Professional confusion

Like all those involved in healthcare I take delirium very seriously. I share in the collective determination to improve our approach, understanding and care of those experiencing this serious condition.

To improve it is important that critical thinking is given room.

This post is about the validated 4AT Rapid Assessment Test for Delirium:

In a recent medical educational lecture organised by Healthcare Improvement Scotland, the 4AT was described as a “screening” test.

One of the authors of the 4AT Rapid Assessment Test described it recently as a “screening tool”:

There seems to be a lack of consistency in the stated purpose of this test/tool. Has this test/tool been validated for screening or has it been validated for assessment? This is an important scientific and ethical matter in terms of how this test/tool may be both validated and implemented

 

 

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.

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.

 

 

Psychiatry Without Borders

The International Congress of the Royal College of Psychiatrists took place in Edinburgh, the city of my birth, between the 26 – 29 June 2017. This International Congress was called “Psychiatry Without Borders”.

As a psychiatrist who has worked in NHS Scotland for 25 years I made a peaceful protest outside the International Congress.

I have previously petitioned the Scottish Parliament to consider a Sunshine Act for Scotland which would make it mandatory for healthcare workers and academics to declare potential financial conflicts of interest on an open public register.

The pharmaceutical Industry has this year increased payments to healthcare workers and academics for ‘promotional activities’ –  from £109 million up to £116.5 million today.

The Association of the British Pharmaceutical Industry (ABPI) has, from 2015, established a voluntary disclosure system with searchable database. It remains the case that 65% of those who have received payments have opted out – and this accounts for 60% of the total payments (as reported in the British Medical Journal (BMJ 2017;357:j3195)

What follows here are the ABPI disclosures made by some of the speakers at the 2017 Royal College of Psychiatrists International Congress.

It is important to note that it is my understanding that no speaker 
was paid for giving presentations at this International Congress. 

These declarations relate simply to the voluntary declarations
for the years 2015 and 2016 respectively.

If you click on each declaration you will get a closer view.

In previous posts I have provided as much public transparency as there is currently available  relating to the potential financial conflicts of interest of those involved with the British Association of Psychopharmacology (BAP). This Association works closely with the Royal College of Psychiatrists in providing Continuing Medical Education.

A number of those involved in BAP have chosen not to declare on the ABPI Register. For this reason, I attach the declarations given along with the new BAP Guidelines for treating dementia as Professor John O’Brien was giving a talk about these guidelines at the 2017 International Congress:

A few personal thoughts:

Well done to those who have declared on the ABPI Register.

However, it remains the case that we cannot scientifically consider the scale of potential biases that financial incentives may bring to the prescribing of medications in the UK. This is because we have an incomplete dataset. This is surprising given that we do have longstanding evidence that exposure to industry promotional activity can lead to doctors recommending worse treatments for patients.

I would like to see the College, of which I am a member, support the public’s request for sunshine legislation.

 

 

‘How to Improve’

The Nuffield Trust has recently published “Learning from Scotland’s NHS”. This report was based on a select group of “30 senior leaders and experts from Scottish health and care”.

One of the primary “learning points” of this report was that Scotland should be considered as “the model of how to improve healthcare across the British isles”. What is not made clear in this report is that the improvement methodology that Scotland has embraced was introduced from the USA not by “30 senior leaders” but by three:

  1. Derek Feeley, President of the Institute for Healthcare Improvement (IHI) and former Director General for NHS Scotland
  2. Professor Jason Leitch, who is a Dental practitioner, IHI Fellow and National Clinical Director of Healthcare Quality and Strategy (Scottish Government)
  3. Dr Brian RobsonIHI Fellow and Clinical Director of Healthcare Improvement Scotland

The “30 senior leaders and experts” would seem to be “marking their own homework”.

A few personal thoughts:

I am a passionate about science but am of the view that passion should not pre-determine scientific method and process.

I have previously argued why it is unhelpful to pre-determine science as “improvement”.

I fully welcome a coordinated approach to improving healthcare.

I worry about the inherent reductionism that is the basis of IHI “improvement science”

IHI promotes learning to healthcare based upon the experience of Industry (mechanical engineering). This may work well for less complex interactional processes, such as Hospital Acquired Infection. However healthcare is rarely linear (it is more often Bayesian) and reductionist interventions (however well intentioned) can cause harm.

I have found that Healthcare Improvement Scotland (IHI) does not routinely include ethical considerations in its approach to “improvement science”.

In summary:

I would suggest that it would have been more accurate (evidence based) for the Nuffield Trust report to have been titled: “Learning from the USA”.

I welcome all learning and from all reaches of the globe. I also seek improvement. But as a philosopher and NHS doctor (of 25 years) I worry about any one-system approach.

Science needs to consider culture, ethics, narrative, and the experience of being.

“How to Improve” needs to consider the voices of people and place. It should not just be the voices of the “senior leaders and experts from Scottish health and care”.

 

 

 

 

freedom to speak

The Director General for NHS Scotland:

  Peter's experience of the Director General for NHS Scotland

 

The Clinical Director of Healthcare Improvement Scotland:

     Peter's experience of the Clinical Director of HIS

 

The Director of Health and Social Care Integration:

Peter's experience of Director of Health & Social Care Integration

 

In my determination to put patients first I have been treated poorly.

These highly paid officials seem to be beyond accountability:

[I have always openly acknowledged that my view is no more important than any other. I am always careful to be clear in what cannot be said with any certainty. I am fully aware of my weaknesses.  I absolutely refute any charge that I am “vexatious”. I do not hold grievances. What matters to me is truth and fairness. I have found that the same cannot always be said of those in genuine positions of power]:

 

It can take courage to care. To resist the threats to your career and the misnaming:

 

Such abuse of power is not new:

 

You are invited to join me for this protest:

 

Early detection: “We need critical thinking”

The following analysis: “Surge in publications on early detection” was recently published in the BMJ. The authors concluded that “we need more critical thinking and more studies that specifically target both benefits and harms of early detection”:

The authors of this analysis will no doubt welcome the following response as a good example of critical thinking. This reply was submitted by Robert Steele (Independent Chair of the UK National Screening Committee); Anne Mackie (Director of Screening, Public Health England); John Marshall and Zeenat Mauthoor (both PHE Screening)

Submissions such as this reinforce my view that the criteria and principles that apply to screening must also be applied to early detection and “case finding”.

Quality Improvement and ethics

Response by Dr Sian F Gordon and Dr Peter J Gordon, 4 June 2017

This Acute Perspective by Dr David Oliver has our interest, in part because we all embarked on our career in medicine around the same time.We very much share Dr Oliver’s advocacy for “the actions and engagement of frontline practitioners and the real world context in which they work” and agree that these “are critical to success.”

We would like to contribute in the spirit of critical thinking  regarding the place of ethics in Quality Improvement (QI).

Dr Oliver states that QI can deliver “tangible outcomes” and that it has “a methodological and theoretical rigour and peer community of its own”.

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.”

Dr Oliver states that “ethical approval is less burdensome” for QI. We are of the view that ethics must be one of the necessary starting principles for any QI work and would argue that any attempt, however well intentioned, to demote ethics from this role might result in outcomes that may not be described as “improvement”.

 

 

Improvement science and consent: a failure of NHS Governance

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

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

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

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

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

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

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

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

A tall, slightly stooping, gaunt figure

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

"From inability to let well alone;

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

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

from treating patients as cases;

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

Good Lord, deliver us."