On Friday the 25th of November 2016 I gave a talk for the Scottish Philosophy and Psychiatry Special Interest Group.
My subject was “Improvement Science”.
The following is based on the slides and the four short films that I presented.
My talk was entitled:
The meeting was held at the Golden Lion Hotel, Stirling:I started the day off:
I gave these declarations:
I explained to the audience that like Dr Rev I M Jolly I can be overly pessimistic:
The dictionary definition of ‘Improvement’:
The dictionary definition of ‘Science’:
My concern is any pre-determinism to science:
The Health Foundation have considered Improvement Science: this is from 2011:
Many different terms are used including “QI” for “Quality Improvement”:
This is where improvement science began, in Boston, Massachusetts:
The Founder of the Institute for Healthcare Improvement (IHI) was Don Berwick:
The first description of this movement in Britain goes back to 1992 by Dr Godlee:
Fifteen years later, Dr Godlee, Editor of the BMJ, said this:
Only last month the BMJ briefly interviewed Don Berwick:
IHI describes improvement science as being based on a “simple, effective tool”:
This tool was developed from the work of an American engineer, W. A. Deming:
The “Model for Improvement” Tool [TM] is described by IHI as a “simple, yet powerful tool”:
The current President and CEO of IHI is Derek Feeley:
Up until 2013, Derek Feeley was Chief Executive [Director General] for NHS Scotland:
In April 2013 Derek Feeley resigned from NHS Scotland:
22nd February 2015 it was reported: “The astonishing and largely hidden influence of an American private healthcare giant at the heart of Scotland’s NHS”:
Dr Brian Robson, Executive Clinical Director for Healthcare Improvement Scotland [HIS] is an “IHI Fellow”:
Professor Jason Leitch, National Clinical Director for the Scottish Government is an “IHI Fellow”:
Might we be facing the biggest change to healthcare in Scotland since the NHS began? Improvement science is moving quickly and widely across Scotland:
This “Masterclass 1” for Board members cost £146,837:
An NHS Board member commented after the Masterclass:
Healthcare Improvement Scotland is one organisation with a very wide remit over NHS Scotland and it works closely with the Scottish Government:
Nine cohorts of Safety Fellows and National Improvers have so far been trained following IHI methodology:
I was reminded of the current enthusiasm for improvement science when the Convener of a recent Scottish Parliament Committee meeting said of targets (another approach enthusiastically taken by NHS Scotland):What is the place of ethics in Improvement Science?
In 2007 the Hastings Centre, USA, looked into this in some depth:
The Hastings Centre argue that Improvement science cannot ignore ethics:
In 2011 the Health Foundation, UK, produced this “Evidence Scan”:The Health Foundation commented that “improvement science is just emerging”:
The Evidence Scan found a “real paucity of evidence about the field of improvement science”:
I would also suggest that there is a real paucity of philosophy about the field of improvement science:
The Health Foundation did find papers on the conceptual nature of Improvement Science but concluded that:
Mary Midgley is a philosopher now aged 95 years who is widely respected for her ethical considerations:
Chapter 7 of her book “Heart and Mind: The Varieties of Moral Experience” begins:
Mary Midgley is concerned about the overuse of reductionist tests in medicine stating that:
This film is about the potential consequences of inappropriate reductionism:
Leon Eisenberg has written many papers about this subject. He argues that reductionism should not be “abandoned” but that we must keep sight of where such an approach is scientifically useful and also where it is inappropriate:
In the Hastings Report, Margaret O’Kane asks:
In my view the answer to this question is YES. I am hopeful that the National Improvers recruited to NHS Scotland would agree:
As an NHS doctor I have seen unintentional harm brought about by National improvement work in Scotland. This related to a “Screening Tool” that was introduced across Scotland as part of this work. I found that the unintended consequences of the use of the following tool included implications for patients’ autonomy and the risk of over treatment:
Both the Hasting Group and the Health Foundation are of the view that improvement science cannot separate itself from the ethical requirements of research:
This article published in February 2016 argues that individual “rights transcend all aspects of Improvement science”
The following is a verbatim representation of a conversation held by National Improvers working in NHS Scotland:
In November 2016 Professor Joshi, also a psychiatrist outlined his concerns about reductionism in a published letter to the BMJ:
In this short film the mechanical language of healthcare improvers is considered:
Professor John Bruce was a Moral Philosopher in Edinburgh University in the 18th century. He built this temple, the “Temple of Decision”, in the grounds of his home by Falkland Palace so that he could consider his thesis:
Professor John Bruce did not succeed in his endeavour. His Temple however stood for many years:
But it eventually collapsed and his endeavour to “reduce the science of morals to the same certainty that attends other sciences” collapsed with it.
Any search of Healthcare Improvement Scotland for “ethics” finds this result:
This film is about more up-to-date buildings – the enthusiasm for which was based on improvement science: The Red Road flats in Glasgow:
The following is an edited clip of the evidence given to the Scottish Parliament by Healthcare Improvement Scotland (HIS) on the 31st January 2017:
The full session can be watched here
The Official Report can be accessed here
In the Scottish Herald on the 1st October 2016:
reminded us all that:
and suggested that we:
Rebecca McQuillan worried, as I do, that:
Our treasured NHS and those who educate us might consider:
As an NHS doctor for those who I value and respect I worry about the promulgation of a reductive language of loss. I often hear our older generation described as a “challenge” and that complex, and unique situations have been reduced to a single word, such as “frailty”, “capacity” and “delirium”. Language evolved over tens of millennia to avoid such simplification.
Rebecca McQuillan closes beautifully:
I shared this post with the British Medical Journal. There was an interesting reaction on social media to my post and to those made by others by the original columnist: "some truly bizarre responses to what was a mainstream common on acute frailty" "I am thinking of changing my BMJ column from 'acute perspective' to 'everybody must get Stoned'"
This is a film about lost Argaty.
This film attempts to ask:
(1) How old is old, and how new is new?
(2) Is new or old better? Or is this a nonsense question?
(3) “Improvement science”… this is term of today in Peter’s work as a doctor. Where might the spirit of enquiry and free speech fit into this “improvement culture”?
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 email@example.com 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”.
Professor Walter Humes, writing in Scottish Review, 21st September 2015:
“For some time I have been copied into email exchanges concerning how complaints against public bodies are dealt with. I have no personal stake in any of the specific sources of concern (which include patient care in the NHS and responses by Police Scotland, the Scottish Government and the Crown Office and Procurator Fiscal Service (COPFS) to requests for formal investigations). I do, however, have a long-standing interest in issues of public accountability and am familiar with the various techniques used by bureaucratic organisations to avoid responsibility when things go wrong: these include silence, delay, evasion, buck-passing and attempts to discredit complainants.”
“Those who hold high office in public bodies are very adept at defending their own interests. They may claim to support openness and transparency but those principles are not always translated into practice. Bureaucratic Scotland often falls short of the democratic ideals which are said to underpin civic life”