‘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”:

It is important to record the narrative of dementia policy in Scotland accurately

I recently wrote to the Minister for Mental Health with concerns about  the way the Scottish Government has chosen to record the narrative of dementia policy in Scotland.

I have received this reply from the Scottish Government:

I have sent this letter of reply:

Tuesday, 1st August 2017

To: Strategic Lead for Dementia
Dementia Strategy and Delivery Division,
Scottish Government.

Copied to: Maureen Watt, Minister for Mental Health

Dear Ms Barclay,
Thank you for your letter of the 28th July 2017 in response to my recent communications.

The 1st Dementia Strategy included specific targets for the “early diagnosis” of dementia and no mention whatsoever of a timely diagnosis.

It is therefore inaccurate for the Minister to state in her foreword to the 3rd Dementia Strategy that “Our first strategy was published in 2010 and focused on improving the quality of dementia services through more timely diagnosis”. It is also inaccurate to describe the 1st Dementia Strategy as a “broad statement of policy intent” when incentivised targets for early diagnosis were involved.

It would be wrong to consider this as simply a matter of vocabulary as these different approaches can and indeed did have significantly different consequences for those affected.. I welcome the consideration of a timely approach from the 2nd Strategy onwards.

I will be sharing our correspondence on my website as I feel it is important to record the narrative of dementia policy in Scotland accurately.

Yours sincerely
Dr Peter J. Gordon

‘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

 

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.

 

 

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:

‘Official Interference’

This is my reply to a blog that was posted in the Holyrood Magazine:

Thursday 13th July 2017

Dear Tom,
I read the blog post titled ‘Official Interference’ written by you in the Holyrood Magazine on the 7th July 2017.

It is welcome to see this matter considered further. I can be a bit slow on the uptake but I wasn’t entirely sure of the main points that you were trying to get across? I am not sure what you mean by “the real story” being about “accusations” of “subjectivity”? I am also not sure what Holyrood’s views may be on the necessary independence of report writers and the public accountability of civil servants?

Let me be entirely open. I have found my experience of communicating with senior civil servants working for the Department of Health and Social Care (DGHSC) most unsettling. In my communications I have put patients first. I have been a longstanding  advocate for ethical considerations in healthcare.

As a public servant (NHS doctor) I have been as open and transparent about my experiences as possible – and I have shared all that I can on my website Hole Ousia.

Over some years I have become aware that my personal experience of communication with senior civil servants has been shared by a significant number of others, many of whom have been labelled by DGHSC as “vexatious” or having a “grievance”.

DGHSC civil servants would seem to follow an approach that Prof Walter Hume described as familiar “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.”

Following the Times report by Helen Puttick and the subsequent report in the Scotsman, I compiled this blog-post:

Honesty and Openness: ‘not an edited official tale’

I should say that I am just an NHS doctor who has a number of interests and that I have neither any skills in politics nor in journalism. I am however interested in ethics and this includes consideration of the integrity of those who occupy positions of genuine power (such as elected politicians and publically paid senior civil servants).

On becoming First Minister, Nicola Sturgeon stated:

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

When giving evidence to the Scottish Parliament, the Director General for NHS Scotland, Paul Gray said:

“I think transparency in the NHS makes sense” (29 January 2014)

I would suggest that there is a growing public concern about senior civil servants working for the Scottish Government in terms of what they say and do.

The Commission on Parliamentary Reform’s “Report on the Scottish Parliament” published on the 20th June 2017 outlined steps that might help improve parliamentary approaches to ensuring necessary accountability of the Scottish Government. I have been made aware, for example, of a number of Petitions under review by the Scottish Parliament that may have been closed as a result of behind-closed-doors “advice” by senior civil servants working for the Scottish Government.

I will stop there Tom. No need to reply unless you so wish.

One closing point. It is most demoralising for hard-working NHS staff to hear repeatedly repeated, parrot-like, from Scottish Government “spokespeople” of “record NHS levels of staffing”. This fighting of reality is not helpful and suggests the sort of “subjectivity” that perhaps you were alluding to in your piece for the Holyrood Magazine?

I will be staging a peaceful protest (I am not party political) about the integrity of senior officials working for the Scottish Government this August at the Martyrs Monument.

Kind wishes,

Peter

Dr Peter J Gordon (writing in my own time and in a personal capacity)

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.

 


‘How to Improve’

The Nuffield Trust has recently published “Learning from Scotland’s NHS”. This report was based on a select group of “30 senior leaders and experts from Scottish health and care”.

One of the primary “learning points” of this report was that Scotland should be considered as “the model of how to improve healthcare across the British isles”. What is not made clear in this report is that the improvement methodology that Scotland has embraced was introduced from the USA not by “30 senior leaders” but by three:

  1. Derek Feeley, President of the Institute for Healthcare Improvement (IHI) and former Director General for NHS Scotland
  2. Professor Jason Leitch, who is a Dental practitioner, IHI Fellow and National Clinical Director of Healthcare Quality and Strategy (Scottish Government)
  3. Dr Brian RobsonIHI Fellow and Clinical Director of Healthcare Improvement Scotland

The “30 senior leaders and experts” would seem to be “marking their own homework”.

A few personal thoughts:

I am a passionate about science but am of the view that passion should not pre-determine scientific method and process.

I have previously argued why it is unhelpful to pre-determine science as “improvement”.

I fully welcome a coordinated approach to improving healthcare.

I worry about the inherent reductionism that is the basis of IHI “improvement science”

IHI promotes learning to healthcare based upon the experience of Industry (mechanical engineering). This may work well for less complex interactional processes, such as Hospital Acquired Infection. However healthcare is rarely linear (it is more often Bayesian) and reductionist interventions (however well intentioned) can cause harm.

I have found that Healthcare Improvement Scotland (IHI) does not routinely include ethical considerations in its approach to “improvement science”.

In summary:

I would suggest that it would have been more accurate (evidence based) for the Nuffield Trust report to have been titled: “Learning from the USA”.

I welcome all learning and from all reaches of the globe. I also seek improvement. But as a philosopher and NHS doctor (of 25 years) I worry about any one-system approach.

Science needs to consider culture, ethics, narrative, and the experience of being.

“How to Improve” needs to consider the voices of people and place. It should not just be the voices of the “senior leaders and experts from Scottish health and care”.

 

 

 

 

Are the public being listened to?

This is a current Editorial in the BMJ:
Below are a few extracts from this editorial: In a similar vein to Carl Heneghan, I have outlined that there is a problem with the E in CME (Continuing Medical Education)

Sharing the BMJ Editors concerns about a failure of the Academy of Medical Sciences to take necessary action to ensure trust in science (EBM) and education (CME) this response was submitted:

“We could not agree more with Dr Tom Robinson in that we can only gain the trust of the public if we listen to them. One of us (Dr Peter J Gordon) raised a petition with the Scottish Parliament to consider a Sunshine Act for Scotland, and as part of this a consultation was undertaken with the Scottish public. The majority of those consulted agreed that it should be mandatory for all financial conflicts of interest to be declared on a public register. The Academy of Medical Sciences has gone no further than recommending the development of “frameworks for declaring and managing interests” . We would suggest that this will do nothing to restore the public’s trust.”

Dr Peter J Gordon and Dr Sian F Gordon