A film about freedom to speak up in NHS Scotland based on an edit of the evidence session of the Health and Sport Committee, Scottish Parliament, held on 13th June 2017.
This is just an edit. A subjective view. Nothing more and nothing less.
A film about freedom to speak up in NHS Scotland based on an edit of the evidence session of the Health and Sport Committee, Scottish Parliament, held on 13th June 2017.
This is just an edit. A subjective view. Nothing more and nothing less.
I have found it impossible to communicate directly with the Director General for NHS Scotland.
The Director General for NHS Scotland does not reply to e-mails sent to him unless you follow this advice from his office:
Please note: The above includes only the first paragraph of the Deputy Director's letter of the 15 October 2015.
It is essential to note that the Director General had repeated opportunities to make it clear to me that this was the process of communication to be followed. Unfortunately this never happened.
My advice to the Scottish Public is to carefully follow the advice as given by the Deputy Director, Colin Brown. Otherwise you may risk being considered “unwell”, as I have been, for contacting the Director General through his, openly available Scottish Government, e-mail address.
Mr Paul Gray, the Director General for NHS Scotland: Year of Listening, 2016: "I've taken time to listen"
Over the last 8 months I felt it would not be constructive to attempt to communicate with the Office of the Director General of NHS Scotland. However, following the EU Referendum the Director General wrote a letter to all NHS Scotland staff in which he stated “I greatly value the contribution of every member of staff in NHS Scotland”. Given that this had not been my experience, I wrote to firstname.lastname@example.org expressing this reality which has led me to consider early retirement and asking: “I would be interested in your thoughts and if you have any words of support for me.”
I received the following reply (reproduced here exactly as it was sent):
Below: an audio recording of a contribution I made to a BBC Radio Scotland discussion on retirement:
My communications in the past to the Director General related to my endeavour to put patients first, specifically in the areas of an ethical approach to the diagnosis of dementia and relating to my petition for a Sunshine Act. The lack of support I received in return is strikingly at odds with the following statement made by the Director General on the Scottish Health Council film below:
“We worry about transfer of power, transfer of responsibility. As far as I am concerned, the more power that patients have, the better. The more power that individuals have, the better. Because they are best placed to decide on what works for them.
To be frank, there is very clear evidence that if people feel powerless their wellbeing is greatly reduced.
If people feel that they have a degree of power, a degree of autonomy that actually helps their wellbeing. So to suggest that it involves something that relates to a loss of power on the part of the service provider, in order for the service user to gain, I think is quite wrong.
I think the service user, the patient, the carer, can have as much power as they are able to exercise without causing any loss or harm to the service provider whatsoever. Indeed I think it is greatly to the benefit of service providers to have powerful voices, powerful patients, and powerful service users, who are able to help us understand what works for them.”
Our Voice: support from senior leaders. Published by the Scottish Health Council
Perhaps the following explains why this admirable rhetoric does not seem to play out in practice:
In Dumfries and Galloway Health: Opinions & ideas, the Director General for NHS Scotland had published in July 2015: “Leadership in a rewarding, complex and demanding world”. The article is worth reading in full but here is one quote:
This was the response of the Deputy Director as shared with the Director General when I shared my experience of the NHS initiative “Everyone matters”:
The above interview was published in the Herald on the 26th September 2016.
In the month before the Director General shared his views with the Herald he had sent the following communication. I acknowledge that I have been persistent but would maintain that this was because of the lack of any substantive responses from his Department. This sort of behind the scenes approach by those in a genuine position of power highlights the very culture that Mr Gray needs to address. I share the conclusions of the Editor of the Herald that “public statements of intent are not enough”.
After sending an update of my petition for a Sunshine Act to the Chief Executive Officer of NHS Forth Valley I received this reply. Whilst I was employed by NHS Forth Valley I raised concerns that HDL 62, the Scottish Government Circular sent to all Chief Executives in NHS Scotland, was not being followed.
Two aspects of this letter from the Chief Executive Officer for NHS Forth Valley are worth further consideration:
When I was an employee of NHS Forth Valley I was formally written to by Dr Rhona Morrison, Associate Medical Director. In this letter from the Associate Medical Director, which was both unsigned and undated, I was described as “unprofessional” and “offensive” for raising concerns that NHS Forth Valley was not following extant Scottish Government guidance on transparency regarding declarations of interest.
This letter confirmed that I would be “invited” to an “informal” meeting by the Associate Medical Director’s immediate peers.
My experience of this “informal” meeting was that my character, reputation and probity were robustly questioned by the Medical Director, Dr Peter Murdoch, and the General Manager, Mrs Kathy O’Neill. This meeting was not minuted. This meeting left me distressed.
A number of weeks after this meeting I resigned from NHS Forth Valley. On my resignation I had this feedback from those who I had cared for and worked with
(2) Freedom to Speak Up:
The Chief Executive Officer reinforces in her letter the “importance of a culture of openness and candour”. However, Jane Grant, the Chief Executive Officer for NHS Forth Valley then goes on to give qualifications: that any concerns raised should be “appropriate” and “correct”.
To conclude: it appears to me that there are still significant barriers to raising concerns in NHS Scotland. If you click on the image below you can read the full review by Sir Robert Francis. I have selected one particular recommendation which I think will require a different mindset to that suggested in the letter from Jane Grant, Chief Executive Officer for NHS Forth Valley:
Update: November 2016: On the 22 March 2016 the following petition was lodged by Pete Gregson with the Scottish Parliament: PE01605: Whistleblowing in the NHS - a safer way to report mismanagement and bullying. On the 24th November 2016 the Public Petitions Committee considered all the submissions requested as part of evidence gathering. This included a letter from the Chief Executive Officer for NHS Forth Valley. This letter was commented on in particular by Angus MacDonald, MSP:
In October 2014, Dr Margaret McCartney, in her “No Holds Barred” BMJ column, asked: “Does the GMC deserve its current powers?”
The full open-access text of Dr McCartney’s BMJ article can be accessed here
On the Friday before Christmas 2014, the GMC (the General Medical Council) published this internal Review: “Doctors who commit suicide while under GMC fitness to practise investigation”
The PULSE reported this inquiry by highlighting the fact that the GMC plan to introduce “emotional resilience” training for all doctors:
This PULSE article on the GMC and doctors’ suicides has so far gathered 331 responses. This would appear to me to be unprecendented in recent PULSE history.
Meantime in the British Medical Journal, two letters have recently been published. The first by Dr Ben Bradley: “Who watches the GMC?”
And the second letter by Christoph Lees: “The GMC and doctors’ suicides“:
I have put together these communications because if the GMC wishes to regulate against “any other behaviour that may undermine public confidence in doctors” it needs to consider the potential consequences of such an approach. One risk is that such action may hamper “duty of candour” and thus patient safety. It may also risk further “disconnect between doctors and managers” (the GMC internal inquiry established that 54% of those who committed suicide had been referred by their employers).
Whilst it is essential that doctors have a strong regulator, the inevitable tensions and risks of the regulatory process need to be considered. I am writing this post to add my voice to those who urge that regulatory approaches taken by the GMC are more openly discussed.
At the time that the Editorial was published my family, many of whom have had a career in healthcare, found themselves discussing it. The Editorial also attracted a significant number of written responses to the BMJ.
Two years on from the publication of Professor Jarman’s Editorial, my thoughts have returned to it given the recent short-life review of quality and safety in Aberdeen Royal Infirmary:
I generally find that narrative is the best way of approaching, and perhaps best appreciating, complex matters such as this.
Here I shall set out a narrative of my two years as an NHS consultant since Professor Jarman’s Editorial. I hope that my experience can add, in some small way, to the wider appreciation of “culture” and the potential consequences for NHS healthcare.
Entry 9.24 of the report seems to capture the disconnect, with words used like “disengagement” and “detached”. It also raises the experience of frontline staff where concerns were “not being satisfactorily addressed” or “being met with silence”:
NHS Forth Valley, at their Board Meeting of April 2014, discussed (under item 8) a “FRANCIS ACTION PLAN”. This plan was led by the Medical Director: “Discussion took place around the detail of the Francis learning. Dr Murdoch advised that this would be an ongoing process which will require regular updating and scrutiny.”
NHS Forth Valley agreed to follow the recommendations of the Real World Group that “Boards should identify the impact of how they work as a board, on their degree of engagement, morale and wellbeing.”
In a wish only to assist the “Real World Group”, in the following posts I humbly offer my feedback to NHS Forth Valley Board:
In response to Professor Jarman’s Editorial, Narinder Kapur said in January 2013: “sadly, in parts of the NHS patient care is sometimes seen as secondary to managerial imperatives. If a clinician is performing to high standards in terms of clinical excellence and professional conduct, yet gets on the wrong side of a manager or a medical director, whether it be for whistleblowing or other reasons, he/she may well suffer serious consequences as a result”
Narinder Kapur considered that “Managers and medical directors need to be held more accountable for their actions. Any disciplinary process brought by managers or medical directors must respect the three key principles of independence, expertise and plurality”
NHS UK provides helpful advice on workplace bullying, which it suggests can involve “excluding and ignoring people and their contribution and unacceptable criticisms”. My workplace narrative, described in the above posts, carries such experiences. This ultimately led me to offer my resignation from NHS Forth Valley after 13 years continuous employment.
Around the time that the Medical Director led NHS Forth Valley’s review into “Francis”, I was “invited” by formal letter to attend an “informal” meeting by him. This meeting left me very distressed. At this “informal” meeting the Medical Director and General Manager for NHS Forth Valley used words to describe my “behaviour” such as “threatening”and “intimidating”. I was reminded at the meeting that I was “obliged contractually to reflect on this”.
Dr Philip Pearson, Consultant Respiratory Physician, Plymouth Hospitals, felt that “perhaps the most disturbing comment” of Professor Jarman’s Editorial was “NHS managers reliance on ‘shame and blame’ and fear of job loss as quality improvement driver.”
I do not regard myself as a “whistleblower”. I raised concerns about patient care by following my employer’s system of line-management. Nevertheless, my experience would seem to have many similarities to those described by whistleblowers, such as bullying, mischaracterisation, stigma and isolation. It was this, and not mental illness, that led my doctor to recommend that I take sick-leave. I was off for 6 months. Whilst I was off, the Consultant Locum covering for me, also had concern about patient safety and wrote to senior managers in NHS Forth Valley. In communication over these clinical concerns the Locum Consultant concluded that the Medical Director demonstrated:
In my experience, NHS Forth Valley management ask their staff to “reflect” on their behaviour. My concern is that managers may not find the same need in themselves.
In my 13 years as a consultant in NHS Forth Valley our service for the older people of Clackmannanshire had not a single visit from any Medical Director.
In the year following my 6 month “sickness” absence, the Service Manager in charge of our service visited once.
I welcome that the Scottish Government supports duty of candour as confirmed by the former Cabinet Secretary for Health & Wellbeing. The recent findings of the inquiry in NHS Grampian reveal many of the barriers to achieving this. It is clear that this is not limited to one Scottish NHS Board: David Prior, the chairman of the Care Quality Commission for NHS England recently disclosed that one in four staff have reported bullying, harassment or abuse from colleagues and managers. Mr Prior was also concerned that the NHS is failing to listen to those who challenge poor care and champion the rights of patients. He says those who try to speak out are too often “ostracised” by their colleagues and managers.
The recent review into suicides by doctors who were undergoing fitness to practice investigations revealed that 54% had been referred by their employers. This has left me reflecting on my own experience with NHS Forth Valley in trying to put patients first. My experience was that senior managers repeatedly reminded me of the GMC and “Good Medical Practice”. I was urged to “reflect”.
In a recent BBC interview, Shona Robison, the current Cabinet Minister for Health, Wellbeing and Sport was asked if she thought the “toxic culture” reported in NHS Grampian could be happening elsewhere in Scotland? The Health Minister seemed almost to sigh, and then momentarily paused, before reminding us of the role of Healthcare Improvement Scotland.
The external inquiry by Healthcare Improvement Scotland into NHS Grampian identified a range of concerns and issues which included “the relationship between some senior medical staff and the NHS Grampian senior leadership”. In consideration of this inquiry the current Medical Director for NHS Forth Valley stated:
In trying to put patients first my recent experience as an NHS Consultant has been very difficult.
Recently at a family gathering I was asked, given the distress that trying to put patients first has caused, “was it worth it?”
This was a difficult question to hear and contemplate. I do know that I am not perfect. I also know that we have now had two external enquiries, one in England and one in Scotland. Two major NHS inquiries in a matter of years. Both inquiries concluded that there seems to be something generally wrong in NHS culture. Both inquiries highlighted a growing “disconnect” between managers and frontline staff.
My fear is that both the “culture” and the “disconnect” are not being effectively addressed. Professionalism and candour risk being further devalued as a result.
So “was it worth it?” Despite the experiences I have outlined, I wish to document some personal successes:
I had several envelopes like this delivered through my letter-box.
Immediately recognisable, even before opening, I felt my heart (‘hairt’ in Scottish) beat much faster.
I shall try and explain why.
This is another pattern that I wish to present.
Alexander McCall Smith, as an admirer of my films, wrote to me about our shared interest in patterns. He recommended this book “A pattern language” which has inspired some of my recent posts:
Here is an example from a letter from the Medical Director of NHS Forth Valley, Dr Peter Murdoch, to me dated 21st May 2014. It was part of a wider letter . The letter made references to my “behaviour”. The letter summoned me to an “informal” meeting with the Medical Director and General Manager for NHS Forth Valley:
When I was off sick, due to work stress, the Locum Consultant who covered for me, had the following experience:
The Locum Consultant concluded that this demonstrated:
This was the Locum Consultant’s experience of the Medical Director, Dr Peter Murdoch. There was no action taken here.
I have many interests: interests which remind me how little I know. One of my interests is in ethics.
In my 13 years with NHS Forth Valley my ethical interests were in three broad areas.
In my time with NHS Forth Valley there was no forum to discuss ethics.
It is fully accurate to say that not one of my consultant medical colleagues in NHS Forth Valley shared my advocacy for a timely approach to the diagnosis of dementia. Today it is the basis to the diagnosis of dementia across Europe
I share the view of most ethicists and many in academia that education and research should be free of marketing. Free of any distortion created by financial incentives. I have petitioned for a Sunshine Act (or clause) for Scotland. I believe that a central, open-access register would be straightforward and not at all costly to set up.
My view is that we need to consider more fully the importance of consent. Any intervention, be it a test, or a “tool”, or a treatment can have potential benefits and potential harms. These need to be shared as best as we can.
The Former Cabinet Minister for Health and Wellbeing, October 2014:
This week, the General Medical Council published:
This report confirmed that 54% of those doctors who committed suicide had been referred by their employers.
One response to this GMC investigation remarked:
“There is a parallel with whistleblowing here. The stress of the situation caused mental health difficulties and the person concerned is therefore dismissed as being unwell. Which comes first?”
My experience in raising ethical considerations, and thus trying to put patients first, was very difficult indeed.
I do hope other healthcare professionals, if they raise genuine concerns, will not face what I have faced for raising ethical considerations.
I see a pattern here. So did a senior NHS doctor who wrote to me recently:
“No wonder NHS doctors live in fear when threatened with the GMC for raising ethical concerns in the workplace.”
I resigned from work on the 6th June 2014. Some folk have been wondering why. Below I offer briefly the background to my decision to resign and why it was a matter of more than just principle.
I have worked for NHS Forth Valley as a Consultant in older adults in Clackmannanshire for nearly 13 years. I leave with an unblemished record.
It has been hugely rewarding for me and indeed a privilege to share in the lives of the wonderful elders of Clackmannanshire often in a time of need. The team of which I was part worked with dedication, compassion and professionalism even though at times we had to make difficult decisions due to the demands placed on our service. The support from colleagues in primary care, social work and third sector was greatly valued and our joint-working a source of satisfaction long before integration of services was ever considered.
As a consultant I faced the steep-learning curve of the non-clinical aspects of today’s medicine and the shifting sands of political mandates and targets.
What follows is a brief account. It is to help explain and perhaps allow wider reflection, including my own. It seems to me that finding the words to express complex matters in writing helps me to “see” better. I am aware that this will be one account, open to challenge as none of us (thank goodness) will have the same view on life.
The factors involved in my resignation were complex. Life is complex after all. The beginnings of all this go back many years when I was faced with a difficult situation. I was concerned that our most elderly were more at risk of mis-diagnosis of dementia. This was at a time of incentivised targets for the early diagnosis of dementia (HEAT target 4 in Scotland) and increasingly I found that elderly patients were being diagnosed with “early Alzheimer’s disease” but in fact did not fulfil internationally accepted clinical definitions of dementia. My concern was that in the late stages of life individuals who would never develop dementia were being told they had it. What was in truth an increased risk of developing dementia was being expressed to patients, families and carers as a definitive diagnosis. My dilemma in speaking out about this was that very few others seemed to share my concerns. This seemed to me to be the case across a range of professions and jurisdictions.
My approach was first to discuss this with colleagues, which only confirmed that my view was that of the minority. I then raised the matter through the appropriate channels of line-management. Initially I was supported in raising my concerns. However this did not last: the most likely reason for support being withdrawn was that I was diverging from the majority.
From that time on my professional life got tough. I wrote an account of my concerns called “Peter’s Lost Marbles” the transcript of which I turned into a short film. This transcript and film were praised by the then Chief Executive of the Mental Welfare Commission and by the then Lead Policy Officer for Alzheimer Scotland. Both these National leads suggested that the transcript should be published in a journal and that the film version be used to encourage wider understandings of the complexities involved in the early diagnosis of dementia.
NHS Forth Valley decided that an “External Review” would be held. I was unaware that it had been documented ahead of this External Review, by the Medical Director, Dr Iain Wallace that“ the main concern is with PG [Peter Gordon]”.
Increasingly isolated, and no longer included in strategic meetings to improve “joint working” it was difficult to know how to proceed. Through stress I was signed off by my GP and was off for 6 months. Interestingly having been off once before in 2004 (my only severe depression caused by discontinuation of Seroxat) I found that I was re-defined by certain Consultant Old age Psychiatrist colleagues as a case of “recurrent illness”. I have found it very difficult to escape this stigma and my experience has been that my profession is just as likely as any other to see “illness” before the person.
I have always taken a pluralistic approach to science and have been a lecturer in Medical Humanities. I am interested in ethics, professionalism, philosophy and their crucial contribution to the evidence-based medicine that I aspire to follow. It was my interest in professionalism and my concern that medical education was inextricably linked to marketing that led me to advocate greater transparency in financial conflicts of interest. I have pursued this with some determination. I have petitioned the Scottish Government for ‘A Sunshine Act’ and have argued that we should at least have transparency of financial interests equivalent to that which we expect of our parlimentarians.
My experience has been that it is not easy to pursue transparency in the health service. If anybody is interested much of this can be followed here.
The final straw for me with NHS Forth Valley was that I no longer felt that my concerns about staffing levels in the team of which I was part were being taken seriously.
Update: March 2017:
NHSG003: Dr Peter J Gordon written submission on NHS Governance in Scotland:
I want to very briefly summarise my experience relating to two of the requirements of the NHS Reform (Scotland) Act 2004, which requires all boards to demonstrate
that staff are:
(1) involved in decisions;
(2) treated fairly and consistently, with dignity and respect, in an environment where diversity is valued;
I have worked as an NHS doctor in Scotland for 25 years. In 2014 I resigned from NHS Forth Valley after working for 13 years as a Consultant because of my
experience that the Board were not complying with the above. I now work for NHS Lothian. I plan to retire early because of my experience when working in NHS Forth Valley.
On my resignation I received this feedback from patients, carers, colleagues and staff in many sectors. I have actively spoken up for patients when I have come across harm (unintentional or otherwise). I spoke up regarding two main areas:
(a) the Timely diagnosis of dementia
(b) Transparency of competing financial interests in NHS healthcare staff
Timely diagnosis has now been adopted right across Europe.
This approach had no support whatsoever in NHS Forth Valley. In terms of the 2004 Act I was not “treated fairly and consistently, with dignity and respect, in an environment where diversity is valued” for advocating a timely approach to the diagnosis of dementia.
Parliament: PE1493: A Sunshine Act for Scotland.
This was taken forward by me as an individual as a petition to the Scottish
The petition was closed last year after a Public Consultation found the Scottish Public supported my petition. In terms of the 2004 Act I was not “treated fairly and consistently, with dignity and respect, in an environment where diversity is valued” by NHS Forth Valley or other NHS Boards for advocating such transparency.
At the time before and after resigning from NHS Forth Valley I was not “involved in decisions” as required in the 2004 Act. There were communications about me with other NHS Boards such as Healthcare Improvement Scotland and NHS Tayside. I now believe I was “blacklisted” and that my references were influenced negatively by input from senior staff in NHS Forth Valley.
I have long since realised that there is no possibility of individual redress for me regarding my past treatment as an NHS Scotland employee. It is my hope that the committee will be able to encourage a genuine change in culture so that other employees working in NHS Scotland feel empowered to put patients first. It is essential that this is the case even when that employee finds him/herself in the minority amongst his/her colleagues or indeed challenging government policy.
I want to thank Dr Brian Robson, Executive Clinical Director for Healthcare Improvement Scotland, for agreeing that I can include his letter to my employers, NHS Forth Valley, dated 22 May 2014. I explained to Dr Brian Robson that I would like to include here his entire letter and my letter of reply.
But first a few quotes from a psychiatrist and professor for older adults (these are not quotes by me):
"I want to make a case and I want to argue why ethics is as important, if not more important than quality" 2011
"Quality is a by-product of ethics and not vice-versa" 2011
"It is extremely important for healthcare organisations to invest in ethics. Who should be trained in ethics? Each and every person in our healthcare organisation: Chief Executive, Directors, Managers, medical and nursing staff, as well as support staff. Each and every person." 2011
Below is Dr Brian Robson’s letter to my employers and below that, the full html transcription:
From: Dr Brian Robson
Executive Clinical Director,
Healthcare Improvement Scotland
50 West Nile Street
0141 225 6999
22 May 2014
To: Dr Peter Murdoch
Interim Medical Director NHS Forth Valley
Castle Business Park
Re Dr Peter Gordon – commuunications and media relationships
It is with regret that I am formally raising my concerns about this individual with you.
Unfortunately Dr Gordon has persisted in his unprofessional, highly selective and concerning approach to providing misinformation in relation to improvement work in the field of older people’s service in NHS Scotland. These behaviours are now having significant impact on the well-being of our staff and I have set out below a selection of the information raised with me in relation to his activities.
Healthcare Improvement Scotland has attempted through discussion and correspondence, to engage professionally however we have exhausted this route with him as an individual and we have modified our approach to attempt to redirect readers to the source of reliable information e.g. our website.
Whilst I appreciate the limitations of your role as employer, I would be grateful for your formal consideration around how his damaging behaviours could be reflecting on NHS Forth Valley, causing unnecessary patient and public concern and also on what consequences these may be having in other aspects of his performance.
I also recognise the risk in raising this formal complaint in that it could be misinterpreted as censorship or worse however I am now sufficiently professionally concerned that I believe this is now necessary.
Oppressive use of social media
The OPAC twitter page has received frequent attention and criticism. He frequently attaches his blog to correspondence between OPAC and clinicians. HIS cannot engage with anyone on Twitter without him sending his blog to the clinician in an attempt to start debate with anyone engaged with us.
Misinformation and scaremongering
The content of the blogs often quote our engaged clinicians out of context. He clearly does not understand the improvement science approach stating that we need to submit a peer review and engage all over 65s. He also complains about his lack of engagement in the programme but continues to write factually inaccurate pieces regarding the work.
He copies his tweets to Alex Neil, MSP etc stating that the improvement work boards must comply with cognitive screening in all over 65s. This is not the case, delirium screening has been very much lead by Boards who have realised that they need to improve recognition and management of delirium, we a asked that over 75s where the group targeted in the testing phase. One ward per hospital.
It is distressing to the team and our clinical colleagues that, blogs and other avenues to distort our work and message. He has been respectfully challenged by respected colleagues regarding his one way criticism of the work. He does not engage when challenged stating he ‘feels uncomfortable’ He has made everyone uncomfortable with his actions.
Waste and impact on improvement for patients
It is very distracting to have daily attention from this individual and efforts to assist his understanding and allow progress to be made have, to date, been ineffective.
Dr Brian Robson
Executive Clinical Director,
Below is internally published NHS Forth Valley position on Delirium Screening:
Below is my reply to Dr Peter Murdoch, Interim Medical Director, NHS Forth Valley, after I had been made aware of this letter:
To Dr Peter Murdoch
Interim Medical Director
Castle Business Park
Dear Dr Murdoch,
Many thanks for sharing this letter from Dr Brian Robson.
I welcome the opportunity to respond to the points made.
First of all I would like to make it clear that I did try to use local mechanisms to feedback into the “improvement” process. The local response was that “improvements” in delirium screening (i.e. mandatory cognitive screening of all over 65s admitted to the acute hospital – see attached) were guided by HIS. I therefore contacted HIS by letter to clarify the ethical considerations and the evidence base behind changes which I could foresee would have an impact on my day-to-day clinical practice and which caused me concern for a range of reasons.
After a partial written response by HIS Inspector, Ian Smith, I was invited to take part in a teleconference with four employees of HIS. I found this experience disappointing in that none of the four appeared to be willing to answer any of my concerns. My overall experience of HIS was of an organisation which was not willing even to consider ethical points or discuss the validity of “screening tools” the use of which it is recommending across Scotland.
My approach has always been one to encourage discussion and debate. I do not expect HIS to necessarily agree with me but I do expect them to consider my concerns seriously.
Oppressive use of social media:
I have only ever written two blogs about delirium. Both relate to ethical considerations and also look at validity of “screening tools”. My first blog “the faltering, unfaltering steps” is based entirely on evidence and material in the public domain, all of which is cited. This is not “misinformation”. My second “blog” called “Delirium Screening” was a summary produced at the request of Professor Alasdair MacLullich. I have had no response from Professor MacLullich or anybody involved in delirium improvements on the legitimate ethical issues which were raised in it. I am of the view that the public deserves a balanced presentation of the complex issue of delirium.
HIS and OPAC use social media very extensively but it appears that only content that accords with the outlook of OPAC or HIS will be considered acceptable responses. Debate is not being allowed by HIS and OPAC and runs counter to HIS claim to be “engaging”. Dr Robson’s letter makes it clear that to be allowed to be “engaged”, one must not question anything in their predetermined approach.
It is certainly not the case that “HIS cannot engage with anyone without him sending his blog to the clinician”.
I have made no films about delirium.
Misinformation and Scaremongering
These are very bold words indeed and I would like to see examples of where I have quoted “out of context”. I agree that I “do not understand the improvement science” if it is a “science” which does not require evidence (e.g. internal and external validation of “screening tools”) and consideration of ethics (e.g. consultation with the population directly affected).
I have come to understand that there has been significant confusion between improvement work for delirium (which are undergoing local pilots and which target patients aged 75 years and over) and the recommendations made to NHS Scotland Boards about routine cognitive screening (which are assessed by HIS Inspection visits and generally refer to all patients aged 65 years and over). From the viewpoint of a grassroots clinician the conflation of these two processes has been unhelpful. It is unfair to say that routine cognitive screening is led by NHS Boards when in fact this is a recommendation against which they are inspected by HIS. My understanding is that this recommendation is based on the Clinical Standards for Acute Care (2002) which are more than a decade old and that the Convener of the Parliamentary Health Committee (January 2013) expressed concern that these need updated. Given this clear political involvement I reserve the right to communicate with elected representatives.
It is not my intention to cause distress to anyone. On a point of principle however, and here I would make reference to the findings of the Francis Report, it is surely essential that critical voices are not silenced because of potential to cause “upset”. There is always a power imbalance between any organisation and any individual and a number of recent examples have illustrated the risks of always assuming that the organisation is right.
The reason that I have stated that I felt “uncomfortable” relates to a specific conversation on twitter. Although HIS and OPAC use twitter extensively it has its limitations in discussing complex issues and it was my intention to move the discussion onwards using more traditional methods of communication.
Waste and impact on improvements for patients
Given the amount of my own time that I have devoted to “engage” with Dr Robson, Prof MacLullich, Scottish Delirium Association, HIS, and OPAC it is disappointing to hear that my contributions have been a “waste” and had only negative “impact”. This is all the more so in that the responses I have had from the above parties have not “assisted my understanding” but have comprehensively failed to address my concerns.
Dr Robson states that he fears that this formal letter to my employers might be “misinterpreted as censorship”. I think that this would indeed be the view of anyone, who like me, has struggled to raise ethical issues.
History tells us that the spirit of scientific progress requires open-minded enquiry. Any organisation which is aiming to take a scientific approach must take care to remember this. My recent experience makes me feel that the headline promise that HIS “engage” meaningfully is but a hollow sound-bite. HIS is going struggle to find more “engaged clinicians” if absolute agreement with the organisation’s approach is a pre-requisite for engagement.
I am replying via e-mail for speed but will be following up by letter to yourself and to Dr Brian Robson.
It would be helpful if you could confirm if I have breached any NHS Forth Valley Policy on the matters covered in this communication.
Dr Peter J Gordon
cc. Dr Brian Robson, Executive Clinical Director, Healthcare Improvement Scotland
I copied my letter to Alex Neil, MSP, Cabinet Minister for Health and Wellbeing, Scottish Government. I attach the reply below:
Immediately following the letter from the Executive Clinical Director for Healthcare Improvement Scotland to NHS Forth Valley I was “invited” to an “informal” meeting by my employers. Where no minute was kept.
At this “informal meeting” the Medical Director repeatedly reminded me of my duty to the organisation. The General Manager for NHS Forth Valley repeated this reminder. Thereafter, my professionalism, character and ethics were robustly questioned.
Within weeks of this "informal meeting" I resigned from NHS Forth Valley.
At the time of this letter to my former employers Dr Brian Robson was working immediately alongside Dr Neil Houston who also works in NHS Forth Valley as does his wife Dr Linda Wolff.
Almost two years on from the letter sent by Healthcare Improvement Scotland to my former employers, NHS Forth Valley, I have sent the following letter to the Executive Clinical Director of HIS. I have done so because I was reminded of the situation that I found myself in following the recent, and most welcome publication of “Realistic Medicine” by the Dr Calderwood, Chief Medical Officer for Scotland.
Wednesday, 2nd March 2016
To: Executive Clinical Director,
Healthcare Improvement Scotland,
50 West Nile Street
Dear Dr Robson,
I hope that you do not mind me writing to you to reflect, a few years on, from the circumstances I found myself in as an NHS employee who had worked in Scotland for over 20 years. My wish in this letter is to reflect and to suggest learning for all, including of course myself. In summary my experience has been that in trying my best to put patients first I did not find what Robert Francis termed “freedom to speak up”: rather that deference was first given to colleagues and to the system.
As Executive Clinical Director for Healthcare Improvement Scotland you sent a letter, dated 22nd May 2014, to the Medical Director of my former employers http://wp.me/p3fTIB-u8 . I was not aware of this letter until I had an “informal” “invitation” to meet with my employers. A month later I resigned after 13 years as a Consultant with unblemished career with NHS Forth Valley. The feedback I had following my resignation confirmed that I was valued as a respected and professional doctor.
I publicly advocated a timely approach to the diagnosis of dementia even though the universal approach was for early diagnosis. From the Health Secretary down, including senior policy makers and senior NHS staff, Alzheimer Scotland, the British Geriatric Society and the Mental Welfare Commission, there was no support for timely diagnosis. I advocated this approach as it included considerations of potential harms as well as potential benefits.
Given the opposition I encountered, it was a welcome but considerable surprise when in summer 2014 the “Glasgow Declaration”, which enshrines the principle of timely diagnosis, was issued. As of the time of writing, 203 organisations, 11613 individuals, 153 Policy Makers, and 84 MEPs, across 25 European countries have signed this declaration.
I mention this as the concerns you raised with my former employers related to my considerations and questions about Delirium Improvement work. I take delirium very seriously indeed: however my concerns about reductionist tools, whether termed “screening” or “detection” remain, as do my concerns about the ethics of consent. I also worry about potential unforeseen outcomes, which may be harmful, such as increased prescribing of antipsychotics such as haloperidol.
Last month, the Chief Medical Officer put forward her proposal for “Realistic Medicine”. This document prompted me to reflect on a culture which may struggle to accommodate questioning voices. The CMO’s report has been welcomed widely and was discussed at the overdiagnosis conference held in Stirling on the 27th February 2016. The afternoon panel was assembled to help us consider “What can policy makers do to help us?” This was the question I raised:
"Would the panel like to comment on the inevitable tension between what the Scottish Government have chosen to call “Improvement work” and over-medicalisation? The reason that I focus on the term improvement is that it makes it very easy for anyone who questions such work to be characterised as a barrier to progress."
As a human, I am very far from perfect. I make mistakes, and find that I am always learning. However I am proud of Scotland’s fine tradition of a critical approach to science. I now feel that I have done my bit and have scars to show it. I have decided that when the time is right for me, and indeed my family, I will retire early from medicine.
If you were able to write your thoughts in response to this letter they would be most welcome.
I wish you all the very best.
Dr Peter J. Gordon
I received this reply from Dr Brian Robson on the 12th March 2016:
This was my letter of response (dated 18th March 2016):
Dear Dr Robson, Your letter was carefully considered and thank you for taking the time to write it. What I found disappointing was the lack of acknowledgment of the harmful consequences for myself and my family following your letter to my former employers. I have now come to the conclusion that there may never be any such acknowledgement. I hope that you might agree that I have contributed significantly to the consideration of potential unforeseen consequences of improvement science. I am particularly proud that the Glasgow Declaration has been adopted. I hope that Healthcare Improvement Scotland is moving in the direction where it will consider questioning voices and treat them respectfully. Scientific enquiry is after all based on asking questions. Yours sincerely, Dr Peter J Gordon
Sir Harry Burns, former Chief Medical Officer for Scotland has also been reflecting on improvement methodologies [the full transcript of his evidence to the Scottish Parliament can be read here]:
Footnote: 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.
2015 Orlando IHI Conference as reported in the Media and including attendance of Dr Brian Robson and Professor Jason Leitch:
2016 Orlando IHI Conference as reported in the Media and including attendance of Dr Brian Robson and Professor Jason Leitch and CEO of Healthcare Improvement Scotland, Robbie Pearson:
The following is an unedited clip of the evidence given to the Scottish Parliament by Dr Brian Robson, Medical Director for Healthcare Improvement Scotland on the 31st January 2017: