‘It was odd being dead’

This is a fictional film. It is about a teddy bear, Dr Hale Bopp and a day of two halves. In the morning Dr Hale Bopp goes exploring in the Scottish Borders and he comes across the ruin of the Monteath mausoleum on Gersit Law. The oak door of the mausoleum has been breached and one can get inside and be with Monteath and the two angels that guard this forgotten statesman. Above him the dome has beautiful window stars to the universe beyond.

Dr Hale Bopp is a well-travelled bear and is constantly exploring, enjoying and reflecting upon the world in which he lives. The guid doctor has come to the view that life is complex, diverse and sometimes “messy”. He leaves the Monteath mausoleum with paws that were muddy and heads for a different afternoon. An afternoon of Appraisal to ensure that as a fictional bear and doctor that he is providing Good Medical Practice.

So that was the day of two halves. This film is about that.

Dr Hale Bopp is getting on a bit now and is at the end of his fictional medical career. One day soon he will retire from being a doctor but meantime he is of the view that his wanderings, philosophical and creative between the arts and sciences, has been nothing but to the benefit of the patients that he cares for.

Important note:
None of the words used in this film are those of the filmmaker. They are “borrowed” from C.P. Snow’s “Corridors of Power”; Evelyn Waugh’s “Decline and Fall”; and Jessie Burton’s novel “The Muse”.

‘It was odd being dead’ from omphalos on Vimeo.

Source material:
(1) Physicians of the future: Renaissance of Polymaths? By B F Piko and W E Stempsey. Published in The Journal of the Royal Society for the Promotion of Health. December 2002, 122(4), pp. 233-237
(2) Time to rethink on appraisal and revalidation for older doctors. By Dr Jonathan D Sleath. Letter published in the BMJ, 30 December 2016, BMJ2016;355:i6749
(3) Career Focus: Appraising Appraisal. Published in the BMJ 21st November 1988, BMJ1988;317:S2-7170
(4) Revalidation: What you need to know. Summary advice for Regulators. General medical Council.
(5) The Good Medical Practice Framework for Appraisal and Revalidation. General medical Council.
(6) Taking Revalidation Forward: Sir Keith Pearson’s Review of Medical Revalidation. January 2017.
(7) GMC response to Sir Keith Pearson’s report on Taking Revalidation Forward.

Music credits (under common license, thank you Dexter Britain):

(1) Perfect I am not – by Dexter Britain
(2) Telling stories – by Dexter Britain


At the end of the corridor

 

Courage to care













 

Reductionism – truly, madly, deeply

On Friday the 25th of November 2016 I gave a talk for the Scottish Philosophy and Psychiatry Special Interest Group.

My subject was “Improvement Science”.

The following is based on the slides and the four short films that I presented.

My talk was entitled:
001-improvement-science The meeting was held at the Golden Lion Hotel, Stirling:golden-lion-hotel-stirling-25-nov-2016-1golden-lion-hotel-stirling-25-nov-2016-2I started the day off:
002-improvement-scienceI gave these declarations:
003-improvement-science
I explained to the audience that like Dr Rev I M Jolly I can be overly pessimistic:


005-improvement-scienceThe dictionary definition of ‘Improvement’:
006-improvement-scienceThe dictionary definition of ‘Science’:
007-improvement-scienceMy concern is any pre-determinism to science:
008-improvement-scienceThe Health Foundation have considered Improvement Science: this is from 2011:
009-improvement-scienceMany different terms are used including “QI” for “Quality Improvement”:
010-improvement-scienceThis is where improvement science began, in Boston, Massachusetts:
011-improvement-scienceThe Founder of the Institute for Healthcare Improvement (IHI) was Don Berwick:
013-improvement-scienceThe first description of this movement in Britain goes back to 1992 by Dr Godlee:
014-improvement-scienceFifteen years later, Dr Godlee, Editor of the BMJ, said this:
015-improvement-scienceOnly last month the BMJ briefly interviewed Don Berwick:
016-improvement-scienceIHI describes improvement science as being based on a “simple, effective tool”:
017-improvement-scienceThis tool was developed from the work of an American engineer, W. A. Deming:
018-improvement-scienceThe “Model for Improvement” Tool [TM] is described by IHI as a “simple, yet powerful tool”:
019-improvement-scienceThe current President and CEO of IHI is Derek Feeley:
024-improvement-scienceUp until 2013, Derek Feeley was Chief Executive [Director General] for NHS Scotland:
021-improvement-scienceIn April 2013 Derek Feeley resigned from NHS Scotland:
022-improvement-science22nd February 2015 it was reported: “The astonishing and largely hidden influence of an American private healthcare giant at the heart of Scotland’s NHS”:
023-improvement-scienceDr Brian Robson, Executive Clinical Director for Healthcare Improvement Scotland [HIS] is an “IHI Fellow”:
dr-brian-robsonProfessor Jason Leitch, National Clinical Director for the Scottish Government is an “IHI Fellow”:
026-improvement-scienceMight we be facing the biggest change to healthcare in Scotland since the NHS began?nhs-scotland-1947 Improvement science is moving quickly and widely across Scotland:
027-improvement-scienceThis “Masterclass 1” for Board members cost  £146,837:
028-improvement-scienceAn NHS Board member commented after the Masterclass:
029-improvement-scienceHealthcare Improvement Scotland is one organisation with a very wide remit over NHS Scotland and it works closely with the Scottish Government:
031-improvement-scienceNine cohorts of Safety Fellows and National Improvers have so far been trained following IHI methodology:
032-improvement-scienceI was reminded of the current enthusiasm for improvement science when the Convener of a recent Scottish Parliament Committee meeting said of targets (another approach enthusiastically taken by NHS Scotland):033-improvement-scienceWhat is the place of ethics in Improvement Science?
034-improvement-scienceIn 2007 the Hastings Centre, USA, looked into this in some depth:
035-improvement-scienceThe Hastings Centre argue that Improvement science cannot ignore ethics:
036-improvement-scienceIn 2011 the Health Foundation, UK, produced this “Evidence Scan”:improvement-science-2011a2The Health Foundation commented that “improvement science is just emerging”:
037-improvement-science
The Evidence Scan found a “real paucity of evidence about the field of improvement science”:
038-improvement-scienceI would also suggest that there is a real paucity of philosophy about the field of improvement science:
039-improvement-scienceThe Health Foundation did find papers on the conceptual nature of Improvement Science but concluded that:
040-improvement-scienceMary Midgley is a philosopher now aged 95 years who is widely respected for her ethical considerations:
041-improvement-scienceChapter 7 of her book “Heart and Mind: The Varieties of Moral Experience” begins:
042-improvement-scienceMary Midgley is concerned about the overuse of reductionist tests in medicine stating that:
043-improvement-science
This film is about the potential consequences of inappropriate reductionism:

Leon Eisenberg has written many papers about this subject. He argues that reductionism should not be “abandoned” but that we must keep sight of where such an approach is scientifically useful and also where it is inappropriate:
045-improvement-scienceIn the Hastings Report, Margaret O’Kane asks:
046-improvement-scienceIn my view the answer to this question is YES. I am hopeful that the National Improvers recruited to NHS Scotland would agree:
047-improvement-scienceAs an NHS doctor I have seen unintentional harm brought about by National improvement work in Scotland. This related to a “Screening Tool” that was introduced across Scotland as part of this work. I found that the unintended consequences of the use of the following tool included implications for patients’ autonomy and the risk of over treatment:
048-improvement-scienceBoth the Hasting Group and the Health Foundation are of the view that improvement science cannot separate itself from the ethical requirements of research:
049-improvement-scienceThis article published in February 2016 argues that individual “rights transcend all aspects of Improvement science”
050-improvement-scienceThe following is a verbatim representation of a conversation held by National Improvers working in NHS Scotland:
051-improvement-scienceIn November 2016 Professor Joshi, also a psychiatrist outlined his concerns about reductionism in a published letter to the BMJ:
052-improvement-science
In this short film the mechanical language of healthcare improvers is considered:

Professor John Bruce was a Moral Philosopher in Edinburgh University in the 18th century. He built this temple, the “Temple of Decision”, in the grounds of his home by Falkland Palace so that he could consider his thesis:
054-improvement-scienceProfessor John Bruce did not succeed in his endeavour. His Temple however stood for many years:
055-improvement-scienceBut it eventually collapsed and his endeavour to “reduce the science of morals to the same certainty that attends other sciences” collapsed with it.
057-improvement-scienceAny search of Healthcare Improvement Scotland for “ethics” finds this result:
056-improvement-science
This film is about more up-to-date buildings – the enthusiasm for which was based on improvement science: The Red Road flats in Glasgow:

 

                         Post-script:

The following is an edited clip of the evidence given to the Scottish Parliament by Healthcare Improvement Scotland (HIS) on the 31st January 2017:

The full session can be watched here

The Official Report can be accessed here

Gavin Francis: ‘incorrigibly plural’

Volume 11, Number 4 of the Scottish Review of Books carried my interest throughout. The interview with Gavin Francis was one of a number of highlights.

At a recent medical conference in Stirling, Gavin Francis introduced himself to Peter and Sian. This made our day.

“Empire Antarctica” by Gavin Francis rightly won the 2013, Scottish Book of the Year. It has wowed all who have read it. Here is an omphpatyp of some of what wowed me.

Gavin Francis in SRB 2016 (9) Gavin Francis in SRBsrb-review-of-serious-sweet-3Gavin Francis (1) Gavin Francis (2) Gavin Francis (3) Gavin Francis (4) Gavin Francis (5) Gavin Francis (6) Gavin Francis (7) Gavin Francis (8) Gavin Francis (9) Gavin Francis (10) Gavin Francis (11) Gavin Francis (12) Gavin Francis (13) Gavin Francis (14) Gavin Francis (15) Gavin Francis (16) Gavin Francis (17) Gavin Francis (18) Gavin Francis (19) Gavin Francis (20) Gavin Francis (21) Gavin Francis (22) Gavin Francis (23) Gavin Francis (24) Gavin Francis (25) Gavin Francis (26) Gavin Francis (27) Gavin Francis (28) Gavin Francis (29) Gavin Francis (30) Gavin Francis (31) Gavin Francis (32) Gavin Francis (33) Gavin Francis (34) Gavin Francis (35) Gavin Francis (36) Gavin Francis (37) Gavin Francis (38) Gavin Francis (39) Gavin Francis (40) Gavin Francis (41) Gavin Francis (42) Gavin Francis (43) Gavin Francis (44) Gavin Francis (45) Gavin Francis (46) Gavin Francis (47) Gavin Francis (48) Gavin Francis (49) Gavin Francis (50) Gavin Francis (51) Gavin Francis (52) Gavin Francis (53) Gavin Francis (54) Gavin Francis (55) Gavin Francis (56) Gavin Francis (57) Gavin Francis (58) Gavin Francis (59) Gavin Francis (60) Gavin Francis (61) Gavin Francis (62) Gavin Francis (63) Gavin Francis (64) Gavin Francis (65) Gavin Francis (66) Gavin Francis (67) Gavin Francis (68) Gavin Francis (69) Gavin Francis (70) Gavin Francis (71) Gavin Francis (72) Gavin Francis (73) Gavin Francis (74) Gavin Francis (75) Gavin Francis (76) Gavin Francis (77) Gavin Francis (78) Gavin Francis (79) Gavin Francis (80) Gavin Francis (81) Gavin Francis (82) Gavin Francis (83) Gavin Francis (84) Gavin Francis (85) Gavin Francis (86) Gavin Francis (87) Gavin Francis (88) Gavin Francis (89) Gavin Francis (90) Gavin Francis (91) Gavin Francis (92) Gavin Francis (93) Gavin Francis (94) Gavin Francis (95) Gavin Francis (96) Gavin Francis (97) Gavin Francis (98) Gavin Francis (99) Gavin Francis (100) Gavin Francis (101) Gavin Francis (102) Gavin Francis (103) Gavin Francis (104) Gavin Francis (105) Gavin Francis (106) Gavin Francis (107) Gavin Francis (108) Gavin Francis (109) Gavin Francis (110) Gavin Francis (111) Gavin Francis (112) Gavin Francis (113) Gavin Francis (114) Gavin Francis (115)

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

The Temple of Decision

When I chatted with Onesiphorus yesterday in the “Temple of Decision” he asked me if ethics had perhaps been overlooked by rather too much of “modern science”?

Yesterday I chatted with Onesiphorus from omphalos on Vimeo.

Fernfield

Dr Eric Dow, General Practitioner for Bridge of Allan, took his life on the last day of January 1947.

He died by cyanide fumes in his home and surgery, Fernfield. A dreadful scene, and real life reminiscent of the opening of “Love in the time of cholera”

Dr Eric Dow, at time of death, was bankrupt and his wife had left him.

[21st May 1947.] from omphalos on Vimeo.

My uncle, John Scott, used to talk fondly of Dr Eric Dow. The images in this film are of my uncle at about the age that he first started attending Dr Dow. [the Margaret mentioned in the diary is my mother, Margaret Scott]

The old doctors of Bridge of Allan liked colour. Dr Paterson, his colourful orchids, and Dr Dow his primary qualia. But sadly all colour went from Dr Dow’s life. So terribly sad for a man that could not bear to ask his patients for payment.

Just over two months after Dr Eric Dow’s suicide, on the 21st May 1947, the NHS in Scotland began. Free at the point of delivery. There for all. And the NHS would have been there for Dr Eric Dow

What you need to know

1 in 7 Scots are on an antidepressant. Some Scottish academics have argued that this is “appropriate prescribing” for “recurrent” and “chronic” conditions.

Antipsychotic prescribing, in all age-groups, has risen year-on-year since the Scottish Government started measuring such prescribing. Last week NHS Scotland was struggling to source one such antipsychotic, namely haloperidol. Intramuscular haloperidol may not be available for 14 months. I do not know if this is a supply or demand issue, however this medication is being most extensively used in NHS hospitals in Scotland despite generally being prescribed “off-label”.

With this in mind I present a pattern that emerged from reading the current British Medical Journal alongside my weekend newspapers.  Here is what they both suggested that “you need to know”:

All the other children are on it, 21 Nov 2015, Guardian Andrew Lansley, Roche 20 Nov 2013 Disney and McDonald's staple, 21 Nov 2015, Guardian Generation meds, 21 Nov 2015, Guardian Long term effects on oor children, Guardian, 21 Nov 2015 Now you are my friend, Nov 21, 2015, Guardian Pharmacological mission creep, BMJ, 20 Nov 2015 What you need to know, Bmj, 21 Nov 2015

Update, 5th October 2016. The following was published on the 
front page of the Scotsman newspaper: 

"Mental health prescriptions hit ten-year high"

prescriptions-for-mental-health-drugs-10-year-high-nhs-scotland-2016-a prescriptions-for-mental-health-drugs-10-year-high-nhs-scotland-2016-b

The figures are from the Scottish Government and can be accessed here.