ‘the scientific determination of the risks associated with the consumption of illicit drugs, and the social management of these risks’ will continue to be separate and antagonistic activities. In Duff's view this will sustain the mistrust of government which appears to be common amongst these groups.