In early June Jeremy Hunt became the longest-serving Health Secretary in British political history. His Commons statements are often delivered strenuously with fixed-smile authority, gripping the despatch box with both hands whilst rocking forwards and glaring wide-eyed at the Opposition front bench. His communication approach often seems designed to generate hostility and negative reaction from the Opposition, the general public and, most of all, the staff of one of the world’s largest employers, the NHS, which he leads. But his statement in the Commons last week, following testing of a new Public Health England (PHE) IT system for managing breast screening appointments, was a new one on me. Here’s an extract of what he said (from Hansard, the parliamentary record):

…earlier this year PHE analysis of trial data from the service found that there was a computer algorithm failure dating back to 2009. The latest estimates I have received from PHE is that, as a result, between 2009 and the start of 2018 an estimated 450,000 women aged between 68 and 71 were not invited to their final breast screening.

A ‘computer algorithm failure’, eh? So not your normal NHS ‘computer error’ or ‘IT systems failure’ but a ‘computer algorithm failure’. That got my attention. I presume Hunt doesn’t know what a computer algorithm failure actually is considering he’s an Oxford Philosophy, Politics, and Economics graduate but I’ll give him the benefit of the doubt. A ‘computer algorithm’ is a set of defined steps of operations that can be undertaken by a computer to solve a problem. In this case the algorithm that defined which women should receive an invitation for a mammogram would be based on their dates of birth, date last checked, etc. A computer program is then written to execute those algorithm instructions then print out the invitation letters. But Hunt didn’t say it was a systems failure, IT glitch or computer error, he said a computer algorithm failure which is odd because an algorithm can only ‘fail’ during testing, i.e. if the steps for solving a problem are incomplete, incorrect or because of data error. For example, the algorithm would be said to have failed if the invitation list contained women who are older than 71 (a date checking error) or don’t have a UK address (another data checking error) or have passed away (another data checking or data timing error) or, in this case, did not include all those women who did meet the criteria. That is, a computer algorithm failure is one normally made when the system is being designed and specified, not when the design is coded or turned into computer instructions or processing thousands or even millions of health records. So Hunt was telling me that this was a PHE design error, i.e. it was attributable to the NHS business design team, i.e. a person or team of people, albeit nearly 10 years’ ago, made a catastrophic design error. But to the Press it’s another NHS IT failure and in a way, I agree it is.

The Daily Telegraph’s Laura Donnelly, health editor & Kate McCann, senior political correspondent wrote: “The apparent IT glitch means that women whose cancer could have been spotted early went on to develop the disease.” Donnelly & McCann compound their error later in their article, “…But a computer error was programmed into the system in 2009, when trials about extending the age range further began.  As a result, women who had reached their 70th birthday were excluded from  the system, meaning that up to 450,000 never received an invitation for their final scan. The blunders were only detected almost a decade later, when PHE attempted  to upgrade its computer systems.”.

What they mean is an incorrectly defined or improperly tested algorithm error was programmed into the invite system in 2009 and the errors were not found until almost a decade later.

The Telegraph wasn’t the only newspaper to misrepresent Hunt’s statement. The Independent’s Health Correspondent Alex Matthews-King wrote: “Nearly half a million women missed out on NHS cancer screening because of an IT error, the government has admitted – adding that hundreds may have died as a result.”.

The Daily Mail’s Tim Sculthorpe, Deputy Political Editor and Martin Robinson, UK Chief Reporter for MailOnline wrote: “The NHS was today engulfed by a breast cancer scandal after it was revealed 450,000 women were denied life-saving scans and up to 270 died early after a ‘colossal’ IT failure lasting almost a decade. The victims aged between 68 and 71 were never sent letters offering them a final routine breast screening because of an IT error lasting from 2009 until this year.”.

Jeremy Hunt MP

The consequences of nearly half a million women not being invited to their final breast screening is disastrous, as Hunt went on to explain,

“…there may be between 135 and 270 women who have had their lives shortened as a result.”

“…had their lives shortened…”? That’s another new phrase to me, (perchance not to deflect attention from or minimise what has actually happened in any way?), a rather unusual way of saying this number of women may have suffered unnecessary pain, late treatments, life inconvenience, debilitation and early death from (complications due to) breast cancer…

And this error was only found by Public Health England after 9 years of operation of their original invitation system? Really? Did none of these half a million women in all that time highlight to their GP or imaging centre that they hadn’t received their last appointment invitation? I can imagine that if an alert woman did point out that she hadn’t received an invitation her GP might indeed put it down to a system glitch and simply arrange for a ‘special’ mammogram appointment without querying their invitation provider. Maybe. But did half a million women not query their missing appointments, over 9 years, and no-one involved recognised that lots of women were querying this? And this was through a date ‘error’ in what is surely not a complex algorithm? And was the error really found only when PHE was testing a new invitation system? It seemed to me that there was likely more to this story than Hunt was saying, probably because he has rightly set up an independent review to look into it.

Whenever a minister reads an urgent statement to the House, particularly one that contains new or technical language, one has to assume that someone with some better knowledge of the event and its possible causes wrote the brief and that person just might have written it with some ‘spin’, i.e. to present the story in as favourable light as possible or, as I suspect in this case, to deflect any immediate blame. (Language so used, per advice from an ex-Cabinet Secretary, Sir Richard Armstrong, may give a misleading impression, without actually lying which could later rebound if found out, or be used in a way that is ‘economical with the truth’.) Surely not in this case? Indeed probably so. With potentially hundreds of debilitating early deaths being attributed by the Minister to this error there is good reason for us to concentrate on the words used in the statement because no government wants to be associated with poor administration that has, in this case, led to catastrophe. This is no normal administrative bungle. Because of the horrendous potential impact of this disease on so many unfortunate women it’s a major public administrative disaster. The Aberfan disaster of 1966 killed 116 children and 28 adults. They also ‘had their lives shortened’ but in this case the numbers could be almost twice as high. Someone, not a computer, is to blame for this inadequate specification, design, testing and subsequent sign-off of the algorithm but by implying it is the fault of a complex IT system it is likely no-one will immediately point fingers at those probably to blame (at least, pending the outcome of the inquiry) and this is exactly what seemed to be happening in the days after Hunt’s announcement.

The following few days played out as we might have expected, unfortunately. There was a major hue and cry in the Press for a few days, some papers and TV channels found and interviewed 72 and 73 year-old women who had been diagnosed with breast cancer in the last two years; charities saying they were shocked by the “colossal failure” of the breast cancer screening services and the “shocking incompetence” which allowed the deadly errors to go undetected for so long; it emerged that Public Health England (PHE) which oversees the breast cancer programme had actually been made aware of the potential problems in mid-January but advised health officials that the risk to patients was limited, and Health ministers were told about the fiasco more than six weeks before the announcement – but PHE advised [them] not to make the matter public until it could set up a helpline and a system of checks for those affected; many thousands of anxious women were reported to be badly served by the new helpline because it was staffed by SERCO contractors who had received only one hour’s training, few or none of whom were medically qualified or had any counselling experience; women were told they faced waits of up to a month to hear whether they are affected by the scandal and, of course, mammogram facilities in England were overwhelmed with new appointment requests meaning these ‘missing’ women were put into a remediation scanning queue which quickly grew to six months.

Jeremy Hunt said himself that families would find it “totally devastating” to learn that they had lost or would lose a loved one as a result of “administrative incompetence”. So this is a big deal. For those women affected it could be the biggest issue they have ever faced. At least Jeremy Hunt got in an early apology on behalf of the government (not their fault but the buck stops with them in a nationalised service), Public Health England ​and the NHS: “I apologise wholeheartedly and unreservedly for the suffering caused. But words alone are not enough. We also need to get to the bottom of precisely how many people were affected, why it actually happened and most importantly, how we can prevent it ever happening again.”. In itself this ‘review’ will be helpful but the delay deliberately introduced after the issue was first discovered could be of huge impact to some of the women affected.

Jeremy Hunt announced that he had commissioned an ‘independent review’ (rather than an ‘Independent Inquiry’ – I wonder what the difference is?) to answer

legitimate questions that need answering: why did the algorithm failure occur in the first place, and how can we guarantee it does not happen again? Why did quality assurance processes not pick up the problem over a decade or more? Were there any warnings, written or otherwise, which should have been heeded earlier? Was the issue escalated to Ministers at the appropriate time? What are the broader patient safety lessons for screening IT systems?

I am therefore commissioning an independent review of the NHS breast screening programme to look at these and other issues, including its processes, IT systems and further changes and improvements that can be made to the system to minimise the risk of any repetition. The review will be chaired by Lynda Thomas, chief executive of Macmillan Cancer Support, and Professor Martin Gore, consultant medical oncologist and professor of cancer medicine at the Royal Mardsen, and is expected to report in six months.

OK, I’m sure Ms Thomas and Prof Gore are professional, competent and experienced in their fields but one wonders what experience they have chairing ‘independent reviews’ and wouldn’t it be better to have the review led by a professional and experienced independent inquiry chairperson such as a High Court judge and by all means invite Ms Thomas and Prof Gore to join the judge to make up a review panel? I don’t know why Hunt didn’t do this but let’s hope these two chairpeople surround themselves with experts and that they probe without mercy and are crystal clear and fearless in their reporting and recommendations.

A few days later, when much of the heat had died down in the Press I read a short, inside-page article about Hitachi Consulting, the IT company providing or supporting the cancer screening invitation system, hitting back at the claims that their software was to blame. (N.B. as the reader will by now appreciate, Jeremy Hunt didn’t say this, the Press inferred it from what he said.) Remarkably, they also questioned why Public Health England (PHE) failed to act after the firm flagged up concerns in March 2017 that women were being denied scans. So now the real story is coming out, on an inside page days after the public are induced to believe another NHS IT problem was to blame.

Until now, PHE had defended itself by insisting that it had been informed by Hitachi that the problems were localised. But a ‘well-placed source’ at the consulting company said: “In March 2017, this was escalated to senior officials at Public Health England. They didn’t call it up.” Presumably this means PHE did nothing following the escalation.

A separate source close to the breast screening programme told The Telegraph that any suggestion of an IT blunder was ill-founded. The source blamed the problem on the specification provided to the computer software companies by the NHS. “The programme was doing exactly what it was supposed to,” said the source, “It was programmed to the correct specification.” The IT source said the problem was caused by health officials providing the wrong instructions in the first place, setting the wrong age cut-off point for the programme. The source said: “It’s like asking a video recorder to record programmes every Thursday and then complaining it didn’t record Tuesday’s television.

A Hitachi spokesman said: “Hitachi Consulting has no responsibility for the error that has led to this situation… and has had no responsibility for decisions made on which patients should be selected for screening.

The Telegraph went on, “the new row came as patients groups said an apology from the man presiding over the breast cancer screening fiasco is “too little, too late”. Duncan Selbie, the head of PHE issued a public statement yesterday [4 May], following calls from cancer sufferers for him to resign. [L]ast night [he] made the extraordinary concession that it had been made aware of problems with the screening scheme as far back as March 2017. He was last seen in public on May 1 and had been silent until today [4 May] when he apologised for the scandal halfway through his ‘Friday Message’ to staff released on his blog – 48 hours after the crisis emerged. He said: ‘We know this will be extremely distressing for many. On behalf of PHE and NHS breast screening services, our apology is heartfelt and unreserved’.

When Mr Selbie took charge of PHE five years ago he famously admitted his public health credentials could fit ‘on a postage stamp’.”

The agency’s helpline has struggled to cope with more than 10,000 calls from anxious women affected by the screening scandal.

Brian Gough, whose wife Trixie died in 2015 after not receiving a scan invitation, told MailOnline: ‘I was saddened when I first heard the news from Jeremy Hunt but now I am along with my family extremely angry and demand that those individuals in PHE and NHS and all others involved are sacked or resign with immediate effect, all trust in them has gone. “Clearly people have been appointed into positions of trust and responsibility for which they are on their own admission not qualified for. But having accepted that position and remuneration they have to be accountable for their actions”. He added: ‘Too often these horrendous events are followed by “we are so sorry” but it cuts no ice at all with those of us who have to try to live with their mistakes’.

My own thoughts are that it is right that the NHS should plan and make such health check invitations/appointments as they need to resource the necessary facilities, doctors and other professionals required to meet these planning outcomes. But we should keep in mind that big institutions are run by humans who sometimes make small mistakes with big consequences and the tone of the debate so far is that the women affected have been victims of a great disservice. Indeed they have but I might also think that, if my life depended on an overworked NHS administrator sending me an invitation for an important health check, even to the right address at approximately the right time, I’d probably keep an eye out for it and if, after a few weeks’ grace I’d not received it, I’d call my GP and make a bit of a fuss. Can it really be the sole responsibility of the NHS to make sure we are all in the right place at the right time to keep us healthy? I don’t think so. An old doctor I saw when I was having a health check-up around my fortieth birthday said that the old medical saying “Your life in their hands” sets the wrong expectation. Your life is surely your own responsibility. Use all available professional help, by all means, but everyone needs to take care of him/herself and their own family’s lives.

Somewhere today, there will be a small group of people who already know what happened – the same people who originally designed and approved this algorithm. They will know who they are, of course, you don’t forget the projects you worked on after only 10 years. They may still be working in the NHS. There may be a good, innocent or even a sorry story behind this ‘blunder’ but there also may not be. In any case I wouldn’t wish to be in their shoes today no matter what the story is. I can’t imagine how they must be feeling. The rest of us will have to wait until Christmas before we learn the full story from the review team report.

I also learned that the ‘automatic’ breast check cutoff age is 71 years. Potentially hundreds of women who missed their ‘last appointment’ have ‘had their lives shortened’. So why don’t simple checks like this one continue beyond age 71 or does a woman aged over this age have to ask her GP for more regular checks? Maybe the review will consider this too.

I’ll look forward to reading the formal review report later in the year with great interest but also with a great sadness for the women who’ve not had the opportunity to fight for every moment of their lives before it was too late.

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