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

 

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

 

 

Improvement science and consent: a failure of NHS Governance

I am an employee of NHS Lothian and have been ‘sign posted’ to the “New Capacity and Consent intranet page: important information for all staff.”

This is a screenshot taken on Friday 2nd June 2017:

The Capacity and Consent intranet page begins by reminding all NHS Lothian staff of the ‘Obtaining Consent’ Policy (2014):

The NHS Lothian ‘Obtaining Consent’ Policy (2014) informs staff that “failure to secure consent may constitute assault under common law in Scotland”.

All NHS Lothian staff are also reminded that “acquiescence when a patient does not know what the intervention entails, or is unaware that he or she can refuse, is not consent”.

Two years ago I wrote about national improvement work undertaken by Healthcare Improvement Scotland for older people in hospital in NHS Scotland and my concern that “compliance” had replaced consent.

Given my experience that the guidance from my employers (NHS Lothian) on consent and the explicit requirements of “compliance” mandated by Healthcare Improvement Scotland seem to go in opposite directions, I wrote seeking further guidance. I have had this reply from Healthcare Improvement Scotland.

In conclusion: I would suggest that a failure of NHS Governance in Scotland has led to a confusion about the rights of older people to give consent.

A tall, slightly stooping, gaunt figure

Dr Robert Hutchison died in 1960, seven years before I was born. However, his appearance as depicted in the portrait (above) reminds me of Roald Dahl. One of his closest friends and colleagues described him in this way:

Dr Robert Hutchison, like Roald Dahl, is recalled for his wonderful way with language. One of my favourite quotes – about the profession in which we have shared across centuries – is by Hutchison. I still find it extraordinary that he wrote this in 1897:

Robert Hutchison was born at Carlowrie Castle, Kirkliston, in 1871.

In the early 1990s I lived with Sian in Kirkliston, at Humbie farm cottages. I was then studying Landscape Architecture at the University of Aberdeen and Sian was completing her GP training in Livingston:

In 1893 Robert Hutchison graduated in Medicine and Surgery at the University of Edinburgh. Like me, he was a very young medical student, but unlike me he was far more promising.

Robert Hutchison delivered his first baby in 1894 at the Simpson Memorial Hospital Edinburgh. I was born in this same hospital 70 years later.

1897, aged just 26 years of age Robert Hutchison co-authored: Clinical Methods: A Guide to the Practical Study of Medicine:

This is still used and is now in its 23rd Edition!

Robert’s sister Isobel Wylie Hutchison was quite amazing. She was a poet, polyglot, painter, botanist and Arctic traveller. She could speak Italian, Gaelic, Greek, Hebrew, Danish, Icelandic, Greenlandic and some Inuit.  Carlowrie remained a home for her to return to from travels, although the upkeep was hard and the castle did not have electricity until 1951. Isobel died at Carlowrie in 1982, aged 92.

I was delighted to see Dr Robert Hutchison quoted in a recent BMJ response by Dr Amr K H  Gohar. This was in response to this BMJ Analysis:

Dr Gohar titled his response: Primum non nocere (first, do no harm). He summarised the potential harms from early detection which he said may include: overdiagnosis and overtreatment, false positive findings, additional invasive procedures, negative psychosocial consequences, and harmful effects on bodily function.

Dr Gohar confirmed his view [that]: “This does not mean that such early detection should be ignored but it means, as this article stresses, that early detection should be balanced. Critical assessment of early detection including early detection technologies and strategies in clinical practice is indispensable to avoid the persisting bias that early detection is only beneficial.”

This returned my thoughts to communications that I have had with Healthcare Improvement Scotland an NHS Board that is primarily guided by the American organisation: the Institute of Healthcare Improvement.

I have in Hole Ousia expressed my concerns about the approach taken to detection by Healthcare Improvement Scotland. My concerns have related to the lack of consideration of harms of  “National Improvement” drives and the continued marginalisation of consent.

Robert Hutchison may have died seven years before I was born. But in 1897 he wrote words that I consider to be most prescient:

"From inability to let well alone;

from too much zeal for the new and contempt for what is old;

from putting knowledge before wisdom, 
science before art, 
and cleverness before common sense;

from treating patients as cases;

and from making the cure of the disease more grievous than 
the endurance of the same,

Good Lord, deliver us."

 

 

 

 

Yellow socks and handstands

There is a lot of effort in NHS Scotland to raise awareness amongst healthcare staff about delirium, using statements like this:

am1

Delirium is a very complex state and it is a shame that awareness is not always accompanied by understanding of this complexity. This is not surprising as delirium is poorly understood. It remains unclear to what extent delirium is itself a risk factor for mortality, rather than simply reflecting a multi-morbid state where each condition carries its own risks:

yellow socks and handstands

[the above is an excerpt from Inside Health last week]

The following slides come from recent awareness-raising events in NHS Scotland:

Resource into OPAC THINK delirium across scotland

These “busy slides” perhaps do reflect some appreciation of the complexity of delirium. What appears to be lacking is meaningful and informed involvement of patients:

Informed choice

Margaret McCartney stated in this:

Rather than submission

In her book “The Patient Paradox” Margaret McCartney said:

awareness

All awareness campaigns can suffer from the difficulty of communicating complexity and recognising gaps in understanding. Oversimplified approaches to what is undoubtedly a serious condition could have unintended consequences and this has to be given serious consideration.

Validation of an OPAC delirium tool

In this post I wish to explore validation of one of the tools recommended by Healthcare Improvement Scotland to identify delirium in acute hospital.

The website for the 4AT can be accessed here. It states that:

4AT validated

Looking at these two published studies in turn:

053Tools

The following caveats are included in this validation study:

  1. One of the  main features of the 4AT test is that “no special training is required”. In this study 4AT assessments were “performed by experienced physicians, though no specific training in the 4AT was given”. The authors conclude that: “Further research is needed to assess the ease of use of 4AT among other professional groups of varying levels of seniority.”
  2. The authors also state that this study “did not assess inter-rater reliability for the 4AT or the reference standard assessment”
  3. This study was not set in A& E or hospital front-door settings.
  4. The authors of this study conclude that “because of insufficient power, we were not able to analyse the characteristics of misclassified (false negative and false positive) patients.”
  5. The authors of this study advise that “future studies in larger populations and other centres should further assess its performance, including the determination of whether detection of delirium using the 4AT may improve the clinical outcomes of patients.”

It seems very clear to me that the authors of this study have recognised that further assessment of the 4AT is required before its use can be considered to be reliable in populations other than that studied by the authors.

Here follows the second published study quoted as evidence of validation of the 4AT test:

054Tools

This study is set specifically in a Stroke Unit and thus its conclusions cannot be generalised to all acute admissions.

It is therefore welcome to see that a major study is being undertaken to further evaluate the 4AT test:

4AT validated UK Gov

Here are some extracts from the study protocol:

055Tools       051Tools

This study is not yet published. The protocol states that: 4AT further research

This research study has had ethical approval and is rigorous in its approach to patient consent. Obviously a research study includes different ethical dimensions when it comes to consent but, as I have reasoned in my last post, the use of a test that still remains to be fully evaluated also requires that ethical rigour.

informed consent

The study protocol outlines the hope that:

NICE delirium 2

However the study protocol also states that:

knowledge-mobilisation-4at-3

Healthcare Improvement Scotland, in their recent reports state that “OPAC tools work and are working in hospitals across Scotland”. One of these tools is the 4AT test.

In summary there must always come a stage where a research tool is evaluated in the ‘real world’. My concern is that Healthcare Improvement Scotland is encouraging the use of the 4AT in hospitals across Scotland without making it clear that it is still under evaluation. Given that “compliance” with the use of “OPAC tools” is being used as a measure of quality of care by Healthcare Improvement Scotland, it would seem justified to express concern about this.

Professor David Oliver recently had an opinion piece published 
in his regular BMJ column; Delirium Matters (24th May 2016). 
I wrote to Professor Oliver by e-mail to say that I agreed with most 
of what he said but that I was not as convinced as he was 
that the 4AT has been validated.

Professor David Oliver replied that it "beggared belief" 
that I would "nit pick" about this.

I replied:

"In terms of the word “validated”: this has a very clear 
scientific definition. My reading of the science so far is 
that the 4AT tool has not been validated either for 
screening or detection. 

My concern is a general one: that “simple”, “quick” and 
“no specialist training required” tools have the potential 
for harm when over-relied upon and that they may give 
the impression that a very complex condition/state 
is more simple and better understood than it really is."

 

 

 

“OPAC tools are working”

It is over a year since I last wrote about delirium. Being aware that the new Care Standards for older people in hospital were to be published this month I had a look on the Healthcare Improvement Scotland web platform for these new standards. As yet these standards have not been published, but I did notice the news that “OPAC tools are working”. I followed the links, read the supporting material, and watched all the associated films:

[The costs of films commissioned from the private sector by NHS 
Healthcare Improvement Scotland has been over £51,000 from 
January 2014 to February 2015]

027Tools

A lot has happened in acute care settings for Scotland’s elders since I last wrote. It is wonderful to see in these films such compassion and dedication to care amongst the healthcare teams: from allied health professionals, nurses and doctors. I agree with Professor Jason Leitch that this demonstrates a caring culture.

It was some years ago that I heard Professor MacLullich give a talk about delirium. I was inspired by his thoughtful presentation which outlined the distressing symptoms that can come with states of delirium and the associated increased risk of mortality.

In this post I will not be considering improvement work undertaken on “frailty”. In what follows I intend to further explore the Healthcare Improvement Scotland strapline: “OPAC tools are working” with particular reference to delirium.

In terms of “working”, only two key figures are given by Healthcare Improvement Scotland. The first confirms that there has been 95% “compliance” with “assessment tools” for delirium.

025Tools

The other key figure demonstrates that length of hospital stay in orthopaedics for older people has been reduced since the introduction of “frailty and delirium assessment tools”:

043Tools

In what follows the OPAC tools currently being used in hospitals across Scotland to “identify” delirium will be considered. Two specific issues continue to concern me:

(1) the risk of too great a reliance on any “brief” “tool” rather than this being part of an overall assessment; and
(2) the marginalisation of consent.

(1) Reliance on a “brief” “tool”:032Tools

The 4AT has been revised since I last wrote. It was previously described by its developers as “a new screening tool for delirium and cognitive impairment” (see below):

006Tools

The latest version (at time of writing) is version 1.2. The developers “have decided to describe” the 4AT now as an “assessment test”:

Version 1.2 4AT

As an “assessment test” the 4AT requires:

011tools

The 4AT “assessment test” is also noted for its:

009Tools

The 4AT:

008tools

The four questions that comprise the AMT4 are as follows:

052Tools

It is important to appreciate that the 4AT test is different from other tools for delirium as it incorporates the AMT4. The AMT4 is a screening tool for cognitive impairment alone. To explain further this test is in effect used to screen for dementia. This is an important point because there has been very wide debate about cognitive screening. Cognitive screening is recommended by neither the UK National Screening Committee nor NICE. Another point is that using brief tests for delirium and cognitive impairment at the same time is an approach novel to the 4AT.

Given that the 4AT test incorporates a test of cognition it is relevant to consider whether our cognitive function can so easily be encapsulated in a “very brief” test. The 95 year old philosopher, Mary Midgley, has said this about “tests”:

031Tools

Mary Midgley then goes on to say:

022Tools

Cognitive ageing has become an area of great interest since Professor Lawrence Whalley of Aberdeen University began research in this area and some of his findings are summarised in his book, the Ageing Brain.

Professor Whalley reminds us that the brain is such an incredible biological wonder. Each of us have 100 billion neurons in our brains, and whilst this may change with ageing, it is still the case that our neurons, even on our last day in life, amount to:

The shock of the fall (9)

Recently this lead Editorial was published in the Lancet:

004Tools

It repeats the reminder of Professor Whalley that:

003Tools

To many it appears counter-intuitive that something so complex as human brain function can be reliably assessed in a test that takes less than 2 minutes. In a follow-up post I will look at the work currently being undertaken to evaluate the 4AT.

(2) Marginalisation of consent:
“Compliance” with the 4AT “assessment test” is being measured in Scotland by Healthcare Improvement Scotland. My concern here, that I have expressed before, is that such an approach marginalises the right of the individual to consent or otherwise to this assessment.

I have become aware through my own clinical practice that even brief cognitive tests can be distressing to patients and can leave them fearful (the following quote is from a patient undergoing a short cognitive screening test but not the 4AT):

039Tools

Another reason to be concerned about consent is that our cognitive abilities tend to follow a parabolic distribution through life. It would be a mistake to disregard this when undertaking complex diagnostic considerations.

In March of this year the UK Supreme Court judged that it was for patients to decide whether the risks, benefits and alternative options of assessments or medical interventions have been adequately communicated:

014Tools

Treatments may bring harms as well as benefits. This is why explanation of risk should be an ethical underpinning in our interactions with a patient.

The Scottish Delirium Association (SDA)  has issued delirium pathways for use across NHS Scotland. The “OPAC tools” are generally the starting point in these pathways. The SDA Comprehensive pathway states very clearly:

040tools

This pathway outlines environmental and general measures, alongside medical and nursing approaches to manage delirium which has been identified using the 4AT test. If these measures are not in themselves sufficient to improve the state of delirium, the Comprehensive Pathway outlines further interventions:

041Tools

A recent audit of Haloperidol prescribing in NHS Scotland has confirmed the findings of the Scottish Government that in our acute hospitals prescribing of antipsychotics has been rising year on year.

To try to identify how much of this rise comes from prescribing for those aged 65 years and over, the 0.5mg capsules and 1mg/ml liquid haloperidol are likely to be indicative.

In one Scottish NHS Board (see table below), we find that haloperidol prescribing in those aged 65 years and over in the acute hospital has nearly doubled since cognitive screening was introduced and monitored at NHS Board level.

042Tools

This is a recent study published in the Lancet:

045Tools

The authors of this study argued that:044Tools

Summary:
In these films Healthcare Improvement Scotland outlines that “OPAC assessment tools work, and are working in hospitals across Scotland”. There is no doubt that delirium is a condition associated with significant morbidity and mortality. It is also clear that we have a long way to go in understanding such a complex condition. Given this, my concerns about the over-reliance on brief tools used at outset and the marginalisation of consent are unchanged.

In a follow-up post I will look at the work currently being undertaken to evaluate the 4AT.

Update, 5th October 2016. The following was published on the 
front page of the Scotsman newspaper: 

"Mental health prescriptions hit ten-year high"

prescriptions-for-mental-health-drugs-10-year-high-nhs-scotland-2016-a prescriptions-for-mental-health-drugs-10-year-high-nhs-scotland-2016-b

The figures are from the Scottish Government and can be accessed here.

Freedom to speak up

Freedom05I am very grateful to the Scottish Government for replying to me on behalf of Jamie Hepburn, MSP, Minister for Sport, Health Improvement and Mental Health. Below you will find the Scottish Government reply and my response to it.

In NHS Scotland I have not found freedom to speak up.

David Berry, Scottish Government

Dear Peter
I refer to your email correspondence of 11 January to the Minister for Sport, Health Improvement and Mental Health. I have been asked to respond to you.

Your main concerns in your email are about the ethics and relative risks and benefits of cognitive screening for older people, including those with dementia. I know that this is an on-going concern and note that you have previously raised this issue with Healthcare Improvement Scotland.

The implication of your email appears to be that you are concerned that there may be what is effectively a national programme of screening for people with cognitive impairment (including dementia) in acute, and that older people do not have the benefit of information or the option to opt out of such screening. I hope I can reassure you that no national programme of that kind has been initiated. HIS have for some time had a focus on improving service response on delirium and I understand you have information on that from HIS.

As you may know, we have a three year strategy to improve dementia care in hospitals, including a 10 point action plan to drive up standards of care. Our approach includes development of clear standards, ensuring strong senior and clinical leadership, getting right staff in the right place and giving healthcare staff the support and training they need to provide safe, effective and person centred care to every patient, every time. Appropriate identification and assessment of dementia is a part of this overall approach. This work is supported by the networks of Dementia Nurse Consultants and Dementia Champions.

The Focus on Dementia in Acute improvement programme, launched in July 2014, has a specific focus on leadership, workforce development, working as equal partners with families and minimising and responding to stress and distress. The aim is to improve the experience, safety and coordination of people with dementia, their families/carers and staff.  Progress to date includes the identification of executive and operational leads within NHS Boards and Boards are currently reporting on progress to date on implementing the 10 Care Actions.

In addition, you know that Healthcare Improvement Scotland’s inspections of care for older people in acute hospitals include a specific focus on dementia and cognitive impairment – and this continues.  You can access their most recent overview report on the HIS website.

With regard to your point about raising concerns and the implication that you feel that recording your concerns has been discouraged at times, I would reiterate that we welcome open debate and discussions around these and other matters and we would welcome the opportunity to get the value of your perspective directly if you should choose at any time to take up our offer to get involved in the implementation of dementia policy.

We do recognise your passion, interest and expertise in these areas and hope you will reconsider the offer.

With best wishes

Scottish Government 
Directorate for Health and Social Care Integration
Mental Health and Protection of Rights Division

Reply to David Berry

Monday 1st April 2015

To the Scottish Government
Directorate for Health and Social Care Integration
Mental Health and Protection of Rights Division
St Andrew’s House, Edinburgh

Many thanks for replying on behalf of the Minister for Sport, Health Improvement and Mental Health after I had written following the debate on Mental Health that the Minister led in the Scottish Parliament on the 6th January 2015. I attended parliament that day to observe the debate. I am writing to acknowledge your reply which I received on the 30th March 2015.

You state that it appears to you that I am “concerned that there may be what is effectively a national programme of screening for people with cognitive impairment (including dementia) in acute care, and that older people do not have the benefit of information or the option to opt out of such screening.” I am writing to confirm this is indeed my concern as an NHS clinician in Scotland who has followed closely developments in this area. It is clear that the screening for cognitive impairment in NHS Scotland fulfils all the criteria of the World Health Organisation definition of screening.

You say “I hope I can reassure you that no national programme of that kind has been initiated.” I am afraid that I am not reassured. Following inspections Healthcare Improvement Scotland ask that all NHS Boards “cognitively screen” all patients 65 and over admitted to acute hospitals. It is also the case that Healthcare Improvement Scotland measure NHS Board “compliance” with “cognitive screening”. Given the dual role that Healthcare Improvement Scotland have (for scrutiny and improvement), it is my view that, not only do patients have no choice whether to be screened or not, but hospital managers and every employee in each NHS Board are disempowered to question such an approach.

Regarding my “implication” “that recording my concerns has been discouraged at times”, the truth is that after raising concerns I felt that I had no other option but to resign from my NHS post of 13 years. This followed a letter from the Executive Clinical Director of Healthcare Improvement Scotland to the Medical Director of the NHS Board I worked for. This letter went much further than “discouragement”. This letter made all sorts of defamatory statements about my professionalism and character, none of which I accept. This has been my experience of raising concerns about patient safety and wellbeing in NHS Scotland. I am glad then to appreciate that the Cabinet Minister for Health, Wellbeing and Sport has indicated that Scotland will be considering the “Freedom to Speak Up” review by Robert Francis. I am very grateful to hear that the Scottish Government “welcome open debate and discussions around these and other matters”. Unfortunately damage has been done to my career in NHS Scotland for raising such matters.

I am grateful that the Scottish Government “would welcome the opportunity to get the value of my perspective.” Currently I do not have time for such a commitment but as I confirmed recently to you I am happy to help, if I can, on specific matters.

In summary, in NHS Scotland we currently find:

  • Cognitive screening (as defined by the World Health Organisation)
  • that the potential harms of such an approach are not being discussed
  • that the individual’s right to consent has been marginalised

I realise and appreciate that the Scottish Government, along with many other organisations, may continue to disagree with me on the above. However I wanted to put my view on record. As this is a matter of public interest I will share your reply and my response on my website Hole Ousia.

I want to thank you again for your reply.

Kind wishes
Peter signature

Dr Peter J Gordon

Cc: Jamie Hepburn, Minister for Sport, Health Improvement and Mental Health
Cc: Shona Robison, Cabinet Minister for Health, Wellbeing and Sport
Cc: Geoff Huggins, Acting Director for Health and Social Care Integration
Cc: Penny Curtis, Acting Head of the Scottish Government’s Mental Health and Protection of Rights Division

Dr Neil Houston and Dr Brian Robson

Karen Goudie & Dr Wolff 4 Dec 2014

Do we care enough about consent?

This leaflet is widely available to patients in NHS Scotland including in the waiting room outside my consulting room: 039

Its first page defines consent as follows:038

This is the front page of the current BMJ:021

It is reporting on a legal ruling which has implications for consent as summarised by the editor:051052 053 054

Previously Sokol has said:013

I have had a longstanding interest in consent:015

Consideration of patient consent goes back to the earliest days of the NHS (and indeed before):032

I have previously highlighted how this difficult area becomes even more complex when we are considering cognitive screening:014

Scotland led the way with an incentivised target-based approach to the “early diagnosis” of dementia. The following is from one of the earliest expert meetings:First Dementia Strategy Meeting

A few years later the Scottish Government were sharing widely league tables:002

The Scottish Government commended its own approach to the Westminster Government:How to improvegeoff-huggins4 Geoff Huggins3

It was this robust approach that led me to consider whether the consent to assessment of the individual patient might be significantly affected by an external target. It was at this stage I contacted the National Clinical Leads for dementia, specifically highlighting my concerns about consent:Dementia Leads1

The Scottish Lead for Dementia replied:Dementia Leads2

I was delighted to attend this Conference in Glasgow which culminated in the signing of a rights-based approach to dementia:034044

At this Conference, the Chief Executive of the Mental Welfare Commission gave an address. Mr Colin McKay reminded us that for any individual deemed to lack capacity certain principles should apply. This includes having one’s own wishes listened to:
020

The previous Chief Executive of the Mental Welfare Commission offered his personal view on consent to examination. For many reasons I believe that cognitive screening is a very different activity to measuring blood pressure:056

I have also been in conversation with parliamentarians regarding consent to cognitive screening. In my letter to Dr Simpson, MSP, I highlighted the following points:

  • my concerns are specifically about obtaining consent to cognitive screening
  • Cognitive screening does not fulfill World Health Organisation criteria (Wilson & Jungner)
  • the UK National Screening Committee do not advise screening for cognitive impairment

Richard Simpson2

This is the view of the former Cabinet Minister for Health & Wellbeing:At liberty

I have also asked the UK’s leading Dementia charities about consent:042

I have recently written to Alzheimer Scotland about their current campaign: “Lets talk about dementia”. Disappointingly this appears to have back-tracked from the Glasgow Declaration and is advocating early rather than timely diagnosis. The “difficult conversation” as suggested by Alzheimer Scotland appears to me to trivialize consent:033

I have also had a number of “difficult conversations” when trying to raise issues of consent:Dr Brian Robson

One of the many reasons why this matters is that cognitive screening is not risk-free. 046047

Off-label anti-psychotic prescribing has increased year-on-year in the elderly across Scotland.

It is my view that those promoting improvement methodologies in NHS Scotland are currently not taking consent sufficiently seriously. It appears that I am not alone in having found these conversations “difficult”:061

The following post was about improvement work in the elderly on the Ayrshire Health blog. The full post and all responses to it can be read here:Flying without wings1

I submitted a reply which outlined my considerations about obtaining consent for cognitive screening. In response to my considerations, the Associate Nurse Director of Mental Health Services in NHS Ayrshire and Arran and Chair of the Mental Health Nursing Forum Scotland, appeared to remain unsure of the basis of my concerns:Flying without wings2

Professor June Andrews, Director of the Dementia Services Development Centre offered the following advice:June Andrews3

A service user shared my concerns about patient consent and raised the matter with the Ethics Committee of the Royal College of Psychiatrists:    John Sawkins

Over a decade ago, NHS Scotland published this Expert Group report:Adding life to years, 2002 aAdding life to years, 2002 cAgeism in NHS Scotlandc

This blog post asks if we care enough about consent? My view is that the principle of patient consent should be a fundamental right for all ages. It is the case that consent is a complex area but this is not a good enough reason for marginalising it. I would argue strongly that wider discussion particularly involving all of our elders is long overdue.

Care of Older People in Hospital Standards

The Chair of Healthcare Improvement Scotland, Dr Denise Coia, has confirmed that the Care of Older People in Hospital Standards are scheduled to be published at the end of March 2015.

I submitted my considerations on the Draft Standards last November and I wrote to Dr Coia to seek an update on further progress made. Dr Coia’s reply was very helpful and I wanted to acknowledge this:

Care-Standards1

My interest in the Care Standards goes back many years.

Although Healthcare Improvement Scotland have not always considered me to be an “interested clinician” I have in fact been an NHS Consultant in NHS Scotland for 14 years:

Care-Standards2

I remain hopeful that Healthcare Improvement Scotland might give some written response to my considerations and questions regarding Delirium screening in Scotland which I wrote almost a year ago. It would have been preferable to have had the thoughts of those involved with delirium improvement methodology ahead of the published Care Standards.


Speaking personally, I would be reassured to learn that the Scottish Parliament may continue to have some oversight of Healthcare Improvement Scotland:

Care Standards3