Delirium screening (some years later)

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:

 

The habits of an improver

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.



 

If NHS Scotland has been genetically-modified with QI

It is most welcome to hear from Philippa Whitford about positive outcomes of NHS Scotland’s collaborative approach to quality improvement and the learning that this might provide for the rest of the UK. I share Philippa Whitford’s concerns about the potential consequences of competitive systems such as occurs more in NHS England with providers, commissioners and contracts and the inevitable fragmentation that this brings. The integrated approach taken in Scotland along with the engagement of patients and frontline practitioners is indeed something to be most positive about.

However, NHS Scotland’s approach to Quality Improvement is based on what is known as “improvement science”. This is a relatively new approach to science introduced from the USA and based on methodologies from the engineering and airline industries. The Health Foundation, in its ‘Evidence Scan’ found a “real paucity of evidence about the field of improvement science” . The Health Foundation found papers on the conceptual nature of Improvement Science but concluded that: “none of these could be said to be seminal pieces of research acting as building blocks for the field as a whole”.

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.”

Scotland has two key National Improvement initiatives for older people in acute hospital care. One is for Delirium and the other is for Frailty.

The QI initiative on Delirium was reliant upon “screening tools” that were effectively made mandatory for all those aged 65 years and over admitted to hospital. Healthcare Improvement Scotland measured the “compliance” with the use of these “screening tools” across Scotland. On the wards I was finding that these tools were not infrequently being interpreted as diagnostic and that older people were sometimes considered as lacking in “capacity” on this basis. I was also concerned that this approach could lead to greater use of antipsychotic medication.

The QI initiative on Frailty is currently being implemented across NHS Scotland. This is despite the fact that there is no internationally accepted clinical definition for Frailty. More “screening tools” have been developed by Healthcare Improvement Scotland and “Frailty Hubs” are now being set up in most NHS Boards. It may be worth noting recent high-level disagreement amongst British Geriatricians about the validity of the “Frailty Industry” as one senior Geriatrician described it.

The experience of these national initiatives perhaps highlights the limitations of approaches which work best in mechanical settings. The same success cannot be guaranteed when applied to more complex presentations such as delirium and frailty.

It has recently been stated that “ethical approval is less burdensome” for QI. However I suggest that we must be wary of taking shortcuts that may result in potential harm as well as potential good. This is why ethics and philosophy have an established role in science.

Another risk is that if science is pre-determined as “improvement”, this may limit the acceptance of critical thinking.

Philippa Whitford concludes that in NHS Scotland “Quality improvement has made its way into the DNA of frontline staff”. I share the view that Quality Improvement has much to offer. However, if NHS Scotland has been genetically-modified with QI let us hope that the wider considerations necessary for science are included in the base-code.

Dr Peter J Gordon
Psychiatrist for Older Adults
NHS Scotland

 

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."

 

 

 

 

Why I left social media

I enjoyed social media.

I left social media on the 31st December 2014.

I did so as I no longer felt safe to be Peter.

Here I refer explicitly to my experience in asking questions of improvement work in NHS Scotland.

Capture2 Capture3 Capture4Karen Goudie - improve conversations

Re-labelling (and a bit)

I read this book recently [below].

I am approaching fifty. With age-related sight changes I find that my arms need to be longer!. So if I have misread “Sixty and a bit”  please do forgive me:

Now we are sixty and a bit

This book reminded my of a protocol issued by an NHS Board in Scotland:

4 april 2014 all over 65 MUST

As a doctor who tries his best to follow evidence-based medicine, I argued against this approach. I found that neither this NHS Board nor indeed NHS Scotland shared my concerns:

Brian Robson

With the recent publication of the Care Standards for Older People, the Chair of Healthcare Improvement Scotland confirmed:

Letter4b

It would appear to me that this “screening instrument” has been re-labelled by Healthcare Improvement Scotland

The 4AT was developed and promoted as:

010Tools

Recently the 4AT has been re-labelled as:

4AT validated UK Gov

The authors  4AT describe its key features:

(1) “brevity” (takes less than 2 minutes”), and

(2) that “no special training is required”

I should confirm that I use rating scales with patients as part of my daily professional life.

However I would never start out with a rating scale. To me, that would seem most disrespectful.

Rating scales can add to wider medical understanding. This is why, despite my awareness of any intrinsic shortcomings, that I continue to feel that they can be helpful.

The 4AT has recently been re-branded an “assessment test”. The 4AT was promoted for several years, with the support of Healthcare Improvement Scotland, as a “screening tool”. The validation studies, still underway, describe the 4AT as a “screening” tool.

Given that there has been no change to the test itself, I would suggest that this is re-labelling (and a  bit.)

Freedom to speak up

Freedom05I am very grateful to the Scottish Government for replying to me on behalf of Jamie Hepburn, MSP, Minister for Sport, Health Improvement and Mental Health. Below you will find the Scottish Government reply and my response to it.

In NHS Scotland I have not found freedom to speak up.

David Berry, Scottish Government

Dear Peter
I refer to your email correspondence of 11 January to the Minister for Sport, Health Improvement and Mental Health. I have been asked to respond to you.

Your main concerns in your email are about the ethics and relative risks and benefits of cognitive screening for older people, including those with dementia. I know that this is an on-going concern and note that you have previously raised this issue with Healthcare Improvement Scotland.

The implication of your email appears to be that you are concerned that there may be what is effectively a national programme of screening for people with cognitive impairment (including dementia) in acute, and that older people do not have the benefit of information or the option to opt out of such screening. I hope I can reassure you that no national programme of that kind has been initiated. HIS have for some time had a focus on improving service response on delirium and I understand you have information on that from HIS.

As you may know, we have a three year strategy to improve dementia care in hospitals, including a 10 point action plan to drive up standards of care. Our approach includes development of clear standards, ensuring strong senior and clinical leadership, getting right staff in the right place and giving healthcare staff the support and training they need to provide safe, effective and person centred care to every patient, every time. Appropriate identification and assessment of dementia is a part of this overall approach. This work is supported by the networks of Dementia Nurse Consultants and Dementia Champions.

The Focus on Dementia in Acute improvement programme, launched in July 2014, has a specific focus on leadership, workforce development, working as equal partners with families and minimising and responding to stress and distress. The aim is to improve the experience, safety and coordination of people with dementia, their families/carers and staff.  Progress to date includes the identification of executive and operational leads within NHS Boards and Boards are currently reporting on progress to date on implementing the 10 Care Actions.

In addition, you know that Healthcare Improvement Scotland’s inspections of care for older people in acute hospitals include a specific focus on dementia and cognitive impairment – and this continues.  You can access their most recent overview report on the HIS website.

With regard to your point about raising concerns and the implication that you feel that recording your concerns has been discouraged at times, I would reiterate that we welcome open debate and discussions around these and other matters and we would welcome the opportunity to get the value of your perspective directly if you should choose at any time to take up our offer to get involved in the implementation of dementia policy.

We do recognise your passion, interest and expertise in these areas and hope you will reconsider the offer.

With best wishes

Scottish Government 
Directorate for Health and Social Care Integration
Mental Health and Protection of Rights Division

Reply to David Berry

Monday 1st April 2015

To the Scottish Government
Directorate for Health and Social Care Integration
Mental Health and Protection of Rights Division
St Andrew’s House, Edinburgh

Many thanks for replying on behalf of the Minister for Sport, Health Improvement and Mental Health after I had written following the debate on Mental Health that the Minister led in the Scottish Parliament on the 6th January 2015. I attended parliament that day to observe the debate. I am writing to acknowledge your reply which I received on the 30th March 2015.

You state that it appears to you that I am “concerned that there may be what is effectively a national programme of screening for people with cognitive impairment (including dementia) in acute care, and that older people do not have the benefit of information or the option to opt out of such screening.” I am writing to confirm this is indeed my concern as an NHS clinician in Scotland who has followed closely developments in this area. It is clear that the screening for cognitive impairment in NHS Scotland fulfils all the criteria of the World Health Organisation definition of screening.

You say “I hope I can reassure you that no national programme of that kind has been initiated.” I am afraid that I am not reassured. Following inspections Healthcare Improvement Scotland ask that all NHS Boards “cognitively screen” all patients 65 and over admitted to acute hospitals. It is also the case that Healthcare Improvement Scotland measure NHS Board “compliance” with “cognitive screening”. Given the dual role that Healthcare Improvement Scotland have (for scrutiny and improvement), it is my view that, not only do patients have no choice whether to be screened or not, but hospital managers and every employee in each NHS Board are disempowered to question such an approach.

Regarding my “implication” “that recording my concerns has been discouraged at times”, the truth is that after raising concerns I felt that I had no other option but to resign from my NHS post of 13 years. This followed a letter from the Executive Clinical Director of Healthcare Improvement Scotland to the Medical Director of the NHS Board I worked for. This letter went much further than “discouragement”. This letter made all sorts of defamatory statements about my professionalism and character, none of which I accept. This has been my experience of raising concerns about patient safety and wellbeing in NHS Scotland. I am glad then to appreciate that the Cabinet Minister for Health, Wellbeing and Sport has indicated that Scotland will be considering the “Freedom to Speak Up” review by Robert Francis. I am very grateful to hear that the Scottish Government “welcome open debate and discussions around these and other matters”. Unfortunately damage has been done to my career in NHS Scotland for raising such matters.

I am grateful that the Scottish Government “would welcome the opportunity to get the value of my perspective.” Currently I do not have time for such a commitment but as I confirmed recently to you I am happy to help, if I can, on specific matters.

In summary, in NHS Scotland we currently find:

  • Cognitive screening (as defined by the World Health Organisation)
  • that the potential harms of such an approach are not being discussed
  • that the individual’s right to consent has been marginalised

I realise and appreciate that the Scottish Government, along with many other organisations, may continue to disagree with me on the above. However I wanted to put my view on record. As this is a matter of public interest I will share your reply and my response on my website Hole Ousia.

I want to thank you again for your reply.

Kind wishes
Peter signature

Dr Peter J Gordon

Cc: Jamie Hepburn, Minister for Sport, Health Improvement and Mental Health
Cc: Shona Robison, Cabinet Minister for Health, Wellbeing and Sport
Cc: Geoff Huggins, Acting Director for Health and Social Care Integration
Cc: Penny Curtis, Acting Head of the Scottish Government’s Mental Health and Protection of Rights Division

Dr Neil Houston and Dr Brian Robson

Karen Goudie & Dr Wolff 4 Dec 2014

Why I have decided to leave Social Media

I have been asked by a few friends why I decided to leave Social Media.

For sometime I had a twitter account @PeterDLROW but I closed this account on the last day of 2014. The-Lumen---on-twitter

There are several reasons why I have decided to leave social media behind however the primary one is that as an NHS employee in Scotland I do not feel safe in using social media.

CropperCapture[4]

The personal consequences for me in raising ethical considerations on twitter to try and help improve care for our most elderly have been most significant. The organisation that appears to have struggled most with my ethical questioning has been Healthcare Improvement Scotland. There are individuals who have not shared my views who have associations with Healthcare Improvement Scotland and may have contributed to this response.

ggg

I miss twitter for sharing with others my many interests which include film-making, the arts, architecture, medical humanities and most things outdoors.

How-drs-use-twitter-7-Dec-2

 

 

Apology from Healthcare Improvement Scotland

On the 30th January 2015 an apology was received from the Deputy Chief Executive and Director of Scrutiny & Assurance for Healthcare Improvement Scotland.

Here is my reply of thanks:

Untitled-1

To: Robbie Pearson
Deputy Chief Executive
Director of Scrutiny & Assurance
Healthcare Improvement Scotland
Gyle Square
1 South Gyle Crescent
Edinburgh, EH12 9EB

Dear Mr Pearson,
Re: Letter to Mrs Muirhead, 29 January 2015
I wanted to write to thank you for copying me into your response letter to Mrs Muirhead dated 29th January 2015. I note that Healthcare Improvement Scottland (HIS) have upheld the complaint. I want to thank you for  apologising for “this incident.” It does make a difference to hear this. I am relieved to hear that Healthcare Improvement Scotland “are reviewing our social media guidance to strengthen understanding, and to ensure that it is consistently complied with across the organisation.”

I hope you will understand, as discussed with Richard Norris recently in Stirling, that I do not wish to spend time going over past communications from employees of Healthcare Improvement Scotland. This just reminds me of the distress caused to me and indeed the significant consequences for my career. I want to say that I found Mr Norris most kind and professional and that our conversation allowed us to reflect more widely on ways forward in terms of the place of critical voices in improvement work.

Mrs Muirhead is a friend of mine. Like me, Mrs Muirhead is of the view that scientific understanding and progress in care benefits from questioning. It is disappointing that we have experienced mischaracterisation and marginalisation from your organisation as a result, particularly when HIS widely promotes its “inclusive engagement”.

I understand the behaviour of Ms Goudie as being based on her enthusiasm for improving care. My experience has been that there is a persistent stream of social media postings by both individuals associated with HIS and the organisation itself. These obviously focus on the successes of the work done by the organisation but in my view rarely cover the downsides. When I have responded to HIS tweets to raise any concerns about potential harms to patients I have had replies such as “this is for interested clinicians only”. I later found out that a letter had also been sent by HIS to my employers.

In summary, as said to Richard Norris, I am sorry if anybody has been upset by my writings on delirium, science and ethics. I would urge HIS as an organisation to consider how it “engages” with questioning voices. The responses of certain HIS staff to any questioning have been instrumental in breaking my career as a respected and highly valued Consultant in NHS Scotland. I have also decided, as a result of my experiences with HIS, that I no longer feel safe to use social media as an employee of NHS Scotland. I do however maintain a blog and will be posting my reply to you on this. I would respectfully suggest that any revised social media guidance within HIS should include a section on expecting responses which will not always be in full agreement with the original post.

I want to thank you again for looking into this matter and for the apology on behalf of Healthcare Improvement Scotland.

Yours sincerely,
Dr Peter J. Gordon

 

Karen Goudie & Dr Wolff 4 Dec 2014

Dr Neil Houston and Dr Brian Robson