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 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.

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."

 

 

 

 

Reductionism – truly, madly, deeply

On Friday the 25th of November 2016 I gave a talk for the Scottish Philosophy and Psychiatry Special Interest Group.

My subject was “Improvement Science”.

The following is based on the slides and the four short films that I presented.

My talk was entitled:
001-improvement-science The meeting was held at the Golden Lion Hotel, Stirling:golden-lion-hotel-stirling-25-nov-2016-1golden-lion-hotel-stirling-25-nov-2016-2I started the day off:
002-improvement-scienceI gave these declarations:
003-improvement-science
I explained to the audience that like Dr Rev I M Jolly I can be overly pessimistic:


005-improvement-scienceThe dictionary definition of ‘Improvement’:
006-improvement-scienceThe dictionary definition of ‘Science’:
007-improvement-scienceMy concern is any pre-determinism to science:
008-improvement-scienceThe Health Foundation have considered Improvement Science: this is from 2011:
009-improvement-scienceMany different terms are used including “QI” for “Quality Improvement”:
010-improvement-scienceThis is where improvement science began, in Boston, Massachusetts:
011-improvement-scienceThe Founder of the Institute for Healthcare Improvement (IHI) was Don Berwick:
013-improvement-scienceThe first description of this movement in Britain goes back to 1992 by Dr Godlee:
014-improvement-scienceFifteen years later, Dr Godlee, Editor of the BMJ, said this:
015-improvement-scienceOnly last month the BMJ briefly interviewed Don Berwick:
016-improvement-scienceIHI describes improvement science as being based on a “simple, effective tool”:
017-improvement-scienceThis tool was developed from the work of an American engineer, W. A. Deming:
018-improvement-scienceThe “Model for Improvement” Tool [TM] is described by IHI as a “simple, yet powerful tool”:
019-improvement-scienceThe current President and CEO of IHI is Derek Feeley:
024-improvement-scienceUp until 2013, Derek Feeley was Chief Executive [Director General] for NHS Scotland:
021-improvement-scienceIn April 2013 Derek Feeley resigned from NHS Scotland:
022-improvement-science22nd February 2015 it was reported: “The astonishing and largely hidden influence of an American private healthcare giant at the heart of Scotland’s NHS”:
023-improvement-scienceDr Brian Robson, Executive Clinical Director for Healthcare Improvement Scotland [HIS] is an “IHI Fellow”:
dr-brian-robsonProfessor Jason Leitch, National Clinical Director for the Scottish Government is an “IHI Fellow”:
026-improvement-scienceMight we be facing the biggest change to healthcare in Scotland since the NHS began?nhs-scotland-1947 Improvement science is moving quickly and widely across Scotland:
027-improvement-scienceThis “Masterclass 1” for Board members cost  £146,837:
028-improvement-scienceAn NHS Board member commented after the Masterclass:
029-improvement-scienceHealthcare Improvement Scotland is one organisation with a very wide remit over NHS Scotland and it works closely with the Scottish Government:
031-improvement-scienceNine cohorts of Safety Fellows and National Improvers have so far been trained following IHI methodology:
032-improvement-scienceI was reminded of the current enthusiasm for improvement science when the Convener of a recent Scottish Parliament Committee meeting said of targets (another approach enthusiastically taken by NHS Scotland):033-improvement-scienceWhat is the place of ethics in Improvement Science?
034-improvement-scienceIn 2007 the Hastings Centre, USA, looked into this in some depth:
035-improvement-scienceThe Hastings Centre argue that Improvement science cannot ignore ethics:
036-improvement-scienceIn 2011 the Health Foundation, UK, produced this “Evidence Scan”:improvement-science-2011a2The Health Foundation commented that “improvement science is just emerging”:
037-improvement-science
The Evidence Scan found a “real paucity of evidence about the field of improvement science”:
038-improvement-scienceI would also suggest that there is a real paucity of philosophy about the field of improvement science:
039-improvement-scienceThe Health Foundation did find papers on the conceptual nature of Improvement Science but concluded that:
040-improvement-scienceMary Midgley is a philosopher now aged 95 years who is widely respected for her ethical considerations:
041-improvement-scienceChapter 7 of her book “Heart and Mind: The Varieties of Moral Experience” begins:
042-improvement-scienceMary Midgley is concerned about the overuse of reductionist tests in medicine stating that:
043-improvement-science
This film is about the potential consequences of inappropriate reductionism:

Leon Eisenberg has written many papers about this subject. He argues that reductionism should not be “abandoned” but that we must keep sight of where such an approach is scientifically useful and also where it is inappropriate:
045-improvement-scienceIn the Hastings Report, Margaret O’Kane asks:
046-improvement-scienceIn my view the answer to this question is YES. I am hopeful that the National Improvers recruited to NHS Scotland would agree:
047-improvement-scienceAs an NHS doctor I have seen unintentional harm brought about by National improvement work in Scotland. This related to a “Screening Tool” that was introduced across Scotland as part of this work. I found that the unintended consequences of the use of the following tool included implications for patients’ autonomy and the risk of over treatment:
048-improvement-scienceBoth the Hasting Group and the Health Foundation are of the view that improvement science cannot separate itself from the ethical requirements of research:
049-improvement-scienceThis article published in February 2016 argues that individual “rights transcend all aspects of Improvement science”
050-improvement-scienceThe following is a verbatim representation of a conversation held by National Improvers working in NHS Scotland:
051-improvement-scienceIn November 2016 Professor Joshi, also a psychiatrist outlined his concerns about reductionism in a published letter to the BMJ:
052-improvement-science
In this short film the mechanical language of healthcare improvers is considered:

Professor John Bruce was a Moral Philosopher in Edinburgh University in the 18th century. He built this temple, the “Temple of Decision”, in the grounds of his home by Falkland Palace so that he could consider his thesis:
054-improvement-scienceProfessor John Bruce did not succeed in his endeavour. His Temple however stood for many years:
055-improvement-scienceBut it eventually collapsed and his endeavour to “reduce the science of morals to the same certainty that attends other sciences” collapsed with it.
057-improvement-scienceAny search of Healthcare Improvement Scotland for “ethics” finds this result:
056-improvement-science
This film is about more up-to-date buildings – the enthusiasm for which was based on improvement science: The Red Road flats in Glasgow:

 

                         Post-script:

The following is an edited clip of the evidence given to the Scottish Parliament by Healthcare Improvement Scotland (HIS) on the 31st January 2017:

The full session can be watched here

The Official Report can be accessed here

Patient safety as delivered in Scotland risks failing to reach an acceptable level

In my last post I included the recent response from the Chair of Healthcare Improvement Scotland regarding regulation of healthcare in Scotland.

In this post I include my reply:

Dear Dr Coia,
Re: Building a comprehensive approach to reviewing the quality of care 

Thank for your letter of 14th August 2015. I am grateful that you wrote to try and clarify the issue of the regulation of healthcare in Scotland.

From your reply it is clear that we have no external regulation of NHS Scotland.

The Board of Healthcare Improvement Scotland will be well aware that in order to comply with the law there must be effective regulation to make sure that legal compliance in Scotland is achieved (HSWA s18).   Healthcare Improvement Scotland will also be aware, from page 1 of the second Francis Report, that the situation we have here in Scotland is untenable as well as illegal.

Healthcare Improvement Scotland will have noted that the Scottish Government have refused to recognise that avoidable deaths take place in Scottish healthcare (Cabinet Minister for Health, Wellbeing & Sport, in answer to PQ June 2015)

The Scottish Government continues to describe Scottish healthcare as “world-leading” when the recent authoritative independent survey, the Nuffield Trust and Health Foundation report of April 2014, provides evidence that reveals starkly otherwise.

Healthcare Improvement Scotland will also be aware of the growing concern of the professional bodies.  There are the recent reports from the Academy of Medical Royal Colleges and Faculties in Scotland and their concerns on patient safety and quality of healthcare.  My understanding is that they have recognised that Scotland has no independent regulator and are urgently looking into the matter.

My view is that the current review of the role of Healthcare Improvement Scotland is fundamentally flawed.  It does not consider what the legal requirement is to have an effective independent regulator verifying compliance by duty holders with the law and supporting standards.

The review by Healthcare Improvement Scotland is supposedly being based on the Crerar Review of 2007 but then seems to disregard it.  The Crerar Review was quite clear: that an effective regulatory body needs to be independent of both the NHS and government: Healthcare Improvement Scotland is neither. This is a missed opportunity for Healthcare Improvement Scotland to highlight and address this major shortcoming in patient safety. NHS Scotland has already seen a number of scandals in patient safety. How many more major enquiries are going to be required before this is remedied? The current document out for consultation is enormously disappointing in this regard.

Without an effective fully independent regulator of health and social care, patient safety as delivered in Scotland risks failing to reach an acceptable level.

Yours sincerely,
Dr Peter J. Gordon

Dr-Denise-Coia,-20-Aug-2015

Re-labelling (and a bit)

I read this book recently [below].

I am approaching fifty. With age-related sight changes I find that my arms need to be longer!. So if I have misread “Sixty and a bit”  please do forgive me:

Now we are sixty and a bit

This book reminded my of a protocol issued by an NHS Board in Scotland:

4 april 2014 all over 65 MUST

As a doctor who tries his best to follow evidence-based medicine, I argued against this approach. I found that neither this NHS Board nor indeed NHS Scotland shared my concerns:

Brian Robson

With the recent publication of the Care Standards for Older People, the Chair of Healthcare Improvement Scotland confirmed:

Letter4b

It would appear to me that this “screening instrument” has been re-labelled by Healthcare Improvement Scotland

The 4AT was developed and promoted as:

010Tools

Recently the 4AT has been re-labelled as:

4AT validated UK Gov

The authors  4AT describe its key features:

(1) “brevity” (takes less than 2 minutes”), and

(2) that “no special training is required”

I should confirm that I use rating scales with patients as part of my daily professional life.

However I would never start out with a rating scale. To me, that would seem most disrespectful.

Rating scales can add to wider medical understanding. This is why, despite my awareness of any intrinsic shortcomings, that I continue to feel that they can be helpful.

The 4AT has recently been re-branded an “assessment test”. The 4AT was promoted for several years, with the support of Healthcare Improvement Scotland, as a “screening tool”. The validation studies, still underway, describe the 4AT as a “screening” tool.

Given that there has been no change to the test itself, I would suggest that this is re-labelling (and a  bit.)

Promises to listen to our elders

The “Care Standards for Older people in Hospital”, which replace the previous 13 year old standards, were published this month.

1345

As a doctor working in NHS Scotland whose work for twenty years has been dedicated to our elders, I submitted feedback on the initial draft. I started out by saying:

002-comment-on-care-standards-2015

With the recent  publication of the Standards I wrote to the Chair of Healthcare Improvement Scotland asking for clarification on the involvement of “older people” in the development of these NHS Scotland standards.

Letter1

In the Scotsman, the Chair of the the group developing the Standards, Dr Christine McAlpine stated that “we need to involve patients”:

Care Standards 12 June 2015a

In this article, Dr MacAlpine said:

Care Standards by Dr MacAlpine1

The Editor of the Scotsman summarised:

Care Standards in Scotsman - 9 June 2015b

Healthcare Improvement Scotland and Dr MacAlpine have stated the following:

care-standards-by-dr-macalpine2b

[please note: my appreciation is that 1345 may not actually 
represent 1345 separate individual comments. I say this as my 
two-page feedback on the drafts was separated into more than a 
dozen entries.  This would appear also to be the case for 
other "stakeholders"]

Having read though all the responses I found that none of the responses read as if ‘first-person’ comments. The comments read as if almost entirely by “stakeholders”. If so, this would represent Scotland’s elders by-proxy.

Unsure about this, I wrote to the Chair of Healthcare Improvement Scotland, for clarification. The following was confirmed:

Letter2

Healthcare Improvement Scotland have fully listed the “stakeholders” involved in the Consultation:

Consultation Feedback Report (stakeholders) Care Standards 2015

Having read carefully through all 1345 comments I am still left wondering whether the voices of our elders have been given reasonable opportunity to be heard? [proportionate to the experts, the stakeholders, and those directly tasked with authorising the final standards]

The ‘ladder of participation’ [below] has been widely cited in collective approaches to developing and drawing-up the best approaches to care:

ladder of involving our elders

In my letter to the Chair of Healthcare Improvement Scotland I asked for the average age of those directly involved in developing the Care Standards.

I also specifically asked if anybody deemed an “older adult” was part of the group who were tasked with drawing up these Care Standards for “older people”.

The reply I received from Healthcare Improvement Scotland stated that such information is exempt “in line with Data protection policy.”

Long before the final Care Standards were published I gave the following personal considerations on the draft Care Standards :

016 comment on Care Standards 2015

In the same week that the Care Standards for Older People  this analysis was published in the BMJ.

2

“This most unusual request”

In August 2013 I read an article published in the BMJ which was entitled Three quarters of guideline panellists have ties to the drug industry”.

Majority-of-Guideline-panel

I have petitioned the Scottish parliament for a Sunshine Act. My petition seeks a single, searchable register of payments made to healthcare workers and academics. My petition has now been considered 6 times by a parliamentary committee. The committee would appear to be coming to the view that such a register would need to have statutory underpinning (just as they have in France and the USA). However, before any decision is made by parliament, the Scottish Government have asked for wider public consultation.

Update, March 2016: 
The public consultation concluded, by majority, that it should be 
mandatory for all financial transactions to be publically declared.

Peter-Sunshine,-Jan-2015

The Scottish Government and the Cabinet Secretary for Health, Wellbeing and Sport, have made comment “that apart from the petitioner” the issue of transparency has not been raised by other NHS healthcare professionals. This brings me to this blog-post which might explain why this has been the case.

we-can-find-no-record

In an entirely anonymised way I shall briefly present the narrative behind a senior healthcare professional who served as a key individual in a panel developing a national guideline. Unfortunately no records of financial interests for this guideline exist and so, as part of my research for a Sunshine Act, I wrote politely to this senior healthcare professional asking for the details of any financial conflicts of interest. I was grateful to receive responses but unfortunately found that they were uninformative and defensive. It was however clear from research publications that this individual had received payments from the pharmaceutical industry.

HDL-62

In Scotland, all NHS Chief Executives were written to by the Scottish Government in 2003 asking that they established registers of interests for all employees including GPs. However, across Scotland, for more than 12 years, this guidance has not been followed. In the hope that this senior healthcare worker had declared to his employers, I wrote to the Health Board involved. In doing so they breached my polite request for anonymity. I asked the Health Board if they could forward the evidence of this senior healthcare worker’s declaration to his employers, as expected in HDL 62 and also for GMC Annual Appraisal.

After many months, I received a reply from the NHS Board. This is the relevant section of the reply which confirms there are no entries for this senior healthcare worker who was involved in developing a national guideline which advises on prescribing.

One a

The NHS Board reply encouraged me to consider confidentiality of this senior healthcare worker but made no apology for my anonymity being broken.

The final paragraph of the NHS Board reply apologised for the time taken to look into this but asked me to “appreciate that this is a most unusual request”.

One b

The GMC does not consider it “unusual” to maintain transparency regarding financial conflicts of interest:

GMC on CoI

My experience for researching whether GMC guidance and extant NHS Scotland guidance on transparency have been followed has been most difficult. It has had negative consequences for me and I have felt as if I have been regarded as “unusual” to be concerned about transparency. Robert Francis in his two recent reviews relating to the NHS has talked of ‘a culture of fear’ where healthcare workers are fearful of the consequences of putting patients first. Perhaps then, this is why, other healthcare workers have not raised concerns about transparency of payments made by industry to colleagues.

Freedom to speak up

It would appear from this example that it is possible that authors of prescribing guidelines may have previously been paid by industry. As things stand there is reasonable chance, as a Scottish patient, that the medication you receive has been informed by such a process. And you will have no way of finding out if this is the case.

Update, September 2016:

SIGN 86, Management of patients with Dementia, has now been withdrawn, 
so is historical. 

I therefore feel that it is entirely reasonable to identify it.

sign-86-guideline-chair-dr-peter-connelly-guideline-now-withdrawn

sign-86-guideline-healthcare-improvement-scotland

 

“A person centred tool”

In a previous post I drew attention to the increasingly mechanical language of Health Improvement.

This current post starts with recent communication by health improvers in Scotland:patient centred tool 01 patient centred tool 02 patient-centred-tool-031One of my favourite writers is Robert Louis Stevenson. In “an apology for idlers”  he considers how humankind tends to approach understanding:RLS 1893rls-quote-001RLS quote 017Midgley002Mary Midgley, now aged 95 years, is one of my favourite moral philosophers. In “Heart and mind” she considers “tests”:mary_midgley_030414_0_450Midgley025Midgley001 Midgley004Midgley005Midgley006 Midgley007Mary Midgley has written a lot about reductionism:Midgley015Healthcare Improvement Scotland outline that they are “one organisation, with all activities aimed at driving improvements in healthcare”:One OrganisationIf you search Healthcare Improvement Scotland for “philosophy” you get three results, none of which actually relate to philosophical study:philosophy HISIf you search Healthcare Improvement Scotland for “ethics” you get zero results:zero mention of ethicsDr Murad Moosa Khan is a psychiatrist for older adults, who like me has an interest in ethics: Dr Murad Moosa Khan. In a recent talk he said:ethics and improvement1 and later concluded:ethics and improvement2