Quality Improvement and Ethics

In a recent Healthcare Improvement Scotland blog, Karen Ritchie asked: “Do we need perfect evidence when making decisions?”

I posted this response on the 26th September 2017:

Dear Karen,
What a carefully considered and thoughtful blog. Thank you for sharing.

I do so agree with this approach: “our underpinning philosophy is that we need to ensure that decisions are evidence informed, rather than evidence based”.

You ask in your blog “Do we need perfect evidence when making decisions?”.

I am of the view that there is no such a thing as perfect evidence, however I do think that science requires philosophy and ethics. That is why I welcome your inclusion of philosophy in the above organisational approach to evidence.

However I am concerned, as I have explained to Dame Denise Coia, Robbie Pearson and Dr Brian Robson, that there is no consideration – or even mention of – ethics as necessary for science by Healthcare Improvement Scotland.

Ethics do not appear in the matrix/diagram that you include as representative of  the “many parts but one purpose” of Healthcare Improvement Scotland:

Some Quality Improvement (QI) proponents have suggested that to address the “perceived slowness” of science – and to “improve” science – we take shortcuts with ethics. I am afraid I could not disagree more. Especially when “pilots” are being scaled-up nationally as part of “good practice”.

I submitted this response on ethics and improvement science (QI) to the BMJ a few months ago.

If you have any thoughts on this subject it would be great if you could post them here.

Kindest wishes,

Dr Peter J Gordon
NHS Scotland
(writing in a personal capacity and in my own time)

A film that considers how we may go about improving health and wellbeing:

By living we learn from omphalos

Frailty – nothing about us without us

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

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

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

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

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


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


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

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

This is the context in which the term is used:

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


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


Back in April 2016 Bergman and Karunananthan, McMaster University were of this view:

“Thus far, research on frailty has been heavily based on establishing associations between various definitions of frailty and poor health outcomes. A limited number of studies on the perspectives of older persons offer a very different characterization of frailty and the potential impact of labelling.

While several expert meetings over the past decade have called for a unified operational definition of frailty, varied definitions continue to abound, suggesting that researchers are still not ready to close the debate on what defines frailty. The integration of findings from the diverse perspectives, including those of the older persons themselves, is essential when considering the potential for a meaningful clinical tool.

Furthermore, studies examining the contribution of frailty in improving prediction of adverse health outcomes are needed in order to assess the potential utility of frailty as a prognostic tool. Despite the enthusiasm of clinicians and researchers to utilize frailty as a prognostic instrument, frailty will only be relevant if it can be empirically demonstrated either that frailty is reversible, or that its adverse outcomes are amenable to intervention.”


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

We are far more than our labels from omphalos

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

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

Delirium screening (some years later)

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:

 

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

 

We are far more than our labels

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

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

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

We are far more than our labels from omphalos.

Professional confusion

Like all those involved in healthcare I take delirium very seriously. I share in the collective determination to improve our approach, understanding and care of those experiencing this serious condition.

To improve it is important that critical thinking is given room.

This post is about the validated 4AT Rapid Assessment Test for Delirium:

In a recent medical educational lecture organised by Healthcare Improvement Scotland, the 4AT was described as a “screening” test.

One of the authors of the 4AT Rapid Assessment Test described it recently as a “screening tool”:

There seems to be a lack of consistency in the stated purpose of this test/tool. Has this test/tool been validated for screening or has it been validated for assessment? This is an important scientific and ethical matter in terms of how this test/tool may be both validated and implemented