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.

 

 

‘How to Improve’

The Nuffield Trust has recently published “Learning from Scotland’s NHS”. This report was based on a select group of “30 senior leaders and experts from Scottish health and care”.

One of the primary “learning points” of this report was that Scotland should be considered as “the model of how to improve healthcare across the British isles”. What is not made clear in this report is that the improvement methodology that Scotland has embraced was introduced from the USA not by “30 senior leaders” but by three:

  1. Derek Feeley, President of the Institute for Healthcare Improvement (IHI) and former Director General for NHS Scotland
  2. Professor Jason Leitch, who is a Dental practitioner, IHI Fellow and National Clinical Director of Healthcare Quality and Strategy (Scottish Government)
  3. Dr Brian RobsonIHI Fellow and Clinical Director of Healthcare Improvement Scotland

The “30 senior leaders and experts” would seem to be “marking their own homework”.

A few personal thoughts:

I am a passionate about science but am of the view that passion should not pre-determine scientific method and process.

I have previously argued why it is unhelpful to pre-determine science as “improvement”.

I fully welcome a coordinated approach to improving healthcare.

I worry about the inherent reductionism that is the basis of IHI “improvement science”

IHI promotes learning to healthcare based upon the experience of Industry (mechanical engineering). This may work well for less complex interactional processes, such as Hospital Acquired Infection. However healthcare is rarely linear (it is more often Bayesian) and reductionist interventions (however well intentioned) can cause harm.

I have found that Healthcare Improvement Scotland (IHI) does not routinely include ethical considerations in its approach to “improvement science”.

In summary:

I would suggest that it would have been more accurate (evidence based) for the Nuffield Trust report to have been titled: “Learning from the USA”.

I welcome all learning and from all reaches of the globe. I also seek improvement. But as a philosopher and NHS doctor (of 25 years) I worry about any one-system approach.

Science needs to consider culture, ethics, narrative, and the experience of being.

“How to Improve” needs to consider the voices of people and place. It should not just be the voices of the “senior leaders and experts from Scottish health and care”.

 

 

 

 

Are the public being listened to?

This is a current Editorial in the BMJ:
Below are a few extracts from this editorial: In a similar vein to Carl Heneghan, I have outlined that there is a problem with the E in CME (Continuing Medical Education)

Sharing the BMJ Editors concerns about a failure of the Academy of Medical Sciences to take necessary action to ensure trust in science (EBM) and education (CME) this response was submitted:

“We could not agree more with Dr Tom Robinson in that we can only gain the trust of the public if we listen to them. One of us (Dr Peter J Gordon) raised a petition with the Scottish Parliament to consider a Sunshine Act for Scotland, and as part of this a consultation was undertaken with the Scottish public. The majority of those consulted agreed that it should be mandatory for all financial conflicts of interest to be declared on a public register. The Academy of Medical Sciences has gone no further than recommending the development of “frameworks for declaring and managing interests” . We would suggest that this will do nothing to restore the public’s trust.”

Dr Peter J Gordon and Dr Sian F Gordon

The Scottish Public: consulted on a Sunshine Act

The Scottish public were consulted on the need for a Sunshine Act for Scotland. Their response, in majority, was that this was necessary.

Almost a year-and-a-half on and the Scottish Government has provided no update to the Scottish people. This is disappointing given the Scottish Government’s assertion that “everyone matters” to them.

The lack of sunshine legislation in the British Isles is raised in this current BMJ News feature:

This response was submitted by Vagish Kumar L Shanbhag:

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

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: