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.



 

‘Have you ever noticed that certain days are injury days?’

I was filming in our garden today as the sky was beautiful, the spring bulbs colourful, and the green as fresh as can be.

By chance, an NHS Forth Valley lorry passed in front of the camera. My heart missed a beat. The lorry was advertising the Minor Injuries Unit.

Three years have nearly passed since I resigned from NHS Forth Valley. When an employee with NHS Forth Valley I championed an ethical and evidenced-based approach to the diagnosis of dementia and for transparency in terms of financial interests of staff.

As a consequence of this, I myself left NHS Forth Valley with injuries. Not physical injuries but just as real.

Looking back, I am proud to have tried my wee best to put ethics at the very heart of my practice. To stand up for those who may not be as able or who may feel frightened to stand up for themselves.

The title of this film comes from the novel “Vinegar Girl” by Anne Tyler

The music is by Steven Lindsay – “Exit Music”

Courage to care













 

A letter that the Scottish Parliament felt unable to publish

With careful thought, and backed with full supporting evidence,  I sent the following letter of the 2nd February 2016 to support my petition for a Sunshine Act for Scotland.

The Senior Clerk of the Parliamentary Committee was of the view that this letter did not comply with the Scottish Parliament’s policy on the treatment of written evidence. I was therefore asked to redact significant sections of the letter.

After considerable communications to and fro, I replied as per this e-mail of the 3rd March 2016:

I fully respect the right of the Scottish Parliament to determine 
what it publishes.

I feel very strongly that my letter without the highlighted text 
merely reiterates what I have already said, and fails to provide 
the evidence that I have repeatedly been asked for.

So my position is that I do not wish to amend my letter of the 
1st February on PE1493.

My petition has since been closed. I therefore have decided to publish my letter to the Scottish Parliament in full along with supporting evidence. I have had professional advice that what is contained in this letter is not defamatory as it is based on veritas and has full supporting evidence:

Dear Mr McMahon
Petition PE01493: A Sunshine Act for Scotland

I realise that the Committee must receive a great amount of correspondence however I hope that the committee might agree that what follows is extremely important when considering PE1493.

Since I last wrote to the committee I attended, for accredited continuing medical education, the Royal College of Psychiatrists in Scotland Winter Meeting held on the 29th January 2016. It is this that has compelled me to write this update as it demonstrates beyond doubt that lack of transparency around financial conflicts of interest remains a serious issue. An issue with implications for both patient safety and healthcare budgets. It also demonstrates that Government action is the only way to address this.

The full powerpoint presentations of this Accredited meeting for 
Continuing Professional Development can be accessed here - but only
for members of the Royal College of Psychiatrists. 

I am a member of the Royal College of Psychiatrists and I am of the 
view, as a scientist, that these lectures should be available to all 
and not just to members.

One speaker highlighted the increase in prescribing costs in her health board area which was due to the high prescribing rate of a new antipsychotic injection, palperidone depot (XEPLION®). The next speaker demonstrated both the inferior effectiveness of this drug when compared to existing (far cheaper) depot medications and the perception amongst Scottish psychiatrists that it was more effective. Below you will see the flyer sent to mental health professionals in Scotland when this drug was launched:

002 Financial Conflicts of Interest, Scottish Psychiatry

I have highlighted one of the paid speakers, Dr Mark Taylor, because he also spoke at this week’s meeting where he reminded us that he was Chair of SIGN Guideline 131: The Management of Schizophrenia, which was published in March 2013.

At this week’s meeting Dr Taylor presented his declarations as follows: “Fees/hospitality: Lundbeck; Janssen, Otsuka; Roche; Sunovion”.

Dr Taylor commented on these declarations with the statement that “you are either abstinent or promiscuous when it comes to industry. Well you can see which side I am on”. Audience laughter followed.

The general question that arises is whether an influential professional such as a Chair of National Guidelines might earn more from the pharmaceutical industry than in his or her role as a healthcare professional? At present it is impossible for anyone to establish the scale of competing financial interests. To remind the committee the following avenues are not illuminating:

1. Royal College of Psychiatrists. This week’s meeting did not appear on the college database. In any case this database is neither searchable nor does it include specific details of payments and dates

2. NHS Boards. The committee has already established that, across Scotland, HDL62 is not being followed.

3. SIGN guidelines. The committee is aware of significant governance failings particularly in comparison with NICE which includes details of financial sums paid and associated dates.

4. Discussions with Senior Managers in NHS Scotland relating to the General Medical Council’s expected level of transparency has brought forth written responses describing my interest as “highly unusual” and “offensive and unprofessional”

5. The forthcoming ABPI register allows any professional to opt out of inclusion.

It is also worth repeating that the information provided to the public consultation on this petition failed to highlight most of the issues identified in points 1 to 5 above.

In terms of cost both to the public purse and the individual patient the Government’s stated wish for a “robust, transparent and proportionate” response would be fulfilled if a single, searchable, open register of financial conflicts of interest that has a statutory basis were to be introduced

NHS Forth Valley – unable to offer reassurance

There were a number of reasons why I left NHS Forth Valley. One of those reasons was a concern that patients, often elderly, were being harmed through the misdiagnosis of dementia.

Shortly after I left I wrote to senior management seeking the following reassurance:

  • that any patients that have been harmed are acknowledged and where appropriate supported in coming to terms with their mis-diagnosis,
  • that practice in NHS Forth Valley now follows Scottish, UK and International guidelines on Dementia.
  • that NHS Forth Valley has, as an organisation, reflected on this matter

Following a reminder I received a reply suggesting that examining comparative data would be helpful but would take some time:

Tracey Gillies 23-Feb-2015

Following another reminder I have now received what I take to be the final position of NHS Forth Valley on the matter. My understanding of this is that NHS Forth Valley cannot provide the reassurance that I was seeking:

Tracey Gillies 16-Mar-2016

Tracey Gillies 16-Mar-2016 Glasgow Declaration

I have sent the following letter to NHS Forth Valley which reiterates my ongoing concerns:

"I remain concerned about the potential for harm relating to the 
over-diagnosis of dementia. I understand that you are not in a 
position to reassure me on this in terms of patients referred to 
NHS Forth Valley. I would welcome it if this “could potentially be 
explored in the future.” 

I note and understand your general comments about reflection. 
The book “Intelligent Kindness”  considers the importance of reflection 
not just at an individual level but also at an organisational one.

I feel that it is now time to conclude our correspondence on this 
matter."

If anybody would wish to see the full context of the letters please contact me.

 

 

 

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:

everyone-matters-0041

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

everyone-matters-005

No manager replied.

everyone-matters-0071

Senior doctors want to speak out for their patients and improve services

The following comes from a report in the BMA Scotland News dated the 6th June 2015 which arrived with my copy of the BMJ:

Consultant Survey 01

Consultant Survey 09a

The following conclusions are based on interviews followed by a survey of 1058 Consultants working in NHS Scotland :

Consultant Survey 02

Consultant Survey 03

Consultant Survey 04

Consultant Survey 05  Consultant Survey 08   Consultant Survey 09d

“Unprofessional”

My view is that we all have conflicts of interest.

Science however cannot ignore financial conflicts of interest.

We can find no record

The above was a recent statement by the Scottish Government in response to my petition for a Sunshine Act.

This statement by the Scottish Government reminded me of why so many of my healthcare colleagues would choose not to express any concern about lack of transparency

My experience in asking, as fairly and politely as I can, about the governance of: Good Medical Practice” (General Medical Council); NHS Scotland (HDL62) and Royal College of Psychiatrists (CR148) has met with calls of being “unprofessional”.

Annexe A, GMCHDL-62CR148 cover

It was disappointing how many colleagues used the term “unprofessional” when asked about governance of the declarations of financial conflicts of interest.

“Trust is generally being eroded”

Last week I watched with much interest the 52nd Maudsley debate. The motion debated was: “This house believes that the use of long term psychiatric medications is causing more harm than good”.

52nd Maudsley debate

The Maudsley debate was covered in a head-to-head BMJ article.

Long-term-use-of-psychiatri

Given that I have petitioned the Scottish Government for a Sunshine Act I was interested in what this Maudsley Debate might say about our approach to transparency of financial conflicts of interest:

Transparency: hold the applause (British Psychiatry) from omphalos on Vimeo.

This particular aspect of the 52nd Maudsley Debate reminded me of a series of letters published in the BMJ a decade ago. It is interesting to consider what has, and what hasn’t changed, in the intervening ten years. The letters were in response to the following 2003 editorial:

No more free lunches (2003)

In a letter of response Dr K S Madhaven argued that “the market has us all in its grip”:

001 Madhaven

Whereas Professor Simon Wessely, in his letter of response, was of a view that “It is time we all grew up”:

001 Simon Wessely

Simon Wessely

Professor Wessely began his letter of 2003:

002 Simon Wessely

and continued:

005 Simon Wessely

It is interesting to reflect on changes that have occurred in the United Kingdom since 2003:

  1. Continuing Professional Development (CPD) has become a requirement of GMC Revalidation:
  2. the pharmaceutical industry now has to follow the ABPI code and healthcare professionals no longer receive branded products such as pens 
  3. “Sandwich lunches” (sponsored Continuing Medical Education – CME) remain core to continuing education. In NHS Scotland, at least two NHS Boards rely entirely on industry sponsorship to support the education of their staff
  4. It remains the case that, at any educational conference, neither the audience nor the public have any idea of how much speakers may have received from the pharmaceutical industry or commercial enterprises in the past three years. The proposed 2016 ABPI register is unlikely to help as any individual can opt out of disclosing payments received. Going by the experience in America, in some cases considerable sums may be routinely involved.

Professor Wessely, in 2003, was concerned about over-regulation, a concern that many of us, including myself have some sympathy with:

006-simon-wessely

Watching the Maudsley debate, in 2015, I was reminded of Professor Wessely’s 2003 fear that “trust [was] gradually being eroded” . It would seem to me that the audience of 2015 would agree with Professor Wessely that this may indeed have happened. However such erosion of trust would seem to be for exactly the opposite reason given by Professor Wessely. It would appear to be the lack of transparency rather than an “Orwellian world of prohibitions” that has contributed to this.

007-simon-wessely

Following the 52nd Maudsley Debate I have written to Professor Wessely, as President of the Royal College of Psychiatrists, to ask if the College might support a single, central, open, searchable database where all payments to healthcare workers, academics and researchers must be disclosed.