How risky is the real world?

Introduction

As a society, do we have a problem with risk as a reality of our lives? People are willing to apportion blame, but are they

willing to accept it? "Fears, phobias and facts", the second in a series of joint policy forums between the New Statesman and Pfizer, aimed to unravel what different groups of people understand about risk and how they respond to it.

One of the most important factors appears to be the level of trust that people have in the information given to them. This is evidenced by the public's response to the MMR debate. But how far does the public understand that scientific knowledge is developed through uncertainty, argument and debate?

The age of the public deferring to experts is over; there has been a decline in trust in traditional institutions. Ordinary people are now subject to a cacophony of news stories. But who edits that information and how does the public decide who to trust? What does government, public authority or industry need to do to inform the public debate?

Participants

John Adams - Professor of geography, University College London
Alasdair Breckenridge - Chair of the Medicines and Healthcare products Regulatory Agency
Liam Byrne - Parliamentary under-secretary of state, Department of Health
Niall Dickson (Chair) - Chief executive, King's Fund
Christine Doyle - Health correspondent, Daily Telegraph
Kate Lloyd - Medical director, Pfizer UK
Ed Mayo - Chief executive, National Consumer Council
Margaret Mythen - Chief executive, New Health Network
Spencer Neal - Publisher, New Statesman
Raj Persaud - Consultant psychiatrist
Andrew Stirling - Senior lecturer, Science and Technology Policy Research, University of Sussex
Colin Tudge - Freelance science writer and fellow of the Linnean Society of London
Ian Wright - Group corporate communications director, Diageo

Niall Dickson Welcome to the King's Fund. Around this table we have people who are responsible for regulating and understanding risk, and people responsible for increasing our fear of risk. I thought we could begin with some reflections on whether, either individually or as a society, we have a problem with risk. Is our perception of risk out of line with reality? Should we be encouraged to take more risks? Fear is a basic human emotion, a product of uncertainty that leads to a feeling of loss of control. Are we chasing a safe world that does not exist? I remember interviewing a leading member of the British Medical Association who said "MMR is safe". His press officers, who are not often wrong, touched him and said, "I don't think we should say anything is absolutely safe." Of course, nothing is absolutely safe and that is one area that we could explore. Who is responsible for improving our analysis and understanding of risk? What is the role of government, the media, industry and academia? Where does the individual come into all this? Is the so-called precautionary principle sensible policy or a recipe for inertia? Finally, what should we do about it? How do we improve the debate? And do we really have a problem with risk?

Ed Mayo We certainly do have a problem with risk - or, rather, risk as a reality of people's lives. We have just been doing research with people approaching retirement, looking at the level of shock and disappointment that exists among people who realise that their pensions are not going to give them the kind of retirement that they wanted and they had hoped for. Is there a degree of resignation about that? Yes. They are willing to apportion blame as well, but they accept the position they are in. We have also been doing work among some of the poorest neighbourhoods in the country. One 28-year-old, in poor health and with a marginal income, said: "My life is over. I need to think of my four-year-old daughter now." Clearly risk is a very real and major part of our lives, and it does affect some people more than others.

In the second part of the research, we have been looking at how half of the poorest households in the UK have no home contents insurance. It's a very small point, but everyone around this table will take something like home contents insurance as a given. It is a way of dealing with risk, and yet some of the people facing the greatest risks have the least ways of responding to them. Obviously, we have no crystal ball to tell us what risks are going to emerge. There are different risks: urgent risks that rise up in the pages of the Daily Telegraph, or elsewhere, but also risks that take place over long periods of time, such as climate change. Above all, my plea would be that regulators and experts in these kinds of debates tune in better to the way that the public understands risk. It is very easy to dismiss the way that ordinary people approach risk as irrational or unscientific. Regulators need to be more emotionally literate and realise that emotion is a tool that evolution has given us to respond to risks. Risk is for all of us.

Alasdair Breckenridge One of the most important things is the level of trust that people have in the information which is given to them. People are much more willing to accept a high rate of risk for voluntary activities such as driving a car, cigarette smoking, drinking alcohol or taking oral contraceptives. But when it comes to taking medicines, their attitudes change because it is something that is imposed on them. Of course, that is illogical. As a regulator, we never like to talk about risk. We talk about risk and benefit in the same phrase. If there were a drug that successfully treated cancer or HIV, then you would accept a much higher rate of risk with that than you would if you had a cough mixture or vaccine. So, we mustn't just talk about risk, but risk and benefit balance.

Andrew Stirling Debates about risk and technology are characterised by misunderstandings, but I think the real misunderstanding of risk lies among the expert community. It is not a question of there being emotion added on so much as the actual nature of risk being misunderstood in a substantive sense. Of course, risk debates are extremely diverse, so I am speaking here with the great debates in mind such as nuclear power, GM crops and MMR.

Niall Dickson So, imagine that you have a parent who is bringing a child into a GP's surgery and saying, "I'm worried about MMR." What would be the right dialogue to have in that instance? I don't want to get bogged down with MMR, but if a doctor were to say, "The odds of MMR having an adverse reaction are one in however many million. If your child gets measles it is a one in something or other chance. And the risk of complication is this or that", then perhaps you could actually talk it through in statistical terms.

Andrew Stirling You are framing that question in terms of a risk debate. But I think there is something else going on here which is about technology. Gordon Brown, and other senior political figures, talk about being pro-innovation, pro-sound science and science-based decisions, as if these things are monolithic, as if there is one sort of innovation and you are either pro or against it. You do not talk about being pro- policy or anti-policy; people realise there are different policies. In the MMR field, there is a range of public health strategies and we cannot pursue all of them in parallel. There are very real resource allocation issues and there is politics in play as to which ones we invest in. With MMR, as with GM and nuclear issues, something is going on with allocating resources to technological pathways, and that is why we have these problems.

John Adams There are three different types of risk. First, directly perceptible risk - climbing a tree, crossing the road. These are risks that we manage using judgement, although there is some mixture of instinct, intuition and experience. We don't do a formal probabilistic risk assessment before we cross the road. Second, there is risk perceived through science where either you have large and stable actuarial databases or science can give good cause-and-effect explanations. That is the quantitative risk assessment that we are all fairly familiar with. And finally there is what I call virtual risk, where respective scientists disagree or they just say, "We don't know." In the virtual circle I would include things such as global warming, climate change, BSE, variant CJD, mobile telephones, low-level radiation, pesticide residues and many more where, at present, science does not speak with a clear voice. I would be inclined to put MMR in the scientific circle because I find the evidence so overwhelming.

Alasdair Breckenridge The MMR story illustrates the level of trust people have in the information source - in this instance, the editor of the Lancet who decided to publish the initial report. It took off from there.

Niall Dickson Is there a problem with science, though? Because even in the hard scientific circle there will be the occasional person saying, "No, no, it's not like that." People assume that science is about saying, "This is true and that's not true", whereas scientific knowledge is developed through uncertainty, argument and debate.

Christine Doyle With MMR, the scientific response was a lot of money being put into trials to prove that MMR was safe, which now seems to be the overwhelming perception.

Alasdair Breckenridge Has been since day one.

Christine Doyle Among quite a lot of people, but not the people who mattered. Actually, I think the problem came from how that crisis was managed. When the paper was published, it was not clear what its status was. Some people thought that it was peer reviewed, and that set up a chain of reactions including the very strong belief among parents that it was bad, a feeling that still exists today.

Niall Dickson When you talk about management of it, whose management of it?

Christine Doyle Well, the media rushed in as soon as that paper was published. And the Department of Health rushed in to try and put the stoppers on it, which immediately led to a suspicion that there was something to be revealed.

Niall Dickson So, you think that the reason why the story took off was because the Department of Health, in particular, so quickly responded by trying to rebut the story.

Christine Doyle Absolutely, yes.

Colin Tudge In all the debates I have been to on risk, I have never heard people take the public seriously. What one often sees in the expert versus the public debate is the experts being very high-handed, saying, "We know because we've got these figures and you lot are below the figures." What I would like to get a feel for from Ed, Andrew and others is whether they think there is a sea change. Are people in high places being more humble in their approach?

Niall Dickson Is it also true that people feel bewildered? They are bombarded by the media, authority and science who one day say that coffee is bad for you and the next that it is good for you. As an individual it is difficult to know how to respond to all this.

John Adams I think maybe the Lancet is given a bit too much credit for the MMR fiasco. The reason why science has not settled the debate has to be looked at in the context of trust. In 1947, Douglas Jay famously said, "The man in Whitehall knows best." Imagine any politician trying that on today. Countless MORI surveys over the years show that there has been a terrible decline in trust in government and big business. I was on the original board of directors for Friends of the Earth in the early 1970s and we commanded no public respect whatsoever. We were people with sandals and beards, and no scientific credibility. But now, MORI surveys show that environmental organisations such as Friends of the Earth command very high levels of respect, probably too high. Highest of all in terms of reported trust levels are family and friends, who get their information from the tabloids or wherever. I think that helps to explain the hysteria and paranoia. Probably the people with the best information are the least trusted. The government has got itself into a position where it is almost incapable of issuing an assurance. An assurance that something is safe is almost taken as evidence that there must be a cover-up going on.

Kate Lloyd Fortunately, one of the characters in society who is still trusted and has been for years is the general practitioner. That gives us an opportunity for people who are concerned about health risks to have a good partnership with their GP. If the British Medical Journal is to be believed, GPs do not necessarily understand risk all that well and they are not particularly good at communicating it and may therefore confuse the patient. But from a survey that Pfizer ran, it seems that most GPs will talk to patients about risk on a regular basis and that, as soon as there is a media scare story, the number of patients coming to GPs for further information and reassurance is greatly increased.

Ian Wright I don't think we credit the public with the level of common sense that we should. We do not live in a particularly risky society in contrast with previous generations. The risk of disease, of death in childbirth or of infant mortality that was commonplace has gone away. The counterpoint to that - and it is easy to blame the media, and business is certainly complicit in this too - is that there is a sense of writing everything as a soap opera. You only get the headlines. Crimewatch is a perfect example of a programme that tells both stories. Every Tuesday for the past 25 years, Nick Ross has said, "Don't have nightmares, do sleep well." Ross is one of our most trusted journalists, but people have the terrible knowledge that Jill Dando, who used to present the programme with him, was killed in horrific circumstances. Yet they still believe Ross, and still sleep easy, because they have more common sense than the people writing about this stuff.

Niall Dickson It was said that people would be frightened to go to their GP because of Harold Shipman, but there is no evidence of that.

Spencer Neal It seems to me that perhaps because of the cacophony of news scare stories, risks have become intolerable. Not so long ago, society somehow tolerated the risk of a child being run over while playing football in the street. These days, almost every risk is regarded as intolerable.

Liam Byrne I think, in a wealthier society, there is more to lose so there is less risk tolerance. Yes, there is that cacophony and we are now asking individuals to process their own risk calculations. That has gone hand in hand with decline in trust. There are these horrifying statistics that only a quarter of the public trusts government ministers. The number of complaints made to the General Medical Council about doctors was 19 a week in 1996. That had gone up to 200 a week by around 2000. When we think about how we ensure proper risk calculations in the future, we probably have to think about a) how we depoliticise communication about risk, and b) how we globalise communication of risk decisions.

John Adams I'd like to add that with MMR the government gave patients a new reason not to trust their doctor by threatening sanctions for GPs who did not meet their quota of vaccinations. Advice from your doctor was made suspect.

Ed Mayo We, and particularly the expert community, should face the fact that the age of deference has gone. The way that ordinary consumers respond to the wealth of information that is out there is to look to frameworks that can act as choice editors for them. It is the magazines or newspapers that you read, it is the shops that you go to, or the organisations that you belong to. They all help us interpret the wealth of information that is out there. We give authority to these institutions. Trust has to be earned and I think it has very significant implications for the organisations that are in a position to manage risk.

On the subject of licensing drugs, we have had the scandal of Seroxat and we have had whistleblowing in food and drugs administration in the US. It seems to me that industry, regulators and officials have put to much emphasis on scientific evidence prior to licensing drugs while neglecting the post-licensing experience of ordinary people. They haven't been fast enough to pick up on people's experiences, adverse or otherwise, in relation to drugs. As a result, we have missed out on what could be the most important information of all. No regulator can get to the point of saying, "This thing is safe." All you can do is reach a judgement, but then you should be open to the knowledge, experience and expertise of ordinary people in how that works.

Liam Byrne Who edits that information?

Ed Mayo Take the gene tech industry. Gene tech is going to be a new world with a whole new set of ethical issues. Who edits the information? Investors have very short timelines in terms of gene tech, so do they have a long-term interest in developing trusted information sources? Governments are competing to offer regulatory discounts to attract industry, so there is a bit of a game going on there. Yet we all lose out if there is a lack of literate people and insufficient trust in an information base. It is a collective action problem.

Alasdair Breckenridge If you go back - and I read this out to the Health Select Committee - to the data sheet on Seroxat when it was licensed in 1991, we spelt out word for word the problems of withdrawal from Seroxat, in words that we could not improve now. This idea that the regulators have been hiding the data is just not true. The so-called scandal of Seroxat is something I want to nail every time I speak in front of compatriots because it is absolute rubbish.

Niall Dickson What about the wider point, about the relationship between the expert world and the patient world? There's a tendency for the expert world and the governmental world to be concerned with science, and so on, in the run-up to the approval of a drug. But once it is out there and the public is starting to comment, because public information is not valued, the system isn't geared to take that on board.

Alasdair Breckenridge Any of you who have either been prescribed or bought a drug over the past five years will know that when you open it up you see a thing called the patient information leaflet, often a pretty impenetrable document. We have been working with a group of patients for the past six months to try to improve this, and the information and views that have come up have been very interesting.

What patients want and need is information on three things: the harmful effects, the probability of them happening and how to minimise or manage that risk. They want information on the size of the risk, verbally and numerically. A lot of government departments have struggled with the numerical aspect of risk. There is now a pretty agreed convention whereby you can equate common, rare and very rare with an absolute figure. We have to work with that and put this level of information out. Patients do understand these things. You have to put that kind of information out in the public domain and trust them to understand it.

Kate Lloyd Industry has failed to communicate how carefully we do take input from patients, as well as the constraints that we face. When a product is launched, we have a responsibility to monitor adverse events fully from then on. Not just side effects; we have to report any untoward experience that a patient may have whether related to the drug or not. But we have a difficulty in that our industry is not allowed to talk to patients. If a patient rings me and says, "I've got an adverse event to report", I have to get their permission to talk to their doctor. Not unreasonably, they may think, "What are you messing about at?" It is an immense frustration.

Andrew Stirling I think we have to be careful in discussions about trust because it becomes a proxy for other things. For example, when you do qualitative research you find that trust embeds a whole series of different features. When environmental or health consumer NGOs attain their high trust scores, you often find that what people are saying is, "Well, we don't mean that we believe what they say, we are just glad they are out there challenging." I do think there is a problem with intolerance of uncertainty, but it's not on the side of the public. It's in the interface between science and policy, even where the quantitative techniques are at their most mature and most sophisticated. For example, a comparative risk assessment was done in the energy sector, which was then acted on and embodied in legislation around the world in OECD countries. But if you step back and look at the literature as a whole for that very same issue - ie, the risks due to coal power, etc, - you find that different studies vary by orders of magnitude. What we end up getting is suppression of uncertainty by processes.

Niall Dickson Is that partly because the politician or the policy-maker has to exist in the media world and therefore, in presenting the policy, they have to say, "Nuclear is the right answer, this is the only thing we can do?" Because they have to make a choice about something, rather than saying, "Well, actually, it is a bit of this and a bit of that" and so on?

Andrew Stirling The decision-makers often want justification. That can take the form of weak justification where they say, "We do not really care what it is that is justified, just for goodness sake give me something I can appear on Newsnight with so I don't get torn apart." The strong form of justification is not entirely absolute, which is, "I know exactly what I want, and unless you find something that approximates it, then there may be trouble". Both have an impact on why, when an advisory committee or an academic study comes to be introduced into the policy world, uncertainties get suppressed. The Stewart report on mobile phones shows that the public has a remarkably high tolerance of uncertainty. A number of papers laid into them, but the public, because there has been no proven adverse reaction, tolerated the uncertainty.

Niall Dickson That is interesting because we have lauded the public a little bit here. If we found out in a couple of years' time that mobile phones were causing brain cancer, or whatever, people would not turn around and say, "You stupid public, why did you do this?" We would all say, "Right, it must be the regulators' fault" or "The message wasn't strong enough". Are we being a bit perverse saying that the public are all wonderful people? Does it not come back to the simple fact that people use their mobile phones because it is a voluntary activity and lots of fun?

Kate Lloyd And there is no immediate risk.

Andrew Stirling You can get very romantic about the public. It is a well-made point, but I think the issue is not that the public are better experts than the experts. That would obviously be ridiculous. It is that the public's perspective is complementary to expertise. We should do more to articulate the two in an intelligent fashion. The public don't have vested interests, disciplinary or institutional, in narrowing things down, and so they pick up broader issues that are relevant; experts likewise have unrivalled experience on specifics.

Liam Byrne This just highlights the point that actually there are several variables in risk calculations that any individual is going to take. They are going to look at what the pay-off is, at the probability issue, at the time-frame, and who the beneficiary of that calculation will be. Is it themselves, their children, their parents, or members of their extended family? People have carried on using mobile phones because the pay-off is very attractive and the risk is deferred, but they sure have a different attitude when a mobile phone mast goes up in their community.

John Adams The mobile phone example again calls attention to the distinction between voluntary and imposed. Unless you are up the mast with your ear to the transmitter, the exposure that you get, even if it is on the school roof and you are in the playground, is less than the thing you are holding to your ear, and yet almost all of the opposition is focused on the masts because they are seen as ugly, nasty impositions. I just wanted to go back to the point made about history and the change in perspective. If you are a doctor and you have to pay for your own insurance, you are usually put in one of four categories - low, medium, high risk or obstetrics and gynaecology, which is way off the chart. Why should that be? Obstetrics and gynaecology can claim a significant share of the credit for the huge increase in average life expectancy over the past 150 years. What is possibly one of the most successful medical disciplines has become one of the most sued.

Niall Dickson I understand the sense of injustice felt by an obstetrician as a result of all that, but is it legitimate when the public now says, "Actually this is no longer a risky thing and they did make a mess of it"? Is it not legitimate for people to hold the system to account because it has failed?

John Adams Nothing is 100 per cent safe. Sometimes you see an opportunity and it looks like a risk worth taking, so you do it. Occasionally it turns out badly. Suddenly, what looked like a risk worth taking becomes culpable negligence. We talked about the trust in doctors, but what I am finding fascinating is the doctors' loss of trust in the patient. I contribute to a course once a year - risk management training for doctors - and at the end of each session for the past few years I have asked the question: how many of you practise defensive medicine? They look nervously from side to side and then all the hands go up, whether it is commissioning more tests than they think are absolutely necessary or prescribing things that again, in their best judgement, they think are not necessary.

Alasdair Breckenridge It is commonly said that the society we live in is increasingly risk-averse. Is that true?

Andrew Stirling I would not want to claim that there is one voice in response to that question. Actually, we are framing the question wrong. If we had institutions and discourses that were better adapted to talking about technology, the politics of technology and which technologies we should reasonably choose, and if we saw that as a matter for democratic politics, then I think this polarisation of the risk debate would really diminish. Part of the contribution to that is this language from the highest political levels about sound science and pro-innovation policy.

Niall Dickson This may be a naive question, but take something like GM crops, for example: in the end, does it not just come down to the environmentalists on one side shouting about the risks and people on the other side shouting about the benefits. Isn't the argument always going to be about that?

Andrew Stirling Yes, risk and benefit, and it is correct that the pharmaceutical and medical area in general is much better at doing that than other areas. So, yes, if you properly address benefits as well as risk, then I think you would essentially be having that debate, as long as one realises that there is no definitive way to characterise benefits. Just like other policies, it is a political matter with embedded value assumptions, and so we should not be asserting one expert view of benefits any more than one of risks. I do want to say that I passionately believe that public services are one means by which society can help individuals cope with the risks around them. They are a way not just of pooling risks, but of equipping people to deal with those risks. It is super to hear that the Medicines and Healthcare products Regulatory Agency is now looking at the impenetrability of the information that goes with drugs. It is about time we looked at the health literacy of people and how we build people's ability to be able to make judgements and use health services. After all, we are investing many billions of pounds in electronic health services and electronic health records, but close to nothing in the capacity of people to use it.

Niall Dickson You are talking about patients?

Andrew Stirling Yes, patients. How do you build that literacy? How do you build and support groups - the diabetes groups, the self-help groups and others that can help people to manage those risks, but also to use public services?

Liam Byrne If, for example, genetic screening is in widespread use by 2010, people will be able to clarify another family of risks to which they are exposed. This is going to be a very interesting debate, because it may change the way we talk about risk. When genetic screening is introduced, not only will you understand better what you are susceptible to - and that may have good consequences because it might induce a sort of prevention culture that we do not necessarily have today - but you will potentially learn about the sort of risks that your family members are exposed to as well. That may have a fundamental impact on the way we discuss risk.

John Adams Are we more risk-averse? About one-third as many children are killed in road accidents every year now as in 1922, when there was hardly any traffic in a nationwide 20mph speed limit. It is not because the roads are three times safer, but because parents see the dangers and so children are not allowed out any more. It is made worse by the fact that we are moving into a hypermobile society, high-speed, full of strangers and low on trust. And schools compound this by routinely running "stranger danger" campaigns - "do not trust anybody you do not know" - inculcating paranoia at a tender age. We are becoming more suspicious of everybody, and if people do not trust you, it is very hard to manage risk on their behalf.

There is overwhelming evidence that, certainly in this country, we are becoming more bureaucratically risk-averse. I will give my favourite example. Just over two years ago, the Cabinet Office Strategy Unit produced a report called, "Improving Government's Capability to Handle Risk and Uncertainty". It was handed it to the delivery unit and the delivery unit invited me to give a seminar. I summed it up by saying that it was "a vacuous, platitudinous document full of menace". It was very unspecific about how you manage risk and uncertainty. I concluded the seminar by predicting that it would generate another avalanche of fatuous risk assessments that had nothing to do with risk minimisation and everything to do with backside protection. To my surprise, I was invited back to give another seminar - but between the first and the second, something quite interesting had happened. The second invitation was accompanied by a contract 25 paragraphs long, the 25th of which regarded health and safety: "The contractor [that is me] shall consider their own health and safety and that of any persons involved with the contract such as programme participants [that is, them listening to me] at all times and not put themselves or others at risk." It is their juju term to fend off lawyers, I assume, and about as effective probably.

Niall Dickson Cases such as this undermine any attempt at health and safety, some of which is actually quite sensible. We have talked about the complexity of the relationship between the expert world on the one hand and the public on the other, but I suppose now the question is: if we need a better dialogue or a better analysis and understanding of risk, what can be done to make this more effective? Without putting all the burden on your shoulders, Christine, is there something that the media can do?

Christine Doyle I am surprised how in newspapers, or my newspaper at least, there is a strong desire to address issues in a well-informed way that gives readers the information they need. I think that comes back at us through the letters we get and through various charitable organisations that bombard us with requests for information. When it is felt that the press is over-exaggerating a scare story, it is not always the responsibility of the individual reporter, who usually believes in balanced stories. Sometimes things just get out of control, and maybe there needs to be more discussion with editors.

The other point I would make about the media that we have not really talked about is the huge explosion in health page coverage over the past 15 years, which has made an enormously positive contribution. We often blame papers or television for getting it wrong or exaggerating a story but there is always another, positive side. Even with alcohol - for example, I had spoken to about half a dozen experts about red wine and it became apparent that the bones, the brain, the bone marrow, in fact every bit of the body, would be much better off from a small glass of red wine. I think health departments are very glad when positive campaigns are run which happen to fit in with whatever their particular issue or campaign is at the time.

Alasdair Breckenridge I was speaking to some editors recently and they told me that a responsible journalist might write a piece for the Daily Telegraph, but it is someone else who writes the title and the subtitle.

Christine Doyle Yes.

Alasdair Breckenridge But the headlines are what grab, such as "Shock horror on MMR". You read the article and it is nothing to do with shock or horror at all. That seems to be supremely irresponsible.

Niall Dickson It is an industry standard.

Alasdair Breckenridge That is what I mean, supremely irresponsible.

Andrew Stirling What John described as risk-averse behaviour is also blame-averse and responsibility-averse behaviour. It is about externalising. The Cabinet Office document you spoke about was trying to adopt corporate risk externalising policies when in fact the government is a backstop and cannot do that. That is not about precaution. Precaution is about being much more humble about what we can do with risk assessment. Precaution is about taking responsibility, not externalising it.

Niall Dickson I guess the critics of the precautionary principle would say that statements such as the absence of evidence is not evidence of absence.

Andrew Stirling Precaution does not mean banning things, it means being much more careful about assessing them, and there is nothing in the precautionary principle that says you should ban something.

John Adams Could I give an example of that? A few years ago I was on a television programme with Edward Teller, the father of the H-bomb. He explicitly invoked the precautionary principle to justify building bigger H-bombs and more powerful rockets to deflect asteroids before they hit us. It was the very same week that the former defence minister of the Soviet Union was all over the media proclaiming that the Soviet Union's nuclear stockpile was out of control. There was also somebody from Greenpeace on the programme saying that their version of the precautionary principle was to abandon nuclear entirely because the technology was far too dangerous to be in human hands. Two totally contrasting versions of the way ahead, both invoking the precautionary principle.

Niall Dickson We've talked about the media. What does government, public authority or industry need to do?

Alasdair Breckenridge This has been a fascinating discussion. We have spoken about the risks of medicine, vaccines, GM foods, mobile phones and goodness knows what else. Wouldn't it be nice if there was a new technology just emerging which would allow us to institute in a relatively controlled way a debate about risks and benefits? Nanotechnology is just that thing. It's going to be very big and important. I believe there is a great opportunity to plan a communication programme about nanotechnology, informing the public in the appropriate way and talking about risks and benefits.

Spencer Neal This is the third event that I have been to in the past two months where somebody has mentioned nanotechnology and how it's going to make a huge difference to our lives, but oddly, between these events, I haven't thought about it at all.

Alasdair Breckenridge There you are, there needs to be a programme to inform you.

Liam Byrne What would incentivise you to commission discussion on that?

Spencer Neal As the publisher of a newspaper? Money.

Liam Byrne What would incentivise you to write about it?

Christine Doyle If I could write about how it would affect people's lives.

John Adams I think the nanotechnology debate will unfold in an entirely predictable way.

Spencer Neal Too little too late.

John Adams A few years back I wrote a report for the Health and Safety Executive with an anthro- pologist, and the title we were given was, "Taking Account of Societal Concerns About Risk". We began by saying there is no such thing as society. We do not live in a monoculture. To the Health and Safety Executive we said, "You are the nation's risk manager." The Executive is the best example within government of the designated risk manager. It draws up the rules, it enforces the rules, and it advises on how to obey the rules. We pointed out that, for the foreseeable future, it would be shot at from two different directions: by the defenders of the environment and the consumer, who are constantly saying, "You are not doing enough to protect us", and by industry, which is constantly saying, "You are doing too much, you are over-regulating, you are stifling enterprise." These two perspectives have very deep cultural roots.

Andrew Stirling There are two things government should do. One is to stop talking about sound science, science-based decisions, and being pro-innovation in an undifferentiated fashion. I think that fosters, among other things, an erosion of the credibility of science and democratic politics. It is supposed to be the case at the moment that scientific advisory committees reflect divergent views in the policy process. Much more could be done, quite easily. Establishments and institutions need to be more relaxed about acknowledging these things - about giving attention to these divergent views and not getting in a panic about them. That would contribute to a general climate where we were more relaxed about it.

Niall Dickson What does industry need?

Kate Lloyd Industry needs to communicate much more about what it does in terms of evaluation and interpretation of both risk and benefit. You cannot do one without the other. We need to be less technical in the way that we communicate and we need to be allowed to communicate with the patients; information - not advertising - and education is the key. It is patients who evaluate their own experience, and they can talk in a more educated way with doctors if they can understand better. Since we cannot talk to them about our products, we feel our hands are tied. We would also like to continue to support the doctor-patient relationship because that is a uniquely valuable forum for reassurance and discussion.

Ian Wright We need to tell government that quite often, corporate risk assessment programmes are actually corporate blame avoidance programmes, and we need to make a distinction between those two. A lot of this is cover-your-arse stuff, because business as opposed to government has a very narrow duty, increasingly acknowledged but not debated, which is to its investors and shareholders beyond its other social duties. Business itself needs to start saying to government, "Actually, we need to understand where you are on widening our duties". Finally, we need to be more willing to engage in general. We deserve to be badly trusted in this respect. We have just got to get our heads up and start talking more.

Niall Dickson I wonder whether industry suffers in the sense that people say, "Oh well, they're just there to make profits", and yet nobody - environmental group, academic or otherwise - does not have a vested interest. The idea that there are good guys and bad guys seems rather simplistic.

Colin Tudge There are good guys and bad guys. Whenever I hear scientists and ordinary people who work for big industry talking I think, "Gosh, what nice people they are and how clever." I used to write very enthusiastically about GMOs in the late 1980s when they were new, talking to government scientists about what they could do. Then you see the realities of Monsanto in action in Mexico, and others, and you say, "My God, these people are ghastly." There is mistrust, and quite right too. But I think the people who are running these things are very often forced by the structure they work in to be very bad guys.

Raj Persaud I must apologise for being so late, but the risk you take in inviting an NHS consultant is that some emergency will crop up which might delay him.

I just wanted to make a brief point about psychology around the public perception of risk. When one is talking about risk, what is always forgotten is that one is dealing with uncertainty, and when you are dealing with uncertainty then a huge amount of psychology comes into play in terms of people's attitude to it. I'll give you an example. When the nuclear power industry was building power stations for the first time and trying to do a lot of work with local communities to reassure them about the risk, it found something very intriguing. It found that the more they talked about the safety precautions it had built into the nuclear power stations, the more it scared the local communities. People concluded that this thing must be really dangerous. So there is an issue about drawing people's attention to risk. People take risks every day, but they just don't think about them. One of the other things we know is that the order in which you present the data has a huge impact. For example, napalm is basically petrol. What we do when we fill our cars with petrol involves a risk, if we were to think about it as napalm. Imagine we lived in a world where we first heard about napalm and then cars came along and then we had to put petrol in our cars.

Niall Dickson We wouldn't.

Raj Persaud Right. We live in a strange world where patients want to take more control but they do not want to take the risk. They do not want me to say, "Listen, you have drug A or drug B, here are the risks associated with them, you choose." They want the doctor to take the risk for them.

A patient might come to me who is taking St John's wort, a natural herbal remedy that can be purchased over the counter. I might offer them something like Prozac, which is basically a pharmaceutical version of St John's wort. The patient will recoil in horror and say, "How exactly does that work and what's in it?" I will say, "Well, how exactly does St John's wort work? What exactly is in that?" They are asking these questions about things such as BSE and GM foods, but not about all the other risks they take in their everyday lives. You have to educate people that uncertainty exists and that they have to make judgement calls. Politicians tend to run away from that.

Andrew Stirling A lot of the things we have been discussing argue against your point. The reasons why the public may or may not be sceptical about a new technology are far more subtle than you are imply. Taking your example of the car, it is in fact the case that petroleum products were first used in the war - Greek fire was petrochemicals - and we have none the less applied them. So the very example you choose is one of how people's willingness to commit to or be sceptical of a new technology is much more subtle than simply an aversion to things not natural, or whatever.

Raj Persaud I still think there is psychology around people's approach to uncertainty and we have to unpack that. My patients labour under the misapprehension that I am taking the risk. I can explain the various risks, but they are the ones who are going to have to make the choice.

Kate Lloyd I was just thinking about a context in which an enormous amount of risk is taken that is often ill considered, and that is adolescence. I do not know whether adolescence is a psychiatric state. But certainly, as an adolescent, one has the impression that one is completely invincible and that the horrendous risks that you take will have no adverse consequences at all. And that is clearly not true.

Christine Doyle I came across a computer game developed at a research institution that was shown to teenagers who had to assess risk in all sorts of different situations by imagining that aliens from a very pure world were coming to land on earth. The aliens would question them about how they could be safe on earth and what things they needed to avoid, or what they had to do to be in the healthiest or almost risk-free situations. I think it would be quite a useful thing to introduce to schools.

John Adams I think a very important and necessary tension should exist between the likes of Ed Mayo and the likes of big bad industry. If the government decided to listen to only one of them, if it listened to the extreme version, then virtually all scientific progress would come to a halt. If big business were allowed to rampage around completely unconstrained, that would not be a very attractive world, either. We need these perspectives. We have to be resigned to the fact that they are never going to agree completely.

I think the Food Standards Agency is having a good go at it at the moment. One committee that did fall apart was on managing radioactive waste. It tried to bring all these different perspectives to the table but the committee members all wrestled with it inconclusively.

Colin Tudge I just really hate the Food Standards Agency. This is to do with risk. They did abandon Sudan1. But so what? This same agency is in place and presides over an agricultural structure that produced foot-and-mouth disease and BSE. This is entirely to do with policy and strategy. It worries about minute details while the whole structure seems designed to spread disease.

Niall Dickson One could challenge some of those statements. For one thing, holding the Food Standards Agency responsible for the entire Common Agricultural Policy seems a little over the top. I think we had better stop on that bombshell. I want to thank you all for your contributions. Thank you to the New Statesman and Pfizer for bringing us together.

Spencer Neal I would also like to thank you on behalf of the New Statesman. This is the second event in a series of six. In the first, in April, we looked at a 2020 vision for the NHS, and forthcoming events will continue to address the most pertinent issues in healthcare today. Thank you.

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