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-2016-1

golden-lion-hotel-stirling-25-nov-2016-2

I started the day off:
002-improvement-science

 

I gave these declarations:
003-improvement-science

I explained to the audience that like Dr Rev I M Jolly I can be overly pessimistic:

005-improvement-science

The dictionary definition of ‘Improvement’:
006-improvement-science

The dictionary definition of ‘Science’:
007-improvement-science

My concern is any pre-determinism to science:

008-improvement-science

 

The Health Foundation have considered Improvement Science: this is from 2011:
009-improvement-science

 

Many different terms are used including “QI” for “Quality Improvement”:
010-improvement-science

 

This is where improvement science began, in Boston, Massachusetts:
011-improvement-science

The Founder of the Institute for Healthcare Improvement (IHI) was Don Berwick:

013-improvement-science

 

The first description of this movement in Britain goes back to 1992 by Dr Godlee:
014-improvement-science

 

Fifteen years later, Dr Godlee, Editor of the BMJ, said this:
015-improvement-science

 

Only last month the BMJ briefly interviewed Don Berwick:

016-improvement-science

 

IHI describes improvement science as being based on a “simple, effective tool”:
017-improvement-science

This tool was developed from the work of an American engineer, W. A. Deming:

018-improvement-science

 

The “Model for Improvement” Tool [TM] is described by IHI as a “simple, yet powerful tool”:

019-improvement-science

 

The current President and CEO of IHI is Derek Feeley:

024-improvement-science

 

Up until 2013, Derek Feeley was Chief Executive [Director General] for NHS Scotland:
021-improvement-science

 

In April 2013 Derek Feeley resigned from NHS Scotland:

022-improvement-science

 

22nd 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-science

 

Dr Brian Robson, Executive Clinical Director for Healthcare Improvement Scotland [HIS] is an “IHI Fellow”:

dr-brian-robson

 

Professor Jason Leitch, National Clinical Director for the Scottish Government is an “IHI Fellow”:

026-improvement-science

 

Might 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-science

 

This “Masterclass 1” for Board members cost  £146,837:
028-improvement-science

An NHS Board member commented after the Masterclass:
029-improvement-science

Healthcare Improvement Scotland is one organisation with a very wide remit over NHS Scotland and it works closely with the Scottish Government:

031-improvement-science

 

Nine cohorts of Safety Fellows and National Improvers have so far been trained following IHI methodology:

032-improvement-science

 

I 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-science

 

What is the place of ethics in Improvement Science?
034-improvement-science

 

In 2007 the Hastings Centre, USA, looked into this in some depth:

035-improvement-science

 

The Hastings Centre argue that Improvement science cannot ignore ethics:

036-improvement-science

 

In 2011 the Health Foundation, UK, produced this “Evidence Scan”:

 

improvement-science-2011a2

The Health Foundation commented that “improvement science is just emerging”:

 

037-improvement-science

 

The Evidence Scan found a “real paucity of evidence about the field of improvement science”:

038-improvement-science

 

I would also suggest that there is a real paucity of philosophy about the field of improvement science:


039-improvement-science

 

The Health Foundation did find papers on the conceptual nature of Improvement Science but concluded that:

040-improvement-science

 

Mary Midgley is a philosopher now aged 95 years who is widely respected for her ethical considerations:

041-improvement-science

 

Chapter 7 of her book “Heart and Mind: The Varieties of Moral Experience” begins:

042-improvement-science

 

Mary Midgley is concerned about the overuse of reductionist tests in medicine stating that:
043-improvement-science
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-science

 

In the Hastings Report, Margaret O’Kane asks:

046-improvement-science

 

In my view the answer to this question is YES. I am hopeful that the National Improvers recruited to NHS Scotland would agree:

047-improvement-science

 

As 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-science

 

Both 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-science

 

This article published in February 2016 argues that individual “rights transcend all aspects of Improvement science”

050-improvement-science

 

The following is a verbatim representation of a conversation held by National Improvers working in NHS Scotland:

051-improvement-science

 

In November 2016 Professor Joshi, also a psychiatrist outlined his concerns about reductionism in a published letter to the BMJ:

052-improvement-science

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-science

Professor John Bruce did not succeed in his endeavour. His Temple however stood for many years:

 

055-improvement-science

But 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-science

 

Any search of Healthcare Improvement Scotland for “ethics” finds this result:

056-improvement-science

 

This film is about more up-to-date buildings – the enthusiasm for which was based on improvement science: The Red Road flats in Glasgow:


 

 

                         Post-script:

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

12 Replies to “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:

    From: PEARSON, Robbie (HEALTHCARE IMPROVEMENT SCOTLAND)
    Sent: 30 November 2016
    To: Peter J Gordon
    Cc: COIA, Denise (HEALTHCARE IMPROVEMENT SCOTLAND)
    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

    Robbie Pearson
    Chief Executive

    ———————————–

    I have replied to Mr Pearson as follows:

    From: Peter J. Gordon
    Sent: 30 November 2016
    To: ‘PEARSON, Robbie (HEALTHCARE IMPROVEMENT SCOTLAND)’
    Cc: ‘COIA, Denise (HEALTHCARE IMPROVEMENT SCOTLAND)’
    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
    Peter

  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.

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