Improvement goggles

What follows are three slides taken from a talk given by Dr Brian Robson, Executive Clinical Director, Healthcare Improvement Scotland and IHI Fellow, given at the Edinburgh International Conference of Medicine in September 2016:



 

I most certainly agree that culture is important. But what kind of culture? Is it healthy just to follow one? In this case the Institute of Healthcare Improvement, Boston.

The “Improvement Goggles”, it would seem, come as part of the “toolkit”?

As a doctor who is passionate about improving care it matters to me that I follow science that does not risk being pre-determined.

It is important that there is philosophical depth to the approaches that we take to healthcare.

I understand the overwhelmingly good intentions of all those involved in “improvement science”, however I would suggest that we should carefully consider the potential benefits and harms of a most determined “one organisation” approach that starts and ends with reductionist and mechanical algorithms.

 

 

Unrealistic Medicine

This BMJ Editorial of the 30th June 2017 has had a number of responses:

The Editorial was a consideration of Academy of Medical Sciences report ‘Enhancing the use of scientific evidence to judge the potential harms and benefits of medicines’.

The President of the Academy of Medical Sciences and the Chair of the Report, Professor Sir John Tooke, has submitted this reply:

It is most welcome for Professor Sir John Tooke to set out his further thoughts but I found that what he said did not reassure me about the future of science and so submitted this response:

Unrealistic Medicine
Written by Peter, 15 July 2017
Submitted as BMJ Rapid Response.

The further thoughts of Professor Sir John Tooke, Chair of the Academy of Medical Sciences report ‘Enhancing the use of scientific evidence to judge the potential harms and benefits of medicines’ are most welcome.

Professor Sir John Tooke does not reassure me that an era of unrealistic medicine and the business of science will change anytime soon. Meantime the NHS is struggling across the United Kingdom and this may be in part due to the promotion of medical interventions whose evidence base lacks the objectivity that we all surely seek.

I would suggest that most of us fully understand the “reminder” from the Academy of Medical Sciences that potential conflicts of interest can come in all forms and not just financial. But like the public I share the view that we should start with potential financial conflicts of interest as evidence has determined that exposure to industry promotional activity can lead to doctors recommending worse treatments for patients  Godlee and Freer remind us that we expect this from our elected politicians and in other areas of public life.

The voluntary ABPI Register is not working. Its database is only a little more than half complete. This really does challenge the “E” in EBM.

The pharmaceutical Industry has, over the preceding year, increased payments to healthcare workers for “promotional activities” from £109 million to £116.5 million.  This is a major part of Industry budget. Furthermore, we do not know how much may be being paid by device makers and other forms of industry for promotion of their products.

It is welcome, but somewhat “after the bell has rung”, that Professor Sir John Tooke confirms that the Academy of Medical Sciences intends to “review” its approach to public transparency. But one wonders how many “houses” do we need to “get in order” to address this issue effectively? I find myself worrying that it could be like a game of Monopoly that never seems to end.

The most effective and cheapest way to address this matter would be Sunshine legislation. This would avoid multiple, overlapping and generally unsearchable databases of interests.

I would suggest that the reputation of science is at stake as is the balance between benefits and harms for us all

Roy Porter, who sadly died prematurely was considered as one of the United Kingdom’s finest historians of science and health. He ends “Madness: A Brief History “ with a teasing question: ‘Is folly jingling its bells again?’

 

We need a Renaissance of Generalists

I aspire to be a generalist.

We live between the microscope and the telescope. I am of the view that the art and science of being a doctor requires such necessary width of focus.

Bettina Piko argued in 2002 that we need a “renaissance of polymaths”. It saddens me to consider that the western world, in the time since, has encouraged, and supported, the greater development of specialisms.

This post is about General Practice. My wife Sian has been a GP for more than 25 years.

This week the Royal College of General Practitioners has accused the Scottish Government of “longstanding under funding” of General Practice.

1 in 4 GP practices have a vacancy in Scotland.

I found myself part of a conversation about the current and future state of General Practice on the Stephen Jardine programme, Radio Scotland, on the 14th July 2017:

Psychiatry Without Borders

The International Congress of the Royal College of Psychiatrists took place in Edinburgh, the city of my birth, between the 26 – 29 June 2017. This International Congress was called “Psychiatry Without Borders”.

As a psychiatrist who has worked in NHS Scotland for 25 years I made a peaceful protest outside the International Congress.

I have previously petitioned the Scottish Parliament to consider a Sunshine Act for Scotland which would make it mandatory for healthcare workers and academics to declare potential financial conflicts of interest on an open public register.

The pharmaceutical Industry has this year increased payments to healthcare workers and academics for ‘promotional activities’ –  from £109 million up to £116.5 million today.

The Association of the British Pharmaceutical Industry (ABPI) has, from 2015, established a voluntary disclosure system with searchable database. It remains the case that 65% of those who have received payments have opted out – and this accounts for 60% of the total payments (as reported in the British Medical Journal (BMJ 2017;357:j3195)

What follows here are the ABPI disclosures made by some of the speakers at the 2017 Royal College of Psychiatrists International Congress.

It is important to note that it is my understanding that no speaker 
was paid for giving presentations at this International Congress. 

These declarations relate simply to the voluntary declarations
for the years 2015 and 2016 respectively.

If you click on each declaration you will get a closer view.

In previous posts I have provided as much public transparency as there is currently available  relating to the potential financial conflicts of interest of those involved with the British Association of Psychopharmacology (BAP). This Association works closely with the Royal College of Psychiatrists in providing Continuing Medical Education.

A number of those involved in BAP have chosen not to declare on the ABPI Register. For this reason, I attach the declarations given along with the new BAP Guidelines for treating dementia as Professor John O’Brien was giving a talk about these guidelines at the 2017 International Congress:

A few personal thoughts:

Well done to those who have declared on the ABPI Register.

However, it remains the case that we cannot scientifically consider the scale of potential biases that financial incentives may bring to the prescribing of medications in the UK. This is because we have an incomplete dataset. This is surprising given that we do have longstanding evidence that exposure to industry promotional activity can lead to doctors recommending worse treatments for patients.

I would like to see the College, of which I am a member, support the public’s request for sunshine legislation.

 

 

How mechanical should healthcare be?

These two fliers are currently being shared by the Royal College of Psychiatrists:

The following words, it seems to me, are appearing more frequently in healthcare:

ToolsTraffic Lights Dashboards toolkits

It is my view that all those involved in healthcare need to consider the potential consequences of the widespread use of such mechanical language.

freedom to speak

The Director General for NHS Scotland:

  Peter's experience of the Director General for NHS Scotland

 

The Clinical Director of Healthcare Improvement Scotland:

     Peter's experience of the Clinical Director of HIS

 

The Director of Health and Social Care Integration:

Peter's experience of Director of Health & Social Care Integration

 

In my determination to put patients first I have been treated poorly.

These highly paid officials seem to be beyond accountability:

[I have always openly acknowledged that my view is no more important than any other. I am always careful to be clear in what cannot be said with any certainty. I am fully aware of my weaknesses.  I absolutely refute any charge that I am “vexatious”. I do not hold grievances. What matters to me is truth and fairness. I have found that the same cannot always be said of those in genuine positions of power]:

 

It can take courage to care. To resist the threats to your career and the misnaming:

 

Such abuse of power is not new:

 

You are invited to join me for this protest:

 

Psychiatry without borders

This week the International Congress for the Royal College of Psychiatrists is taking place in Edinburgh. It is titled “Psychiatry without Borders”.

Given my concerns about the harms associated with over-medicalisation I decided to make a peaceful protest outside.

I was born in Edinburgh in 1967.

This was a home-made protest.

I have no associations with Critical Psychiatry, Anti-Psychiatry, Scientologists, the Citizens Commission on Human Rights.

I am simply a doctor who is interested in ethics.

I am of the view that critical thinking is an essential part of science.

I understand that biases come in all forms. However there is longstanding evidence that exposure to industry promotional activity can lead to doctors recommending worse treatments for patients.

Thank you to all who came to talk to me on the day. Particular thanks to Chrys Muirhead and her son Daniel for all their support

I waited the full day as I wanted to meet the Cabinet Minister for Health (Scottish Government) outside the International Congress. This was my experience:

More details about a Sunshine Act for Scotland can be found here and here.

The public consultation can be found here.

 

The Rounall

This is a film based on my exploration of Dupplin castle estate in Perthshire on Thursday 15th June 2017.

This film is about circles; the circles of life and the circle of consciousness that each of us inhabit. In this sense we are all narcissistic and the world has more than 7 billion realities.

Credits: Thomas Mann and Dexter Britain. The rest is by Peter.