In May 2014 the Executive Clinical Director for Healthcare Improvement Scotland [HIS] sent a letter to my employers NHS Forth Valley setting out formally a range of concerns about my determination to put patients first. In practice, as a psychiatrist for older adults, I was finding as a direct consequence of mandatory [HIS] screening that elderly and frail patients were frequently being prescribed powerful anti-psychotics such as Haloperidol.
Below is my reply to Dr Peter Murdoch, Interim Medical Director, NHS Forth Valley, after I had been made aware of this letter:
To Dr Peter Murdoch
Interim Medical Director
Castle Business Park
Dear Dr Murdoch,
Many thanks for sharing this letter from Dr Brian Robson.
I welcome the opportunity to respond to the points made.
First of all I would like to make it clear that I did try to use local mechanisms to feedback into the “improvement” process. The local response was that “improvements” in delirium screening (i.e. mandatory cognitive screening of all over 65s admitted to the acute hospital – see attached) were guided by HIS. I therefore contacted HIS by letter to clarify the ethical considerations and the evidence base behind changes which I could foresee would have an impact on my day-to-day clinical practice and which caused me concern for a range of reasons.
After a partial written response by HIS Inspector, Ian Smith, I was invited to take part in a teleconference with four employees of HIS. I found this experience disappointing in that none of the four appeared to be willing to answer any of my concerns. My overall experience of HIS was of an organisation which was not willing even to consider ethical points or discuss the validity of “screening tools” the use of which it is recommending across Scotland.
My approach has always been one to encourage discussion and debate. I do not expect HIS to necessarily agree with me but I do expect them to consider my concerns seriously.
“Oppressive use of social media”:
I have only ever written two blogs about delirium. Both relate to ethical considerations and also look at validity of “screening tools”. My first blog “the faltering, unfaltering steps” is based entirely on evidence and material in the public domain, all of which is cited. This is not “misinformation”. My second “blog” called “Delirium Screening” was a summary produced at the request of Professor Alasdair MacLullich. I have had no response from Professor MacLullich or anybody involved in delirium improvements on the legitimate ethical issues which were raised in it. I am of the view that the public deserves a balanced presentation of the complex issue of delirium.
HIS and OPAC use social media very extensively but it appears that only content that accords with the outlook of OPAC or HIS will be considered acceptable responses. Debate is not being allowed by HIS and OPAC and runs counter to HIS claim to be “engaging”. Dr Robson’s letter makes it clear that to be allowed to be “engaged”, one must not question anything in their predetermined approach.
It is certainly not the case that “HIS cannot engage with anyone without him sending his blog to the clinician”.
I have made no films about delirium.
“Misinformation and Scaremongering”
These are very bold words indeed and I would like to see examples of where I have quoted “out of context”. I agree that I “do not understand the improvement science” if it is a “science” which does not require evidence (e.g. internal and external validation of “screening tools”) and consideration of ethics (e.g. consultation with the population directly affected).
I have come to understand that there has been significant confusion between improvement work for delirium (which are undergoing local pilots and which target patients aged 75 years and over) and the recommendations made to NHS Scotland Boards about routine cognitive screening (which are assessed by HIS Inspection visits and generally refer to all patients aged 65 years and over). From the viewpoint of a grassroots clinician the conflation of these two processes has been unhelpful. It is unfair to say that routine cognitive screening is led by NHS Boards when in fact this is a recommendation against which they are inspected by HIS. My understanding is that this recommendation is based on the Clinical Standards for Acute Care (2002) which are more than a decade old and that the Convener of the Parliamentary Health Committee (January 2013) expressed concern that these need updated. Given this clear political involvement I reserve the right to communicate with elected representatives.
It is not my intention to cause distress to anyone. On a point of principle however, and here I would make reference to the findings of the Francis Report, it is surely essential that critical voices are not silenced because of potential to cause “upset”. There is always a power imbalance between any organisation and any individual and a number of recent examples have illustrated the risks of always assuming that the organisation is right.
The reason that I have stated that I felt “uncomfortable” relates to a specific conversation on twitter. Although HIS and OPAC use twitter extensively it has its limitations in discussing complex issues and it was my intention to move the discussion onwards using more traditional methods of communication.
“Waste and impact on improvements for patients”
Given the amount of my own time that I have devoted to “engage” with Dr Robson, Prof MacLullich, Scottish Delirium Association, HIS, and OPAC it is disappointing to hear that my contributions have been a “waste” and had only negative “impact”. This is all the more so in that the responses I have had from the above parties have not “assisted my understanding” but have comprehensively failed to address my concerns.
Dr Robson states that he fears that this formal letter to my employers might be “misinterpreted as censorship”. I think that this would indeed be the view of anyone, who like me, has struggled to raise ethical issues.
History tells us that the spirit of scientific progress requires open-minded enquiry. Any organisation which is aiming to take a scientific approach must take care to remember this. My recent experience makes me feel that the headline promise that HIS “engage” meaningfully is but a hollow sound-bite. HIS is going struggle to find more “engaged clinicians” if absolute agreement with the organisation’s approach is a pre-requisite for engagement.
I am replying via e-mail for speed but will be following up by letter to yourself and to Dr Brian Robson.
It would be helpful if you could confirm if I have breached any NHS Forth Valley Policy on the matters covered in this communication.
Dr Peter J Gordon
cc. Dr Brian Robson, Executive Clinical Director, Healthcare Improvement Scotland
I copied my letter to Alex Neil, MSP, Cabinet Minister for Health and Wellbeing, Scottish Government. I attach the reply below:
Immediately following the letter from the Executive Clinical Director for Healthcare Improvement Scotland to NHS Forth Valley I was “invited” to an “informal” meeting by my employers. Where no minute was kept.
At this “informal meeting” the Medical Director repeatedly reminded me of my duty to the organisation. The General Manager for NHS Forth Valley repeated this reminder. Thereafter, my professionalism, character and ethics were robustly questioned.
Within weeks of this “informal meeting” I resigned from NHS Forth Valley.
Almost two years on from the letter sent by Healthcare Improvement Scotland to my former employers, NHS Forth Valley, I have sent the following letter to the Executive Clinical Director of HIS. I have done so because I was reminded of the situation that I found myself in following the recent, and most welcome publication of “Realistic Medicine” by the Dr Calderwood, Chief Medical Officer for Scotland.
Wednesday, 2nd March 2016
To: Executive Clinical Director, Healthcare Improvement Scotland,
Dear Dr Robson,
I hope that you do not mind me writing to you to reflect, a few years on, from the circumstances I found myself in as an NHS employee who had worked in Scotland for over 20 years. My wish in this letter is to reflect and to suggest learning for all, including of course myself. In summary my experience has been that in trying my best to put patients first I did not find what Robert Francis termed “freedom to speak up”: rather that deference was first given to colleagues and to the system.
As Executive Clinical Director for Healthcare Improvement Scotland you sent a letter, dated 22nd May 2014, to the Medical Director of my former employers http://wp.me/p3fTIB-u8 . I was not aware of this letter until I had an “informal” “invitation” to meet with my employers. A month later I resigned after 13 years as a Consultant with unblemished career with NHS Forth Valley. The feedback I had following my resignation confirmed that I was valued as a respected and professional doctor. I publicly advocated a timely approach to the diagnosis of dementia even though the universal approach was for early diagnosis. From the Health Secretary down, including senior policy makers and senior NHS staff, Alzheimer Scotland, the British Geriatric Society and the Mental Welfare Commission, there was no support for timely diagnosis. I advocated this approach as it included considerations of potential harms as well as potential benefits. Given the opposition I encountered, it was a welcome but considerable surprise when in summer 2014 the “Glasgow Declaration”, which enshrines the principle of timely diagnosis, was issued. As of the time of writing, 203 organisations, 11613 individuals, 153 Policy Makers, and 84 MEPs, across 25 European countries have signed this declaration.
I mention this as the concerns you raised with my former employers related to my considerations and questions about Delirium Improvement work. I take delirium very seriously indeed: however my concerns about reductionist tools, whether termed “screening” or “detection” remain, as do my concerns about the ethics of consent. I also worry about potential unforeseen outcomes, which may be harmful, such as increased prescribing of antipsychotics such as haloperidol. Last month, the Chief Medical Officer put forward her proposal for “Realistic Medicine”. This document prompted me to reflect on a culture which may struggle to accommodate questioning voices. The CMO’s report has been welcomed widely and was discussed at the overdiagnosis conference held in Stirling on the 27th February 2016. The afternoon panel was assembled to help us consider “What can policy makers do to help us?” This was the question I raised:
“Would the panel like to comment on the inevitable tension between what the Scottish Government has chosen to call “Improvement work” and over-medicalisation? The reason that I focus on the term improvement is that it makes it very easy for anyone who questions such work to be characterised as a barrier to progress.”
As a human, I am very far from perfect. I make mistakes, and find that I am always learning. However I am proud of Scotland’s fine tradition of a critical approach to science. I now feel that I have done my bit and have scars to show it. I have decided that when the time is right for me, and indeed my family, I will retire early from medicine.
If you were able to write your thoughts in response to this letter they would be most welcome.
I wish you all the very best.
Dr Peter J. Gordon
I received this reply from Dr Brian Robson on the 12th March 2016:
This was my letter of response:
Bridge of Allan,
8th March 2016
Dear Dr Robson,
Your letter was carefully considered and thank you for taking the time to write it.
What I found disappointing was the lack of acknowledgment of the harmful consequences for myself and my family following your letter to my former employers. I have now come to the conclusion that there may never be any such acknowledgement. I hope that you might agree that I have contributed significantly to the consideration of potential unforeseen consequences of improvement science. I am particularly proud that the Glasgow Declaration has been adopted.
I hope that Healthcare Improvement Scotland is moving in the direction where it will consider questioning voices and treat them respectfully. Scientific enquiry is after all based on asking questions.
Dr Peter J Gordon
The following quotes are by a senior medical professional and ethicist:
"I want to make a case and I want to argue why ethics is as important, if not more important than quality" 2011
"Quality is a by-product of ethics and not vice-versa" 2011
"It is extremely important for healthcare organisations to invest in ethics. Who should be trained in ethics? Each and every person in our healthcare organisation: Chief Executive, Directors, Managers, medical and nursing staff, as well as support staff. Each and every person." 2011