Frailty – nothing about us without us

Posted on September 10, 2017 by Snow-Leavis

In September 2016, Professor Martin Vernon, National Clinical Director for Older People and Integrated Care at NHS England stated why diagnosing frailty is important:

In the same month Professor David Oliver had this Acute Perspective published in the British Medical Journal. It attracted over twenty responses many of which, but not all, were supportive.

I submitted this response as I was not convinced that “frailty” was inherently any less likely to stigmatise our older generation:

A year later, Dr Steve Parry, the Vice President of the British Geriatrics Society (BGS) had this perspective published on the British Geriatrics Society Blog , asking “when does a well-meaning medical fashion become a potentially destructive fad?” This perspective also attracted over twenty responses.

A week later, the former President of the British Geriatrics Society, Professor David Oliver argued why he was “fine with Frailty”:

Dr Shibley Rahman, an Academic in Frailty and Dementia and has outlined why he is of the view that such a model, based on deficits only, if applied to our older generation could cause harm. This article also attracted many responses.

In a recent Acute Perspective Professor Oliver outlined his concern that the British public may not have realistic expectations when it comes to frailty and “progressive dwindling”:

My understanding is that the term “progressive dwindling” was first used by George J. Romanes in this 1893 book:

This is the context in which the term is used:

The dictionary definition of “inutility” is: uselessness or a useless thing or person.

Healthcare Improvement Scotland has been concentrating on frailty as one of its National Improvement initiatives. This first started in April 2012 and so has developed significantly in the five years that have followed. NHS Scotland staff have been reminded to “THINK FRAILTY”. Up until now the focus has been on deficits and how to “screen” for these with “toolkits”.

In a BBC Radio Scotland “Thought for the Day”, the broadcaster and writer Anna Magnusson recently considered the language that we use in relation to our older generation. I made this short film using her words and voice. I have shared it with Anna Magnusson and she wrote a kind personal response to me:

We are far more than our labels from omphalos

These words from an Edwin Morgan poem resonated with me as a description of the complexity of ageing:

The people best placed to assist in understanding the complexities of ageing and the language best used to describe it are surely the older generation themselves.

Delirium screening (some years later)

Posted on September 7, 2017 by Snow-Leavis

Over three years ago I wrote this summary of my concerns about mandatory delirium screening. The consequences for me in writing this were life changing: the reality of having the courage to care in NHS Scotland.

Time has moved on and we should consider recent statements on this subject:

6th June 2017: Dr Claire Copeland:
“Two heavyweights of the delirium world: Wes Daly takes on Professor Alasdair Maclullich: to screen or not to screen. Let the battle commence”

5th August 2017: Dr Sharon Inoyue:
“Very important. Studies show dramatic increase in antipsychotic treatment with mandatory delirium screening”

31st August 2017: Dr Dan Thomas:
“In the UK I would be very surprised if many with delirium in hospital left on antipsychotics (which is good!)”. This is a speculative response to an article in the Journal of the American Geriatrics Society which had found that “most patients with delirium discharged on a new antipsychotic had no instructions for discontinuation”

Footnote:
Whilst evidence cannot ever be complete there has been
consideration of antipsychotic use for delirium:

Improvement science: engineering 42 – ethics 0

Posted on September 7, 2017 by Snow-Leavis

In my last post I considered a “thought paper” entitled “The habits of an improver” and welcomed that critical thinking was considered a necessary habit.

The word “engineer” or “engineering” is to be found on 42 separate occasions in this Health Foundation thought paper.

The word “ethics” does not appear at all. Despite the fact that the introduction begins with this quote:

That ethics do not seem to be considered amongst the “habits” necessary for “improvement science” is concerning.

The last time I looked, I found this result using the Healthcare Improvement Scotland search facility:

The former Chief Executive for the Mental Welfare Commission for Scotland used to introduce me as “Bayesian Peter”. Bayesian is the name given to interpretations of probability and returns to Reverend Thomas Bayes original considerations of complexity.

Healthcare, like life, is complex. We are human and live in an ever changing world.

This is not all so simply “engineered”.

Ethics is integral to science. I do not deserve the epithet “Bayesian Peter” – for whilst I am interested in ethics this does not mean that I am more ethical than you the reader.

However, I want to say as clearly as I can, and yes with passion, that without ethical considerations “improvement science” should linger in quotes.

The habits of an improver

Posted on September 7, 2017 by Snow-Leavis

I have recently read this most interesting “thought paper” entitled “The habits of an improver” which was published by the Health Foundation in October 2015.

Several months before this was published, the Executive Clinical Director for Healthcare Improvement Scotland wrote to my employers stating that “[this individual] clearly does not understand the improvement science approach”. This defamatory letter almost ended my unblemished career as an NHS doctor. I subsequently felt that I had no option but to resign from NHS Forth Valley after 13 years as a Consultant working in Clackmannanshire. The glowing and unsolicited feedback that I received on my resignation can be read here.

‘The habits of an improver’ would seem to confirm that it was in fact the Executive Clinical Director for Healthcare Improvement Scotland who lacked understanding of the “improvement science approach”. Two of the key ‘habits’ include (1) a willingness to consider conflicting points of view and (2) a requirement of critical thinking.

I have asked for an apology from Healthcare Improvement Scotland but it has been confirmed from the Chair, Dame Denise Coia, that this will not be forthcoming.

In a follow up post I will share evidence that appears to 
substantiate the concerns that I raised about mandatory 
screening for delirium.

We are far more than our labels

Posted on August 5, 2017 by Snow-Leavis

“National Improvement” work for older people has focused on Frailty and in NHS Scotland we are reminded by healthcare Improvement Scotland to “THINK frailty”

This short film is based on “thought for the day” by Anna Magnusson, BBC Radio Scotland, Friday 5th August 2017.

Music is “Seeing the future” by Dexter Britain (under common license)

We are far more than our labels from omphalos.

Improvement goggles

Posted on July 17, 2017 by Snow-Leavis

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’

Posted on July 6, 2017 by Snow-Leavis

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:

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

‘Informed consent is a fundamental principle underlying all healthcare’

Posted on May 17, 2017 by Snow-Leavis

A recent Independent Review for NHS Scotland stated that: “Informed consent is a fundamental principle underlying all healthcare”

The Cabinet Secretary for Health and Sport, Shona Robison stated to the Scottish Parliament (17 March 2017): “Informed consent and shared decision making are expected prior to any procedure being carried out.”

On the 20th April 2017, I wrote to Healthcare Improvement Scotland 
about Patient consent in NHS Scotland:

I have just completed my annual Appraisal which is a General Medical Council requirement as part of 5 yearly Revalidation. As part of this I was informed by my Appraiser that I must comply with all the LearnPro modules which I have now done.

The following screenshot comes from the NHS Lothian mandatory LearnPro module on Capacity and Consent:

I apologise as the text is small, so I have reproduced verbatim what it states to me as an NHS Lothian employee:

“Consent is both a legal requirement and an ethical principle and requires to be obtained by healthcare professionals, prior to the start of any examination, treatment, therapy or episode of care.”

“In Scotland, everyone over the age of 16 is an adult. The law assumes that adults can make their own decisions and can sign legal documents, such as consent to medical treatment (in some circumstances this also can apply to children under the age of 16) provided they have the capacity. This means that they are able to understand what is involved in the proposed treatment, retain the information, be able to weigh up the information needed to make the decision and then communicate that decision. Treatment might be delivered in a hospital, clinic or in someone’s home.”

In years past I have written about consent for older adults in hospital in NHS Scotland:

Do we care enough about consent?

‘OPAC tools are working’

I am writing to Healthcare Improvement Scotland as I find myself confused.

Do I follow the mandatory requirements of my employers on consent? Or do I follow the National Improvement requirements of OPAC-HIS where consent is not required for assessments such as the 4AT assessment test? (formerly called “4AT screening tool”)

I know, from the re-drafted Care Standards, that Healthcare Improvement Scotland take consent very seriously.

I should state that I am writing in my own capacity and in my own time.

12 May 2017 - I sent this update to Healthcare Improvement Scotland:

Forgive me for this further correspondence but I felt that I should update you on the learning that I received as part of my attendance for Continuing Medical Education (CME) yesterday.

This CME event was for the Royal College of Psychiatrists in Scotland – Faculty of Old Age Psychiatry and was held in Falkirk.

At this event the Chair of Old Age Psychiatry for the Royal College of Psychiatry was giving a talk and when the time came for questions I asked about the wide use of haloperidol in older adults in hospitals in NHS Scotland. Dr Thompsell replied “evidence has found that Haloperidol actually worsens the outcome of delirium”.

Another lecturer at this meeting, who was giving a talk on her area of expertise: anti-psychotics and older adults, was Dr Suzanne Reeve. She replied: “Haloperidol does increase mortality in older people compared with other antipsychotics. That message has been out for a while but has not really got across.”

The next talk was entitled “Successes of Old Age Psychiatry Liaison team” and one of the slides shown had the headline “Compliance with 4AT”. The impressive “compliance” figures then followed. The dictionary definition of compliance is “the act of yielding”.

My concern here is for patient harm and indeed increased patient mortality. National Improvement work undertaken by HIS has been instrumental in increasing “compliance” with tools such as the 4AT and it is clear that no consent is deemed necessary. I have argued that this is not ethical as these tools are often the beginning of “pathways” and “protocols” that may result in the administration of haloperidol.

I am genuinely worried that National Improvement work undertaken by Healthcare Improvement Scotland has not properly considered ethics, available evidence and the potential for unforeseen consequences. You will understand that I am also nervous about writing this letter given the consequences for me when I first “spoke up” three years ago:

I would very much value your advice. I am not sure that I can work in a profession if it loses sight of Hippocrates and “first do no harm”.

This is the response from Healthcare Improvement Scotland,
dated 17th May 2017:

“Thank you for your letter of the 20th April and your letter of 12th May, in which you raise the interesting issue of taking consent in relation to cognitive screening.

I understand from staff involved in the inspections of older people’s care in hospital that taking of written consent prior to initial assessment for frailty is not routinely undertaken. Assessment at the point of admission, or where a change in a patient’s cognitive presentation is giving cause for concern, can alert staff to possible increased risk and enables planning of care for the patient. In these circumstances staff adopt a proportionate approach such as asking, for example, if they may ask some questions.

For absolute clarity though, as an employee of NHS Lothian, the requirements set out in the Board’s policies and mandatory training are those that you should follow.”

Reductionism – truly, madly, deeply

Posted on November 24, 2016 by Snow-Leavis

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: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:
015-improvement-science

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”:
026-improvement-science

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:
028-improvement-science

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:
032-improvement-science

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:
036-improvement-science

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:
048-improvement-science

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:

                         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

Glared like an irritated owl

Posted on May 26, 2016 by Snow-Leavis

Glared like an irritated owl from omphalos on Vimeo.

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”?

Hole Ousia

The whole being: the cultures of science & arts together

Tag Archives: improvement science

Frailty – nothing about us without us

Delirium screening (some years later)

Improvement science: engineering 42 – ethics 0

The habits of an improver

We are far more than our labels

Improvement goggles

‘How to Improve’

Reductionism – truly, madly, deeply

Glared like an irritated owl