‘Bad Science’ by Ben Goldacre has lessons for us all and should be required reading for all ‘opinion formers’

I have just finished reading Ben Goldacre’s book, ‘Bad Science’. Much of the book will be familiar to assiduous readers of his regular column in ‘The Guardian’ each Saturday, but even for them it is worth having all the arguments in a fuller form with the detailed references cited.
Ben Goldacre should be essential reading for all ‘opinion formers’ and indeed, given the prevalence in the media of misrepresentation of scientific stories and of pseudo-science masquerading as fact, we would all benefit from the crash course that Goldacre offers.

The book takes the reader through what constitutes a good scientific experiment and a meaningful clinical trial and then looks at how various widely-reported issues measure up. Along the way ear candles, the Brain Gym (shamefully promoted – with the connivance of the Department of Children, Schools and Families – throughout the school system), homeopathy, and most commercial nutritionism are systematically debunked. This leads into a discussion on the ways in which the pharmaceutical industry’s products are promoted and concludes with the way in which the media hyped up a manufactured scare about the MMR vaccine.

So why are people so taken in by pseudo-science, by health scares and health fads? I suspect, while the media should take a large chunk of the blame, the real reason is that as a society we have been collectively undervaluing science and technology for several decades. Not enough is done in schools to promote not only the wonder and excitement of science, but also a basic understanding of scientific principles and method. Perhaps as a first step Ed Balls and senior officials at the DCSF should have as their New Year Resolution to read ‘Bad Science’ and figure out how to include its central message in the National Curriculum.

So how dangerous is Mayor Johnson’s new Routemaster bus going to be?

Mayor Boris Johnson unveiled his Christmas present to Londoners last Friday when he announced the results of the competition to design a new Routemaster bus for the capital.
Now far be it from me to mistrust Greek scholars bearing gifts, but the earliest Londoners will even see a prototype of the new bus will be 2011.

Of course, people have nostalgic memories of the old Routemaster. The open platform at the back provided an incentive to hop off and on at will – even when the bus was moving. One of the spectator sports for tourists was to watch City gents (ideally in bowler hats) run full pelt along the pavement into the road and then with a flying leap hurl themselves onto the open rear platform of an accelerating Routemaster. (I have to confess that even I did it on occasion, although – I know this is difficult to believe – I was young and foolish then and considerably less well-upholstered.)
However, there was a reason why the Routemasters were phased out (apart from them being colder inside than buses with doors). And that reason, of course, was that the encouragement to jump on and off them led to some appalling injuries to those who misjudged the jump.
An urban myth has been created that the bendie-buses have killed dozens of cyclists and pedestrians. (Mayor Johnson didn’t create this myth though he certainly fed it during his election campaign.)
The statistics I saw, when I was a member of Transport for London’s Safety, Health and Environment Committee, certainly didn’t bear out the myth: there were none of the falls down the stairs associated with double-deckers and serious injuries involving other road users were not statistically different from those for other types of bus.
So the question we will have to ask of the new Routemaster (if it is ever commissioned) is how many extra people will it kill or seriously injure? And is this really less important than nostalgic feelings and aesthetics?

Huge chaos remains in the arrangements for public and patient involvement in health

I have just been to a meeting of the All-Party Parliamentary Group for Patient and Public Involvement in Health, which heard from representatives of the National Association of LINks’ Members. 

For those with long memories, each health district used to have a local Community Health Council (CHC) which was there to represent the interests of NHS users in that area (I should declare an interest in that from 1987 to 1998, I was the Director of the Association of CHCs for England and Wales.)  In 1999, the Government decided to abolish CHCs on the basis that the reforms then being introduced in the NHS would make separate patients’ representation unnecessary.  After a big campaign, the Government conceded that, while CHCs in England would still be abolished, new structures called Patient and Public Involvement Forums would replace them around the country.  These were still finding their feet (and were still in many instances weak and watery substitutes for the old-style CHCs) when their abolition in turn was announced.  Again there was a campaign and as a result the Forums did not finally close until the end of March this year.  In the Forums’ place were to be new structures to be called Local Involvement Networks (LINks).   These would be funded via a Department of Health allocation to the local authorities in their areas.  The local authorities would then contract with another organisation to “host” the LINk for the area.

Inevitably, the new arrangements took some time to be set up and the Department of Health has acknowleded that they will not really be ready to operate until next year – leaving a gap of nine months to a year when there will have been no formal mechanism for patient representation in place.

The evidence from the National Association of LINks’ Members (an informal grouping of individuals who were involved in the Forums and want to see the new system work as well as it can) is that there are huge variations around the country in what has been done to get LINks up and running.  As indicated above, the process is a convoluted one: local councils receive an allocation for this work and must appoint a “host” organisation to run the local network.  According to the Association, some local authorities have retained substantial sums for “administration” and have not passed all of the allocation on to the “hosts”.  There is in most parts of the country a lack of clarity about what the “hosts” will provide for their allocation of money (what guidelines there are from the Department of Health are very permissive to allow local variation).  The Association feel that some “hosts” see their role as a money-making venture for their organisations (and in a number of instances have bidded to act as “hosts” in several local authority areas) and that often only limited resources have been made available to support the local volunteers who are trying to act as patient representatives and visit/inspect healthcare establishments.

All in all the Association presented a picture of precisely the sort of chaos that was predicted when the legislation went through Parliament.

Doctor’s sick notes to be replaced by “fit” notes?

It was good to see reports this morning that Health Secretary, Alan Johnson, has agreed that GPs should no longer issue sick notes to patients excusing them from work, but that instead “fit” notes should be issued, focusing on what their patients can do at work rather than what they can’t.

At the beginning of this year, I initiated a debate in the House of Lords on precisely this issue.  My focus was on back pain – or in Parliamentary language, musculo-skeletal disorder.  As I ponted out, over 2.5 million people in the UK visit their GP with back pain each year.  At any one time, a third of the population is suffering with back problems and it is estimated that up to 80% of the adult population will suffer significant back pain at some time in their life.

Most people – certainly fellow-members of the House of Lords – know how debilitating severe back pain can be.  It affects mobility and agility and reduces stamina.  The pain affects concentration, the ability to think rationally, and the pain affects the sufferer’s mood, may make them irritable and can lead to severe depression.

According to the Health and Safety Executive back pain was responsible for 9.5 million lost working days in 2005/6 – at a cost to society in 2007 prices of over £7 billion.


So, what happens when these people visit their GP with a complaint? All too often, out of compassion and concern for their patient, the GP will issue a sick note advising they take time off work.  They may be advised to stay home for weeks or months, while they wait for tests, then treatments, to make them feel well again.  


For those of us who fall ill with flu or minor infections, and spend a week in bed, this probably sounds like common sense.  However, for many people with long-term acute conditions it may not always be the right approach.  The physical conditions of work may indeed have caused or will aggravate a musculoskeletal condition, but equally prolonged inactivity may well make the condition worse.  Moreover, absence from the work environment, and the associated isolation, may worsen the depression associated with the pain and make recovery even less likely.


Certainly, many GPs and many employers mistakenly believe that sufferers from musculoskeletal disorders must be 100% well before any return to work can be contemplated.

I contrasted this approach with that of Transport for London (TfL), of which I was then an Advisor to the Board (before Mayor Johnson sacked me).  TfL’s occupational health service has been pro-active in tackling back pain.  There has been an in-house physiotherapy service for low back pain since 2001.  Attractive educational materials including a CD-ROM with amusing video clips and job-dependent exercises for staff were developed and widely distributed in 2005-6 and are now provided as a part of some types of training. 

A back exercise class has been introduced and is run three times a week at different times to allow employees to attend without interfering with their shifts.  Employees are encouraged to continue to attend once their back pain is resolved, if they would like to, in order to keep up the level of back fitness that they have achieved.


A pilot study carried out in 2001 demonstrated that employees who received physiotherapy intervention returned to work 12.6 days sooner than predicted using historical data when employees did not have access to a physiotherapy service.


A more recent study in 2003/4 found that employees who were referred to the back pain service after more than 6 weeks absent had twice the length of absence of those referred within 6 weeks and four times the absence of those referred within 2 weeks. Hence early referral for physiotherapy significantly reduced further time off. Sitting at home waiting for the problem to resolve just prolonged further time off.


Moreover, only 13% employees referred to the low back pain service in September to December 2005 for first episode low back pain had a recurrent episode leading to absence during the following year. This compares favourably with recurrence rates of 26-37% reported in research. 

The evidence is that with enlightened and supportive  employers an early return to work is in everyone’s best interest: it is better for the individual, it is better for their employer, and it saves in NHS and benefits costs.  Ending the sick note culture and replacing it with a fit note culture has to be the right approach.