The word trust has received a considerable airing in the UK over the past few months with covid-19. Much of this relates to the erosion of public trust in the government for various reasons. There been the Cummings affair, including the incredible justification given for his visit to Barnard Castle. There has been the massaging of data on the supply of personal protective equipment (PPE), and number of covid-19 tests done. The delay in implementing lockdown, the mishandling of safety in care homes, the disorganisation of testing, case finding, and contact tracing services, and absence of a clear strategy for the re-opening of schools, have raised questions about government competence. 

Caught up in this whirlwind of damage has been the reputation and public understanding of science. This government took office having cheered on a populist surge in anti-science and anti-expert sentiment, and has further undermined trust in professional expertise and science by falsely attributing its covid-19 policy mistakes and omissions to scientific opinion. And instead of a clear, cogent, and authoritative campaign of information and education about covid-19, the public has had to contend with political spin, a dizzying array of expert opinion (including from a rival and independent Scientific Advisory Group for Emergencies), while being simultaneously exposed to disinformation on social media. 

The erosion of trust in experts and science is dangerous—and not just with respects to covid-19. When we lose the distinctions between fact and fiction, truth and falsehood, or expert and casual opinion, the foundations of democracy are weakened, and the gains and virtues of the enlightenment are placed in jeopardy. [1] Scientific and professional expertise is not infallible, but it has a critical role in serving the public good and should be effectively harnessed to do so. Restoring public trust in government, experts, and science is a mission for everyone in society, but the health community may have a particularly important role for four reasons.  

First, the health sector can provide many illustrations of science being captured and compromised to serve private and commercial interests at the expense of those of the public. Second, it can also provide examples of the limits and limitations of scientific knowledge and evidence, and reveal how and when reliable and trusted experience, expertise, and moral judgement are equally important in the formulation of clinical or public health policy. Third, the health sector’s long history of using professional and ethical codes, coupled with rigorous systems of training, licensing, and regulation, provides it with a great deal of experience and expertise that can be applied to broader discussions about the retention of public trust in scientific and professional opinion. Finally, the recent rise in respect and affection for frontline NHS staff, alongside the greater appreciation of public service and professionalism more generally, gives the health community an important voice in the debate about the role of scientific and professional expertise in society. 

There may be no clear consensus on how funding, structures, and systems should be designed to enable science and professional expertise to better serve the public interest, or be more reliable, trustworthy, and moral. There are ontological and epistemological debates about truth. And there are different ideological positions about the role of the state in funding and protecting the academic sector and independent expert opinion. However, there are also deficiencies and weaknesses that most people would identify and want to see remedied. Examples would include the inappropriate commodification and control of health data which is a root cause of intrusions into personal privacy, as well as inefficiency in the research system, and a weakening of independent and public interest research capacity. A related concern is the commercialisation of higher education (and the effective privatisation of a public good) which has undermined many important social functions of universities including contributing towards informed public discourse, and helping to hold power to account. 

Trust also plays an important functional and instrumental role in helping society to function. Indeed, this dimension of trust has been highlighted by the heroic efforts of NHS and local government staff, as well as the community and voluntary sector, in mitigating the effects of an acute epidemic and a harmful lockdown. These efforts were largely built on trust-based systems and values of mutual cooperation and compassion. Even in normal times, the highly complex and relational nature of health systems, which involve millions of interdependent transactions between people and organisations every day, occurs with minimal friction because of the invisible commodity of trust. [2] Trust is a cost-effective solution for numerous systemic and organisational problems, including those related to information asymmetry; free-riding; and the problem of scarce resources and competing needs. [3-7]

In an acute pandemic, it is vital in ensuring that different parts of the health system are not only working synergistically, but also rapidly and efficiently; and in allowing local actors to tailor operational plans to suit local circumstances and context-specific factors while adhering to the strategy, guidelines, and standards set by central actors. But one of the most conspicuous faults of the government’s approach to covid-19 was its unwillingness to decentralise operational responsibility and authority to local actors, including local government public health departments and primary care providers. Instead, it adopted an over-centralised, top-down approach that ignored evidence of good practice and which still leaves the country’s case detection and contact tracing programmes inadequately organised to deal with covid-19.

There may be several reasons for this failure. One is that the government mistakenly believed that centralised decision-making would be more effective and efficient in a crisis. Another is that the government wished to centralise certain functions so that they could then be outsourced to the private sector. But a third reason is a general mistrust of local structures and systems government, some of which is rooted in the ideological assumptions of New Public Management which has been liberally applied across the public sector in the past few decades. [8] One of the results of this has been to replace high-trust relationships with low-trust ones, often through the use of competition, financial incentives and market discipline as well as performance-based management systems that exaggerate the value of selected and quantifiable performance indicators as a substitute for more traditional forms of management that are based on shared values and trust. [9]

Covid-19 has revealed the vital role of trust in enabling the cooperation and rapid action needed to ensure effective crisis management. But it should cause us to see its importance in the everyday functioning of the health system, for those who have no choice but to depend on the health system being fair and competent, as well as for the different NHS organisations and staff who have an interest in the health system functioning effectively and efficiently, and who would want more trust in the health system because it feels better when we can trust and be trusted; and when our work cultures and systems are designed to actively promote cooperation, goodwill and professionalism. [10] Moreover, the spillover of trust from the health system to society more generally will have wider public benefits, including improvements in mental wellbeing and social cohesion, as well as the strengthening of democracy and civic life. [11-13]     

 

David McCoy is Professor of Global Public Health at Queen Mary University London, and the former Director of Medact, a UK-based public health charity that is an affiliate of ICAN and the host organisation for ICAN-UK.

Competing interests: None declared.

 

References:

1] Warren, M. E. (1999b). Democratic theory and trust. In M. E. Warren (Ed.), Democracy and trust. Cambridge: Cambridge University Press

2] Gilson L, 2002. Trust and the development of health care as a social institution. Social Science & Medicine 56 (2003) 1453–1468

3] Mechanic, D. (1998). Public trust and initiatives for new health care partnerships. The Milbank Quarterly, 76(2), 281–302.

4] Coulson, A. (1998). Trust: The foundation of public sector management. In A. Coulson (Ed.), Trust and contracts: Relationships in local government, health and public services. Bristol: The Polity Press

5] Goddard, M., & Mannion, R. (1998). From competition to cooperation: New economic relationships in the National Health Service. Health Economics, 7(2), 105–119.

6] Moore, M. (1999). Truth, trust and market transactions: What do we know? The Journal of Development Studies, 36(1), 74–88.

7] Mechanic, D. (1998). Public trust and initiatives for new health care partnerships. The Milbank Quarterly, 76(2), 281–302

8] Segall, M. (2000). From cooperation to competition in national health systems—and back? Impact on professional ethics and quality of care. International Journal of Health Planning and Management, 15, 61–79.

9] Hunter, D. J. (1996). The changing roles of health care personnel in health and health care management. Social Science and Medicine, 43(5), 799–808.

10] Newman, J. (1998). The dynamics of trust. In A. Coulson (Ed.), Trust and contracts: Relationships in local government, health and public services. Bristol: The Polity Press.

11] Misztal, B. A. (1996). Trust in modern societies: The search for the bases of moral order. Cambridge: Polity Press.

12] Kramer, R. M., Brewer, M. B., & Hanna, B. A. (1996). Collective trust and collective action: the decision to trust as a social decision. In R. M. Kramer, & T. R. Tyler (Eds.), Trust in organizations: Frontiers of theory and research. Thousand Oaks: CA, Sage.

13] Mansbridge, J. (1999). Altruistic trust. In M. E. Warren (Ed.), Democracy and trust. Cambridge: Cambridge University Press.