Sunday 8th July 2018, Bridge of Allan.
Dear Dame Coia,
I received your reply to my open letter yesterday. I wanted to write and thank you for your most helpful and prompt response.
I welcome the initiatives that you outline. I was aware of some of them.
I have never argued that the IHI methodology does not have a place in healthcare (please excuse my use of a double negative). I have however expressed concerns that this methodology has a reductionist basis (adapted from the Engineering industry) and so it may apply best to relatively straightforward interventions and consequently may struggle with complexity (which is commonplace in health and social care).
Forgive me repeating myself, but I do worry about the marginalisation of ethics in “improvement science” (QI or however this new science may be termed). I am of the view that there is a lack of philosophy in general in the IHI approach. What philosophy there is strongly focuses on that of Edward Denning and Don Berwick. Evidence informed medicine has (of course) my support, but data is not sufficient as a guide to health and social care. Evidence also comes in the form of experience. Subjectivity (that which makes us human) should not simply roll over to data, that in its collection has losses [experience “translated” to words, and then words “translated” to numbers]. Data can only do time over a certain period, most usually this is the short term rather than the life span.
Realistic medicine also needs to consider the drivers to what the BMJ term “too much medicine”. We are all responsible here, that is my view. The medicalisation of life (life viewed through the lens of the microscope) and capitalism (business first) stridently march on. I recently read ‘The Plague” by Albert Camus and I felt it could be read today as a commentary on Western over-medicalisation. I do worry that IHI will not help Scotland here. In my opinion IHI is not dissimilar to the pharmaceutical industry in that it seems to invest a lot of time, finance and human resource to the promotion of its products (I mean methodology). I worry about the cost of this, alongside what seems to me to be an endless series of worldwide conferences. Is this realistic use of NHS money in a time of austerity?
A few examples of current NHS Scotland issues:
• In Scotland we have at least 1 in 7 adults on antidepressants, many of whom are taking them long term or indefinitely. Yet we do not have evidence to support such prescribing. Is this realistic? The same is now happening with gabapentinoids for pain /anxiety. Also for amphetamines for ADHD (child and adult).
• Delirium. Well I won’t cover old ground. However, HIS national improvement work introduced screening where “compliance” was measured to determine the level of “improvement”. I have always understood that the intentions of all those involved were nothing but good. However the pathways, still in place today, include use of Haloperidol with no mention of necessary ECG. As you will be aware, Haloperidol has now been found to increase mortality in those experiencing delirium. You will recall that your Medical Director wrote to my former employers that I was “scaremongering” about this: a letter that almost ended my career and for which I have had no apology.
• Frailty. The science in this area is evolving. I again understand the good intentions. I have outlined my concerns to Dr Ellis, the National Lead in this open correspondence (HIS blog):
In terms of openness and transparency, my view is that HIS and the Scottish Government should make it clear to the Scottish public that Healthcare Improvement Scotland “#followthefellows” or should that be, if I may say so, “follow the fellas”? IHI methodology has been implemented across Scotland by just three IHI fellows: Derek Feeley, Jason Leitch and Brian Robson. Given this, it seems to me entirely reasonable to ask questions of an approach that has been imported from industry, from another culture and is based on IHI “immersion” [IHI use this term in association with their condensed Masters degree].
Unfortunately, it is not easy to speak up in the NHS. I passionately advocate genuine listening to experience so it will be good to collect views on realistic medicine through the ‘Our Voice’ initiative.
I make films on all sorts and mostly not medical. However two films may interest you:
Thank you for being so kind Dame Coia. I realise that I am persistent but make no apologies for this. Having studied in the arts and the sciences I have followed a different path to many others.
Kindest wishes Peter
I have put your response in the public domain alongside my original open letter and I will add this e-mail to you in a linked post.