Reductionism – truly, madly, deeply

On Friday the 25th of November 2016 I gave a talk for the Scottish Philosophy and Psychiatry Special Interest Group.

My subject was “Improvement Science”.

The following is based on the slides and the four short films that I presented.

My talk was entitled:
001-improvement-science The meeting was held at the Golden Lion Hotel, Stirling:golden-lion-hotel-stirling-25-nov-2016-1golden-lion-hotel-stirling-25-nov-2016-2I started the day off:
002-improvement-scienceI gave these declarations:
I explained to the audience that like Dr Rev I M Jolly I can be overly pessimistic:

005-improvement-scienceThe dictionary definition of ‘Improvement’:
006-improvement-scienceThe dictionary definition of ‘Science’:
007-improvement-scienceMy concern is any pre-determinism to science:
008-improvement-scienceThe Health Foundation have considered Improvement Science: this is from 2011:
009-improvement-scienceMany different terms are used including “QI” for “Quality Improvement”:
010-improvement-scienceThis is where improvement science began, in Boston, Massachusetts:
011-improvement-scienceThe Founder of the Institute for Healthcare Improvement (IHI) was Don Berwick:
013-improvement-scienceThe first description of this movement in Britain goes back to 1992 by Dr Godlee:
014-improvement-scienceFifteen years later, Dr Godlee, Editor of the BMJ, said this:
015-improvement-scienceOnly last month the BMJ briefly interviewed Don Berwick:
016-improvement-scienceIHI describes improvement science as being based on a “simple, effective tool”:
017-improvement-scienceThis tool was developed from the work of an American engineer, W. A. Deming:
018-improvement-scienceThe “Model for Improvement” Tool [TM] is described by IHI as a “simple, yet powerful tool”:
019-improvement-scienceThe current President and CEO of IHI is Derek Feeley:
024-improvement-scienceUp until 2013, Derek Feeley was Chief Executive [Director General] for NHS Scotland:
021-improvement-scienceIn April 2013 Derek Feeley resigned from NHS Scotland:
022-improvement-science22nd February 2015 it was reported: “The astonishing and largely hidden influence of an American private healthcare giant at the heart of Scotland’s NHS”:
023-improvement-scienceDr Brian Robson, Executive Clinical Director for Healthcare Improvement Scotland [HIS] is an “IHI Fellow”:
dr-brian-robsonProfessor Jason Leitch, National Clinical Director for the Scottish Government is an “IHI Fellow”:
026-improvement-scienceMight we be facing the biggest change to healthcare in Scotland since the NHS began?nhs-scotland-1947 Improvement science is moving quickly and widely across Scotland:
027-improvement-scienceThis “Masterclass 1” for Board members cost  £146,837:
028-improvement-scienceAn NHS Board member commented after the Masterclass:
029-improvement-scienceHealthcare Improvement Scotland is one organisation with a very wide remit over NHS Scotland and it works closely with the Scottish Government:
031-improvement-scienceNine cohorts of Safety Fellows and National Improvers have so far been trained following IHI methodology:
032-improvement-scienceI was reminded of the current enthusiasm for improvement science when the Convener of a recent Scottish Parliament Committee meeting said of targets (another approach enthusiastically taken by NHS Scotland):033-improvement-scienceWhat is the place of ethics in Improvement Science?
034-improvement-scienceIn 2007 the Hastings Centre, USA, looked into this in some depth:
035-improvement-scienceThe Hastings Centre argue that Improvement science cannot ignore ethics:
036-improvement-scienceIn 2011 the Health Foundation, UK, produced this “Evidence Scan”:improvement-science-2011a2The Health Foundation commented that “improvement science is just emerging”:
The Evidence Scan found a “real paucity of evidence about the field of improvement science”:
038-improvement-scienceI would also suggest that there is a real paucity of philosophy about the field of improvement science:
039-improvement-scienceThe Health Foundation did find papers on the conceptual nature of Improvement Science but concluded that:
040-improvement-scienceMary Midgley is a philosopher now aged 95 years who is widely respected for her ethical considerations:
041-improvement-scienceChapter 7 of her book “Heart and Mind: The Varieties of Moral Experience” begins:
042-improvement-scienceMary Midgley is concerned about the overuse of reductionist tests in medicine stating that:
This film is about the potential consequences of inappropriate reductionism:

Leon Eisenberg has written many papers about this subject. He argues that reductionism should not be “abandoned” but that we must keep sight of where such an approach is scientifically useful and also where it is inappropriate:
045-improvement-scienceIn the Hastings Report, Margaret O’Kane asks:
046-improvement-scienceIn my view the answer to this question is YES. I am hopeful that the National Improvers recruited to NHS Scotland would agree:
047-improvement-scienceAs an NHS doctor I have seen unintentional harm brought about by National improvement work in Scotland. This related to a “Screening Tool” that was introduced across Scotland as part of this work. I found that the unintended consequences of the use of the following tool included implications for patients’ autonomy and the risk of over treatment:
048-improvement-scienceBoth the Hasting Group and the Health Foundation are of the view that improvement science cannot separate itself from the ethical requirements of research:
049-improvement-scienceThis article published in February 2016 argues that individual “rights transcend all aspects of Improvement science”
050-improvement-scienceThe following is a verbatim representation of a conversation held by National Improvers working in NHS Scotland:
051-improvement-scienceIn November 2016 Professor Joshi, also a psychiatrist outlined his concerns about reductionism in a published letter to the BMJ:
In this short film the mechanical language of healthcare improvers is considered:

Professor John Bruce was a Moral Philosopher in Edinburgh University in the 18th century. He built this temple, the “Temple of Decision”, in the grounds of his home by Falkland Palace so that he could consider his thesis:
054-improvement-scienceProfessor John Bruce did not succeed in his endeavour. His Temple however stood for many years:
055-improvement-scienceBut it eventually collapsed and his endeavour to “reduce the science of morals to the same certainty that attends other sciences” collapsed with it.
057-improvement-scienceAny search of Healthcare Improvement Scotland for “ethics” finds this result:
This film is about more up-to-date buildings – the enthusiasm for which was based on improvement science: The Red Road flats in Glasgow:



The following is an edited clip of the evidence given to the Scottish Parliament by Healthcare Improvement Scotland (HIS) on the 31st January 2017:

The full session can be watched here

The Official Report can be accessed here

11 thoughts on “Reductionism – truly, madly, deeply

  1. Thanks Peter for letting us browse a second time through your line up of other people’s thoughts and letting us see your own train of quality thinking shining through them. And now the rest of the world can see them for a first time. In case the importance of your concerns needs emphasising I add my voice to yours. Ethics becomes one vote more political. The more voices the more likely it won’t be dismissed.

    The point is that if a single minded mob of health board members and managers et al storm gleefully forward, convinced of their valuable mission, without thinking carefully and checking systematically with the patients who are supposed to get the benefit for their permission and experience of their stampede, the mob may be more like a cult that does no one any good and wastes a lot of time and money.

  2. What is lawful is not always ethical because insufficient attention was given to human rights when some laws related to non-consensual treatment were passed.

  3. I have received this encouragingly open response from the Chief Executive of Healthcare Improvement Scotland:

    Sent: 30 November 2016
    To: Peter J Gordon
    Subject: Re: My talk on Improvement Science 25 November 2016

    Dear Dr Gordon
    Many thanks for sharing the slides with me.

    I was interested to hear your thoughts and views on this issue, and the challenges in delivering sustained improvements in an increasingly complex environment. In such circumstances, there will inevitably be a need to have a broad range of approaches, and which are sensitive to the service and context in which we operate.

    As Healthcare Improvement Scotland’s range of stakeholders becomes more diverse, it becomes even more important that we adjust our approach to local needs and circumstances. Our planning process for 2017 onwards, has that as an important theme.

    My thanks again for sharing your presentation with me.

    With best wishes

    Robbie Pearson
    Chief Executive


    I have replied to Mr Pearson as follows:

    From: Peter J. Gordon
    Sent: 30 November 2016
    Subject: RE: My talk on Improvement Science 25 November 2016

    Mossgrove, Bridge of Allan

    St Andrew’s day 2016

    Dear Mr Pearson,
    Thank you for this kind reply which indicates that Healthcare Improvement Scotland is open to approaches beyond improvement science/methodology. Many would argue that ethics, philosophy, culture and history are integral to a deeper understanding of healthcare.

    I realise that I am a critical thinker but I hope that you understand that does not mean I have a fundamental problem with improvement or science. Critical analysis is essential to counter an understandable tendency to follow the crowd.

    I must congratulate you on your well-deserved appointment as Chief Executive of Healthcare Improvement Scotland.

    Kind wishes

  4. Nowadays a consumer rather than a supplier of any proposed or established healthcare improvements, I congratulate you, Peter, on your deep-thinking approach to these matters.

  5. Pingback: Correspondence with Healthcare Improvement Scotland (HIS) | Hole Ousia

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