2+2 equals 5

The unilateral imposition of a new contract is the latest instalment in the ongoing junior doctors’ dispute. This is the most recent development in a long line of NHS reforms which stretch to the limits the standards of credibility, objectivity and truth that are supposed to be the bedrock of our representative democracy. Given the calculated way in which the Government has misused statistical evidence I am reminded of Orwell’s musings about how 2+2 is made to equal five:

“In the end the Party would announce that two and two made five, and you would have to believe it. It was inevitable that they should make that claim sooner or later: the logic of their position demanded it. Not merely the validity of experience, but the very existence of external reality, was tacitly denied by their philosophy. The heresy of heresies was common sense. And what was terrifying was not that they would kill you for thinking otherwise, but that they might be right. For, after all, how do we know that two and two make four? Or that the force of gravity works? Or that the past is unchangeable? If both the past and the external world exist only in the mind, and if the mind itself is controllable – what then? (Orwell, 1984).”

There have been numerous examples of this ‘doublethink’ during the current junior doctors’ dispute. In a statement to parliament after imposing the contract on the Junior Doctors, Hunt said:

“We have now had eight independent studies in the last five years identifying higher mortality rates at weekends as a key challenge to be addressed…”

Contra to these claims, Peter Holt, author of one of the papers has stated that their analysis ‘could never have shown that higher staffing on weekends reduced mortality’, because they didn’t have the data to test for this. Another of the mythical ‘eight’ is a report by Nick Freemantle. This study found that 11000 more people died on a weekend than on a weekday. Hunt claimed these excess deaths were due to poor staffing at weekends. However, as David Craven points out in snappily titled paper ‘the statistical sins of Jeremy Hunt’, the report authors did not make any claims regarding the cause of these deaths, nor did they take a view on what proportion of those deaths may have been avoidable. In other words the authors did not say that any patients had died because they were admitted on a weekend. Fiona Godlee, editor in chief of the British Medical Journal (BMJ) wrote to Hunt, pointing out how his repeated and erroneous assertions that excess deaths were due to poor staffing implied that the deaths were avoidable. The report did not make any such judgement. In his reply to Godlee, Hunt stated that his “comments…while giving a rough estimation of the BMJ article, [are] also drawn on…other evidence.” Given the stakes of the debate utilizing a rough estimation would seem to be ill-advised, to put it mildly. More seriously it may be indicative of wilfully misleading parliament.

Paul Taylor writing in the London Review of Books highlights that the Freemantle paper actually shows people are less likely to die in hospital at the weekend. This is because their analysis related to the risk of death for patients admitted to hospital at the weekend, not being treated in hospital at the weekend. This is a crucial difference. For Taylor, a plausible explanation for this pattern might relate to out of hours care in nursing homes or at GP surgeries on Saturday mornings. Excess deaths may have nothing to do with junior doctors’ working practices, at the weekend or any other time. Somewhat tragically Hoong-Wei Gan demonstrated a so-called ‘Hunt effect’, whereby a significant number of patients were shown to have delayed their presentations to frontline services at the weekend. This was based on the wrong idea that they were more likely to die.

We could say that these debates about statistical analysis are in something of a ‘geek zone’. They are beyond the grasp of many non-specialists (lay, academic and political) in terms of their grip of the statistical reality of the situation (to borrow from Orwell). In this context, we might be reminded of Carlyle’s 1840s observation ‘a witty statesman once said, you might prove anything by figures’. Whilst there is sufficient wriggle room within the data to make claims that may not be entirely true (or false), we are still broadly in the realm of 2+2 equalling 4.

Tweet from Andy Cowper, Editor of ‘Health Policy Insight’ commenting on that letter

In terms of a substantive shift in the rules of arithmetic, this occurs, paradoxically, outside the realm of the statistical. Where the ‘very existence of an external reality’ is challenged is in the publication of the NHS bosses letter. This letter appeared in papers the day after Hunt announced the unilateral imposition of the contract. It was apparently signed by 20 eminent NHS bosses, including 14 NHS chief executives. It claimed that they supported the imposition of the contract and that they backed the government to do ‘whatever it deems necessary’ to break the deadlock. This was the version that appeared in the media. Following its initial publication, 14 of those named on the letter subsequently claimed that they did not support any such imposition. One chief executive claimed that she had not even known her name was on the letter, whilst the Chief Executive of the Wrightington, Wigan and Leigh NHS Foundation Trust said that the letter they had signed did not advise the government to do “whatever it deems necessary”.

When credibility, objectivity and truth are sacrificed in the name of political point scoring, then we have surely ceased to live in a representative democracy. We are creeping (some may say running) inexorably closer to a position where 2+2 equals 5 simply because those in power say this is true.

POSTSCRIPT: In the intervening time between writing and publishing this post it appears there has been a violent re-assertion of the external reality that 2+2 equals 4. The Guardian has cited a leaked report from within the Department of Health in which Hunt’s own officials cast doubt on claims for link between 7-day NHS and reduced mortality rates. It’s too soon to say that we are witnessing a re-assertion of ‘evidence-based-policy’ over the previously dominant ‘policy-based-evidence’ regime.