At the end of the corridor


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:
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”:
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:
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:
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:
This film is about more up-to-date buildings – the enthusiasm for which was based on improvement science: The Red Road flats in Glasgow:



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

“Meet you at the statue in an hour”

A poem for my wife Sian. Written 10th November 2016:

Thank you:
For meeting me (we are part of serendipity)
‘at the statue in an hour’
(more than serendipity)

Thank you:
For marrying me (we are part of serendipity)
We are arresting in our togetherness
(more than serendipity)

Thank you:
For being there for a temperamental artist
We are all scientists!
(more than serendipity)

Thank you:
For your beauty (beyond serendipity)
I have no sky without Cimbrone

Thank you:
Our world together.

“I wish to be independent”

The latest film by Omphalos is a “two culture” film. There are of course many more  than two cultures, as Ian Hamilton Finlay rightly pointed out:


This film is for James Sheridan Knowles. Thanks go to Hale Bopp, the teddy bear, for ‘dropping by’ this auld doctor, playwright and artist.

Only the grave from omphalos on Vimeo.

Andrew’s year in Guyana

My son Andrew is going to be teaching as a volunteer in Guyana. He is now busy preparing and raising funds.Andrew---Jan-2015-(2)

As parents we are really proud of Andrew.


This tells a little more about Andrew’s Project Trust trip to Guyana where he will teach maths and science:


Online donations can be made here

Death divided friends

This is Chapter Fifteen of ‘This is Not yesterday’


Death divided friends – The Wilkies of Errol
At 43 Lady Menzies Place, near to the volcanic crags of Edinburgh’s Old Town, Esther Ann Wilkie was born. She arrived into this world at 8.20pm on the last Thursday of September 1870. Esther was my father’s Granny.

Esther was born into a large family and had a balance of siblings: five brothers and five sisters. Her parents, James Wilkie and Ann McIntosh, both hailed from the banks of the Tay, in the hamlet of Errol, just east of Perth.

All of Esther’s older brothers and sisters were born in Perth; in-fact Esther was the first of the family to be born in Edinburgh just after the family flitted there in 1869. Esther’s father, James Wilkie (1828-1893), worked for the Caledonian Railway where he served as a passenger inspector. It may be that James moved to Edinburgh to improve his job prospects with the Caledonian Railway. However the tragic Wilkie family was to suffer deeply from endemic illness which may offer more morbid reasons for their relocation from Perth to Edinburgh.


Figure 1: Esther Wilkie pushing her grandson Stuart (my father) in the pram

The story of Esther’s elder siblings is dreadfully heartbreaking. They were to be victims of tuberculosis at a time when there was no effective cure.

Little John Alexander, aged just three years, was the first to succumb, dying on Christmas Eve 1871. Just three years later Robert Mackintosh, the second oldest child, died of pulmonary tuberculosis. He had just celebrated his eighteenth Birthday, and his father was called for a second time to register the death of a child.

Esther was nine years old when her beloved sister Susan Ann lost her life. Like Robert her lungs had been ravaged by tuberculosis, and as if in a dreadful sororal mirror she had also just turned eighteen. A photograph of Susan survives, taken just before her death. In it she appears pale, graceful and vulnerable. The sadness tells through the words of her sister Esther who had written on the back of the photograph….”Susan the lady of the family”.


Figure 2: Susan Wilkie died a few weeks after this photograph aged 18 years

James, who was the eldest child, and worked as a telegraph Clerk in Edinburgh, died in early August 1885. He had endured a seven month battle against the rigours of the deadly disease. He was nursed by his parents and wife. His insurance policy, honoured on his death, was to be entirely consumed by the debts for medical & nursing care, and by the cost of transporting his body by train to Errol, for internment in the family grave.


Figure 3: James Wilkie died August 1885 aged 29 years

The poor Wilkies they did not have to seek their troubles. Further heartache came with the death of Agnes in 1894, just two years short of her thirtieth birthday. Esther (my father’s Granny) had been very close to her sister Agnes, especially as there only being a couple of years of age between them, and she was devastated by her death. Agnes had also battled in wheezing, breathless gasps, pulmonary tuberculosis. When Esther was later to marry and have children, she was to name her first child after her dear sister Agnes.

Tuberculosis, before science brought cure, had no mercy and most unspeakably it had not finished with Esther’s siblings. David Ritchie Wilkie succumbed to the bacterium in April 1893 he was 21 years of age. Not much more than a year before he himself had lost his infant son to this Nebuchadnezzar.


Figure 4: The Wilkie tombstone greets you to the churchyard

At the entrance to Errol churchyard, and the first to greet the visitor, is the tombstone to the Wilkie family. I have visited myself many decades after any family. I laid flowers for this my forgotten family and in the name of science. With my interest in the medical humanities sometimes others have seemed confused as to what matters to me. I have no such confusion. As an atheist it is written for me on the Wilkie tombstone: ‘death divided friends.’ 


Hold hands among the atoms

A reply by Peter J. Gordon to the Editorial: Erving Goffman’s Asylums 50 years on.  The British Journal of Psychiatry (2011) 198.

It so happened that as I opened up this month’s yellow journal, I had been reading ‘A life history of Edwin Morgan,’[1] the Scottish poet and Makar. Like our Editor[2], Edwin Morgan considers in his poetry the circular nature of wisdom and science, living together in a world that an atheist regarded as beautifully complex. Many everyday folk like myself have been drawn to Morgan because he was one of very few who wilfully embraced science within poetry.

“Science must somehow someday be brought into literature to a far greater extent than it has been { . . . ] in fact one of my strongest feelings is that of being on the threshold of a great epoch of history, and I only hope I live long enough to see the developments that are coming. I am very susceptible to the ‘epic’ feeling, to the idea of exploration, adventure, endurance, discovery, and I think this feeling is very important to man as a species.”[3]

I personally find that the fifty year old terminology of Goffman does not always recognise the horrid mental suffering that first necessitated medical care. It is evidently still the case that it is to doctors and nurses, and not sociologists nor philosophers, that troubled folk and family return. When talking of recent historical anniversaries, it was Johann Christian Reil who first understood such necessary medicalisation, and psychiatry as a discipline was born; a disciplinary frame that he avowed must not let go of either humanity or philosophy.[4]

Wake-up call

Wake-up call for British Psychiatry by Craddock et al: This Editorial had more responses than any other in the history of the British Journal of Psychiatry. They are all worth reading

Why psychiatry can’t afford to be neurophobic by Bullmore:

I really do not think that Craddock[5], Bullmore[6] et al need to lose too much sleep that we have yet to ‘wake up.’ On the contrary, I would posit that they have not fully considered historical lessons, unlike Mac Suibhne. In my view, having spent many hours reading the first hand experiences of our predecessors, the most important of these lessons is not to take too narrow a view of the sciences relevant to medicine. The only psychiatrist to cover this field, avoiding both tired dichotomy and defensive split was Leon Eisenberg who died only just last year:

“The very success of biomedicine has exacted a price in the way it has narrowed the physician’s focus exclusively to the biology of disease. However, the remedy does not lie in abandoning reductionism where it is appropriate but in incorporating it within a larger social framework to enable the physician to attend to the patient as well as to the disease.”[7]

With Leon Eisenberg concluding so, I would like to congratulate our Editor and his team in bringing our journal roundedness. As Edwin Morgan would say:  ‘let us hold hands amongst the atoms.’[8]


[1] McGonigal, J; Beyond the last dragon – A life of Edwin Morgan; Sandstone Press, 2010.

[2] Tyrer, P; A coterie of rotaries; The British Journal of Psychiatry (2011) 198, p82.

[3] Edwin Morgan (2000)

[4] Marneros, A; Psychiatry’s 200th birthday; The British Journal of Psychiatry 2008 193: 1-3

[5] Craddock N, et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193: 6 –9

[6] Bullmore, E; Why psychiatry can’t afford to be neurophobic; The British Journal of Psychiatry (2009) 194: 293-295.

[7] Eisenberg, L; Science in Medicine: Too much or too little and too limited in scope? Am J Med. 1988 Mar; 84.

[8] Morgan, E: Hold Hands Among the Atoms. 70 Poems. Glasgow: Mariscat Press, 1991.