NHS Forth Valley: “Everyone matters”

NHS Scotland has stated its intention to involve its staff in developing services for the future:Everyone matters

I worked as a consultant for NHS Forth Valley for 13 years.

I resigned last year.

I received this feedback after my resignation.

Whilst I was an employee with NHS Forth Valley I raised concerns about the approach that my organisation took to  the care of our elderly.

In raising concerns I did my best to carefully follow the NHS Forth Valley ‘line-management’ pathway. I was never a “whistleblower”.

Yet I got nowhere.

For politely raising concerns, I was isolated within NHS Forth Valley, mischaracterised and sometimes left to feel like a pathological specimen.

Without any doubt, certain senior colleagues did their best to misrepresent my concerns.

Nobody from  “Everyone Matters” ever visited the community team that I was doctor for. It felt to me at the time that the elders of Clackmannanshire may have mattered less to my employers.

However here is what is said by NHS Forth Valley in this film:

 

What follows is communication with my employers from this time:

The “Conversation” was introduced as follows, stating that “we [NHS Forth Valley] want staff to feel that they are valued, appreciated [and] that they are fairly treated”:

everyone-matters-001

The meeting I arranged to go to was cancelled:

everyone-matters-002

NHS Forth Valley promised in “Everyone Matters” to visit all staff. Yet this was the response Clackmannanshire CMHTE had:

everyone-matters-003

So, on behalf of the team I was part, I wrote to our Service Manager:

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I also confirmed to all levels of NHS Forth Valley management, CEO, Medical Director, Associate Medical Director, General Manager and Service Manager:

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No manager replied.

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“appropriate” and “correct” concerns in NHS Scotland

After sending an update of my petition for a Sunshine Act to the Chief Executive Officer of NHS Forth Valley I received this reply. Whilst I was employed by NHS Forth Valley I raised concerns that HDL 62, the Scottish Government Circular sent to all Chief Executives in NHS Scotland, was not being followed.

Jane-Grant,-NHS-Forth-Valle

Two aspects of this letter from the Chief Executive Officer for NHS Forth Valley are worth further consideration:

(1) Transparency:

When I was an employee of NHS Forth Valley I was formally written to by Dr Rhona Morrison, Associate Medical Director. In this letter from the Associate Medical Director, which was both unsigned and undated, I was described as “unprofessional” and “offensive” for raising concerns that NHS Forth Valley was not following extant Scottish Government guidance on transparency regarding declarations of interest.

This letter confirmed that I would be “invited” to  an “informal” meeting by the Associate Medical Director’s immediate peers.

My experience of this “informal” meeting was that my character, reputation and probity were robustly questioned by the Medical Director, Dr Peter Murdoch, and the General Manager, Mrs Kathy O’Neill. This meeting was not minuted. This meeting left me distressed.

A number of weeks after this meeting I resigned from NHS Forth Valley. On my resignation I had this  feedback from those who I had cared for and worked with

(2) Freedom to Speak Up:

The Chief Executive Officer reinforces in her letter the “importance of a culture of openness and candour”. However, Jane Grant, the Chief Executive Officer for NHS Forth Valley then goes on to give qualifications: that any concerns raised should be “appropriate” and “correct”.

Whistleblowing in NHS Scotland from omphalos on Vimeo.

To conclude: it appears to me that there are still significant barriers to raising concerns in NHS Scotland. If you click on the image below you can read the full review by Sir Robert Francis. I have selected one particular recommendation which I think will require a different mindset to that suggested in the letter from Jane Grant, Chief Executive Officer for NHS Forth Valley:

Freedom05002

Update: November 2016:
On the 22 March 2016 the following petition was lodged by 
Pete Gregson with the Scottish Parliament: PE01605: Whistleblowing 
in the NHS - a safer way to report mismanagement and bullying.

On the 24th November 2016 the Public Petitions Committee considered 
all the submissions requested as part of evidence gathering. 
This included a letter from the Chief Executive Officer for 
NHS Forth Valley. This letter was commented on in particular 
by Angus MacDonald, MSP:

pe1605-nhs-scotland-whistlblowing-jane-grant-nhs-forth-valley

After raising a concern …

This report was published recently:Freedom05

I was particularly interested in the following excerpt:003

In his Report, Robert Francis gives:002

I was a Consultant in one NHS Board for 13 years until I resigned in the summer of 2014. I then applied for a post in another Board. I was the only candidate but was unsuccessful. The  same post has now been readvertised:    NHS Tayside job advertised in BMJ, 27 March 2015

Written submission by Dr Peter J Gordon to the Scottish Parliament on NHS Governance

Ethics, a doctor and his hairt-beat

I had several envelopes like this delivered through my letter-box.

Immediately recognisable, even before opening, I felt my heart (‘hairt’ in Scottish) beat much faster.

I shall try and explain why.

hairt-beat

This is another pattern that I wish to present.

Alexander McCall Smith, as an admirer of my films, wrote to me about our shared interest in patterns. He recommended this book “A pattern language” which has inspired some of my recent posts:

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The envelopes from NHS Forth Valley to my home address were always from Senior Managers and nearly always officially reminded me of “Good Medical Practice” as issued by the General Medical Council.

Here is an example from a letter from the Medical Director of NHS Forth Valley, Dr Peter Murdoch, to me dated 21st May 2014. It was part of a wider letter .  The letter made references to my “behaviour”. The letter summoned me to an “informal” meeting with the Medical Director and General Manager for NHS Forth Valley:

21-may-2014

When I was off sick, due to work stress, the Locum Consultant who covered for me, had the following experience:

annoyed & demanding

The Locum Consultant concluded that this demonstrated:

disregard

This was the Locum Consultant’s experience of the Medical Director, Dr Peter Murdoch. There was no action taken here.

three

I have many interests: interests which remind me how little I know. One of my interests is in ethics.

In my 13 years with NHS Forth Valley my ethical interests were in three broad areas.

In my time with NHS Forth Valley there was no forum to discuss ethics.

The FIRST was:Timely-can-we-do-better

It is fully accurate to say that not one of my consultant medical colleagues in NHS Forth Valley shared my advocacy for a timely approach to the diagnosis of dementia. Today it is the basis to the diagnosis of dementia across Europe

The SECOND was:
transparency1

I share the view of most ethicists and many in academia that education and research should be free of marketing. Free of any distortion created by financial incentives. I have petitioned for a Sunshine Act (or clause) for Scotland. I believe that a central, open-access register would be straightforward and not at all costly to set up.

The THIRD was:
consent

My view is that we need to consider more fully the importance of consent. Any intervention, be it a test, or a “tool”, or a treatment can have potential benefits and potential harms. These need to be shared as best as we can.

The Former Cabinet Minister for Health and Wellbeing, October 2014:

Neil-12-Oct-14

This week, the General Medical Council published:

CropperCapture[1]

This report confirmed that 54% of those doctors who committed suicide had been referred by their employers.

One response to this GMC investigation remarked:

“There is a parallel with whistleblowing here. The stress of the situation caused mental health difficulties and the person concerned is therefore dismissed as being unwell. Which comes first?”

My experience in raising ethical considerations, and thus trying to put patients first, was very difficult indeed.

I do hope other healthcare professionals, if they raise genuine concerns, will not face what I have faced for raising ethical considerations.

I see a pattern here. So did a senior NHS doctor who wrote to me recently:

“No wonder NHS doctors live in fear when threatened with the GMC for raising ethical concerns in the workplace.”

Social Media policies (NHS Scotland)

In the previous post I outlined my experience of seeking transparency in the Health Board in which I was employed.

I was asked by senior managers to reflect on my “behaviour” for seeking transparency. From the senior managers perspective I had not followed the social media policy issued by my Health Board. I was thus invited to meet with senior managers about this. It was eventually concluded that I had not breached any of my employers’ policies.

More than a year on I still feel the angst that this meeting caused me. A meeting where I had been summoned, was told I could “bring” a union representative, and where I ended up having to defend my professional character. This meeting was designated by my employers as an “informal meeting” (I assume in terms of employment law). The result is that any such “informal” meetings do not need to be recorded by the Health Board. My concern over such an arrangement is that it risks facilitating an imbalance of power that favours the employer. I am aware of health professionals who have resigned from health boards following such “informal meetings”.

In my particular case, the senior managers  focussed on one policy in particular. This was the Social Media policy of the Health Board. Actually to be factually correct, the NHS Board in which I was employed had two social media policies: one for “personal use” and another for “business use”. To me it felt like these policies were being used to stop me seeking transparency. Furthermore it was very much as if the Health Board’s priority was not the same as mine. I was trying to put patients first.

I have no expertise in developing policies for Health Boards. However, it is clear that there are significant differences between different Scottish Health Boards in terms of their approach to employees use of social media.

For example, employees of Healthcare Improvement Scotland are encouraged to use social media at work. Many staff, including senior staff have what would appear to be professional social media accounts. It is most surprising then that Healthcare Improvement Scotland have no social media policy for their staff. [FOI request: reply from Healthcare Improvement Scotland, dated 18 June 2014 “We do not hold a formal policy on employee use of social media”]. It has recently been clarified that Healthcare Improvement Scotland staff are guided by” a “code of conduct policy” and a “Social Media Guidance” document.

NHS Ayrshire and Arran has a social media policy (now 4 months beyond review date) that is publicly accessible. It is a clearly written 6 page policy that is strikingly different in approach to that of NHS Forth Valley

NHS Highland takes a similar approach to NHS Ayrshire and Arran and both would appear to be of the view that social media can bring benefits to continuing education of healthcare staff when used with careful guidance but not exhaustive restrictions.

Some thoughts;
Views on use of social media will naturally vary. Social media have the potential for both good and harm. Rev Eli Jenkins in “Under Milkwood” would likely agree.

“We are not wholly bad or good
Who live our lives under Milk Wood,
And Thou, I know, wilt be the first
To see our best side, not our worst.”

Some NHS Boards encourage use of social media as part of employment whilst other NHS Boards ban it outright. Some boards seem to go as far as monitoring personal use.

My view is that having no policy, such as Healthcare Improvement Scotland, risks loss of reasonable professional boundaries. The other problem is that if Healthcare Improvement Scotland wishes to use social media to support improvement work and education across Scotland, social media policies in some areas will prevent this.

To CONCLUDE:
I would like to see greater consistency across NHS Scotland in terms of extant policies in the use of social media.

Personally I would support the approach taken by NHS Ayrshire and Arran where there is a clear policy in place which allows the use of social media as long as this is consistent with good professional practice for all healthcare workers.

“Believe me, that is not the way to get things done”

This post is about medical education in NHS healthcare: this is called “Continuing Professional Development” (“CPD”).

In this post I will explore the current relationship between medical education with commerce.

The title of this post is taken from a quote by the current Director of Medical Education for NHS Forth Valley in a communication to me on this matter. The Director of Medical Education was scolding me for asking about transparency.

As I get older I find that I see more patterns.

How we “see” such patterns will differ for us all!  My previous post was about a pattern that I had noticed regarding ageing and memory: The parabolic pattern

The pattern in this post is not one of light. It is a dark pattern. A pattern not easily seen.

Before trying to shed some light on this pattern, I want you to know that I am a scientist (as well as an artist) who supports innovation, scientific realism and progression. This is why the Scottish physicist, and poet, James Clerk Maxwell has long been my guide.

The pattern of images that follow (where I will try to keep my words spare) represent my very real concern that science today (and not just “in the past”) has rather too readily become the pocket of industry.

It was Alexander McCall Smith who wrote to me recommending this book:

026

This week I faced a repeating pattern with this “educational” circular from my new NHS employers:

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Professor David Taylor is an Academic Pharmacist and so not registered with the General Medical Council. Prof Taylor has had significant input into the development of UK-wide guidelines on prescribing in mental health. He has been open about his significant financial conflicts of interest

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Professor David Taylor, paid by the Pharmaceutical Company Janssen, had earlier this year, given an “educational” talk to CPD teaching with my former employers:

008

I refused to go to this. Why? Well through much of the previous 6 months, my NHS e-mail in-box had received e-mails (not at my request) from the makers of Asenapine. Several “key opinion leaders” featured in these promotions, including Professor Alan Young (whom more of later) and Prof David Taylor. The following slide comes from this online powerpoint:002

The next in this slide demonstrates good practice as in it Professor David Taylor outlines his comprehensive, and well-spread, financial conflicts of interest:

003

Even though not a doctor, after I wrote to him, Prof David Taylor submitted his declarations to whopaysthisdoctor.com . We should commend this openness, as here Professor Taylor is a leading example of necessary transparency. It is important however that we consider that in “offering” “education”  Professor Taylor has significant financial under-writing. Professor Taylor has had a significant role in the development of UK-wide guidelines on prescribing in mental health.

Three years back: On the 17th May 2011 I wrote to NHS Forth Valley to say that I found that the link to the “Hospitality Register” was non-functioning. It took two years of polite inquiry for NHS Forth Valley to finally confirm that as an NHS Board it had NO register of interests for ALL staff. I was later to discover (through Freedom of Information requests) that this was a pattern spread across ALL twenty-two of NHS Boards in Scotland:

007

Eleven years back: in circular HDL(2003) 62 The Scottish Government stated that “Chief Executives are asked to establish a register of interest for ALL NHS employees and primary care contractors”: 

027

This year: The Director of Medical Education for NHS Forth Valley, said (25 February 2014) “Traditionally we have not registered the various meetings on the list as it was not required of us”. 

I will post some recent examples of sponsored education involving NHS Forth Valley employees. I do so without wishing to focus on any individual. It is important that what I present is understood only as part of a wider pattern.

It may be my error, but I cannot find any declarations made, by those involved in these sponsored educational meetings in any NHS Forth Valley Register. I wrote to the CHP General Manager of NHS Forth Valley on the 20th March 2014, where I included ALL the following examples of employees involved in what would appear to be sponsored meetings.

[the coloured highlights in the following promotions are mine (they are only part of my much wider effort to bring transparency). My endeavour is not to single any individual out.]

[I recognise that the sample I present (based on my much wider pinterest page) is simply the promotions for “education” which have come my way.]

023

024

022020

Patterns appear at all levels and not just “local”. For the governance of conflicts of interest, at a UK level, we follow the General Medical Council.  At annual appraisal and at five-yearly revalidation all doctors are asked to sign a probity section where each individual doctor confirms (or not) the following (this screenshot is from my recent Revalidation):

012

Before closing: the following example of an “educational” “CPD” event reveals a pattern that does not just involve those employed by the NHS such as charities and third-sector organisations:

021

The pattern is broad. I have no doubt. I recently debated with Professor Clive Ballard at a Royal College of Psychiatry Conference in Durham. I suggested to the organisers, well in advance of the conference, that all those involved might consider that they declared any financial interests in the programme. The organisers agreed that this was a good suggestion. As it turned out I was the only one to declare.

011

Professor Clive Ballard chose not to reveal in the RCPsych programme, or in his presentation, any potential financial conflicts of interest.

Another speaker at this RCPsych Conference was Professor Allan Young. Like Professor David Taylor he had given hearty support to the promotion of Asenapine (my NHS email in-box was frequent witness to all of the promotions).

At the RCPsych conference, where I was a fellow speaker, Professor Allan Young started out by mocking any need for transparency: “for those of you who watch panorama, I do not give my consent for you to film this”. Professor Allan Young then presented his “Conflict of Interest Statement”. He did not talk his interests through (unlike the rest of his presentation) and my image is thus blurry. Professor Allan Young presented his multiple financial interests in a blink of an eye but also fortunately in a camera click.

In my camera click, I resisted Professor Allan Young’s wishes. Light is important to all patterns.

015

Following my advocacy, NHS Forth Valley, would seem to be the only NHS Board, out of Scotland’s twenty-two NHS Boards to have an open access register for all employees.

From the evidence I have gathered it seems clear to me that Scottish Health Boards continue to fall very far short of complying with HDL 62. Yet this guidance delivered to ALL NHS Board Chief Executives is now 11 years old!

I am not legally minded. Senior Health Board Managers in Scotland are signing off annual Appraisals and five yearly Revalidation that staff are individually following their employers Guidance (including Scottish Government HDL 62 guidance: guidance issued to all Chief Executives in 2003) . The GMC are clear on what is expected regarding “probity”

It is for this reason that I submitted a petition to the Scottish Parliament suggesting that they might consider a Sunshine Act. Other countries have instituted such legislation. Like John Betjeman, I do not welcome bureaucracy, however a central, open access register, enshrined-in-law, should be neither difficult nor burdensome to implement.

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:

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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