If NHS Scotland has been genetically-modified with QI

It is most welcome to hear from Philippa Whitford about positive outcomes of NHS Scotland’s collaborative approach to quality improvement and the learning that this might provide for the rest of the UK. I share Philippa Whitford’s concerns about the potential consequences of competitive systems such as occurs more in NHS England with providers, commissioners and contracts and the inevitable fragmentation that this brings. The integrated approach taken in Scotland along with the engagement of patients and frontline practitioners is indeed something to be most positive about.

However, NHS Scotland’s approach to Quality Improvement is based on what is known as “improvement science”. This is a relatively new approach to science introduced from the USA and based on methodologies from the engineering and airline industries. The Health Foundation, in its ‘Evidence Scan’ found a “real paucity of evidence about the field of improvement science” . The Health Foundation found papers on the conceptual nature of Improvement Science but concluded that: “none of these could be said to be seminal pieces of research acting as building blocks for the field as a whole”.

As far back as 2007 Brent et al identified that “ethical issues arise in QI because attempts to improve quality may inadvertently cause harm, waste scarce resources, or affect some patients unfairly.”

Scotland has two key National Improvement initiatives for older people in acute hospital care. One is for Delirium and the other is for Frailty.

The QI initiative on Delirium was reliant upon “screening tools” that were effectively made mandatory for all those aged 65 years and over admitted to hospital. Healthcare Improvement Scotland measured the “compliance” with the use of these “screening tools” across Scotland. On the wards I was finding that these tools were not infrequently being interpreted as diagnostic and that older people were sometimes considered as lacking in “capacity” on this basis. I was also concerned that this approach could lead to greater use of antipsychotic medication.

The QI initiative on Frailty is currently being implemented across NHS Scotland. This is despite the fact that there is no internationally accepted clinical definition for Frailty. More “screening tools” have been developed by Healthcare Improvement Scotland and “Frailty Hubs” are now being set up in most NHS Boards. It may be worth noting recent high-level disagreement amongst British Geriatricians about the validity of the “Frailty Industry” as one senior Geriatrician described it.

The experience of these national initiatives perhaps highlights the limitations of approaches which work best in mechanical settings. The same success cannot be guaranteed when applied to more complex presentations such as delirium and frailty.

It has recently been stated that “ethical approval is less burdensome” for QI. However I suggest that we must be wary of taking shortcuts that may result in potential harm as well as potential good. This is why ethics and philosophy have an established role in science.

Another risk is that if science is pre-determined as “improvement”, this may limit the acceptance of critical thinking.

Philippa Whitford concludes that in NHS Scotland “Quality improvement has made its way into the DNA of frontline staff”. I share the view that Quality Improvement has much to offer. However, if NHS Scotland has been genetically-modified with QI let us hope that the wider considerations necessary for science are included in the base-code.

Dr Peter J Gordon
Psychiatrist for Older Adults
NHS Scotland

 

The end of something

In this film I attempt to tell a bit of the story of the beginning of the end of Usan.

Behind the Keith Mausoleum on the rock of Skae I noticed a Celtic cross that commemorated a doctor: Dr W A Mackintosh who died in 1911 just before the war. I wondered who he was?

Back home I discovered that he was the last Laird of Usan and had died suddenly in his bath. This was the beginning of the end for the Fishertoon of Usan.

In this film I find a connection between an enamel bath (vessel) and the Trawlers (vessels) that did an end to the laird and hand-line fishing respectively. Usan then went into decline.

At the time of this Angus adventure I was reading Ernest Hemingway’s short stories “in our time”. They were written not long after WWI and reflect his terrible experiences. They are somewhat brutal.

The music in this film all comes from the BBC Proms: Scott Walker Revisited. I have been rather moved by this performance of words and music of yesteryear (words and music that were barely noticed for decades)

The end of something from omphalos.

We are far more than our labels

“National Improvement” work for older people has focused on Frailty and in NHS Scotland we are reminded by healthcare Improvement Scotland to “THINK frailty”

This short film is based on “thought for the day” by Anna Magnusson, BBC Radio Scotland, Friday 5th August 2017.

Music is “Seeing the future” by Dexter Britain (under common license)

We are far more than our labels from omphalos.

two ragged soldiers

This is a short film with some images from the east of Scotland. I explored with my friend Ian and we visited many places, including Fishtown of Usan, St Skae, Bridge of Dun, Brechin and Montrose.

two ragged soldiers from omphalos on Vimeo.

Music credit: Scott Walker Revisited http://www.bbc.co.uk/iplayer/episode/b08z2x62/bbc-proms-2017-scott-walker-revisited

‘Progress depends on the unreasonable man’

Professor David Oliver is a doctor that I have huge respect for. His views, as expressed in the BMJ, and thus in short form, generally accord with mine [this is an observation and not a statement about the merit of our opinions].

As an NHS doctor who has ‘spoken up’ I read this ‘BMJ Acute Perspective’ by Professor Oliver with both interest and with gratitude.

I worry (perhaps I am not alone in this worry) if I might be considered as either “reasonable” or “unreasonable”? However I have a greater need, and that is to be true to who I am.

Truth generally rests between words like “reasonable” and “unreasonable”. This is  territory that needs freedom.

 

‘The medical untouchables’

The following is a recent opinion piece by Dr Des Spence published in the British Journal of General Practice.

I had been lined up to do the media interviews on BBC Scotland in relation to petition PE1651. However, on the day, due to changed travel arrangements, I was not available. Dr Des Spence was interviewed instead and did a better job than I could have done.

As an NHS doctor and specialist, I fully support this petition (PE1651) which calls on the Scottish parliament “to urge the Scottish Government to take action to appropriately recognise and effectively support individuals affected and harmed by prescribed drug dependence and withdrawal.”

I have submitted my response.

I feel it would be helpful to hear the views of the Chief Medical Officer for Scotland and in particular, how this matter might be considered as part of Realistic Medicine.

Three recent posts by me demonstrate the scale of competing financial interests in medical education in the UK. If you have a moment, you should have a look. Perhaps you might then share the worry that I have about this matter:

I have previously raised my own petition, PE1493, which the Scottish Public has supported. This was a petition for a Sunshine Act for Scotland, to make it mandatory for all financial conflicts of interest to be declared by healthcare professionals and academics.

My petition, supported by the public, had no support from “Realistic Medicine”. The public has had no update from the Scottish Government on my petition in 18 months. My view is that this is a shocking failure of governance and would seem to demonstrate a lack of respect for democracy.

We ignore them at our peril

This recent Audit Scotland report was considered in the BMJ:

The Scotsman of the 1st August 2017 had this as the front-page story

The Scotsman Editor concluded: “The nurses surveyed are not scoring points or using the NHS as a political football. We ignore them at our peril”:

The Laird of Asloss and Sliddery Braes

A film about John Glen Parker of Asloss and Slidderybraes, Kilmarnock.

This Laird was able to be completely comfortable with who he was. He put others first.

His father was the first to recognise brilliance in Rabbie Burns.

    This film is for my mother Margaret and my daughter Rachel

The laird of Asloss and Slidderybraes from omphalos.

It is important to record the narrative of dementia policy in Scotland accurately

I recently wrote to the Minister for Mental Health with concerns about  the way the Scottish Government has chosen to record the narrative of dementia policy in Scotland.

I have received this reply from the Scottish Government:

I have sent this letter of reply:

Tuesday, 1st August 2017

To: Strategic Lead for Dementia
Dementia Strategy and Delivery Division,
Scottish Government.

Copied to: Maureen Watt, Minister for Mental Health

Dear Ms Barclay,
Thank you for your letter of the 28th July 2017 in response to my recent communications.

The 1st Dementia Strategy included specific targets for the “early diagnosis” of dementia and no mention whatsoever of a timely diagnosis.

It is therefore inaccurate for the Minister to state in her foreword to the 3rd Dementia Strategy that “Our first strategy was published in 2010 and focused on improving the quality of dementia services through more timely diagnosis”. It is also inaccurate to describe the 1st Dementia Strategy as a “broad statement of policy intent” when incentivised targets for early diagnosis were involved.

It would be wrong to consider this as simply a matter of vocabulary as these different approaches can and indeed did have significantly different consequences for those affected.. I welcome the consideration of a timely approach from the 2nd Strategy onwards.

I will be sharing our correspondence on my website as I feel it is important to record the narrative of dementia policy in Scotland accurately.

Yours sincerely
Dr Peter J. Gordon