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


Improvement goggles

What follows are three slides taken from a talk given by Dr Brian Robson, Executive Clinical Director, Healthcare Improvement Scotland and IHI Fellow, given at the Edinburgh International Conference of Medicine in September 2016:


I most certainly agree that culture is important. But what kind of culture? Is it healthy just to follow one? In this case the Institute of Healthcare Improvement, Boston.

The “Improvement Goggles”, it would seem, come as part of the “toolkit”?

As a doctor who is passionate about improving care it matters to me that I follow science that does not risk being pre-determined.

It is important that there is philosophical depth to the approaches that we take to healthcare.

I understand the overwhelmingly good intentions of all those involved in “improvement science”, however I would suggest that we should carefully consider the potential benefits and harms of a most determined “one organisation” approach that starts and ends with reductionist and mechanical algorithms.



The mechanical language of Health Improvement

The following words appear frequently in the language of Health Improvement:

ToolsTraffic Lights Dashboards toolkits

It is my view that Healthcare Improvement needs to consider the potential consequences of the widespread use of such mechanical language.

“Pathological” language: on what basis and decided by who?

This post is about our use of language.

Recently I made a film called “language is the dwelling place of being” about the poet and artist Ian Hamilton Finlay who is recognised as one of Scotland’s most internationally renowned poet’s.

Language is the dwelling place of Being from omphalos on Vimeo.

In his letters, Ian Hamilton Finlay describes, without fondness, several periods in hospital. Ian Hamilton Finlay’s earlier periods of psychiatric hospitalisation were described in “Selections” by his son Alec.

In middle to late life, but not right up to the end, Ian Hamilton Finlay lived his life in exile, in his kingdom of “Little Sparta”


Hamilton Finlay was an artist and wordsmith. His ideas were conceptualised in the form that he termed “concrete poetry” which he defined as: “a model of order, even if set in a place full of doubt”

Hamilton Finlay’s creative ability with language developed into a whole new form of language as an art form in itself. Such ideas, explored with other poets and artists were developed in Poor.Old.Tired.Horse. a journal published by Finlay.


I have often wondered what my colleagues in psychiatry made of Ian Hamilton Finlay. My suspicion is that they might have designated his language as “pathological” I say this as I was taught in my medical training that “language disorder” can be a cardinal feature of mental illness. Indeed in psychotic illnesses, one form of this “disorder” is described as “loosening of associations” and another form, the making of new words “neologisms”. I once heard an eminent professor and his wife, who had met R D Laing at a conference, say “well we think he was mad, he used to Clang a lot”. To Clang is another form of “pathology” and is defined as: “a mode of speech characterized by association of words based upon sound rather than concepts”

Hamilton Finlay used to describe his garden “not as a retreat but an attack”. I now wonder if he was attacking the “pathological” view of psychiatry and/or medical reductionism. If this is the case, I for one, welcome Hamilton Finlay’s attack.


A year or two back, I attended an NHS meeting that had a mixture of senior medical staff and senior managers. I struggled at this meeting to follow some of the language of medical and managerial discourse. I gave up trying to understand and thus simply recorded (as much as I could bear) the language used in the meeting:

“Sign-off the work done to date and migrate into RAG report”

“We need to use the same mapping & gapping analysis”

“It is all about generic input with cognizance of those factors that tie-in to the Work Plan or GAP analysis that we have agreed in the Improvement Team. I am happy to populate that.

Below is a short extract of text from Julian Barnes novel “Talking it over”odd-word

I would argue that this sort of language could also be considered “pathological” but those at the meeting would surely resist any label of “mental illness”.

My own pet-hates are mechanical metaphors which are now everywhere in “healthcare improvement work”: toolboxes, dashboards, kits, route maps etc. These words imply that we can be treated as machines.

I am wondering if the language of my profession is changing to become more detached.