It’s been an interesting day. First in a very good way – I attended a very interesting event ‘Journalists and the new health system’, met some very good people and ended up on the panel, and had a lot of fun.

The next part was no less interesting but somewhat less fun, at least initially. An email was forwarded to me that has been sent by Private Eye – a fairly aggressive and accusatory one (although things did mellow a little after a few responses had been exchanged) which asked whether I (and another writer who has blogged on Mid Staffs) was being paid by the Labour party to write my articles on Mid Staffs and HSMRs, and accusing me ( and the other writer) of attacking people who are ‘trying to expose poor care‘.

Both are nonsense (although I have certainly criticised the Eye’s columnist(s) for lazily assuming that the headlines about HSMRs were true instead of checking the facts first). But rather than me write on them at length, I’m going to show you the initial email, my response, and then the emails that followed, so you can judge for yourself.

I’ve deleted the details of the other parties to preserve their privacy, but the content of the emails is, as far as I’m concerned, fair game. Emphases are mine, and my responses are in blue:

From: xxxxx xxxxxx <xxxxxx.xxxxxx@gmail.com>
Date: 26 March 2013 10:57:17 AM GMT
Subject: Private Eye

Dear Ms xxxxx

I am writing for Private Eye and have noted both yours and Steve Pleb Walker’s tweets. Please could you tell me whether your tweeted opinions on HSMR are Labour funded – how much funding you receive from your local party – and what scientific basis you have for making any of the claims you do? Further are you linked in any way to the BMA?

It would be really helpful if you could respond, as poor care is not resolved by attacking those who might expose it. Or is it not? [sic]

Yours sincerely,

XXXXXX XXXXXX
Private Eye

Dear Mr XXXXX,

XXXXXX forwarded me your email. She’ll answer for her own part, but I will answer for myself. To your questions (with a few additional facts thrown in):

• I receive no funding from anyone for my blog, nor from any political party for any purpose whatever.
• My ‘claims’ are made based on evidence gathered from various sources, including the transcripts of witness evidence to the Francis inquiry. All my sources are fully stated in my articles, with links where applicable – as you’ll know if you’ve actually read them – so anyone is free to check whether what I’ve pointed out, and the conclusions I’ve drawn, are correct and valid.
• I am not linked in any way to the BMA.
• I have no link to Stafford or Cannock hospitals, no relatives work there, and I live a long way from Staffordshire.

It’s not a matter of ‘attacking those who might expose poor care’. Poor care is not at issue, at least in anything I’ve written. My articles acknowledge poor care very frankly and explicitly.

What is at issue is the mishandling and misrepresentation of statistics, and the damaging headlines that have been spun out of the misrepresentation. Media from the BBC to the Telegraph to – yes – the Eye have repeated as fact the idea that ‘hundreds of needless deaths’ occurred at Stafford hospital, but the statistics say no such thing.

Robert Francis took care to say that HSMRs cannot be used to extrapolate numbers of avoidable deaths, and Prof Jarman and Roger Taylor admitted the same in their testimony to the inquiry – yes Prof Jarman is now giving interviews to TV and press saying there were 20,000 avoidable NHS deaths on exactly the same basis that he acknowledged could not be used for Stafford.

Many of the media have a clear and negative agenda in proclaiming these headlines. I trust that is not the case with the Eye – but recent articles have still been extremely misleading.

‘Avoidable’ deaths occur in NHS hospitals every day – and in every other hospital and healthcare system in the world. Healthcare is intrinsically risky, and because it is delivered by fallible human beings things will be missed, or done incorrectly.

Did people die avoidably at Stafford? Without question. Was the poor care at Stafford resulting in an elevated death rate that could justify headlines of ‘hundreds of needless deaths’? Absolutely not.

The corrected HSMRS (reflecting proper depth of coding and fully-audited palliative care codes) were substantially below the national average.

Since the existence of poor care in parts of Stafford because of severe short-staffing (as recognised by the Francis report) is uncontested, the fact that the death rate was below average means the headlines should be telling a completely different story – one in which overstretched staff managed to hold the essentials together well enough to prevent the understaffing from increasing the death rate.

The headlines say something else, and the end result is that the people of Stafford look likely to lose their hospital altogether.

I’m trying to present the facts in a proper light to redress the balance a little, and I have attacked unfounded/ill-founded statements, shoddy interpretations and lazy/malicious journalism, not individuals.

Steve

Within a minute or two of sending my response, I received another (and answered it):

Thanks for that Steve. Perhaps you could set out your qualifications – any mathematical or statisical or medical – to make the assertions you do about lazy malicious and shoddy journalism.

I have asked the Labour Party today who have distanced themselves from the views of yourself and XXXXX XXXXXX.

Yours sincerely,

XXXXXX

Labour will have to take a wider political view than I (happily) do. I have no qualifications other than intelligence, common sense and a certain dogged analytical bent – nor is it remotely relevant whether I do or don’t. If you can show my facts and conclusions to be wrong, do so. My qualifications have no bearing on the correctness or otherwise of what I’ve written.

and then..

Thanks for that Steve. Are you happy for me to forward this to the letters page of the Eye?

As you should be aware, HSMR is based on the coding of hospital episode statistics. That process can be “gamed” and your claim that Stafford was below average is a bizarre one which implies to me you simply haven’t looked at the HSMR figures (before attacking them).

Your point about a ratio of actua/expect as opposed to data on actual deaths is a fair one. And the media have sometimes taken a ratio to denote something else. However, HSMR do show up problems confirmed by real intelligence in the hospitals – surgeons, doctors, nurses. Even in failing hospitals there will be good doctors who are unfairly maligned. Nevertheless, apart from your general intelligence and common sense it might also be worth speaking to people who work in hospitals.

XXXXX,

Feel free – I’m going to post the exchange to my blog, so you’re welcome to print them in the magazine (which I buy, btw).

My articles address ‘gaming’, so your inference is incorrect. Gamingat Stafford is out of the question – the hospital’s statistics were audited by the Audit Commission and by Capita and graded 97-98% accurate. Gaming at other hospitals is possible – though more likely for income purposes rather than specifically to affect HSMRs – but the fact that they can be ‘gamed’ shows the system as it stands now and stood in the critical period at Stafford to be useless in terms of actually identifying genuine problem areas.

Hospitals might conceivably have poor HSMRs simply because they’re more honest than some others and are not gaming their figures. Or they might have genuine issues – or might just not be very good at coding, since the vast majority of coders are unqualified (and usually overstretched since theirs is a ‘back office’ function likely to be an easy target for cuts by people who don’t understand the potential consequences).

This is a tragedy, since HSMRs could be a vital tool – but only if money is invested in training coders and auditing coding strictly and regularly, to ensure consistency of input. Otherwise, ‘rubbish in, rubbish out’.

I do suspect you haven’t read most of what I’ve written, though – or else you’d know I’ve spoken to a lot of people in hospitals, both on the clinical side and an in-depth interview with Stafford’s unfairly-maligned (and proven by audit to be capable and rigorously honest) coding manager, who joined halfway through the debacle and ‘righted the [coding] ship’.

There have been hospitals with poor HSMRs who had clinical problems, it’s quite true. It’s also true that there have been hospitals with poor HSMRs and no substantial clinical problems, and hospitals with great HSMRs who, on inspection, were found to be riddled with problems. That’s the problem – HSMRs are too random to be useful, because of the problems with poor coding, lack of training and auditing, etc.

Steve

The rest of the emails so far then get into details of evidence etc that won’t make very interesting reading here.

By the point in the correspondence shown above, the tone seemed to have shifted considerably and were turning into an interesting and much less confrontational correspondence.

But it’s interesting, given the clear way in which much of the media (though not, I trust, the Eye)are clearly marching to a Tory-mandated, anti-NHS drumbeat, that it should be assumed that I would only be putting forward a different interpretation because Labour were funding me.In any event,

Either way, it shows that the alternative (and I would contend far more accurate) story is catching the attention of the professional media, which is great. I’ve had calls from regional BBC correspondents over the last week or so looking for more information because their hospitals are being targeted for supposed similarities to Mid Staffs, when Mid Staffs was never what it has been portrayed as being.

It’s been a fairly intense few weeks, one way or another. But if a more balanced, less damaging view percolates out into the public consciousness, I’ll consider it all more than worthwhile.

This ought to be on Skepchick’s Bad Chart Thursday. The Daily Mail — hey, why are you already groaning? — put up a graph to prove that global warming forecasts are WRONG. They say:

The graph on this page blows apart the ‘scientific basis’ for Britain reshaping its entire economy and spending billions in taxes and subsidies in order to cut emissions of greenhouse gases. These moves have already added £100 a year to household energy bills.

…

The estimates – given with 75 per cent and 95 per cent certainty – suggest only a five per cent chance of the real temperature falling outside both bands.

But when the latest official global temperature figures from the Met Office are placed over the predictions, they show how wrong the estimates have been, to the point of falling out of the ‘95 per cent’ band completely.

Now here’s the graph. Let’s see if you can detect where they mangled the interpretation.

(Note: I haven’t looked to see whether the underlying data is correctly presented. I’m only examining the Mail’s ability to read their own chart.)

One error of interpretation is the claim that the ‘predictions’ were plotted in retrospect…as if the scientists had just made up the data. That’s not true — what they did was enter the same kinds of measurements available in the past as we have now, plug them into the computer as inputs, and let it generate predictions. This is an important part of testing the validity of the model — if it gave a poor fit to past data, we’d know not to trust it. That it worked well when giving the past 50 years worth of data is a positive result.

The big error of interpretation is to look at that graph and claim it demonstrates a “spectacular miscalculation.” To the contrary, it shows that the predictions so far have been right. As Lance Parkin says,

It’s an argument presented entirely in their own terms, using only data they presented, framed in language of their choosing. It’s been spun and distorted and shaped as much as they possibly can to get the result they want to get and it still says that the scientists who have consistently and accurately predicted that the world is warming were right. That’s their best shot? It’s rubbish.

Need a cleanser after seeing that? Here are ten charts interpreted correctly and demonstrating the reality of climate change.

People actually read the Daily Mail in the UK, huh? I guess it’s like the US’s Fox News…unaccountably popular.

Slate has an interesting article, by Tara Haelle, discussing a math problem that recently received some attention on Facebook. The problem is to evaluate this expression:

Obviously, the challenge here is not the arithmetic itself. It is to figure out the order in which to do the operations. I suspect most people would naturally do
the parentheses first, leading to this:

,

but what now? We could argue that we should first multiply the two by the three, leading to this:

,

which is obviously equal to 1. Alternatively, we could break up the expression this way:

,

which is equal to 9. The first one strikes me, personally, as more natural, but as it happens, the accepted convention says the second one is correct.

You surely learned the acronym PEMDAS back in elementary school. (Perhaps you also learned the mnemonic, “Please excuse my dear aunt Sally.”) The acronym stands for: Parentheses, Exponents, Multiplication, Division, Addition, Subtraction. That is, it tells you the order in which to carry out the operations in an expression like this. Even with the acronym, however, there is still some interpreting to be done. Doing the parentheses and the exponents first rarely causes confusion, but it needs to be understood that multiplication and division are done at the same time, working from left to right.

As I said, this is purely a convention. It’s not that the first interpretation is unreasonable, it’s just that, as it happens, that’s not the convention that’s been agreed upon. Haelle provides a very good discussion of these conventions, as well as some of the various notations that have been used for division over the years.

Frankly, though, PEMDAS is an abomination. I periodically teach courses intended for future elementary school mathematics teachers, and we inevitably spend a lot of time teaching about PEMDAS. The powers that be have decided that interpreting ambiguous algebraic expressions is a terribly important skill.

As a mathematician I find this all stupid and offensive. You see, no mathematician would ever write something as ridiculous as the expression with which we started. In fact, mathematicians never use the symbol for division. I just now had to look up how to make LaTeX produce such a thing. We always use the fraction notation. For example, if we meant our first interpretation we could have written:

,

whereas the second interpretation could have been written

,

which rather takes the fun out of the problem, since either one is completely unambiguous. Especially in research-level math, we routinely write very complicated algebraic expressions with tons of elaborately arranged symbols. It’s hard enough to decipher these expressions without adding the burden of an ambiguous order of operations. We’ve actually gotten pretty good at writing things clearly. It’s amazing what you can do with the careful use of parentheses and brackets, along with some sensibly chosen notation.

Yet we take school children at the peak of their curiosity, and teach them that math is all about memorizing arbitrary conventions for interpreting unnecessarily ambiguous algebraic expressions. And then we wonder why people hate math!

On a related note, I’m not a big fan of using a diagonal line for fractions. It can be useful for simple fractions, like 1/2 or 2/3. Formatting things in the more usual “vertical” manner can mess up the line spacing. But what are we to make of something like this: 1/2+3? Is that the fraction 1/5, or are we adding the whole number 3 to the fraction 1/2? Ugh!

One more thing. Mathematicians routinely refer to the top and bottom of a fraction. We say numerator and denominator too, but top and bottom is just fine. The reason it’s fine is that if you talk about the top and bottom of a fraction everyone knows what you mean, and clarity is what we care about. But if any schoolkid uses such language, he gets told that he is wrong to do so, and that he has to learn the jawbreakers if he wants to do math. Ridiculous!