Hole Ousia

As a writer I have collected my thoughts here in my “blog” called Hole Ousia.63 This Ancient Greek expression translates approximately as “whole being”. My view is that at the heart of a liberal education is the notion that human beings need to return to science that is more broad in its inclusion: this is an idea which ought to unite scientists, literary intellectuals and artists alike.

Healthcare Improvement Scotland is a developing organisation that has such well-intentioned aims that they could surely only be welcomed across our nation. However it is a small organisation which is aware of the difficulties that it faces in being responsible for such high national ideals. This is why the Executive Clinical Director is rightly so passionate about seeking wider engagement with healthcare staff (and I hope also) patients.

This is described by Dr Brian Robson Executive Clinical Director of Healthcare Improvement Scotland when giving evidence to the Scottish Parliament last year:

“We have a small core clinical team in the organisation with a chief pharmacist, a chief nurse, midwife and allied health professional and a consultant in public health medicine and me. Our engagement strategy means that we bring in national clinical leads from the service experts in their field to work with us. At any one time, 20 or 30 of those will be working with us each session to help us to support our improvement programmes. Beyond that, we have access to thousands of clinical staff across the NHS in Scotland and the United Kingdom as well as internationally, to help us with our work. We do not have a large employed clinical staff, but clinical staff and clinical assurance run across all the programmes.”44 

Robbie Pearson Director of Scrutiny and Assurance, continued for Healthcare Improvement Scotland “However, what is fundamental is not the raw numbers but the skills, experience, capability and competence that we bring to our inspection work. Again, that emphasises the importance of the additional expertise that we may bring in from the service. As Dr Robson mentioned earlier in the context of our clinical engagement strategy, we need to consider how we can use the breadth of experience, skills and expertise that are out there to support us in our work as a relatively small organisation.”44

You will recall that we have been told that the improvement work undertaken by Healthcare Improvement Scotland, followed the guidance of the Clinical Standards for Acute Care35. It is interesting then, at Parliament last year, Ian Smith, Senior Inspector, Healthcare Improvement Scotland, stated that “for the inspections of acute care services for older people, we had no baseline from which to work because the inspections were new.”44

Duncan McNeil (Lab) the Convener of the Parliamentary Health Committee followed up this statement by Senior Inspector Ian Smith and asked Healthcare Improvement Scotland: “I understand that a review of the methodology of inspections is going on. When the committee reported on its inquiry into regulation of care of older people, we recommended that there be a review of the national care standards for older people, which were then 10 years old. How is that review progressing and what is your role in it? When can we expect to see the fruits of your work and that of the Scottish Government, which accepted our recommendation?”44

Dr Coia, Chair of Healthcare Improvement Scotland, offered a detailed response, but the Convener was still uncertain and so perhaps a little bluntly asked again: “has the review process begun formally?”44

Dr Coia replied “it has not yet begun.”44

This parliamentary committee met last year, and since then a review, chaired by Pam Whittle, CBE, has been published. This report is entitled National standards, guidance and best practice. As used as basis for Inspections and it was published in November 2013. [59]

The Whittle Report sets out that “the following national standards, guidance and best practice are used to underpin the inspection of the care provided to older people in acute care.”8 This includes 10 separate guidance documents (see table 2). I have read carefully the Whittle Report and I think it is important to confirm what this report does not actually make clear. This being that there has yet been no further update on the 2002 Clinical Standards for Older People in Acute Care which still form the basis for the national standards for inspection of acute care for older adults in Scotland.

It is worth noting that the Whittle Report does not mention NICE Clinical Guideline 103: Delirium.5 It should also be noted that the Whittle Report confirms that SIGN Guideline 86 – Management of Patients with Dementia is one of the guidelines it follows. This guideline, by SIGN’s own timetable, is now four years out of date and has recently been rated in a meta-analysis of 12 National Guidelines on dementia as the second poorest in terms of ethical considerations.[60] I published on-line in the BMJ a letter where I considered the possible reasons why ethical matters were generally not part of SIGN guidelines on dementia: “this appears to confirm an imbalance between the consideration of bio-medical aspects of dementia and those which focus on more general aspects of care. Just because the latter are harder to measure does not make them any less important.”[61]

Table 2; The Whittle recommendations are “underpinned” by the following:

  1. Adults with Incapacity (Scotland) Act 2000 Part 5 – Medical treatment and research
  2. Best Practice Statement for Prevention and Management of Pressure Ulcers (NHS Quality Improvement Scotland, March 2009)
  3. Clinical Standards for Food, Fluid and Nutritional Care in Hospitals (NHS Quality Improvement Scotland, September 2003)
  4. Dementia: decisions for dignity (Mental Welfare Commission, March 2011)
  5. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Integrated Adult Policy – Decision Making and Communication (Scottish Government, May 2010)
  6. Health Department Letter (HDL) (2007)13: Delivery Framework for Adult Rehabilitation – Prevention of Falls in Older People (Scottish Executive, February 2007)
  7. National Standards for Clinical Governance and Risk Management (NHS Quality Improvement Scotland, October 2005)
  8. Scottish Intercollegiate Guideline Network (SIGN) Guideline 86 – Management of Patients with Dementia (SIGN, February 2006)
  9. SIGN Guideline 111 – Management of Hip Fracture in Older People (SIGN, June 2009)
  10. Standards of Care for Dementia in Scotland (Scottish Government, June 2011)

As confirmed already the Clinical Standards for Acute Care35 are now twelve years old despite the enshrined promise that they would be “regularly reviewed and revised to make sure they remain relevant and up-to-date.”35 I am also of the understanding that these 12 year old Clinical Standards were not as broadly inclusive as is suggested: “have been developed and finalised in consultation with many people across Scotland.”35 The membership of the Older People in Acute Care Project Group, the group that determined the final Clinical Standards for Acute Care had only one patient representative, no consultant in psychiatry, no academic neuroscientist, no clinical ethicists, no involvement with medical humanities, no carers. Critical thinking for critical matters that critically may at sometime involve most of our elders requires width rather than narrowness.

My concern, exemplified in this piece of writing about delirium experienced in acute care is that that “improvement” and “assessment” are being undertaken by the same organisational body. Let me summarise this as best I can: Healthcare Improvement Scotland comes along to you as a clinician and tells you that they are “testing” intervention X which, they tell you, they think is going to improve patient care. They then come back to assess how well you are doing this. Are you going to risk failing your assessment by telling them that intervention X is poor? The risk here is of self-fulfilling prophecies.

Robbie Pearson, Director of Scrutiny and Assurance, continued for Healthcare Improvement Scotland, confirmed this with the Scottish Parliament:

“The crucial thing is that the NHS board owns and values the inspection improvement plans and that the NHS board demonstrates, within the board’s governance system, that it is making progress.”44 Mr Pearson then goes on to confirm that Healthcare Improvement Scotland “are not a regulatory body with enforcement powers, but we have significant powers under the Public Services Reform (Scotland) Act 2010 that allow us to carry out our duties.”44

Dr Denise Coia, Chair of Healthcare Improvement Scotland, was equally clear on this: “… what is important is not only the reaction of health boards to our findings but what they do about them. Our organisation is unique in that no other—apart from one, I think, in the Netherlands—provides both a scrutiny and an improvement function44

Dr Coia also outlines the vital need for NHS Health Boards to demonstrate that they have acted on the recommendations made by Healthcare Improvement Scotland following inspections of acute services for older people:

“We can also refer beyond that to the Scottish Government’s performance management unit and to the director-general in our sponsor division in the Scottish Government. From there, the issue can be escalated up to a minister, so there are ultimate sanctions. Scotland is a very small country and you can go up that ladder fairly quickly if you need to.”44

This is why the basis of inspections needs to be evidenced-based, ethically considered and more broadly inclusive. Without such, despite the intention, person-centred care, respect and dignity for the individual in hospital may not have been properly considered.

For a small organisation like Healthcare Improvement Scotland, an organisation that is in its infancy, it is entirely understandable why it cannot cover all matters of healthcare from community to hospital (or vice-versa). The risk however is that improvement work focuses on specific areas and that these lose sight of necessary hole-ousia (the wider journey and the real life and circumstances of the unwell person). In trying to provide the most holistic understanding and care perhaps we may always falter but we should be aware of our falterings and never give up on this.

In evidence to the Scottish Parliament, Healthcare Improvement Scotland was asked by the Health Committee about their role in community services and how this informed approaches to acute care recommendations. Dr Denise Coia, Chair of Healthcare Improvement Scotland, stated that “…. when pathways of care get blocked because there are not enough community services and we find that acute hospitals are managing patients who would probably be more appropriately managed in the community, we might say that the care is inappropriate at that point and we need to do something about it …”44

One member of the Health Committee, Gil Paterson, SNP, asked more about this: “If, in your expert opinion, some of what is going wrong may be due to funding and may be causing a lack of resource at the coalface, would you put that in your report? Would that see the light of day? Would it get into the public domain in some way if you thought that that was genuinely a problem, as with Southern Cross? Would we get to know about such issues through your work?”44

Robbie Pearson, Director of Scrutiny and Assurance, answered this on behalf of Healthcare Improvement Scotland stating that “I do not believe that that is our role”44

The Deputy Convener of the Health Committee, Bob Doris, SNP then commented “Do you have to wait for the integration of health and social care bill to do that?”44

Considering time-honoured holistic assessment, Bob Doris, Deputy Convener, went on to ask another most important question: “Is any assessment done of older people’s general mental health?”44

Dr Coia answered on behalf of Healthcare Improvement Scotland. It is a reply, I must be honest, that has caused me concern: “I will answer that because I am a psychiatrist by background. We talk about “dementia and cognitive impairment” because many older people who are depressed do not require a full mental health assessment, but they become cognitively impaired as a result of their depression, so that is a good proxy indicator. That is why, when we were thinking about the inspection of older people’s care, I was keen that we looked at not only dementia but cognitive impairment, because that is a good proxy measure of what is going wrong with an older person’s mental health. We do not do a full mental health assessment as such, but picking up on cognitive impairment begins to get us into the area that you talked about.”44

Following this logic, our elders are being understood in a more “holistic” way, in terms of who they are, how they feel and their unique individual circumstances and life-stories (most commonly) by a 4-item screening test, that is a mandatory recommendation for “improvement” that asks: your name, age, where you are and the current year.

I really would ask that Healthcare Improvement Scotland think again about this. I say this as NHS Boards will not do so. They will understandably follow all the recommendations. Whilst our elders, on the specifics of such improvement work, appear to have no voice, either individually or collectively. This can hardly be reasoned as respectful, dignified or plain-simply “patient-centred”

It occurs to me that there are parallels with the improvement work in delirium with the recent drive in policy for early diagnosis of dementia.[62] Both these wide ranging initiatives are based on conditions/diseases that affect the individual. Both conditions can be very serious where ethical medicine and nursing have a duty of care. However, these initiatives must recall they start on a “pathway” that is orientated by the condition and/or disease. This is not the same as starting with the person.

Dr Leon Eisenberg has written about this in less faltering way than I can:

“I have elsewhere proposed the usefulness of distinguishing between “disease” and “illness,” terms employed synonymously in ordinary usage. Physicians are taught to conceptualize diseases as abnormalities in the structure and function of body organs and tissues. However, patients suffer illnesses; that is, experiences of disvalued changes in states of being and in social function.”45

We can, and should continue such improvement work, but I would argue that we must be mindful that we collectively have an ethical duty first and foremost, one that is central to respecting the autonomy and dignity of patients. The King’s Fund has just this week published a report that concludes that the way that the United  Kingdom manages its ageing population needs to “change radically so that care is coordinated around all of a person’s needs rather than being based on single diseases.”[63]

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s