#followthefellows

 

Footnote:

The two quotes about industrialisation and healthcare 
come from Intelligent Kindness by Ballat and Campling.

The considerations on conferences are included in a
this BMJ perspective

This post is creative, made in my own time and intended 
to ask questions in the spirit of the Freedom to Speak Up 
recommendations by Sir Robert Francis.

My forebear, Alexander MacCallum Scott grew up in Polmont, 
Scotland. He became an MP and was Private Secretary to 
Winston Churchill. I mention this as he turned down an OBE 
for his work connected with the war (WWI)

 

 

NHS Scotland – it should not take courage to care

On the 17th July 2017, the Scottish Government announced an “Enhanced service for NHS Scotland staff”

The Scottish Government began this announcement stating that:

“Staff in Scotland’s health service will continue to benefit from external support should they have any concerns about patient safety or malpractice”

From 1 August, the NHS Scotland Confidential Alert Line will be re-branded as the Whistleblowing Alert and Advice Services for NHS Scotland (AALS).

This was reported in the Scotsman of the 17th July 2017:

The Scottish Government confirm the enhancements that have been made:

Some personal thoughts:

I have never been a “whistleblower”. I have however raised concerns relating to patient wellbeing and safety in NHS Scotland, and in particular for our older generation. I share the view of Sir Robert Francis that “freedom to speak up” is a better and more encompassing term.

My experience of trying my best to put patients first in NHS Scotland has left me with an interest in this matter and I have followed developments over several years now.

My concern is that this “enhanced service” has taken little account of the evidence presented to the Scottish Parliament from a wide range of individuals and professional bodies, including Sir Robert Francis.

Lifeboat NHS from omphalos on Vimeo.

The “enhanced” service will still not be able to independently deal with any concerns raised and so can offer only to “pass concerns on to the appropriate Health Board or scrutiny body for further investigation”. In practice this will be either to the NHS Board the employee works with or to Healthcare Improvement Scotland which is neither independent of Government nor of any of Scotland’s 23 other NHS Boards.

It worries me that senior Scottish Government officials continue to use words such as “grievance” or “pursuers” when talking about those who are trying to put patients first in NHS Scotland. It seems that the Scottish Government are as quick as any of us may be to label individuals.  This “expanded service” has been re-labelled in a positive way when the opposite has happened to many of us who have raised concerns about patient care.

In summary:

I feel that this is a disappointing outcome given the determination of the Scottish Parliament, and the Health and Sport Committee in particular, to ensure that there is freedom in NHS Scotland to speak up and put patients first.

I would suggest that despite this “enhanced service” that it is still going to take a great deal of courage to care in NHS Scotland:

Courage to care from omphalos on Vimeo.

Lifeboat NHS

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.

‘Have you ever noticed that certain days are injury days?’

I was filming in our garden today as the sky was beautiful, the spring bulbs colourful, and the green as fresh as can be.

By chance, an NHS Forth Valley lorry passed in front of the camera. My heart missed a beat. The lorry was advertising the Minor Injuries Unit.

Three years have nearly passed since I resigned from NHS Forth Valley. When an employee with NHS Forth Valley I championed an ethical and evidenced-based approach to the diagnosis of dementia and for transparency in terms of financial interests of staff.

As a consequence of this, I myself left NHS Forth Valley with injuries. Not physical injuries but just as real.

Looking back, I am proud to have tried my wee best to put ethics at the very heart of my practice. To stand up for those who may not be as able or who may feel frightened to stand up for themselves.

The title of this film comes from the novel “Vinegar Girl” by Anne Tyler

The music is by Steven Lindsay – “Exit Music”

Courage to care













 

“The shadowy mandarin class deserves greater scrutiny”

This was a recent post by Walter Humes for the Scottish Review. 

I read this as a personal view about the civil service in Scotland 
(and not just about the governance of the NHS) so I (presume) 
that I am safe to share Professor Hume's view without worrying 
about any potential consequences for me as an NHS employee 
working in Scotland

Wednesday 14th October
I wonder how many SR readers would recognise one or more of the following names: Leslie Evans; Paul Johnston; Alyson Stafford; Graeme Dickson; Paul Gray; Sarah Davidson; Ken Thomson. They all hold important positions which enable them to influence decisions about the future direction of Scottish society. Leslie Evans is the most senior civil servant in Scotland, with the title of permanent secretary. The others head different directorates within the Scottish Government (Learning and Justice; Finance; Enterprise, Environment and Innovation; Health and Social Care; Communities; Strategy and External Affairs). They are called directors-general, a title that manages to carry both bureaucratic and military associations. Brief biographies of each can be found on the Scottish Government website.

Notwithstanding all the talk about openness in public administration, civil servants continue to prefer to remain in the background. They play down the power that they exercise, colluding with politicians in maintaining the fiction that it is always the latter who determine policy, the former merely advising and supporting. One of the most important ways in which senior civil servants can shape events is through their capacity to influence public discourse. They draft minutes, reports, consultation documents and policy statements. The skilful use of language can serve as a form of intellectual control.

The shadowy work of the mandarin class deserves to be subject to greater scrutiny than it normally receives. I offer this as a topic which the recently formed group of investigative journalists in Scotland – called The Ferret – might wish to pursue. They see their role as ‘sniffing up the trouser leg of power’. Sounds good to me.

I no longer feel safe

I have reluctantly decided that I am no longer going to write any posts about NHS Scotland on Hole Ousia. I will however still continue to discuss health and wellbeing in the context of the “two cultures”.

My reason is that I no longer feel safe to speak out individually as an employee of NHS Scotland.

I will continue to advocate for transparency and accountability.

I feel very lucky to be a doctor. The NHS is so important to me. I have so many wonderful colleagues and I never cease to learn from the Scottish folk that I try to help when in a time of need.

I will always try my best to put patients first. That is the way I am. I do not agree with those who suggest that such a determination might be considered as a sign of illness.

Dr Peter J. Gordon

The Friends of Liberty from omphalos on Vimeo.

Director General for NHS Scotland

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:

Paul Gray 02

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.

Paul Gray, PAG1962, Year of Listening, NHS Scotland

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 dghsc@gov.scot 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):

paul-gray-director-general-chief-executive-1-july-2016

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:

Whistleblowing in NHS Scotland from omphalos on Vimeo.

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:

paul-gray-nhs-scotland-scottish-government-1

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”:

deputy-director-to-director-of-nhs-scotland-hes-another-of-our-regular-correspondents

This report in the National describes the Director General’s approach to whistleblowing, an approach that would seem to address only selected recommendations of Sir Robert Francis:

No if yer a whistleblower it's no

all-nhs-workers-should-have-the-confidence-to-speak-up-without-fear-pag1962-paul-gray-chief-executiveThe above interview was published in the Herald on the 26th September 2016.

nhs-staff-too-scared-to-speak-out-paul-gray-chief-executive-pag1962

first-steps-towards-a-more-open-nhs-scotland-paul-gray-herald-chief-executive

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”.

from-the-director-general-nhs-scotland-15-aug-2016

It is very difficult to challenge a powerful organisation

This week  the Cabinet Secretary for Health, Wellbeing and Sport welcomed a new report into management of frailty and delirium

cabinet secretary welcomes OPAC

This reminded me, that 6 months on, I do not recall having received an answer to this letter:

Shona-Robison-delirium

“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