Professional confusion

Like all those involved in healthcare I take delirium very seriously. I share in the collective determination to improve our approach, understanding and care of those experiencing this serious condition.

To improve it is important that critical thinking is given room.

This post is about the validated 4AT Rapid Assessment Test for Delirium:

In a recent medical educational lecture organised by Healthcare Improvement Scotland, the 4AT was described as a “screening” test.

One of the authors of the 4AT Rapid Assessment Test described it recently as a “screening tool”:

There seems to be a lack of consistency in the stated purpose of this test/tool. Has this test/tool been validated for screening or has it been validated for assessment? This is an important scientific and ethical matter in terms of how this test/tool may be both validated and implemented

 

 

NHS Scotland – it should not take courage to care

On the 17th July 2017, the Scottish Government announced an “Enhanced service for NHS Scotland staff”

The Scottish Government began this announcement stating that:

“Staff in Scotland’s health service will continue to benefit from external support should they have any concerns about patient safety or malpractice”

From 1 August, the NHS Scotland Confidential Alert Line will be re-branded as the Whistleblowing Alert and Advice Services for NHS Scotland (AALS).

This was reported in the Scotsman of the 17th July 2017:

The Scottish Government confirm the enhancements that have been made:

Some personal thoughts:

I have never been a “whistleblower”. I have however raised concerns relating to patient wellbeing and safety in NHS Scotland, and in particular for our older generation. I share the view of Sir Robert Francis that “freedom to speak up” is a better and more encompassing term.

My experience of trying my best to put patients first in NHS Scotland has left me with an interest in this matter and I have followed developments over several years now.

My concern is that this “enhanced service” has taken little account of the evidence presented to the Scottish Parliament from a wide range of individuals and professional bodies, including Sir Robert Francis.

Lifeboat NHS from omphalos on Vimeo.

The “enhanced” service will still not be able to independently deal with any concerns raised and so can offer only to “pass concerns on to the appropriate Health Board or scrutiny body for further investigation”. In practice this will be either to the NHS Board the employee works with or to Healthcare Improvement Scotland which is neither independent of Government nor of any of Scotland’s 23 other NHS Boards.

It worries me that senior Scottish Government officials continue to use words such as “grievance” or “pursuers” when talking about those who are trying to put patients first in NHS Scotland. It seems that the Scottish Government are as quick as any of us may be to label individuals.  This “expanded service” has been re-labelled in a positive way when the opposite has happened to many of us who have raised concerns about patient care.

In summary:

I feel that this is a disappointing outcome given the determination of the Scottish Parliament, and the Health and Sport Committee in particular, to ensure that there is freedom in NHS Scotland to speak up and put patients first.

I would suggest that despite this “enhanced service” that it is still going to take a great deal of courage to care in NHS Scotland:

Courage to care from omphalos on Vimeo.

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.

 

 

Pitmiddle village

On Thursday 6th July 2017, on a wet summer morning, I set off to find the deserted village of Pitmiddle, in the Carse of Gowrie, Perthshire.

What follows is a storyboard of images and text. I have tried my best not to overwhelm with explanatory text and what I present, is by no means, “a history” It is the case that all histories have gaps in them and I would suggest that Pitmiddle is no exception.


All brief quotes (within images) come from the novel “All that man is” by David Szalay, which I have just finished reading.

By the time I reached Pitmiddle my map was soaked:

This is a map from the first part of the nineteenth century:

This is how Colin Gibson, in 1955 recorded his first visit to Pitmiddle:

This is Pitmiddle as depicted on the 1st Ordinance Survey map of c1860:

And this was how Pitmiddle was described by the surveyor of 1860:

Pitmiddle survived most of a millennium and was first recorded in1172:

This was how Pitmiddle looked at the century’s turn (early 1900s):

A sketch of one of Pitmiddle’s last occupied houses:

One villager, James Smith, who died in Pitmiddle in 1860 was involved in the Napoleonic wars and whose last vessel was the HMS Semiramis:

In July 1897 some of the Longforgan  congregation went on a picnic to Pitmiddle:

This is report from the Dundee Courier of 1896:

Generations of the Gillies family lived and worked Pitmiddle. Here is James Gillies, mason and his wife Margaret Gray pictured on their Golden Wedding in 1903:

There is a lovely account of this Golden Wedding Celebration that can be read here.

James Gillies, Mason died at Pitmiddle in October 1920, aged 87 years:

Unfortunately this report below, from 1891, was overly optimistic. As you can see from the death certificate above, Mary Ellen Clark, aged 45 years, died at Pitmiddle of tuberculosis.

I came across a number of Pitmiddle villagers who had died as a result of tuberculosis, such as Betty White who died aged 36 years of age in 1862.

It is true though that those who did not succumb to the mycoplasma bacterium often lived long lives at Pitmiddle.

This is the 1930 valuation Roll for Pitmiddle (click on image for closer view). Only two houses are occupied:

In 1917 the Inchmartine Estate, including Pitmiddle and its wood, were put up for sale:

This is how David R Perry finishes his account of Pitmiddle’s history:

I find myself wondering what happened to the grandson of James Gillies after he left Pitmiddle:

Pitmiddle is a special place. I am a late visitor. 

I want to thank all of the following and to acknowledge 
the sources of material that this post contains. 

If I have inadvertently omitted any out please let me know.

Bon Hambley who has set up a Pimiddle Facebook page 
and who has been nothing but helpful to me and 
permitted me to share the old images of Pitmiddle.

Pitmiddle Village - by David R Perry (published 1988 
by Perthshire Society for Natural Sciences)

Soldiering On - a wonderful account of the Gillies family

David Szalay - "All that is man is"

Scotlands People and Scotlands Places

All maps from the National Library of Scotland

British Newspaper Archive

This beautiful aerial film of Pitmiddle from November 2014

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.

 

 

Statements made by senior Psychiatrists working in the British Isles

“you are either abstinent or promiscuous when it comes to industry. Well you can see which side I am on”.

“For those of you who watch Panorama, I do not give my consent for you to film this”

“Who would have thought that Pharma Hospitality could cause excessive weight gain and type II diabetes? They kept that quiet”, I replied, ruefully patting my stomach.

“this latest non-problem”

“it is time we all grew up”

 

Justice must be seen to be even-handed

This is a short film about my experience of attending the Scottish Parliament on Thursday 29th June 2017.

I was there to support Marion Brown in her presentation of petition PE01651: Prescribed drug dependence and withdrawal:

However this film is based on an old petition that was being reconsidered by the Petitions Committee, that being, PE01458: Register of Interests for members of Scotland’s judiciary.

Lord Carloway was giving evidence. I was sitting right behind him. I found that I did not share his views on this subject.

This film is an edit of the full evidence session which can be watched (in entirety) here:

Credits:

‘Chasing Time’ by Dexter Britain (free, under common licence)

A Diary of Injustice in Scotland

The Scotsman – Leader comment of 30 June 2017

Painting of Holyrood, Scottish Parliament was sourced from here