## A&E

There was a flurry of news reports last week about A&E. The Health Select Committee took oral evidence on Tuesday 21 May from three senior doctors: Mike Farrar, from the NHS Confederation; Patrick Cadigan of the Royal College of Physicians; and Mike Clancy of the College of Emergency Medicine (CEM). I have delayed writing about it partly because it took a week for a transcript of the oral evidence to appear on the web.

Various doctors took the opportunity to lobby. A letter from 20 consultants in the West Midlands was leaked to the Independent warning about the pressure on emergency medicine:

… All of our EDs have been under immense pressure for the last few months. This pressure has been unprecedented and relentless, and felt by every ED in the region. All have shown inexorable rises in attendance rates, year on year, coupled with increasing intensity in workload, as we care for a rapidly aging population with complex needs. There is toxic ED overcrowding, the likes of which we have never seen before. Nurses and doctors are forced to deliver care in corridors … Our departments are simply not equipped to safely care for such numbers of patients, an increasing proportion of whom are elderly and frail with complex medical, nursing and social needs. All of the available evidence demonstrates that in-hospital mortality is increased when the ED is overcrowded and patients have to wait excessively for beds. Such overcrowding is now the norm in our EDs. In addition, we are seeing an inevitable and unsurprising increase in serious clinical incidents and complaints, as well as delays and deficiencies in care…The position is such that we can no longer guarantee the provision of safe and high quality medical and nursing care in our EDs.

The CEM took the opportunity to put out a report showing that a survey of 46k patients in Jan-Mar 2012 showed that 33% spent more than 4 hours in A&E, up from 27% in 2008. Peter Carter of the Royal College or Nurses said it showed we needed more beds and nurses.

Jeremy Hunt, who became Health Secretary last September when Andrew Lansley got sacked after the disastrous handling of the Health and Social Care Bill, has been busy blaming Labour for overloading A&E by freeing GPs from the obligation to provide out-of-hours care. Andy Burnham (his shadow) put down an Urgent Question which forced Hunt to turn up to the Commons at 12:35pm on 21 May (Hansard col 1055). He repeated his view:

The changes the Labour Government made to the GP contract took responsibility for out-of-hours care away from GPs. [[Interruption.] Labour Members may not like to hear the facts about the consequences of those changes, but let us go through them—they asked the question. Since those changes, 90% of GPs have opted out of providing out-of-hours care, and they got a pay rise in addition. As a result of those disastrous changes to the GP contract, we have seen a significant rise in attendances at A and E—4 million more people are using A and E every year than when the contract was changed.

It turned into classic political knock-about stuff with little light shed.

The most surprising thing about the oral evidence for me was the serious confusion about the numbers. We started with a statement from Clancy that the number of patients (“attendances”) at “urgent care services” had increased by 50% from 2003 to 2011. Apparently urgent care services = emergency departments + minor injuries units + walk-in centres. But “type 1 emergency departments” had only seen a 17% increase from 2003 to 2011, although the “latest data from the A&E statistics” had shown a change of 250k new attendances between this year and last year.

According to the CEM website (eg Apr 2010 doc CEM5324, appendix, table 1) Type 1 ED = a consultant led 24 hour service with full resuscitation facilities and designated accommodation for the reception of emergency patients. That sounds like what most of us think of as an A&E department.

Stephen Dorrell (chairing the Committee) queried the 250k:

… can I push you on this? Where does the figure come from that suggests there has been a 1.7%—I think it is, but I do not know the absolute number—decline in attendances year on year for the first quarter of this year?
Dr Clancy: It may be a function of when you choose to measure it—if you are combining quarters in a different sequence, for example—but I have taken the four quarters that constitute 2012-13 against 2011-12.
Mike Farrar: Just for clarity, the 1.7% reduction I think is a comparison of the previous full quarter against that same quarter a year earlier. In aggregate, the total number has been increased over the 12 months, but actually a quarter comparison of the last quarter compared with the year before in that quarter shows that 1.7% rise.

Q6 Chair: So the 250,000 is a full-year number.
Dr Clancy: Yes, absolutely.
Q7 Chair: Taking full-year numbers and accepting that there is not a major seasonal variation, it is a rising trend.
Dr Clancy: Yes.

So that is clear as mud. But trying to find these figures on the web is a nightmare. Most of the figures, apart from being “provisional” are also marked as “(Experimental Data)”. The latest data I can find is for the 12 months from Feb 2012 to Jan 2013. “Recorded A&E attendances” were 18.30M versus 17.27M for Feb 2011 to Jan 2012, an increase of 6.0%. The year to date figures are for Apr 2012 to Jan 2013 at 15.31M compared to 14.63M the previous year, an increase of 4.7%.

The public sector generally works on years 1 April to 31 March, so the quarters are Q1 Apr-Jun, Q2 Jul-Sep, Q3 Oct-Dec, Q4 Jan-Mar. Presumably that means the 1.7% figure (rise or fall) is from comparing Oct-Dec 2012 with Oct-Dec 2011. Downloading the spreadsheet and taking the figures from the “Emergency Admissions” column gives a 3.3% increase. But the total for Apr 2012 to Jan 2013 is 4.46M, so that must be the wrong data.

But some data, also marked “Experimental”, seems to lag a year behind. HESonline (Hospital Episode Statistics) provides a report dated 23 Jan 2013 giving a “Summary Report” on “Accident and Emergency Attendances in England 2011-2012″. Presumably that means it cover the 12 months to 31 Mar 2012. Under Key facts we find

Data is incomplete; there are 17.3 million attendances reported in A&E HES (excluding planned follow-up attendances), compared to 21.5 million reported in the Department of Health’s Weekly A&E situation reports (Sit Reps) aggregate data for the equivalent period.

When I worked in the Treasury we got much exercised about a difference of around 1-2% between the figures from two ways of measuring GDP, but apparently A&E find it difficult to count patients to within 25%.

Giving up on figures, I watched a C4 news item. A reporter had gone to the A&E at the Royal Devon & Exeter Hospital to interview Dr Adrian Harris, apparently head of A&E. He had spent two years implementing a plan to improve the situation there. It had become intolerable (for him) when he had patients stacked up in A&E with no understanding of which of them were dying and which were merely the worried well. He had managed to get more resources, but even more important he had managed to reduce the number of patients turning up by an ad campaign aimed at teenagers and those in their 20s, suggesting that they go to their GP for minor ailments.

I am left fairly confused. However, one point seems indisputable. The 70% rule is totally dotty. For those who missed it, the government decided to give A&E departments an incentive not to take too many patients, so they decreed that payments by commissioning bodies for patients above 2009 levels should be paid 30% to the A&E and 70% to NHS England. In other words, A&E got a massive fine (of 70% of their costs) for treating patients above 2009 levels.

The justification was that the funding to NHS England could be used to fund ways of treating these patients outside A&E (eg paramedics on ambulances treating the patient themselves, or GPs providing better out-of-hours care). But it is quite simply bizarre. A&E have no control over who turns up. What are they supposed to do? Turn away car crash victims in February on the basis that they have reached their quota for the year? Surely governments have had time by now to start to grasp the limitations and dangers of ill-thought out targetry.

But worry not, Hunt is on top of the situation:

Last week, NHS England announced that it would change the basis on which tariff money for certain A&E cases is spent. For the first time, hospitals will have say in how money is spent to alleviate demand when that money is withheld for numbers exceeding the 2009 baseline.

Having a say. Well, that solves that one.

## EBCs

Education is infested with jargon. The English Baccalaureate Certificates were announced by Michael Gove last September with teaching to begin in September 2015. For those with short memories, the Fixed-Term Parliaments Act 2011 fixed the date of the next election as 7 May 2015 (see s1(2)), but Gove presumably hoped that an incoming Labour governement would be too late to stop it even if it wanted to.

Part of the reason the new courses were almost instantly referred to as EBacc is no doubt that many people found Baccalaureate hard to pronounce. But inevitably it was instantly confused with the English Baccalaureate which Gove had already introduced in 2010. That EBacc simply meant that you had got a C grade or above in English, Maths, two sciences, one foreign language and history or geography at GCSE. There was talk of an additional certificate but it never materialised. So the new EBacc is now officially known as the EBC (English Baccalaureate Certificate).

A consultation followed until 10 December 2012. Before the consultation was over, the Education Committee jumped in with a quick inquiry of its own, which was published at the end of January.

The only oral evidence it took was to grill Gove on 5 December. The chairman, Graham Stuart (Tory), who makes a virtue out of having failed his degree at Cambridge, made clear in the first few questions that he had no intention of giving Gove an easy ride.

Things got almost farcical in a protracted exchange in Qs 11-35. Gove declined to state the independent regulator’s concerns (Glenys Stacey, head of OfQual) and suggested the Committee summon her to give evidence:

Q16 Chair: Secretary of State, as Chairman of the Committee whose job it is to hold you to account, my judgment is that I would like to hear from you what Ofqual’s concerns are, as expressed to you.
Gove: I am not going to do that.

Q17 Chair: You are refusing?
Gove: I will say that Ofqual should probably state what their concerns are. It is not my job to state what an independent regulator believes to be right or wrong about what we are doing. I will not put words into their mouth.

This farce dragged on for many more questions. After a while Bill Esterson (Labour) and Alex Cunningham (Labour) weighed in to support their chairman.

Q25 Bill Esterson: This is a matter of public policy. This is not a confidential matter to do with individuals in individual schools.
Michael Gove: It is a letter from Ofqual to me, and if you want to ask the regulator about that letter, or about any other concerns that she has or may have, you should ask her, not me.

Q26 Alex Cunningham: Do you think, Secretary of State, that there are things she said in that letter that she would not necessarily want to make public and embarrass you?
Michael Gove: I do not know. I am not a mind reader.

Some timetabling subtlety must have lain behind this. Gove pointed out that it would be easy to ask Stacey for the letter, or to summon her to give evidence, and then to ask him further questions. Presumably everyone knew that Stuart’s rush to help scupper the changes did not permit the necessary delays.

Thereafter the session became more substantive, but the many objections from the Committee were all somewhat contradictory. By talking about change Gove was “destabilising” the “GCSE brand”. Gove pointed out it was already damaged beyond repair. But by moving too quickly on this and other fronts, he was causing “massive volatility”. He wasn’t consulting enough and building enough consensus, but he was also failing to set out a “coherent plan at the beginning” – in other words to present a cut and dried set of firm proposals with no room for change during the consultation process.

After some inconclusive discussion about “gaming” (picking easy subjects and more generally focussing on how to get good marks rather than on learning something worthwhile), and “linear” assessment (a single exam, instead of modules you can endlessly retake), the Committee focussed on the claim that the timetable for picking a single examining body was too short and the fact that it would fall foul of EU procurement law – a point I have not really got my head around, given:

Q79 … [Gove] … there are, I think, no other nations that have the system of competing exam boards that we have. In other countries you will have an effective monopoly …

Unsurprisingly, the Committee’s report was fairly damning. The government was moving too fast. It was doing things in the wrong order (a revised National Curriculum should come first). The changes would not help the 40% of children failing to get 5 GCSEs (C or above and including English and Maths). The move to a single exam board (known confusingly as “franchising”, because each subject becomes a separate “franchise” and may be awarded to a different company) had serious downsides.

A week later, Gove threw in the towel, although what influence the Committee had is hard to judge. Maybe politicians were more moved by Andrew Lloyd Webber and Nicholas Serota complaining about the arts becoming second-class subjects. According to the Telegraph :

The Lib Dems are believed to have blocked the move because of high-profile criticism that it would marginalise other disciplines such as the arts and sport.
A Whitehall source said a combination of problems “meant it was better to reform GCSEs rather than accelerate into a morass of judicial reviews and bankrupt exam boards”.

Of course, the name (EBC or GCSE) is only a minor detail. The only reform which Gove said he was definitely dropping was “franchising”. In his statement to Parliament (video here, if you are happy to sit through ooyala.com’s video ad first), he said he would push ahead with the rest. We will see.

## Checking, always checking …

If I had to sum up what I see as my purpose in life, it is searching for truth. Stated baldly, it is a fairly self-indulgent purpose. What difference does it make to anyone else if my search is a brilliant success or a dismal failure?

Partly things happened that way by chance. I spent my teens in College at Winchester. At that time the school had a strong focus on competence in seeking truth.

Then my main academic subject up until I was 23 was maths, which is unique in being the only subject in which success in searching for truth is provable. Once something has been proved, the proof can be demonstrated to anyone with sufficient interest, talent and patience to listen. Occasionally, bogus proofs remain in the literature for long periods, but that is usually because no one is much interested in that area. There is essentially no room for controversy. Either the proof is right or it is wrong, there is no room for debate.

Grand claims are made for science. Indeed science does seem to be a reliable way of acquiring knowledge, but it can go badly off the rails in the short term. In many ways that is surprising. If one looks at the most egregious examples – like classical statistics, or large parts of cosmology (which is highly speculative, but treated by almost all practitioners as certainly true) – the evidence appears to have been in plain view for decades, or more than a century in the case of classical statistics, yet it fails to persuade most practitioners.

The fact is that we are all deeply attached to our ideas, irrespective of whether they are right or wrong. A mathematical proof is just too hard to argue with, but with almost anything else we manage to find ways to reject things that contradict our pet prejudices.

Again by chance, I moved from maths to auditing. That was a less theoretical discipline, but it did have some extremely important nuggets of practical advice. The most important was the concept of being put on inquiry. You cannot check everything in detail, so you have to be selective. There are various techniques for doing that. You can pick things at random for careful checking. You can focus on things that are particularly important; systems for recording transactions or preventing fraud; unusual transactions; large transactions; checking various things direct with the company’s bankers or creditors. But the most important concept is to investigate in more detail if anything arouses your suspicions. You find something odd. You ask someone in the company about it. They give you 3 minutes of plausible sounding explanation. Is that enough? Usually not. You typically need some documentary evidence to back up that explanation. But even if you get that, if you still feel uncomfortable about it, then you must pursue the matter further. You have been put on inquiry.

Of course, all that is a matter of judgment. Judgment is easily swayed by internal matters, like going over budget on the job and irritating more senior management in the auditing firm. It is also easily swayed by external pressures – the CEO ranting on that you are wasting his staff’s time pursuing trivia. The problem, of course, is that you have nothing really convincing until you have done the work, so how do you justify doing it?

Equally by chance, I acquired several barristers as friends and became deeply interested in how the law works. That is a quite different approach to truth, also with much hard-won wisdom on how to find it, and on the pitfalls and difficulties.

By then – my late 20s – I had become interested in the subject more generally. I became interested in other major approaches, such as historical enquiry, mystical experiences, and the widely varying approaches actually used across different scientific disciplines.

Over the last five years I have spent a great deal of time on theology, which turns out to have a far bigger literature than I had expected. In some areas historical and archaeological data are relevant, and I am currently discovering painfully how flaky much archaeology can be.

For example, over a year ago, I read a popular book by two leading Jewish scholars which suggested that much of the Hebrew Bible had been written far later than normally believed. Reading further, I discovered that most scholars seem to regard the Exodus (the epic journey of the Jewish people out of Egypt into the promised land) as non-historical. But since then I have read a variety of other perspectives that have made me realize that I have to delve much more deeply into exactly why archeologists think they know various things.

That long ramble was brought to mind by reading another book by Bart Ehrman, whom I first encountered two years ago. He has the great advantage of being a clear, lively writer. It is always quick and easy to grasp his point. Unfortunately, as I learnt when reading Fred Hoyle’s works, that does not necessarily mean his point is correct. I have become increasingly cautious about accepting Ehrman’s judgments. But this morning, after being up half the night making a fool of myself on the latest round of the Google Code Jam, I was recovering in bed reading yet another of Ehrman’s books. I came across the charming story of Petaus:

He was an Egyptian scribe called on to deal with complaints about another scribe’s illiteracy in 184 AD. It emerged that Petaus himself could only write with difficulty:

We have a scrap of papyrus on which Petaus had practiced his writing, on which he wrote, twelve times over, the words (in Greek) that he had to sign on official documents: “I, Petaus, the village scribe, have submitted this”. What is odd is that he copied the words correctly the first four times, but the fifth time he left off the first letter of the final word, and for the remaining seven times he continued to leave off the letter, indicating that he was not writing words that he knew how to write but was merely copying the preceding line. He evidently couldn’t even read the simple words he was putting on the page. And he was the official local scribe!

An charming story – with significant implications for the formation of the biblical canon. Bart is scholarly enough to give references even in his popular works, so I looked up Kim Haines-Eitzen’s Guardians of Letters. That gave the exact same story at slightly greater length, referring to a more scholarly work in German about some archive relating to Petaus. But I was lucky enough to be able to do a full-text search for Petaus in Guardians on books.google and that threw up a sentence on another page referring in passing to the unusual case of Petaus.

So I have got as far as ordering the German work into a British Library Reading Room to glance at later today. My German is poor, so I have no intention of spending much time on it, particularly since I have a sinking feeling that there will turn out to be few Petaus’s for whom detailed records have been found, so that it will be tough to assess how typical or untypical he really was.

Of course, that is the benefit of working in a Cambridge College, a short stroll usually takes you to the room of some expert who can quickly summarise the relevant evidence. That way you gain the ability to avoid howlers in exchange for the danger of accepting fashionable nonsense too easily.

## The odd fruitcake

There seems to be some confusion about whether Nigel Farage said it on Tuesday or Wednesday. Or both.

Whilst from time to time we may attract the odd fruitcake, the odd loony, the odd nutcase, doesn’t every voluntary organisation?

According to the Telegraph, the comments were in the context of Karim Ayoubi, a candidate in next week’s council elections in Northampton who turns out to run Urban Tiger, “the best lap dancing club in the Midlands”. The more straightlaced hacks at the Parliamentary Press Gallery claimed to find that shockingly inappropriate.

But Karim was soon trumped by the discovery of Anna-Marie Crampton, a candidate for East Sussex County Council. The Brighton Argus noticed comments made two months ago on a nutty website coming from someone who had signed in from Crampton’s Facebook account.

The main article on the relevant webpage was nonsense dressed up as a series of questions. Had the Knights of Malta somehow forced Benedict to resign, maybe wrecking his health with poison? The headline encapsulated this as “Was Pope Benedict fired by the Knights of Malta?”

The first Crampton comment seems to be saying “yes, he was”. Well, there is a rich tradition of nutty Vatican stories, which I have no time to go into here.

Here second comment is a link to another website which has captured a 3m45s clip from Channel 4 News last November showing an interview with Keith Gregory, a councillor in the Wrexham area, and Bill Brereton, a retired deputy chief constable of the North Wales Police. The clip is mainly about possible Freemason involvement in protecting paedophiles and the need for further investigations. Both of them took a measured line.

The problems now start. We get some classic fruitcake material about the Illuminati, which them moves seemlessly into attacking the “Zionist jews” (with lowercase j):

The Second World Wide War was engineered by the Zionist jews and financed by the banksters to make the general public all over the world to feel so guilty and outraged by the Holocaust that a treaty would be signed to create the State of Israel as we know it today.

A conspiracy theorist in full cry is beyond parody. All I can do with this particular explanation for how the Second World War came about is laugh. Trying to get this kind of ranter to look at the evidence is usually a total waste of time. They are not interested in anything which does not support their theories. Then it goes on, without a break:

By the way, Holocaust means a sacrifice by fire. Only the Zionists could sacrifice their own in the gas chambers. No others, since you and I cannot sacrifice that which is not ours.

Well, she is right about the word holocaust, it comes from the Greek, literally translated “whole burnt”, and yes it originally referred to animal sacrifices to a god. But it later came to mean massacres of people and was used in that way for hundreds of years. It is now almost impossible to dissociate from the massacre of 5.5 million Jews organized by Hitler.

However, the idea that because this word is applied to that event, it must therefore have been organized by the Zionists is a logical fallacy and without any significant historical evidence to support it. Even in its own nutty terms it is a non-sequitur, since the term had plainly been divorced from sacrificing animals which you owned to killing people you did not like for centuries before the Holocaust. In any case, is she seriously suggesting that in the days of more widespread animal sacrifice a group of animals collaborated with humans in organizing the killing?

Then 8 minutes later she moves on to the Protocols of Zion, a notorious forgery, before defending herself against anti-Semitism:

I am anti Zionist, not antisemit [sic]. I love the true Israel and the Jews, but I love the son and daughters of Ihsmel [sic], who are also the children of Abraham. We need to defend Palestine by joining the true Jews… thanks go to Alan Schiller for this info.

I have no time to go into Ishmael in any depth here. He was Abraham’s first son, born of Hagar, an Egyptian slave introduced to Abraham by his wife to bear him children (Genesis 16). The three Abrahamic faiths (Jews, Christians and Muslims) have rather different views about the biblical story. I imagine that Crampton’s invocation of Ishmael is just a shorthand plea for treating the Palestinians better.

So a mix of the measured, the way-out nutty and the reasonable.

Farage sacked her within hours of the Brighton Argus discovery hitting the mainstream national media, which is probably prudent, and also suggests that she did indeed make the comments. Until she departed there was always the nagging possibility that someone might have got hold of her facebook password and tried to undermine her candidacy.

But I am waiting with interest to see the reaction of the Jewish lobby. Whilst I have no sympathy with Holocaust-deniers, I also have little sympathy with Jewish sympathisers who spend too much time focussing on events of 70 years ago and too little on Israel’s own bad behaviour towards the Palestinians today.

## Watching Eyes

TV and radio’s treatment of science can be fairly shambolic, particularly on news programmes like Today. Sometimes, I get the impression that they simply have a stockpile of “news items” ready to fill embarrassing holes in the schedule when a satellite line to a Syria goes down. On Wednesday, the evening news explained how a poster of Watching Eyes protected bicycles at Newcastle University.

It turns out that the relevant journal article was published in December on the PLoS ONE site (plosone.org) (for the curious, PLoS=Public Library of Science, which sounds like a long-standing US institution, but isn’t, it is just the full name for PLoS).

PLoS is a brave venture trying since 2006 to swim against the tide of Elsevier et al. All its articles are published free on the web. It got $10M in start-up funding from the Gordon & Betty Moore Foundation and now seems to be self-sustaining, because it charges authors of papers (or more usually their institutions). The charge seems to be typically$1400, waived or reduced for authors who are sufficiently poor or who live in sufficiently poor countries.

To put that in perspective, there are about 25,000 active scholarly peer-reviewed journals, publishing around 1.5 million articles a year. A trade association estimates revenues at around \$8 billion/year (pdf).

But returning to Watching Eyes, the driving force seems to be Daniel Nettle at Newcastle University. Here is his explanation:

Behavioural scientists increasingly appreciate that human decision-making can be strongly affected by manipulating the way the environment appears or information is presented. Because the mind often relies on fast, simple, non-conscious ‘rules of thumb’ to make decisions, changes to the situation that ought rationally to make little or no difference actually lead to large changes in behaviour. A good example is the ‘watching eyes’ effect. The original demonstrations of this effect showed that displaying images of eyes caused participants to behave more prosocially in laboratory contexts. These laboratory findings have since been replicated and extended.

In other words, we are easily scared into behaving better (or worse). The intrepid researchers put a poster up at three campus cycle racks (top picture above). This successfully shifted theft to the campus racks without the poster: total thefts almost constant at 70 for the year before and the year after, but down from 39 to 15 at the three sites with the poster.

Of course, there is nothing new in any of this. Budget pressures have forced police into not collecting film from many speed cameras, but for a while at least they still encourage people to slow down while driving past them.

In 1500 words in the Discussion section the authors make the obvious points that the experiment was small-scale and raised more questions than it answered.

I suppose I have got old and grouchy. I am mildly amused at the thought of petty crooks being scared enough by the thought that a poster might indicate some new high tech surveillance device hidden in the bushes to move to another rack. But mainly I am depressed at the trivia that fills our science journals, whether to swell Elsevier’s profits or simply to divert relatively smart people from more productive activity.