#followthefellows

 

Footnote:

The two quotes about industrialisation and healthcare 
come from Intelligent Kindness by Ballat and Campling.

The considerations on conferences are included in a
this BMJ perspective

This post is creative, made in my own time and intended 
to ask questions in the spirit of the Freedom to Speak Up 
recommendations by Sir Robert Francis.

My forebear, Alexander MacCallum Scott grew up in Polmont, 
Scotland. He became an MP and was Private Secretary to 
Winston Churchill. I mention this as he turned down an OBE 
for his work connected with the war (WWI)

 

 

I am a worrier and I worry for Scotland’s Minister for Health

If this headline represents the approach of the Scottish Government, well I worry.

It is doctors, not pharmacists, that are licensed to prescribe and to withdraw any prescription.

The scientific community shares the conclusion that it easier to start medications than to stop them.

Scotland’s Minister for Health would seem to be asking pharmacists (unregulated by the General Medical Council) to provide:

“stricter checks on medication involving addictive medications”.

Meantime, my profession and our regulators would seem to avoid issues such as:

  • the continuing “education” of NHS doctors (those who are licensed to prescribe) by financially vested interests
  • that withdrawal from psychotropic medications may precipitate (for some) a “relapse” with symptoms worse than those for which medication was first prescribed.
  • that long-term exposure to psychotropic medication may have unforeseen consequences.

I am a worrier and I worry.

 

I have a question about Duty of Candour

This post considers the question that  Maree Todd, MSP, asked at this Parliamentary committee.

As an NHS employee of 25 years I will close this post with a similar question.

Shona Robison Paul Gray NHS Scotland (1)

Shona Robison Paul Gray NHS Scotland (2)

Shona Robison Paul Gray NHS Scotland (3)

Shona Robison Paul Gray NHS Scotland (4)

Shona Robison Paul Gray NHS Scotland (5)

The role of prescribed persons from omphalos

Shona Robison Paul Gray NHS Scotland (6)

Shona Robison Paul Gray NHS Scotland (7)

Shona Robison Paul Gray NHS Scotland (8)

My question:
Is there any reason why Government officials (elected or otherwise) should not be included in Duty of Candour legislation?

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

The role of prescribed persons

Health & Sport Committee, Scottish Parliament, 26 September 2017: NHS Governance:

Miles Briggs, MSP, asked this question of the Cabinet Secretary for Health and the Director General for NHS Scotland:

“I wondered if you could outline the role to the committee your role as a Prescribed Person within the Public Disclosure Act”

The role of prescribed persons from omphalos

Definition of Prescribed Persons:

“Prescribed persons, as prescribed under the Public Interest Disclosure Act 1998, are independent bodies or individuals that can be approached by whistleblowers, where an approach to their employers would not be appropriate.”

Full coverage of this parliamentary committee can be watched here [full minutes can also be accessed from this page]

Music credit: “Collapsing time” by Dexter Britain (under common license)

Patrick Geddes: insights into improving health and wellbeing

Sunday, 17th September 2017.

To the Chair of Healthcare Improvement Scotland.

Dear Dame Coia,
I do hope that you may appreciate that I write out of the shared wish to make health and social care better in Scotland.

I realise that my concerns about the mechanistic approach of improvement science (derived from a different culture) may not be shared. My perspective, I like to think, is taken from a wee shift of stance and perhaps reflects my interest and learning in a range of different subjects.

My voice matters no more than any other, and like any other I can be wrong.

I speak up not because I am “brave” or “right” but out of conscience when I find harm. The history of medicine has repeatedly revealed that harm can result from most well-intended interventions. This is why I keep arguing that scientific method needs philosophy, ethics and grounding in the culture of life.

I am of the view that Healthcare Improvement Scotland has time to re-orientate itself around these principles. I am also of the view that your organisation might do well to keep a healthy distance from the Institute for Healthcare Improvement (IHI), Boston, which has a business and cultural ethos that is quite different to NHS Scotland.

As to regulation. I do not personally want to see over-regulation. Such can have harmful consequences. However Healthcare Improvement Scotland needs to be independent of the Scottish Government otherwise any “scrutiny” will not be viewed as such by the public. Your organisation works closely alongside the Scottish Government with links that started and continue through several IHI fellows.

Please forgive me for setting my thoughts out in this way but I have been reading the work of Patrick Geddes who was considered a “social maverick”. I found that in reading about his work that it seemed to me he has lessons that could be relevant to the organisation that you Chair?

I want to thank you again for being so kind to me. I realise that I may come across as an oddity but I am actually every-day.

Kindest wishes Peter

If you have any thoughts on how Patrick Geddes might improve your organisation I would be delighted to hear.

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

By living we learn from omphalos

General practice is the best job in the world

In a previous post of earlier this summer I explained why I share Dr Margaret McCartney’s view that “General practice is the best job in the world”.

It is sad then to read this quote by the Chair of the Royal College of General Practioners Scotland, in one of today’s Sunday newspapers:
(24th September 2017)

For too long now the Scottish Government has failed to acknowledge how serious this matter is. We all realise that this is a most difficult problem, however I find  – when it comes to the responses of the ‘official Government spokesperson’ – that I am reminded of a sentence in Serious Sweet by A. L Kennedy:

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.