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”.

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:

 

Improvement science: engineering 42 – ethics 0

In my last post I considered a “thought paper” entitled “The habits of an improver” and welcomed that critical thinking was considered a necessary habit.

The word “engineer” or “engineering” is to be found on 42 separate occasions in this Health Foundation thought paper.

The word “ethics” does not appear at all. Despite the fact that the introduction begins with this quote:

That ethics do not seem to be considered amongst the “habits” necessary for “improvement science” is concerning.

The last time I looked, I found this result using the Healthcare Improvement Scotland search facility:

The former Chief Executive for the Mental Welfare Commission for Scotland used to introduce me as “Bayesian Peter”. Bayesian is the name given to interpretations of probability and returns to Reverend Thomas Bayes original considerations of complexity.

Healthcare, like life, is complex. We are human and live in an ever changing world.

This is not all so simply “engineered”.

Ethics is integral to science.  I do not deserve the epithet “Bayesian Peter” – for whilst I am interested in ethics this does not mean that I am more ethical than you the reader.

However, I want to say as clearly as I can, and yes with passion, that without ethical considerations “improvement science” should linger in quotes.

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

 

‘The medical untouchables’

The following is a recent opinion piece by Dr Des Spence published in the British Journal of General Practice.

I had been lined up to do the media interviews on BBC Scotland in relation to petition PE1651. However, on the day, due to changed travel arrangements, I was not available. Dr Des Spence was interviewed instead and did a better job than I could have done.

As an NHS doctor and specialist, I fully support this petition (PE1651) which calls on the Scottish parliament “to urge the Scottish Government to take action to appropriately recognise and effectively support individuals affected and harmed by prescribed drug dependence and withdrawal.”

I have submitted my response.

I feel it would be helpful to hear the views of the Chief Medical Officer for Scotland and in particular, how this matter might be considered as part of Realistic Medicine.

Three recent posts by me demonstrate the scale of competing financial interests in medical education in the UK. If you have a moment, you should have a look. Perhaps you might then share the worry that I have about this matter:

I have previously raised my own petition, PE1493, which the Scottish Public has supported. This was a petition for a Sunshine Act for Scotland, to make it mandatory for all financial conflicts of interest to be declared by healthcare professionals and academics.

My petition, supported by the public, had no support from “Realistic Medicine”. The public has had no update from the Scottish Government on my petition in 18 months. My view is that this is a shocking failure of governance and would seem to demonstrate a lack of respect for democracy.

We ignore them at our peril

This recent Audit Scotland report was considered in the BMJ:

The Scotsman of the 1st August 2017 had this as the front-page story

The Scotsman Editor concluded: “The nurses surveyed are not scoring points or using the NHS as a political football. We ignore them at our peril”:

‘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?’