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 Robisonstated 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:
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.”
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:
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:
(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”?
There is a lot of effort in NHS Scotland to raise awareness amongst healthcare staff about delirium, using statements like this:
Delirium is a very complex state and it is a shame that awareness is not always accompanied by understanding of this complexity. This is not surprising as delirium is poorly understood. It remains unclear to what extent delirium is itself a risk factor for mortality, rather than simply reflecting a multi-morbid state where each condition carries its own risks:
[the above is an excerpt from Inside Health last week]
The following slides come from recent awareness-raising events in NHS Scotland:
These “busy slides” perhaps do reflect some appreciation of the complexity of delirium. What appears to be lacking is meaningful and informed involvement of patients:
All awareness campaigns can suffer from the difficulty of communicating complexity and recognising gaps in understanding. Oversimplified approaches to what is undoubtedly a serious condition could have unintended consequences and this has to be given serious consideration.
What follows are the costs of films made for NHS Healthcare Improvement Scotland. The period covered is 1 Jan 2014 to 26 Feb 2015. Costs for all other photography commissioned by Healthcare Improvement Scotland are not included. The total cost is over £51,000.
In a previous post I drew attention to the increasingly mechanical language of Health Improvement.
This current post starts with recent communication by health improvers in Scotland:One of my favourite writers is Robert Louis Stevenson. In “an apology for idlers” he considers how humankind tends to approach understanding:Mary Midgley, now aged 95 years, is one of my favourite moral philosophers. In “Heart and mind” she considers “tests”:Mary Midgley has written a lot about reductionism:Healthcare Improvement Scotland outline that they are “one organisation, with all activities aimed at driving improvements in healthcare”:If you search Healthcare Improvement Scotland for “philosophy” you get three results, none of which actually relate to philosophical study:If you search Healthcare Improvement Scotland for “ethics” you get zero results:Dr Murad Moosa Khan is a psychiatrist for older adults, who like me has an interest in ethics: . In a recent talk he said: and later concluded:
I want to thank Dr Brian Robson, Executive Clinical Director for Healthcare Improvement Scotland, for agreeing that I can include his letter to my employers, NHS Forth Valley, dated 22 May 2014. I explained to Dr Brian Robson that I would like to include here his entire letter and my letter of reply.
But first a few quotes from a psychiatrist and professor for older adults (these are not quotes by me):
"I want to make a case and I want to argue why ethics
is as important, if not more important than quality"
2011
"Quality is a by-product of ethics and not vice-versa"
2011
"It is extremely important for healthcare organisations to invest
in ethics. Who should be trained in ethics? Each and every person
in our healthcare organisation: Chief Executive, Directors,
Managers, medical and nursing staff, as well as support staff.
Each and every person."
2011
Below is Dr Brian Robson’s letter to my employers and below that, the full html transcription:
From: Dr Brian Robson
Executive Clinical Director,
Healthcare Improvement Scotland
Delta House
50 West Nile Street
Glasgow
G1 2NP
0141 225 6999
22 May 2014
To: Dr Peter Murdoch
Interim Medical Director NHS Forth Valley
Carseview House
Castle Business Park
Stirling
FK9 4SW
Dear Peter, Re Dr Peter Gordon – commuunications and media relationships
It is with regret that I am formally raising my concerns about this individual with you.
Unfortunately Dr Gordon has persisted in his unprofessional, highly selective and concerning approach to providing misinformation in relation to improvement work in the field of older people’s service in NHS Scotland. These behaviours are now having significant impact on the well-being of our staff and I have set out below a selection of the information raised with me in relation to his activities.
Healthcare Improvement Scotland has attempted through discussion and correspondence, to engage professionally however we have exhausted this route with him as an individual and we have modified our approach to attempt to redirect readers to the source of reliable information e.g. our website.
Whilst I appreciate the limitations of your role as employer, I would be grateful for your formal consideration around how his damaging behaviours could be reflecting on NHS Forth Valley, causing unnecessary patient and public concern and also on what consequences these may be having in other aspects of his performance.
I also recognise the risk in raising this formal complaint in that it could be misinterpreted as censorship or worse however I am now sufficiently professionally concerned that I believe this is now necessary.
Oppressive use of social media
The OPAC twitter page has received frequent attention and criticism. He frequently attaches his blog to correspondence between OPAC and clinicians. HIS cannot engage with anyone on Twitter without him sending his blog to the clinician in an attempt to start debate with anyone engaged with us.
Misinformation and scaremongering
The content of the blogs often quote our engaged clinicians out of context. He clearly does not understand the improvement science approach stating that we need to submit a peer review and engage all over 65s. He also complains about his lack of engagement in the programme but continues to write factually inaccurate pieces regarding the work.
Political disruption
He copies his tweets to Alex Neil, MSP etc stating that the improvement work boards must comply with cognitive screening in all over 65s. This is not the case, delirium screening has been very much lead by Boards who have realised that they need to improve recognition and management of delirium, we a asked that over 75s where the group targeted in the testing phase. One ward per hospital.
Staff distress
It is distressing to the team and our clinical colleagues that, blogs and other avenues to distort our work and message. He has been respectfully challenged by respected colleagues regarding his one way criticism of the work. He does not engage when challenged stating he ‘feels uncomfortable’ He has made everyone uncomfortable with his actions.
Waste and impact on improvement for patients
It is very distracting to have daily attention from this individual and efforts to assist his understanding and allow progress to be made have, to date, been ineffective.
Yours sincerely
Dr Brian Robson Executive Clinical Director,
Below is internally published NHS Forth Valley position on Delirium Screening:
Below is my reply to Dr Peter Murdoch, Interim Medical Director, NHS Forth Valley, after I had been made aware of this letter:
To Dr Peter Murdoch Interim Medical Director Carseview House CastleBusinessPark Stirling FK9 4SW
13thJune 2014
Dear Dr Murdoch,
Many thanks for sharing this letter from Dr Brian Robson.
I welcome the opportunity to respond to the points made.
First of all I would like to make it clear that I did try to use local mechanisms to feedback into the “improvement” process. The local response was that “improvements” in delirium screening (i.e. mandatory cognitive screening of all over 65s admitted to the acute hospital – see attached) were guided by HIS. I therefore contacted HIS by letter to clarify the ethical considerations and the evidence base behind changes which I could foresee would have an impact on my day-to-day clinical practice and which caused me concern for a range of reasons.
After a partial written response by HIS Inspector, Ian Smith, I was invited to take part in a teleconference with four employees of HIS. I found this experience disappointing in that none of the four appeared to be willing to answer any of my concerns. My overall experience of HIS was of an organisation which was not willing even to consider ethical points or discuss the validity of “screening tools” the use of which it is recommending across Scotland.
My approach has always been one to encourage discussion and debate. I do not expect HIS to necessarily agree with me but I do expect them to consider my concerns seriously.
Oppressive use of social media:
I have only ever written two blogs about delirium. Both relate to ethical considerations and also look at validity of “screening tools”. My first blog “the faltering, unfaltering steps” is based entirely on evidence and material in the public domain, all of which is cited. This is not “misinformation”. My second “blog” called “Delirium Screening” was a summary produced at the request of Professor Alasdair MacLullich. I have had no response from Professor MacLullich or anybody involved in delirium improvements on the legitimate ethical issues which were raised in it. I am of the view that the public deserves a balanced presentation of the complex issue of delirium.
HIS and OPAC use social media very extensively but it appears that only content that accords with the outlook of OPAC or HIS will be considered acceptable responses. Debate is not being allowed by HIS and OPAC and runs counter to HIS claim to be “engaging”. Dr Robson’s letter makes it clear that to be allowed to be “engaged”, one must not question anything in their predetermined approach.
It is certainly not the case that “HIS cannot engage with anyone without him sending his blog to the clinician”.
I have made no films about delirium.
Misinformation and Scaremongering
These are very bold words indeed and I would like to see examples of where I have quoted “out of context”. I agree that I “do not understand the improvement science” if it is a “science” which does not require evidence (e.g. internal and external validation of “screening tools”) and consideration of ethics (e.g. consultation with the population directly affected).
Political disruption
I have come to understand that there has been significant confusion between improvement work for delirium (which are undergoing local pilots and which target patients aged 75 years and over) and the recommendations made to NHS Scotland Boards about routine cognitive screening (which are assessed by HIS Inspection visits and generally refer to all patients aged 65 years and over). From the viewpoint of a grassroots clinician the conflation of these two processes has been unhelpful. It is unfair to say that routine cognitive screening is led by NHS Boards when in fact this is a recommendation against which they are inspected by HIS. My understanding is that this recommendation is based on the Clinical Standards for Acute Care (2002) which are more than a decade old and that the Convener of the Parliamentary Health Committee (January 2013) expressed concern that these need updated. Given this clear political involvement I reserve the right to communicate with elected representatives.
Staff distress
It is not my intention to cause distress to anyone. On a point of principle however, and here I would make reference to the findings of the Francis Report, it is surely essential that critical voices are not silenced because of potential to cause “upset”. There is always a power imbalance between any organisation and any individual and a number of recent examples have illustrated the risks of always assuming that the organisation is right.
The reason that I have stated that I felt “uncomfortable” relates to a specific conversation on twitter. Although HIS and OPAC use twitter extensively it has its limitations in discussing complex issues and it was my intention to move the discussion onwards using more traditional methods of communication.
Waste and impact on improvements for patients
Given the amount of my own time that I have devoted to “engage” with Dr Robson, Prof MacLullich, Scottish Delirium Association, HIS, and OPAC it is disappointing to hear that my contributions have been a “waste” and had only negative “impact”. This is all the more so in that the responses I have had from the above parties have not “assisted my understanding” but have comprehensively failed to address my concerns.
Dr Robson states that he fears that this formal letter to my employers might be “misinterpreted as censorship”. I think that this would indeed be the view of anyone, who like me, has struggled to raise ethical issues.
History tells us that the spirit of scientific progress requires open-minded enquiry. Any organisation which is aiming to take a scientific approach must take care to remember this. My recent experience makes me feel that the headline promise that HIS “engage” meaningfully is but a hollow sound-bite. HIS is going struggle to find more “engaged clinicians” if absolute agreement with the organisation’s approach is a pre-requisite for engagement.
I am replying via e-mail for speed but will be following up by letter to yourself and to Dr Brian Robson.
It would be helpful if you could confirm if I have breached any NHS Forth Valley Policy on the matters covered in this communication.
Yours sincerely, Dr Peter J Gordon
cc. Dr Brian Robson, Executive Clinical Director, Healthcare Improvement Scotland
I copied my letter to Alex Neil, MSP, Cabinet Minister for Health and Wellbeing, Scottish Government. I attach the reply below:
Immediately following the letter from the Executive Clinical Director for Healthcare Improvement Scotland to NHS Forth Valley I was “invited” to an “informal” meeting by my employers. Where no minute was kept.
At this “informal meeting” the Medical Director repeatedly reminded me of my duty to the organisation. The General Manager for NHS Forth Valley repeated this reminder. Thereafter, my professionalism, character and ethics were robustly questioned.
Within weeks of this "informal meeting"
I resigned from NHS Forth Valley.
At the time of this letter to my former employers Dr Brian Robson
was working immediately alongside Dr Neil Houston who also works
in NHS Forth Valley as does his wife Dr Linda Wolff.
Almost two years on from the letter sent by Healthcare Improvement Scotland to my former employers, NHS Forth Valley, I have sent the following letter to the Executive Clinical Director of HIS. I have done so because I was reminded of the situation that I found myself in following the recent, and most welcome publication of “Realistic Medicine” by the Dr Calderwood, Chief Medical Officer for Scotland.
Wednesday, 2nd March 2016
To: Executive Clinical Director,
Healthcare Improvement Scotland,
Delta House,
50 West Nile Street
Glasgow
G1 2NP
Dear Dr Robson,
I hope that you do not mind me writing to you to reflect, a few years on, from the circumstances I found myself in as an NHS employee who had worked in Scotland for over 20 years. My wish in this letter is to reflect and to suggest learning for all, including of course myself. In summary my experience has been that in trying my best to put patients first I did not find what Robert Francis termed “freedom to speak up”: rather that deference was first given to colleagues and to the system.
As Executive Clinical Director for Healthcare Improvement Scotland you sent a letter, dated 22nd May 2014, to the Medical Director of my former employers http://wp.me/p3fTIB-u8 . I was not aware of this letter until I had an “informal” “invitation” to meet with my employers. A month later I resigned after 13 years as a Consultant with unblemished career with NHS Forth Valley. The feedback I had following my resignation confirmed that I was valued as a respected and professional doctor.
I publicly advocated a timely approach to the diagnosis of dementia even though the universal approach was for early diagnosis. From the Health Secretary down, including senior policy makers and senior NHS staff, Alzheimer Scotland, the British Geriatric Society and the Mental Welfare Commission, there was no support for timely diagnosis. I advocated this approach as it included considerations of potential harms as well as potential benefits.
Given the opposition I encountered, it was a welcome but considerable surprise when in summer 2014 the “Glasgow Declaration”, which enshrines the principle of timely diagnosis, was issued. As of the time of writing, 203 organisations, 11613 individuals, 153 Policy Makers, and 84 MEPs, across 25 European countries have signed this declaration.
I mention this as the concerns you raised with my former employers related to my considerations and questions about Delirium Improvement work. I take delirium very seriously indeed: however my concerns about reductionist tools, whether termed “screening” or “detection” remain, as do my concerns about the ethics of consent. I also worry about potential unforeseen outcomes, which may be harmful, such as increased prescribing of antipsychotics such as haloperidol.
Last month, the Chief Medical Officer put forward her proposal for “Realistic Medicine”. This document prompted me to reflect on a culture which may struggle to accommodate questioning voices. The CMO’s report has been welcomed widely and was discussed at the overdiagnosis conference held in Stirling on the 27th February 2016. The afternoon panel was assembled to help us consider “What can policy makers do to help us?” This was the question I raised:
"Would the panel like to comment on the inevitable tension between
what the Scottish Government have chosen to call “Improvement work”
and over-medicalisation?
The reason that I focus on the term improvement is that it makes it
very easy for anyone who questions such work to be characterised
as a barrier to progress."
As a human, I am very far from perfect. I make mistakes, and find that I am always learning. However I am proud of Scotland’s fine tradition of a critical approach to science. I now feel that I have done my bit and have scars to show it. I have decided that when the time is right for me, and indeed my family, I will retire early from medicine.
If you were able to write your thoughts in response to this letter they would be most welcome.
I wish you all the very best.
Yours sincerely
Dr Peter J. Gordon
I received this reply from Dr Brian Robson on the 12th March 2016:
This was my letter of response (dated 18th March 2016):
Dear Dr Robson,
Your letter was carefully considered and thank you for taking the
time to write it. What I found disappointing was the lack of
acknowledgment of the harmful consequences for myself and my family
following your letter to my former employers. I have now come to
the conclusion that there may never be any such acknowledgement.
I hope that you might agree that I have contributed significantly
to the consideration of potential unforeseen consequences of
improvement science. I am particularly proud that the
Glasgow Declaration has been adopted.
I hope that Healthcare Improvement Scotland is moving in the
direction where it will consider questioning voices and treat
them respectfully. Scientific enquiry is after all based on
asking questions.
Yours sincerely,
Dr Peter J Gordon
Sir Harry Burns, former Chief Medical Officer for Scotland has
also been reflecting on improvement methodologies
[the full transcript of his evidence to the Scottish Parliament
can be read here]:
2015 Orlando IHI Conference as reported in the Media and including attendance of Dr Brian Robson and Professor Jason Leitch:
2016 Orlando IHI Conference as reported in the Media and including attendance of Dr Brian Robson and Professor Jason Leitch and CEO of Healthcare Improvement Scotland, Robbie Pearson:
The following is an unedited clip of the evidence given to the Scottish Parliament by Dr Brian Robson, Medical Director for Healthcare Improvement Scotland on the 31st January 2017:
The full session can be watched here:
The Official Report can be accessed here:
The meeting was held at the Golden Lion Hotel, Stirling:
Only last month the BMJ briefly interviewed Don Berwick:
Might we be facing the biggest change to healthcare in Scotland since the NHS began?
An NHS Board member commented after the Masterclass:
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):
In 2011 the Health Foundation, UK, produced this 
Both the Hasting Group and the Health Foundation are of the view that improvement science cannot separate itself from the ethical requirements of research:
Mary Midgley, now aged 95 years, is one of my favourite moral philosophers. In “
