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.

 

 

‘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”.

 

 

 

 

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”.

 

 

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."

 

 

 

 

Were we asleep at the wheel?

At the beginning of June 2008 I sent an e-mail to Dr Leon Eisenberg, a former child psychiatrist, and a man of philosophy and science:
leon-eisenberg
Dr Eisenberg was then 89 years old and I wanted to convey how important his writings had been to me:mindlessness-and-brainlessness-in-psychiatry-1986
I did not expect a reply:
leon-eisenberg-to-peter-gordon-8-june-2016

A year later Leon Eisenberg died.

were-we-asleep-at-the-switch

After his death a memoir was discovered: which Eisenberg had named “Were We Asleep at the Switch?”.

Eisenberg suggested that a switch from ‘mind’ to ‘body’ has taken place in psychiatry as a discipline, which has led to overuse of medication.

He also argued that “monied interests” had been making de facto decisions on behalf of us all about the “science” of things that might affect us.

Eisenberg was worried that the overwhelming impact of economic considerations may have rendered, and might continue to render futile, the professional contributions of many brilliant, timely, and concerned working scientists.

leon-eisenberg-1987b

Reductionism – truly, madly, deeply

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:
001-improvement-science The meeting was held at the Golden Lion Hotel, Stirling:golden-lion-hotel-stirling-25-nov-2016-1golden-lion-hotel-stirling-25-nov-2016-2I started the day off:
002-improvement-scienceI gave these declarations:
003-improvement-science
I explained to the audience that like Dr Rev I M Jolly I can be overly pessimistic:


005-improvement-scienceThe dictionary definition of ‘Improvement’:
006-improvement-scienceThe dictionary definition of ‘Science’:
007-improvement-scienceMy concern is any pre-determinism to science:
008-improvement-scienceThe Health Foundation have considered Improvement Science: this is from 2011:
009-improvement-scienceMany different terms are used including “QI” for “Quality Improvement”:
010-improvement-scienceThis is where improvement science began, in Boston, Massachusetts:
011-improvement-scienceThe Founder of the Institute for Healthcare Improvement (IHI) was Don Berwick:
013-improvement-scienceThe first description of this movement in Britain goes back to 1992 by Dr Godlee:
014-improvement-scienceFifteen years later, Dr Godlee, Editor of the BMJ, said this:
015-improvement-scienceOnly last month the BMJ briefly interviewed Don Berwick:
016-improvement-scienceIHI describes improvement science as being based on a “simple, effective tool”:
017-improvement-scienceThis tool was developed from the work of an American engineer, W. A. Deming:
018-improvement-scienceThe “Model for Improvement” Tool [TM] is described by IHI as a “simple, yet powerful tool”:
019-improvement-scienceThe current President and CEO of IHI is Derek Feeley:
024-improvement-scienceUp until 2013, Derek Feeley was Chief Executive [Director General] for NHS Scotland:
021-improvement-scienceIn April 2013 Derek Feeley resigned from NHS Scotland:
022-improvement-science22nd February 2015 it was reported: “The astonishing and largely hidden influence of an American private healthcare giant at the heart of Scotland’s NHS”:
023-improvement-scienceDr Brian Robson, Executive Clinical Director for Healthcare Improvement Scotland [HIS] is an “IHI Fellow”:
dr-brian-robsonProfessor Jason Leitch, National Clinical Director for the Scottish Government is an “IHI Fellow”:
026-improvement-scienceMight we be facing the biggest change to healthcare in Scotland since the NHS began?nhs-scotland-1947 Improvement science is moving quickly and widely across Scotland:
027-improvement-scienceThis “Masterclass 1” for Board members cost  £146,837:
028-improvement-scienceAn NHS Board member commented after the Masterclass:
029-improvement-scienceHealthcare Improvement Scotland is one organisation with a very wide remit over NHS Scotland and it works closely with the Scottish Government:
031-improvement-scienceNine cohorts of Safety Fellows and National Improvers have so far been trained following IHI methodology:
032-improvement-scienceI 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):033-improvement-scienceWhat is the place of ethics in Improvement Science?
034-improvement-scienceIn 2007 the Hastings Centre, USA, looked into this in some depth:
035-improvement-scienceThe Hastings Centre argue that Improvement science cannot ignore ethics:
036-improvement-scienceIn 2011 the Health Foundation, UK, produced this “Evidence Scan”:improvement-science-2011a2The Health Foundation commented that “improvement science is just emerging”:
037-improvement-science
The Evidence Scan found a “real paucity of evidence about the field of improvement science”:
038-improvement-scienceI would also suggest that there is a real paucity of philosophy about the field of improvement science:
039-improvement-scienceThe Health Foundation did find papers on the conceptual nature of Improvement Science but concluded that:
040-improvement-scienceMary Midgley is a philosopher now aged 95 years who is widely respected for her ethical considerations:
041-improvement-scienceChapter 7 of her book “Heart and Mind: The Varieties of Moral Experience” begins:
042-improvement-scienceMary Midgley is concerned about the overuse of reductionist tests in medicine stating that:
043-improvement-science
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:
045-improvement-scienceIn the Hastings Report, Margaret O’Kane asks:
046-improvement-scienceIn my view the answer to this question is YES. I am hopeful that the National Improvers recruited to NHS Scotland would agree:
047-improvement-scienceAs 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:
048-improvement-scienceBoth the Hasting Group and the Health Foundation are of the view that improvement science cannot separate itself from the ethical requirements of research:
049-improvement-scienceThis article published in February 2016 argues that individual “rights transcend all aspects of Improvement science”
050-improvement-scienceThe following is a verbatim representation of a conversation held by National Improvers working in NHS Scotland:
051-improvement-scienceIn November 2016 Professor Joshi, also a psychiatrist outlined his concerns about reductionism in a published letter to the BMJ:
052-improvement-science
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:
054-improvement-scienceProfessor John Bruce did not succeed in his endeavour. His Temple however stood for many years:
055-improvement-scienceBut it eventually collapsed and his endeavour to “reduce the science of morals to the same certainty that attends other sciences” collapsed with it.
057-improvement-scienceAny search of Healthcare Improvement Scotland for “ethics” finds this result:
056-improvement-science
This film is about more up-to-date buildings – the enthusiasm for which was based on improvement science: The Red Road flats in Glasgow:

 

                         Post-script:

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

A Friend of Liberty: Professor Walter Humes

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.”

The Friends of Liberty from omphalos on Vimeo.

“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”

The contributions of those “retired” often prove invaluable

The contributions of those “retired” often prove invaluable

BMJ submission by Dr Peter J Gordon.

2nd September 2015

Yesterday I was at a consultation event held by Healthcare Improvement Scotland which sought wider views on a proposed national approach to “Scrutiny” of health and social care in Scotland. At the meeting I met a number of individuals who had been designated “retired” on their name badge. I was not surprised to find that during the course of the consultation event, the contributions of those “retired” proved to be invaluable.

Returning home on the train I thought about this a little more. Names like J K Anand, L Sam Lewis and Susanne Stevens, all regular submitters to the BMJ rapid responses came into my mind. All describe themselves as “retired” and one happily calls himself “an old man”. The contributions by retired folk have always struck me as having a different quality to those by people who are still employees of today’s NHS. In “retirement” there may be a greater freedom to ask questions of prevailing approaches. Our older generation also has great experience which should be considered as “evidence” in itself.

Yet in my job as a doctor for older adults, I see the world around me as seeming to do its best to reduce our elders. The language used in discussing our elders commonly denotes some sort of loss. For example the “guru” of Healthcare Improvement Don Berwick talks about the “Silver Tsunami”. Other healthcare leaders talk of “epidemics” and “challenges”, implying that our elders are a burden to younger generations. To address these “challenges” the healthcare improvers, it seems to me, are devising shortcuts. Today these are often termed “tools” and may be part of “toolkits”.  I have even heard healthcare improvers discussing the need to “invent” a “tool” for patient centredness. I think our elders, or those “retired”, might consider this to be particularly ridiculous.

So I would like to say three cheers for the “retired” folk. To discourse they bring wisdom, to the prevailing methodologies they are more willing to ask critical questions, and when it comes to cutting through to what matters, being true to oneself, our elders are superior to many, if not most, policy makers.

       The following are quotes by Raymond Tallis:

Raymond-Tallis-(30)

Raymond-Tallis-(32)

Unpacking the miracle of everyday life (parcel 2) from omphalos on Vimeo.

Scotland’s approach to Dementia Diagnosis

On the 30th October I received this most helpful reply from Alex Neil, MSP, Cabinet Minister for Health and Wellbeing for the Scottish Government.

The full letter is as follows and my full response below that. My view is that the lesson Scotland has for NHS England as to regards our approach to the diagnosis of dementia is important. My view is that it is not the lesson as portrayed by the Scottish Government. Please read my letter and see what you think?30 Oct 2014 Alex Neil

My reply as posted to Alex Neil:

page-1

page-2

page-3

It is not always easy to read image files, so below is an html version with a few added photographs that were taken at the Alzheimer’s Europe Conference held in Glasgow between 20th and 23rd November 2014.

Friday, 31st October 2014
To Alex Neil,
Cabinet Secretary for Health & Wellbeing,
The Scottish Government.

Your ref: 2014/0032642

Dear Cabinet Secretary for Health & Wellbeing,
I wanted to write and thank you for your letter dated 31st October 2014 which actually arrived by e-mail on the 30th October. It was very helpful for you to outline so clearly the Scottish Government’s position on the diagnosis of dementia. I thought it might be helpful if I replied to some of the points you made in this letter but first I wanted to say that I thought your speech to the Alzheimer’s Europe Conference held in Glasgow was very good.

A-Neil

I was delighted to hear about the “Glasgow Agreement” based on rights & dignity of individuals and to see this signed by representatives of all walks of life. I think to have Scotland lead the way here is a matter in which we can take much pride. The level of inclusion at the conference of those living with dementia was inspirational. The value of experience in terms of shaping policy should never be lost. My only concern is that many of the patients I see with cognitive changes are very elderly and frail and with multiple health problems. So we must be careful to include this group’s very quiet voice. They tend not to have straightforward “Alzheimer’s”.

Glasgae

I have many interests and so I am an advocate for scientific pluralism when it comes to the subject of wellbeing. As a general point I would like to reflect on my experience in the last four years or so where I have not found it easy to raise ethical considerations. I refer both to my experience as an employee of NHS Scotland and indeed my “engagement” with Healthcare Improvement Scotland. I would hope you might investigate how ethical matters can have a routine place in healthcare in Scotland. It is also my view that scientific methodology requires to include critical voices. History reminds us time and again that well-intentioned policies can have unforeseen consequences. I am hugely impressed at your personal determination to see that concerns can be raised without what has happened to me and others:  isolation and mischaracterization. I want to thank you for this.

Sunday-Herald-12-Oct-2014-(

Above newspaper extract is from the Sunday Herald, 12 October 2014

My experience in NHS Forth Valley for raising ethical considerations and trying to be a voice for those most vulnerable (generally our very elderly) was far from easy. I had the same experience for raising transparency and following HDL 62 which has been extant for over 10 years.

The incentivised approach to the “early diagnosis of dementia” as set out explicitly in HEAT Target 4 first raised concerns for me in day-to-day practice. This target was pursued by senior Scottish Government officials most rigorously. Here it is worth looking at the evidence presented to Westminster’s All Party Parliamentary Group by senior Scottish Officials (Government and Clinical). Phrases used included “being careful to take out saboteurs” and an approach suggested that Senior Managers and Clinicians should be taken around the “back of the bike shed” if they disagreed with policy. I am of the view that such approaches are unhelpful and unethical.

HEAT Target 4 and the first Dementia Strategy (covering a combined period of 5 years – 2008-2013) were based on early diagnosis. It was only following my meeting with a senior Government official raising ethical concerns that a “timely” approach to diagnosis was included in 2013 for the second Dementia Strategy. It is welcome to see this now as the basis of a rights based approach as advocated across Europe in the Glasgow Agreement”. The Keynote address to the Alzheimer’s Europe Conference I felt misrepresented the truth. The audience were given the impression that “timely diagnosis” had been a founding principle of the Scotland’s Dementia Strategy when in fact it was only introduced last year.

Timely

You are correct that I am concerned about the over-diagnosis of dementia. Dementia diagnosis is a complex matter and must not be simplified or rushed in my opinion. I am equally concerned about mis-diagnosis. When I left NHS Forth Valley this summer I had a series of patients who had been given an ”early diagnosis” of “early Alzheimer’s disease” even though clinically they did not fulfil International criteria for Dementia.  Five years on (or more) these individuals still have no signs or features of dementia. Our elderly are generally deferential folk who respect medical authority. We owe it to them to take better care.

It is my view that HEAT Target 4 and the first Dementia Strategy encouraged loosened diagnostic boundaries to become accepted practice. I wrote to the Scottish Government about this but received no written reply. Then I found that my NHS Board, who had initially supported my concerns, no longer agreed with me and the Medical Director at the time concluded I was “the main concern”. Following this an “External Review” was held with the two senior doctors mentioned  this month in the Dementia in Europe magazine (see below).dr-gary-morrison-and-professor-graham-jackson-scotland

In private the former Chief Executive of the Mental Welfare Commission acknowledged that he agreed with timely diagnosis. But in public discourse about policy, strategies and targets he endorsed early diagnosis. I have looked at all the online Scottish Government minutes of meetings about the first Dementia Strategy and HEAT Target 4. All involved with these policy meetings endorsed early diagnosis and wished to “educate” other doctors, especially GPs, about this. There was no mention of a timely approach anywhere.

The summary that you mention was a fair reflection of my conversation with a senior Government official until it stated that ”the Scottish Government’s shift  from early to timely diagnosis between the first and second National Dementia Strategy has been quite a subtle and nuanced one reflecting the balance of clinical and other opinion in favour of the latter” [bolding mine]. It is my opinion that, far from being “subtle and nuanced”, this is a significant change in emphasis. I welcome it whole heartedly as it addressed the potentially harmful consequences of a focus on early diagnosis. The current debate in England would have been better informed had the Scottish Government acknowledged the significance of this change.

Be-heard

I hope this letter helps you understand a little better where my concerns come from. I want to help policy makers and to find it easier in the future for my voice or the voices of those far less able to be heard.

Kindest wishes,
Yours sincerely,

Dr Peter J Gordon

 

Update: November 2016:

The Scottish Government lead for Dementia has said  (behind closed doors to his Scottish Government colleagues) about my advocacy of ethical issues relating to dementia :
geoff-huggins-acting-director-for-health-and-social-care-2-dec-2015

Such a statement seems back-to-front.

It was Geoff Huggins who addressed Westminster Parliament in person to say that any “saboteurs” to HEAT Target 4 would be addressed by taking them “behind the bike shed”.

How to improve dementia diagnosis rates in the UK from omphalos on Vimeo.

As of  November 2016, those who across Europe who support timely diagnosis of dementia as opposed to screening or early diagnosis:
glasgow-declarationas-of-5-nov-2016

An Edit from omphalos on Vimeo.

November 2016:
Sir Harry Burns, former Chief Medical Officer for Scotland has 
agreed to lead a review into Targets:

[the full transcript of his initial thoughts to the Scottish 
Parliament can be read here]:

01-health-and-sport-committee-15-nov-2016

04-health-and-sport-committee-15-nov-201602-health-and-sport-committee-15-nov-2016

Why I resigned from NHS Forth Valley

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.