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.

 

 

Courage to care













 

Why I left social media

I enjoyed social media.

I left social media on the 31st December 2014.

I did so as I no longer felt safe to be Peter.

Here I refer explicitly to my experience in asking questions of improvement work in NHS Scotland.

Capture2 Capture3 Capture4Karen Goudie - improve conversations

Haloperidol prescribing to Scotland’s elders

In a previous post the FOI returns on Haloperidol prescribing in NHS Scotland were shared.  This followed on from my consideration of a BMJ report regarding the scale and potential harms of  such “off-label” prescribing to our elderly in hospital.

Since that time I have had a response from Professor Jason Leitch, National Clinical Director, Healthcare Quality, Scottish Government:

Letter from Prof Leitch

Today I have sent this reply to Professor Leitch:

To: Professor J. Leitch,
National Clinical Director, Healthcare Quality,
Healthcare Quality and Strategy Directorate
Planning and Quality Division
St Andrew’s House,
Regent Road,
Edinburgh EH1 3DG

8th June 2015

Dear Professor Leitch,
I was most grateful to receive your letter of reply dated 2nd June 2015.

I thought it best to reply to you to clarify the focus of my concerns. I wish to try and keep my reply short and focussed on the points you raise.

Point ONE:
You state that the Scottish Clinical Advisor for Dementia informed you that the “off-label use of Haloperidol for dementia is not especially unusual”. This would seem to diverge from  this BMJ change page made by NHS England’s National Clinical Director for Dementia, Professor Alastair Burns (I attach the full paper)

Dont use

You cite SIGN 86 guidelines on Dementia. These guidelines were issued 9 years ago when it was stated that “they will be considered for review in three years.” SIGN 86 is specifically for dementia and not delirium. The SIGN website indicates that there is no current plan to update SIGN 86 nor to introduce a Guideline on Delirium:

SIGN 86 was criticised in this research: Knűppel H, Mertz M, Schmidhuber M, Neitzke G, Strech D (2013) Inclusion of Ethical Issues in Dementia Guidelines: A Thematic Text Analysis. PLoS Med 10(8): e1001498. doi:10.1371/journal.pmed.1001498. I find it disappointing that an outdated and flawed guideline is still the basis for prescribing in dementia.

Ethical issues

Point TWO:
Haloperidol prescribing is part of the “Comprehensive Delirium pathway” introduced across NHS Scotland by the Scottish Delirium Association (SDA) and Healthcare Improvement Scotland (OPAC). You will be aware of this as I note that you are giving the key-note talk this week at the conference: Transforming delirium care in the real world”. Over a year ago the Secretary of the Scottish Delirium Association asked me to summarise my views on delirium improvements happening in Scotland. I did so and shared these with the SDA and with OPAC. I am disappointed to note that no reply has been forthcoming. I attach this summary for you with this letter.

Transforming delirium care in the real world

Conclusion:
It is welcome to hear that the Scottish Government are taking actions here. It is the case, by Scottish Government figures, that antipsychotic prescribing is increasing year-on-year in NHS Scotland. I seek improved care for individuals with delirium and dementia. I am concerned that current approaches, along with staff shortages and increased demands on staff time, are making it more rather than less likely that our elders may receive antipsychotic medication that can result in significant harms.

Yours sincerely,
Dr Peter J. Gordon

Included with letter:

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.

“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.

“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

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

Why I have decided to leave Social Media

I have been asked by a few friends why I decided to leave Social Media.

For sometime I had a twitter account @PeterDLROW but I closed this account on the last day of 2014. The-Lumen---on-twitter

There are several reasons why I have decided to leave social media behind however the primary one is that as an NHS employee in Scotland I do not feel safe in using social media.

CropperCapture[4]

The personal consequences for me in raising ethical considerations on twitter to try and help improve care for our most elderly have been most significant. The organisation that appears to have struggled most with my ethical questioning has been Healthcare Improvement Scotland. There are individuals who have not shared my views who have associations with Healthcare Improvement Scotland and may have contributed to this response.

ggg

I miss twitter for sharing with others my many interests which include film-making, the arts, architecture, medical humanities and most things outdoors.

How-drs-use-twitter-7-Dec-2

 

 

Apology from Healthcare Improvement Scotland

On the 30th January 2015 an apology was received from the Deputy Chief Executive and Director of Scrutiny & Assurance for Healthcare Improvement Scotland.

Here is my reply of thanks:

Untitled-1

To: Robbie Pearson
Deputy Chief Executive
Director of Scrutiny & Assurance
Healthcare Improvement Scotland
Gyle Square
1 South Gyle Crescent
Edinburgh, EH12 9EB

Dear Mr Pearson,
Re: Letter to Mrs Muirhead, 29 January 2015
I wanted to write to thank you for copying me into your response letter to Mrs Muirhead dated 29th January 2015. I note that Healthcare Improvement Scottland (HIS) have upheld the complaint. I want to thank you for  apologising for “this incident.” It does make a difference to hear this. I am relieved to hear that Healthcare Improvement Scotland “are reviewing our social media guidance to strengthen understanding, and to ensure that it is consistently complied with across the organisation.”

I hope you will understand, as discussed with Richard Norris recently in Stirling, that I do not wish to spend time going over past communications from employees of Healthcare Improvement Scotland. This just reminds me of the distress caused to me and indeed the significant consequences for my career. I want to say that I found Mr Norris most kind and professional and that our conversation allowed us to reflect more widely on ways forward in terms of the place of critical voices in improvement work.

Mrs Muirhead is a friend of mine. Like me, Mrs Muirhead is of the view that scientific understanding and progress in care benefits from questioning. It is disappointing that we have experienced mischaracterisation and marginalisation from your organisation as a result, particularly when HIS widely promotes its “inclusive engagement”.

I understand the behaviour of Ms Goudie as being based on her enthusiasm for improving care. My experience has been that there is a persistent stream of social media postings by both individuals associated with HIS and the organisation itself. These obviously focus on the successes of the work done by the organisation but in my view rarely cover the downsides. When I have responded to HIS tweets to raise any concerns about potential harms to patients I have had replies such as “this is for interested clinicians only”. I later found out that a letter had also been sent by HIS to my employers.

In summary, as said to Richard Norris, I am sorry if anybody has been upset by my writings on delirium, science and ethics. I would urge HIS as an organisation to consider how it “engages” with questioning voices. The responses of certain HIS staff to any questioning have been instrumental in breaking my career as a respected and highly valued Consultant in NHS Scotland. I have also decided, as a result of my experiences with HIS, that I no longer feel safe to use social media as an employee of NHS Scotland. I do however maintain a blog and will be posting my reply to you on this. I would respectfully suggest that any revised social media guidance within HIS should include a section on expecting responses which will not always be in full agreement with the original post.

I want to thank you again for looking into this matter and for the apology on behalf of Healthcare Improvement Scotland.

Yours sincerely,
Dr Peter J. Gordon

 

Karen Goudie & Dr Wolff 4 Dec 2014

Dr Neil Houston and Dr Brian Robson

A little tearful (and McCall Smith)

I was left a little tearful after Alexander McCall Smith contacted me this year to say that he was an admirer of my short films.

amsnot2chriswatt

Why might I have been left a little tearful?

Well of course it is wonderful to be appreciated by an Internationally renowned writer like McCall Smith.

We also share family experience in Africa.

But my tearfulness, and here I can only explain what I feel, was my appreciation that McCall Smith portrays in his writings, that moments of being really do matter.

Alexander McCall Smith had a career in bio-ethics.

Some time ago I made a film about the varied responses to my short films. This followed a formal letter, from NHS Forth Valley expressing “concerns” about my “films”. It later came to light that the senior manager who wrote to me expressing concerns about my films had not watched a single film made by me.

More recently, the Executive Clinical Director of Healthcare Improvement Scotland, wrote to my employers, stating that “this individual resorts to making films”. [bolding is mine]

Make of this as you will. I am interested in all responses, but I would prefer if they come from those that have actually watched my films.

Responses from omphalos on Vimeo.