Whether we are concerned with individuals or social systems, trust is fundamentally about expectations about the future when we cannot know the outcome or consequences of a decision to act in a particular way (Messick & Kramer 2001 p 91, Misztal 1996). In other words, making a choice involves risk. Risk is a concept that describes the uncertainty of the outcomes of human action in a complex world (Luhmann 1979). Risks, from a social perspective, 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 is chosen ‘in spite of the possibility of being disappointed by the actions of others, you define the situation as one of trust’ (Luhmann 1988 p 97). Trust also requires knowledge upon which to base a decision to trust. In regard to individuals, the knowledge may be about a person’s circumstances, behaviour or motivations, based on prior interactions or recommendations of others. In regard to a system, it is knowledge of ‘the ability of the system to maintain conditions and to perform its functions’ (Misztal 1996 p 21), built up through ‘continual, affirmative experiences with the system’, or the experience of ‘taken-for-granted routines’ (Mollering 2006 p 72). Mollering (2006) argues that we cannot possibly have all the knowledge required to make a fully informed decision to trust individuals or systems, so the decision to trust necessarily involves a ‘leap of faith’ or the ‘suspension of doubt’. The word risk is not only used to describe a quality of the relationship between people and social systems, the perspective that is being discussed here. It is also used to describe ‘objective risk’ or the risk posed by factors external to people and social relationships; for example, risk posed by infective agents or by other environmental hazards. In this chapter trust is not being discussed in relation to these ‘objective’ risks.
The emphasis on knowledge and rational decisions reflects one tradition within the study of trust. The alternative tradition views trust as a quality of relationships that have emotional and ethical roots. From the latter perspective the decision to trust is based on expectations that the other will abide by ethical rules relevant to the situation (Messick & Kramer 2001 p 91). One key ethical rule is the principle of not knowingly doing harm to the person bestowing trust. Ethical rules are an element of culture and people gain knowledge of them through social learning.
Papadakis (1999 p 75) argues that many changes in Australia in the last two decades of the 20th century have lead to significant change in perception of the ‘effectiveness and value of many institutions’. At least some of these changes were made to the institutions that help sustain trust in democratic government. Using data from the Australian Values Survey (1983) and the World Values Survey (Australia) (1995) Papadakis was able to demonstrate ‘a sharp decline in confidence in governmental and non-governmental organisations between 1983 and 1995’ (Papadakis 1999 p 75). The significance of the substantial decline in confidence (confidence is conflated with trust in this work) is arguable, but concern is widespread (Hudson 2006, Job 2005, Levi 1998, Papadakis 1999).
IN WHAT WAY IS TRUST A PROBLEM IN PUBLIC POLICY?
The issue of trust in government and public institutions is a significant issue in many countries; in Britain (Alaszewski 2003, Taylor-Gooby 2006a), Europe (Organisation of Economic Cooperation and Development [OECD] 2001), the United States (ANES 2006), and in Australia (Job 2005). The factors influencing citizen trust in government and public institutions are complex and, to some extent, dependent on historical and social context. For example, in the emerging democracies of Eastern Europe trust is influenced by social and political history in ways not experienced in the established democracies of the West (e.g. Mishler & Rose 2005). In the West, factors influencing trust in government can be classified as economic (citizen evaluations of the national economy), socio-cultural (crime rates and child poverty), and political (citizen evaluation of incumbents, institutions, scandals and corruption) (e.g. Chanley et al. 2000). The recurring themes underlying concern about trust in government are legitimacy and effectiveness of elected government, and public institutions consisting of the public service and publicly funded organisations such as hospitals and health centres that provide services to the community. The following discussion will focus on trust in public institutions with particular emphasis on the health sector.
If one is interested in the condition of trust in public policy the issues that might lead to it being defined as a problem depend on whether it is viewed through the lens of the rational or relational policy traditions (Job 2005, Taylor-Gooby 2006a). From a rational perspective, embodied in the new public management (NPM), rational calculation of performance provides the foundation for trust in systems or public institutions. If the public is informed about an institution (such as a health service), and it is meeting performance targets, then citizens are able to calculate the benefits to them and their trust in the institution should increase. From the relational perspective a good experience of those systems or institutions, by the people who use them, should create trust. There is substantial evidence that, in reality, trust in public institutions is founded on both rational and relational factors (Job 2005, Taylor-Gooby 2006a).
Taylor-Gooby (2006a p 4) explores the question of why trust in the British National Health Service (NHS) is low at the same time that there is more funding, greater transparency and higher output, suggesting that the NHS is both efficient and competent. Further, trust in health professionals in the NHS remains high. Under these conditions trust in the NHS could be expected to rise, but it has not. From Taylor-Gooby’s perspective the problem is that the dual nature of trust, the cognitive and relational foundations, has not been addressed in a balanced way. The NHS:
reforms draw on a particular tradition in economics and economic psychology, transmitted through organizational theory, that stresses the role of cognitive factors. The central focus is on service providers and service consumers as market actors, behaving in response to their interests as they understand them. This is a world in which action is essentially driven by rational deliberative processes, both for the provider in seeking greater efficiency and for the consumer in deciding where to place trust, and in which the non-rational aspects of trust are discounted. Crucially, the stress on a competitive and consumerist logic may undermine a core component of trust, since the motivation of providers is declared to be self interest, in response to market signals, rather than public interest.
To explore in more depth the issue raised by Taylor-Gooby we will turn to some of the evidence available about public trust in MMR (mumps, measles and rubella) vaccine in the United Kingdom (UK). Vaccination is a private good for individuals who gain immunity, and a public good when a sufficiently large proportion of the population (for MMR 95% of the population) is vaccinated to make it impossible for the infective agent to survive in the community. In Britain, vaccination is voluntary and high vaccination rates declined after publication of a report suggesting a link between MMR vaccination, autism and inflammatory bowel disease (Brownlie & Howson 2006, Petts & Niemeyer 2004). The link between MMR vaccination and specific ‘objective’ health risks, and the necessity for parents to decide whether or not to have a child vaccinated, raises the question of trust in primary healthcare practitioners and the system in which they are embedded. In the UK the primary healthcare system has been reformed in line with the rational principles described above by Taylor-Gooby. No longer does the primary healthcare system rely on professionals to act voluntarily in the public good, instead a system of ‘auditable rules and procedures’ has been instituted to ensure they do so (Brownlie & Howson 2006). Specifically, general practices have targets to achieve in terms of the proportion of eligible children vaccinated and receive financial rewards and penalties based on target attainment (Brownlie & Howson 2006). For parents the financial incentives raised questions about the trustworthiness of general practitioners, and for general practitioners and health visitors who assisted parents to make informed choices, they raised questions about the trustworthiness of the information available through the NHS to parents (Brownlie & Howson 2006).
Petts and Niemeyer (2004) undertook a qualitative study of the information strategies used by parents of young children to make sense of the risks of immunisation, especially MMR. Necessarily, the question of who and what information to trust arose. The sources of information used included: official publications (40% of informants), discussion with family and friends (60%), and discussion with a general practitioner (25%) (Petts & Niemeyer 2004). In general, parents actively evaluated information received and the trustworthiness of the source was important. Broadly speaking there were two major foundations of trust against which sources were evaluated. One was empathy and concern for the wellbeing of the parent and child, and the second was scientific expertise. The most trusted sources, in descending order, were: the national Department of Health, the local health authority and local general practitioners (Petts & Niemeyer 2004 p 15). All of these were considered to combine concern for the wellbeing of parents and children and scientific expertise, although the question of immunisation targets made some informants sceptical of general practitioners’ concern for the parents and children. Friends and family were a frequent source of information and were considered trustworthy in terms of their concern but not in terms of their scientific expertise. Politicians and the mass media were towards the untrustworthy end of the scale on the grounds that they were viewed as ‘in it for themselves’ and not concerned about the wellbeing of the parents and children (Petts & Niemeyer 2004 p 15). Reflected in this study, as in others, are the two foundations of trust in public institutions: a focus on the wellbeing of the public and competent performance. The incentives created by immunisation targets was considered, by a subset of the public, as shifting the focus of general practitioners away from public wellbeing toward private benefits for general practitioners, therefore diminishing trust in general practitioners.
The discussion of MMR illustrates some of the major issues influencing public trust in a national health system, in particular the way that rational and relational issues appear to work in combination. For a broader analysis we can turn to the work of Straten et al. (2002) who developed a valid and reliable measurement scale, using standard scale development methods, to measure trust in the Dutch national health system. Out of this work emerged six dimensions of trust; that is, areas that were strongly related to public trust in the Dutch health system. The dimensions are:
3. Healthcare providers’ expertise, meaning the technical competence of providers.
6. Quality of cooperation, meaning that providers will work together for the patient’s benefit (Straten et al. 2002 p 231).
Straten et al. (2002 p 233) argue that only two of these dimensions, expertise and quality of care, relate to provider practice. Arguably, patient focus could also be included in this group of factors. The remaining dimensions relate to the health system. The overview of factors influencing trust is summarised by Straten et al. thus:
At the micro level, people are worried about information supply, and, in more general terms, about the behavior of providers. They wonder whether providers will pay enough attention to them, take enough time, and listen and take their problem seriously. At the meso-level, the worries are about cooperation in the health system among providers. Can the patient be sure that that providers will work together and cooperate? At the macro-level, people fear developments with possible consequences for accessibility and quality of healthcare. These last two dimensions emphasise the fact that public trust is not solely related to the relation between patients and healthcare providers.Stay updated, free articles. Join our Telegram channel
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