Professional confusion

Like all those involved in healthcare I take delirium very seriously. I share in the collective determination to improve our approach, understanding and care of those experiencing this serious condition.

To improve it is important that critical thinking is given room.

This post is about the validated 4AT Rapid Assessment Test for Delirium:

In a recent medical educational lecture organised by Healthcare Improvement Scotland, the 4AT was described as a “screening” test.

One of the authors of the 4AT Rapid Assessment Test described it recently as a “screening tool”:

There seems to be a lack of consistency in the stated purpose of this test/tool. Has this test/tool been validated for screening or has it been validated for assessment? This is an important scientific and ethical matter in terms of how this test/tool may be both validated and implemented

 

 

Improvement goggles

What follows are three slides taken from a talk given by Dr Brian Robson, Executive Clinical Director, Healthcare Improvement Scotland and IHI Fellow, given at the Edinburgh International Conference of Medicine in September 2016:



 

I most certainly agree that culture is important. But what kind of culture? Is it healthy just to follow one? In this case the Institute of Healthcare Improvement, Boston.

The “Improvement Goggles”, it would seem, come as part of the “toolkit”?

As a doctor who is passionate about improving care it matters to me that I follow science that does not risk being pre-determined.

It is important that there is philosophical depth to the approaches that we take to healthcare.

I understand the overwhelmingly good intentions of all those involved in “improvement science”, however I would suggest that we should carefully consider the potential benefits and harms of a most determined “one organisation” approach that starts and ends with reductionist and mechanical algorithms.

 

 

Improvement science and consent: a failure of NHS Governance

I am an employee of NHS Lothian and have been ‘sign posted’ to the “New Capacity and Consent intranet page: important information for all staff.”

This is a screenshot taken on Friday 2nd June 2017:

The Capacity and Consent intranet page begins by reminding all NHS Lothian staff of the ‘Obtaining Consent’ Policy (2014):

The NHS Lothian ‘Obtaining Consent’ Policy (2014) informs staff that “failure to secure consent may constitute assault under common law in Scotland”.

All NHS Lothian staff are also reminded that “acquiescence when a patient does not know what the intervention entails, or is unaware that he or she can refuse, is not consent”.

Two years ago I wrote about national improvement work undertaken by Healthcare Improvement Scotland for older people in hospital in NHS Scotland and my concern that “compliance” had replaced consent.

Given my experience that the guidance from my employers (NHS Lothian) on consent and the explicit requirements of “compliance” mandated by Healthcare Improvement Scotland seem to go in opposite directions, I wrote seeking further guidance. I have had this reply from Healthcare Improvement Scotland.

In conclusion: I would suggest that a failure of NHS Governance in Scotland has led to a confusion about the rights of older people to give consent.

Decline and Fall



Nelson Place

Christina Paterson Danks who died of a broken hairt. Stirling, 10th May 1889.

To root in these very specific places

T S Eliot rooted poems about ideas in very specific places. He was very interested in yew trees:


The following film is on the Fortingall Yew.

Time passes. Listen.

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

To learn from and cherish

In the Scottish Herald on the 1st October 2016:

the-elderly-should-be-valued-and-respected-1-oct-2016-2

reminded us all that:

the-elderly-should-be-valued-and-respected-1-oct-2016-1

and suggested that we:

the-elderly-should-be-valued-and-respected-1-oct-2016-3

Rebecca McQuillan  worried, as I do, that:

the-elderly-should-be-valued-and-respected-1-oct-2016-4

Our treasured NHS and those who educate us might consider:

the-elderly-should-be-valued-and-respected-1-oct-2016-5

As an NHS doctor for those who I value and respect I worry about the promulgation of a reductive language of loss. I often hear our older generation described as a “challenge” and that complex, and unique situations have been reduced to a single word, such as “frailty”, “capacity” and “delirium”. Language evolved over tens of millennia to avoid such simplification.

Rebecca McQuillan closes beautifully:

the-elderly-should-be-valued-and-respected-1-oct-2016-6

I shared this post with the British Medical Journal. There was 
an interesting reaction on social media to my post and to those made 
by others by the original columnist:

"some truly bizarre responses to what was a mainstream common 
on acute frailty"

"I am thinking of changing my BMJ column from 'acute perspective' 
to 'everybody must get Stoned'"