The first argument against the Bill is that we don’t need legislation. Those who articulate this argument all of a sudden should be asked why, then, do they oppose it?

Because it isn’t needed, perhaps? This utterly bizarre defence of the Health and Social Care Bill by Baroness Warsi is car-crash online commentary. It’s poorly informed and logically flawed.

With friends like these, does the Health and Social Care Bill even need enemies?

Which of the following numbers represents the biggest risk of getting a disease? 1 in 100, 1 in 1000, or 1 in 10?

Almost 30% of Germans and 25% of Americans answered this question incorrectly in this study of statistical numeracy.

It’s an interesting reminder that healthcare professionals shouldn’t underestimate the statistical complexity of risk concepts: I think I’d previously have thought that these descriptions were fairly clear, but clearly they are not well understood.

This morning, I was sent a list of seven papers in medical journals by a colleague. The titles looked intriguing, and I wanted to read further.

I have access to various journals via a number of means: the NHS provides me with access to a given selection via Athens, comprising about 1,500 journals; I personally pay the RSM to give me access to another 1,000 or so; and my BMA membership allows me to access perhaps 100 others. Clearly, the numbers are too large for me to retain details of which portal gives me access to which journal.

So, having found a given article, I then have to cycle through the three access methods, generally in the order outlined above, to find which works. That’s three sets of logins to three different sites (neither the BMA nor the RSM allows direct login from journals’ own sites). This is maddeningly frustrating, especially when I’m trying to glance through seven articles. Accessing each article can take, perhaps, five or ten minutes, which is sheer lunacy. I often don’t have that kind of time.

Now, let me share with you the process for just a couple of the seven papers I happened to be accessing this morning.

First was the Journal of Medical Ethics. I stuck the article title into Google (1 click). The second result was on a bmj.com domain. I often read things in JME, so I knew that I could access this via the BMJ domain with my NHS password. So I clicked the link (2 clicks), and ended up on the abstract page. I hunted for the “Full Text” link, which took me (3 clicks) to a login page. I clicked the “Login via Athens” button (4 clicks), which took me to an institutional login page. I clicked the “Login via Athens” link on this page (5 clicks), entered my username and password, and got redirected (6 clicks) back to the full article.

I make that six clicks and one login to get from my email to the article, for something I know how to access. Clearly, no-one in the field has heard of the three click rule.

Second on the list was a 2011 article from the Journal of the National Cancer Institute. Again, I copied and pasted the title into Google (1 click). The top result was from Oxford Journals, taking me to the abstract page (2 clicks). I clicked the “Full Text” link (3 clicks) to be taken to a log-in page. I clicked “Login via Athens” (4 clicks), and then “Sign in via Athens” (5 clicks) on the resulting page. I entered my NHS Athens details (6 clicks), and got redirected back to the journal’s login page, with no explanation as to why. Out of confusion, I clicked “Login via Athens” again (7 clicks), then “Sign in via Athens” (8 clicks), and again got redirected to the login page with no explanation as to why.

I assumed (correctly) that the NHS doesn’t pay for access to this journal. So I accessed the RSM website (9 clicks), and clicked “Library” (10 clicks), then “E-journals collection” (11 clicks). I logged in (12 clicks), and searched for “National Cancer Institute” (13 clicks). No results.

So I accessed the BMA website (14 clicks) and logged in (15 clicks). I went to “Library Services” (16 clicks), chose “E-resources” (17 clicks), and “Login now” under e-journals (18 clicks), despite having already logged on earlier. This gave a list of journals, on which JNCI didn’t feature.

At this point, I gave up. I could’ve requested the article from the BMJ or the RSM for a couple of quid, or emailed round to see if anyone else had access (e.g. via a university). But for an article I’m browsing for interest and to casually increase my own knowledge, it’s not worth the hassle or cost.

So now, I’m left more ignorant than I need be because of incompetence (the system is crazy), stinginess (my employer isn’t paying for access), and a touch of defeatism.

I struggle to see how conducting research and then hiding it from people is ethical – isn’t that precisely what skeptics constantly berate Big Pharma for doing? Granted, there’s are important ethical and practical differences between non-publication and sticking an article behind a crazily high pay-wall, but I’m sure there’s an extent to which people on the ground are less informed than would ideally be the case because of this broken system.

Why can’t somebody (perhaps the UK Access Management Federation) compile a composite list of journals I have from various sources, and provide some kind of auto-login toolbar or cookie that gets me straight from the abstract page to the full-text page without the faff, or morosely reports my lack of paid access if none of my providers subscribe?

And why can’t journals like PLoS and BMJ Open have more sensible publication fees for individual authors who, for want of a better metaphor, don’t want to hide their light under a bushel? Funded research should factor in the cost of publication in such journals into it’s funding; un-funded research should be admitted for a nominal fee (or, preferably, nothing).

Anyway, it strikes me that the whole system is pretty crazy – something I’ve thought frankly since I started reading medical journals almost a decade ago. And I needed a cathartic rant. Thanks for reading it.

The news reader announces a 30% chance of rain tomorrow. Thirty per cent of what? Most people in Berlin think that it will rain tomorrow 30% of the time. Others believe that it will rain tomorrow in 30% of the region. In New York the majority believe that it will rain on 30% of the days for which the prediction was made.

This is the (edited) opening of BMJ 2012;344:e245, a fascinating paper about single event probabilities by Gigerenza and Galesic. It’s only short, quite fun, and may convince you to change your practice. Well worth a read.

Whilst portfolios may encourage students to reflect, the quality of those reflections cannot be assumed. The substantial time commitment required for completion of a portfolio may detract from other important aspects of learning. It is vital to ensure that portfolios can be completed as easily and efficiently as possible, perhaps through encouraging students to include fewer pieces of evidence.

Select sentences from Buckley et al, 2009, Medical Teacher 31: 282-298. Just thought this might brighten up the day of some of my medical colleagues.

Five reasons why this video (whilst it makes an important and valid wider point) irritates me:
1. It doesn’t acknowledge that both A (on the left) and B (on the right) are both, ultimately, working for profit rather than purely for the benefit of patients.
2. It doesn’t acknowledge that A likely employs salaried doctors like B, with similar issues.
3. It doesn’t acknowledge that since A opted out of providing out-of-hours care, B has stepped in to provide it. In fact, it’s B who’s illustrated at walking out at the end, just when B’s colleagues are kicking into action.
4. It suggests that non-partner doctors hold less professionalism, and are less concerned with patient welfare. Such doctors include many GPs, as well as virtually all secondary and tertiary care physicians and surgeons.
5. It doesn’t acknowledge a single advantage of the corporate model. A’s approach may well be preferable as a whole, but B’s approach is not without merit, and it’s idiotic to suggest that it is.

This #nhsreform mythbuster from DH is overtly party political (“we will never, ever privatise the NHS”).

I’m not comfortable with statements which are so clearly partisan being ascribed to DH, and I’m surprised the Civil Service didn’t prevent it. Such bodies shouldn’t be political puppets.

Also, some of the “myths” are blatantly not “myths” – e.g. “You are introducing competition in the NHS”

This has really got me riled – and I’m not the only one.

Re: this article.

A mother chooses to disclose the contents of a private letter telling her that her son that he’s on the 98th centile for BMI. She does this by calling him “fat”. This upsets him. So she has a picture of him printed in a national newspaper with a report explaining that he’s reportedly “fat”. And then blames the NHS. Exasperating!

Perhaps the letter she received needs refining. Perhaps a letter isn’t the appropriate way to communicate this info.

But the bare choice is between:
a) Not monitoring children’s health
b) Monitoring but not disclosing the results
c) Monitoring and giving advice to parents of children with a high BMI

I can only ever see “c” being the ethical option.

Would this mother really have preferred not to know that her child is at statistically increased risk of a variety of diseases? Would she really rather not have been given advice on how to help? Was it really ethical of the Daily Mail to cash in on her unhappiness rather than pointing her in the direction of her GP?

I suspect the answer to all three is “no”.

Rant over.

There’s a certain air of truculence on this blog at the moment. Yesterday, I took NatWest to task (again) over their awful customer charter, and only last Thursday, I slated Who Wants to be a Millionaire HD. And now, I’m about to moan again. Sorry about that – I know it’s spring, and perhaps my disposition should be sunnier, but there seems to be a queue of things I have to get off my chest at the moment.

Today, I want to moan about NHS Mail. This may seem utterly irrelevant to those outside of the NHS, and, in fact, to the majority within the NHS who choose not to have an account, but actually I hope it gives a reasonable insight into how not to design a user interface.

The user interface of NHS Mail is bloody awful. Really, really terrible. It’s designed by Microsoft, which perhaps goes some way to explaining that, but even for them, it’s bad. Let me give you a tour.

Firstly, the homepage, conveniently located at nhs.net. This looks utterly different depending on whether you are accessing it from an N3 connection, or a plain old internet connection. Neither of the homepages is particularly pretty, but the inconsistency bothers me in particular.

This is a bad thing for a whole plethora of reasons, but primarily because a lack of consistent branding surely presents a security risk. Anyone could knock up a log-in page in a couple of minutes, and a lack of branding would not make it appear untrustworthy.

Now, let’s look at that ex-net login page more closely. The password must be entered in two parts – the first three characters must be entered using the on-screen keyboard, presumably as some sort of protection against keystroke logging software. Yet this isn’t explained anywhere on screen, and it clearly reduces the accessibility of the site for those with disabilities. And the username and password boxes don’t even line up, which is just irritating.

You’re also asked to select whether the computer is private or public – but no explanation is given of the impact of this choice. It took me some considerable time to discover that the impact was actually that selecting ‘public’ prevents download of email attachments. This is hardly common behaviour for email systems – perhaps a little explanation might have been useful.

Assuming you manage to log in, you’re presented with this page.

Now consider some common – perhaps predictable – workflows.

Let’s imagine that  I want to send a new fax message. Where do I click? Logically, I would choose to click “New Message”. That sounds sensible. But it’s also very wrong. Perhaps the envelope in the blue bar at the top? No, that just reloads the current page.

In fact, the correct place to click is the “Spanner and Screwdriver” icon at the top – tool-tipped as “User Tools”, which brings up the following page.

From here, you jump to the icon at the bottom-left of the page labelled “SMS and Fax”, followed by a button on the top-left of the resulting page labelled “Create Fax”.

In precisely whose world is that a logical series of clicks?

Another example. We’re back at the inbox, as pictured above. I want to change my password. Simple – I click “Options” in the top-right. Wrong. On some pages, there’s a “Preferences” button appears the top-right, above “Options”. Is it there? No. Sharper readers will already have noticed from the above screenshot that it is, in fact, in “User Tools” again. Bizarre.

Something I frequently forget is the IMAP settings for NHS Mail. So where would one hope to locate those? Perhaps you’d consider clicking the “?” help icon? You’d be wrong. “User Tools”? Yes.

Perhaps you’d then be tempted to click on “Configure Microsoft Outlook”. That would be wrong. Perhaps you’d click “Help”. That would also be wrong. You must click “Guidance”, down on the bottom right, followed by “Training and Guidance” – not any of the other options, which include “User Guide”.

Again, something which should be really easy to locate is hidden away.

Frankly, the organsiation of the UI of NHS Mail is not fit for purpose. It’s virtually unusable, and I suspect that goes a long way to explaining why so few NHS people have NHS Mail accounts. And yet, I understand that Connecting for Health pays Microsoft £1.90 per user per month – that’s over £12m per year – for the service.

You’d think that, for that money, there would be at least some usability testing, yet it’s hard to see that assumption evidenced by results.

A story is doing the rounds today, much like recent similar stories, about a child called Tom Halton and receipt of a letter telling his parents that his BMI was higher than expected for his age.

Before I go any further with this post, I need to point out that the BBC are talking rubbish about the story. Their second paragraph:

Tom Halton, 11, of Barnsley was told he was overweight after taking part in a national scheme which measured children’s body mass index.

Not true. The letter was sent to Tom’s parents, not Tom. They chose to share it with him. This upset Tom, and he didn’t eat his dinner that night.

The facts are these: Tom’s BMI is heavier than 93% of children his age. The World Health Organisation classifies him as overweight. An increased childhood BMI is associated with lifelong adult illness, in particular Type II Diabetes.

Yes, there are problems with using BMI for purposes like these, particularly in children, and the letter should have acknowledged those more clearly. But it is wrong to simply ignore the best indicators we have in children of their future adult health.

Tom’s dad said:

These letters are doing more harm than good. You might as well send a T shirt with FATTY on it. The impression it gives is that your child is fat, it’s your fault and they will die from a horrible disease.

The letter is not the best written in the world, but it makes the point fairly clearly that the high BMI increased Tom’s risk of future illness. Which, to be blunt, it does.

As for the T-shirt comment, it strikes me firstly that it was the parents who shared this letter with their child, and have now plastered him over the papers with headlines calling him “fat”. Why?

I note that the “grovelling apology” from the DoH actually apologises for causing the parents offence if they felt their parenting skills were being derided – which is not suggested at any point in the letter.

So where do Dan and Tracy Halton suggest we go from here? I’m genuinely interested to hear their views – and yours. Do we inform parents of modifiable statistical risks to their children’s health and wellbeing, or not? If so, how do we go about it? Is writing to parents not the best way to tackle this? Would individual consultation where the full facts could be clearly explained be a better option? Or does that come across as being “summoned to the headmaster’s office”, and yet more punitive (and expensive)?

What do we do? How do we tackle this? I’d love to know your thoughts.