‘Dementia overload?’

Sunday 23rd July 2017.

Dementia overload“: how the Scotland on Sunday titled their front cover

My view is that there is no shortage of “awareness” of dementia in Scotland!

The Editor of the Scotland on Sunday outlined a related concern:

The Scottish Government continues to struggle to understand the difference between “timely diagnosis” and “early diagnosis”. The response to “delayed diagnosis” should not be one which encourages earlier and earlier diagnosis which is increasingly likely to be wrong. Another worry is that if this top-down approach continues we will struggle to support those most in need.

A few closing thoughts:

(1) We need to hear the thoughts and views of Scotland’s older generation

(2) An approach based on human rights must include recognition of biological ageing

(3) “Realistic Medicine” has the potential to encourage a more healthy approach to caring

 

NHS Scotland – it should not take courage to care

On the 17th July 2017, the Scottish Government announced an “Enhanced service for NHS Scotland staff”

The Scottish Government began this announcement stating that:

“Staff in Scotland’s health service will continue to benefit from external support should they have any concerns about patient safety or malpractice”

From 1 August, the NHS Scotland Confidential Alert Line will be re-branded as the Whistleblowing Alert and Advice Services for NHS Scotland (AALS).

This was reported in the Scotsman of the 17th July 2017:

The Scottish Government confirm the enhancements that have been made:

Some personal thoughts:

I have never been a “whistleblower”. I have however raised concerns relating to patient wellbeing and safety in NHS Scotland, and in particular for our older generation. I share the view of Sir Robert Francis that “freedom to speak up” is a better and more encompassing term.

My experience of trying my best to put patients first in NHS Scotland has left me with an interest in this matter and I have followed developments over several years now.

My concern is that this “enhanced service” has taken little account of the evidence presented to the Scottish Parliament from a wide range of individuals and professional bodies, including Sir Robert Francis.

Lifeboat NHS from omphalos on Vimeo.

The “enhanced” service will still not be able to independently deal with any concerns raised and so can offer only to “pass concerns on to the appropriate Health Board or scrutiny body for further investigation”. In practice this will be either to the NHS Board the employee works with or to Healthcare Improvement Scotland which is neither independent of Government nor of any of Scotland’s 23 other NHS Boards.

It worries me that senior Scottish Government officials continue to use words such as “grievance” or “pursuers” when talking about those who are trying to put patients first in NHS Scotland. It seems that the Scottish Government are as quick as any of us may be to label individuals.  This “expanded service” has been re-labelled in a positive way when the opposite has happened to many of us who have raised concerns about patient care.

In summary:

I feel that this is a disappointing outcome given the determination of the Scottish Parliament, and the Health and Sport Committee in particular, to ensure that there is freedom in NHS Scotland to speak up and put patients first.

I would suggest that despite this “enhanced service” that it is still going to take a great deal of courage to care in NHS Scotland:

Courage to care from omphalos on Vimeo.

Unrealistic Medicine

This BMJ Editorial of the 30th June 2017 has had a number of responses:

The Editorial was a consideration of Academy of Medical Sciences report ‘Enhancing the use of scientific evidence to judge the potential harms and benefits of medicines’.

The President of the Academy of Medical Sciences and the Chair of the Report, Professor Sir John Tooke, has submitted this reply:

It is most welcome for Professor Sir John Tooke to set out his further thoughts but I found that what he said did not reassure me about the future of science and so submitted this response:

Unrealistic Medicine
Written by Peter, 15 July 2017
Submitted as BMJ Rapid Response.

The further thoughts of Professor Sir John Tooke, Chair of the Academy of Medical Sciences report ‘Enhancing the use of scientific evidence to judge the potential harms and benefits of medicines’ are most welcome.

Professor Sir John Tooke does not reassure me that an era of unrealistic medicine and the business of science will change anytime soon. Meantime the NHS is struggling across the United Kingdom and this may be in part due to the promotion of medical interventions whose evidence base lacks the objectivity that we all surely seek.

I would suggest that most of us fully understand the “reminder” from the Academy of Medical Sciences that potential conflicts of interest can come in all forms and not just financial. But like the public I share the view that we should start with potential financial conflicts of interest as evidence has determined that exposure to industry promotional activity can lead to doctors recommending worse treatments for patients  Godlee and Freer remind us that we expect this from our elected politicians and in other areas of public life.

The voluntary ABPI Register is not working. Its database is only a little more than half complete. This really does challenge the “E” in EBM.

The pharmaceutical Industry has, over the preceding year, increased payments to healthcare workers for “promotional activities” from £109 million to £116.5 million.  This is a major part of Industry budget. Furthermore, we do not know how much may be being paid by device makers and other forms of industry for promotion of their products.

It is welcome, but somewhat “after the bell has rung”, that Professor Sir John Tooke confirms that the Academy of Medical Sciences intends to “review” its approach to public transparency. But one wonders how many “houses” do we need to “get in order” to address this issue effectively? I find myself worrying that it could be like a game of Monopoly that never seems to end.

The most effective and cheapest way to address this matter would be Sunshine legislation. This would avoid multiple, overlapping and generally unsearchable databases of interests.

I would suggest that the reputation of science is at stake as is the balance between benefits and harms for us all

Roy Porter, who sadly died prematurely was considered as one of the United Kingdom’s finest historians of science and health. He ends “Madness: A Brief History “ with a teasing question: ‘Is folly jingling its bells again?’

 

We need a Renaissance of Generalists

I aspire to be a generalist.

We live between the microscope and the telescope. I am of the view that the art and science of being a doctor requires such necessary width of focus.

Bettina Piko argued in 2002 that we need a “renaissance of polymaths”. It saddens me to consider that the western world, in the time since, has encouraged, and supported, the greater development of specialisms.

This post is about General Practice. My wife Sian has been a GP for more than 25 years.

This week the Royal College of General Practitioners has accused the Scottish Government of “longstanding under funding” of General Practice.

1 in 4 GP practices have a vacancy in Scotland.

I found myself part of a conversation about the current and future state of General Practice on the Stephen Jardine programme, Radio Scotland, on the 14th July 2017:

Honesty and openness: ‘not an edited official tale’

When Nicola Surgeon became First Minister of Scotland she said:

“I intend that we will be an open and accessible Government” (26 November 2014)

On the Front page of the Times of  the 7th July 2017 was a report by the Scottish Health Correspondent, Helen Puttick that outlined the considerable efforts, made behind closed doors, of senior civil servants working for the Scottish Government to “tone down” this Report by Audit Scotland.



Further pressure was made to influence the Audit Scotland Report:

In considering the findings of this FOI inquiry, the Editor of the Times said that “the public deserve to know the true story on NHS funding and not an edited official tale”

The Civil Service Code of Conduct for Scotland outlines these core values:

These core values are what the public should expect from its civil servants if they are to fulfil the intention of Scotland’s First Minister.

 


freedom to speak

The Director General for NHS Scotland:

  Peter's experience of the Director General for NHS Scotland

 

The Clinical Director of Healthcare Improvement Scotland:

     Peter's experience of the Clinical Director of HIS

 

The Director of Health and Social Care Integration:

Peter's experience of Director of Health & Social Care Integration

 

In my determination to put patients first I have been treated poorly.

These highly paid officials seem to be beyond accountability:

[I have always openly acknowledged that my view is no more important than any other. I am always careful to be clear in what cannot be said with any certainty. I am fully aware of my weaknesses.  I absolutely refute any charge that I am “vexatious”. I do not hold grievances. What matters to me is truth and fairness. I have found that the same cannot always be said of those in genuine positions of power]:

 

It can take courage to care. To resist the threats to your career and the misnaming:

 

Such abuse of power is not new:

 

You are invited to join me for this protest:

 

Stifling distortions












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Has your experience of comunicating with high public office in Scotland been difficult?

If so, might you join me for a demonstration at the Martyrs monument, Calton Hill, Edinburgh on the evening of the 21st August 2017?

My idea is to recreate a gathering around the Martyrs Monument on Calton Hill which stands next to, but taller than, St Andrew’s House (the seat of power).

The foundation stone of the Martyrs Monument was laid by Joseph Hume, MP, on  the 21st of August 1844, when 3,000 people gathered for the occasion.

This year, on the anniversary of this foundation, a total solar eclipse will take place.


Prof Walter Hume in the Scottish Review, 21st September 2015:

“For some time I have been copied into email exchanges concerning how complaints against public bodies are dealt with. I have no personal stake in any of the specific sources of concern (which include patient care in the NHS and responses by Police Scotland, the Scottish Government and the Crown Office and Procurator Fiscal Service (COPFS) to requests for formal investigations). I do, however, have a long-standing interest in issues of public accountability and am familiar with the various techniques used by bureaucratic organisations to avoid responsibility when things go wrong: these include silence, delay, evasion, buck-passing and attempts to discredit complainants.”

Prof Humes went on to say:

“Those who hold high office in public bodies are very adept at defending their own interests. They may claim to support openness and transparency but those principles are not always translated into practice. Bureaucratic Scotland often falls short of the democratic ideals which are said to underpin civic life”

 

To seek balance in the appreciation of where expertise rests: my submission on PE01651

Submission on PE01651: Prescribed drug dependence and withdrawal

Made by Dr Peter J Gordon

Date of submission: 3rd June 2017.

Submission made in a personal capacity.

I am writing in support of this petition. I am an NHS Consultant Psychiatrist who has worked in this specialty in Scotland for almost 25 years now. My wife has worked as a General Practitioner in Scotland over the same period. I have an interest in ethics, human rights and the medical humanities generally. One of the areas I have taken much interest in is informed consent.

I would argue that this backdrop may mean that I can add some thoughts and reflections that might help the Committee in the consideration of this particular petition.

I should make it clear that as an NHS psychiatrist I do prescribe antidepressants and other psychotropic medications. I try to do so following the best available evidence as considered as relevant or not to my professional understanding of each unique patient and their life circumstances.

I wish to keep this summary short as I am aware that the Committee receives a great deal of evidence. So I offer a few points of evidence that I would be willing at a future date to expand upon if that were felt to be helpful:

• Antidepressant prescribing In Scotland (ISD figures) has been rising year-on-year in Scotland for at least the last ten years (this is also true of all other prescribed psychotropic medications). It is estimated that 1 in 7 Scots are now taking antidepressants and many of these in the long-term.

• At a recent Parliamentary Cross Party Meeting on Mental Health and older adults an invited speaker stated that: “depression is under-recognised across all age groups” and that “maintenance treatment has a good risk-benefit ratio.”

• A key opinion leader and Government advisor has previously argued that prescribing of antidepressants in Scotland is “conservative” and “appropriate”.

• Many of the key opinion leaders “educating” doctors prescribing antidepressants in Scotland appear to have significant financial interests with the makers of these medications. Across the UK, £340 million was paid by the pharmaceutical industry in the last recorded year to healthcare workers and academics for such “promotional activities”.

• “Informed Consent” will not be possible if the information that doctors base prescribing on follows such promotion rather than independent, and more objective, continuing medical education. This issue is now at the fore of the Mesh Inquiry.

A few questions that need to be considered:

  • When patients are prescribed antidepressants are they informed that as many as 1 in 2 will be taking antidepressants long-term?
  • Are patients informed that there may be a significant risk of pharmacological dependence on antidepressants?
  • Do patients know that their experience of antidepressants may be considered less valid than the experts (who may have been paid by the pharmaceutical industry) who educate other doctors (who may be unaware of this potential financial bias)?

Summary:

My view is that antidepressants are over-prescribed in Scotland.

My view is that patients have not been properly informed of benefits and risks.

My view is that appropriate prescribing has not been realised due to a number of factors: the lack of access to psychological therapies or other meaningful supports; the wide promotion of antidepressants where marketing is routinely conflated with education; and a culture of increasing medicalisation generally.

I would suggest that this petition might be considered in light of the Chief Medical Officer’s Realistic Medicine campaign. It is time for balance to be re-established between “medical paternalism” and the valued, vital and real-world experiences of patients who are taking medications like antidepressants. I am particularly disappointed in my own College, the Royal College of Psychiatrists for not making greater effort to facilitate such balance. Without such, I fear more harm will result from inappropriate and costly prescribing in NHS Scotland.

Finally, due to widespread “off-label” promotion of antidepressants in Scotland, patients may experience withdrawal syndromes which can be most severe and precipitate mental states far more serious than the mental state for which they may have originally been prescribed.

I would urge the committee to consider this petition most carefully and to seek balance in their appreciation of where expertise rests.

‘Informed consent is a fundamental principle underlying all healthcare’

A recent Independent Review for NHS Scotland stated that: “Informed consent is a fundamental principle underlying all healthcare”

The Cabinet Secretary for Health and Sport, Shona Robison stated to the Scottish Parliament (17 March 2017): “Informed consent and shared decision making are expected prior to any procedure being carried out.”

On the 20th April 2017, I wrote to Healthcare Improvement Scotland 
about Patient consent in NHS Scotland:

I have just completed my annual Appraisal which is a General Medical Council requirement as part of 5 yearly Revalidation. As part of this I was informed by my Appraiser that I must comply with all the LearnPro modules which I have now done.

The following screenshot comes from the NHS Lothian mandatory LearnPro module on Capacity and Consent:

I apologise as the text is small, so I have reproduced verbatim what it states to me as an NHS Lothian employee:

“Consent is both a legal requirement and an ethical principle and requires to be obtained by healthcare professionals, prior to the start of any examination, treatment, therapy or episode of care.”

“In Scotland, everyone over the age of 16 is an adult. The law assumes that adults can make their own decisions and can sign legal documents, such as consent to medical treatment (in some circumstances this also can apply to children under the age of 16) provided they have the capacity. This means that they are able to understand what is involved in the proposed treatment, retain the information, be able to weigh up the information needed to make the decision and then communicate that decision. Treatment might be delivered in a hospital, clinic or in someone’s home.”

In years past I have written about consent for older adults in hospital in NHS Scotland:

Do we care enough about consent?

‘OPAC tools are working’

I am writing to Healthcare Improvement Scotland as I find myself confused.

Do I follow the mandatory requirements of my employers on consent? Or do I follow the National Improvement requirements of OPAC-HIS where consent is not required for assessments such as the 4AT assessment test? (formerly called “4AT screening tool”)

I know, from the re-drafted Care Standards, that Healthcare Improvement Scotland take consent very seriously.

I should state that I am writing in my own capacity and in my own time.

12 May 2017 - I sent this update to Healthcare Improvement Scotland:

Forgive me for this further correspondence but I felt that I should update you on the learning that I received as part of my attendance for Continuing Medical Education (CME) yesterday.

This CME event was for the Royal College of Psychiatrists in Scotland – Faculty of Old Age Psychiatry and was held in Falkirk.

At this event the Chair of Old Age Psychiatry for the Royal College of Psychiatry was giving a talk and when the time came for questions I asked about the wide use of haloperidol in older adults in hospitals in NHS Scotland. Dr Thompsell replied “evidence has found that Haloperidol actually worsens the outcome of delirium”.

Another lecturer at this meeting, who was giving a talk on her area of expertise: anti-psychotics and older adults, was Dr Suzanne Reeve. She replied: “Haloperidol does increase mortality in older people compared with other antipsychotics. That message has been out for a while but has not really got across.”

The next talk was entitled “Successes of Old Age Psychiatry Liaison team” and one of the slides shown had the headline “Compliance with 4AT”. The impressive “compliance” figures then followed. The dictionary definition of compliance is “the act of yielding”.

My concern here is for patient harm and indeed increased patient mortality. National Improvement work undertaken by HIS has been instrumental in increasing “compliance” with tools such as the 4AT and it is clear that no consent is deemed necessary. I have argued that this is not ethical as these tools are often the beginning of “pathways” and “protocols” that may result in the administration of haloperidol.

I am genuinely worried that National Improvement work undertaken by Healthcare Improvement Scotland has not properly considered ethics, available evidence and the potential for unforeseen consequences. You will understand that I am also nervous about writing this letter given the consequences for me when I first “spoke up” three years ago:

I would very much value your advice. I am not sure that I can work in a profession if it loses sight of Hippocrates and “first do no harm”.

This is the response from Healthcare Improvement Scotland,
dated 17th May 2017:

“Thank you for your letter of the 20th April and your letter of 12th May, in which you raise the interesting issue of taking consent in relation to cognitive screening.

I understand from staff involved in the inspections of older people’s care in hospital that taking of written consent prior to initial assessment for frailty is not routinely undertaken. Assessment at the point of admission, or where a change in a patient’s cognitive presentation is giving cause for concern, can alert staff to possible increased risk and enables planning of care for the patient. In these circumstances staff adopt a proportionate approach such as asking, for example, if they may ask some questions.

For absolute clarity though, as an employee of NHS Lothian, the requirements set out in the Board’s policies and mandatory training are those that you should follow.”