‘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.

‘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.

 


Justice must be seen to be even-handed

This is a short film about my experience of attending the Scottish Parliament on Thursday 29th June 2017.

I was there to support Marion Brown in her presentation of petition PE01651: Prescribed drug dependence and withdrawal:

However this film is based on an old petition that was being reconsidered by the Petitions Committee, that being, PE01458: Register of Interests for members of Scotland’s judiciary.

Lord Carloway was giving evidence. I was sitting right behind him. I found that I did not share his views on this subject.

This film is an edit of the full evidence session which can be watched (in entirety) here:

Credits:

‘Chasing Time’ by Dexter Britain (free, under common licence)

A Diary of Injustice in Scotland

The Scotsman – Leader comment of 30 June 2017

Painting of Holyrood, Scottish Parliament was sourced from here

freedom to speak

The Director General for NHS Scotland:

  Peter's experience of the Director General for NHS Scotland

 

The Clinical Director of Healthcare Improvement Scotland:

     Peter's experience of the Clinical Director of HIS

 

The Director of Health and Social Care Integration:

Peter's experience of Director of Health & Social Care Integration

 

In my determination to put patients first I have been treated poorly.

These highly paid officials seem to be beyond accountability:

[I have always openly acknowledged that my view is no more important than any other. I am always careful to be clear in what cannot be said with any certainty. I am fully aware of my weaknesses.  I absolutely refute any charge that I am “vexatious”. I do not hold grievances. What matters to me is truth and fairness. I have found that the same cannot always be said of those in genuine positions of power]:

 

It can take courage to care. To resist the threats to your career and the misnaming:

 

Such abuse of power is not new:

 

You are invited to join me for this protest:

 

Your Parliament, Your Voice

The Commission on Parliamentary Reform published its Report on the Scottish Parliament this week. It is a most welcome review and one that has my full support.

The Editor of the Scotsman gave his view (21 June 2017):

Johann Lamont, MSP is quoted in the Scotsman of 21 June 2017:

My petition to the Scottish Parliament, PE1493, “A Sunshine Act for Scotland” was closed in early Spring of 2016. I was impressed by the organisation and the effort put into the wider consideration of my petition by all involved with the Public Petitions Committee.

A Public Consultation was carried out on my petition by the Scottish Health Council and this was published in March 2016. The public, in majority, agreed with the petition.

More than 15 months on since my petition was closed and the public have had no update from the Scottish Government. I wrote to the Scottish Parliament to ask that an update be requested from the Scottish Government but the short reply that they received lacked any substantial content. It has become familiar to many of those engaging with the Scottish Government to receive replies such as this that lack in transparency and openness.

The Scottish Parliament has told me that they can do no more and advised me to seek help from a constituency MSP. To me, this is like going backwards to the start.

I thus very much support the Review published by the Commission on Parliamentary Reform and hope that it will ensure that the public have a meaningful voice in helping the Scottish Parliament hold the Scottish Government to account.

Lifeboat NHS

A film about freedom to speak up in NHS Scotland based on an edit of the evidence session of the Health and Sport Committee, Scottish Parliament, held on 13th June 2017.

This is just an edit. A subjective view. Nothing more and nothing less.

Stifling distortions












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To seek balance in the appreciation of where expertise rests: my submission on PE01651

Submission on PE01651: Prescribed drug dependence and withdrawal

Made by Dr Peter J Gordon

Date of submission: 3rd June 2017.

Submission made in a personal capacity.

I am writing in support of this petition. I am an NHS Consultant Psychiatrist who has worked in this specialty in Scotland for almost 25 years now. My wife has worked as a General Practitioner in Scotland over the same period. I have an interest in ethics, human rights and the medical humanities generally. One of the areas I have taken much interest in is informed consent.

I would argue that this backdrop may mean that I can add some thoughts and reflections that might help the Committee in the consideration of this particular petition.

I should make it clear that as an NHS psychiatrist I do prescribe antidepressants and other psychotropic medications. I try to do so following the best available evidence as considered as relevant or not to my professional understanding of each unique patient and their life circumstances.

I wish to keep this summary short as I am aware that the Committee receives a great deal of evidence. So I offer a few points of evidence that I would be willing at a future date to expand upon if that were felt to be helpful:

• Antidepressant prescribing In Scotland (ISD figures) has been rising year-on-year in Scotland for at least the last ten years (this is also true of all other prescribed psychotropic medications). It is estimated that 1 in 7 Scots are now taking antidepressants and many of these in the long-term.

• At a recent Parliamentary Cross Party Meeting on Mental Health and older adults an invited speaker stated that: “depression is under-recognised across all age groups” and that “maintenance treatment has a good risk-benefit ratio.”

• A key opinion leader and Government advisor has previously argued that prescribing of antidepressants in Scotland is “conservative” and “appropriate”.

• Many of the key opinion leaders “educating” doctors prescribing antidepressants in Scotland appear to have significant financial interests with the makers of these medications. Across the UK, £340 million was paid by the pharmaceutical industry in the last recorded year to healthcare workers and academics for such “promotional activities”.

• “Informed Consent” will not be possible if the information that doctors base prescribing on follows such promotion rather than independent, and more objective, continuing medical education. This issue is now at the fore of the Mesh Inquiry.

A few questions that need to be considered:

  • When patients are prescribed antidepressants are they informed that as many as 1 in 2 will be taking antidepressants long-term?
  • Are patients informed that there may be a significant risk of pharmacological dependence on antidepressants?
  • Do patients know that their experience of antidepressants may be considered less valid than the experts (who may have been paid by the pharmaceutical industry) who educate other doctors (who may be unaware of this potential financial bias)?

Summary:

My view is that antidepressants are over-prescribed in Scotland.

My view is that patients have not been properly informed of benefits and risks.

My view is that appropriate prescribing has not been realised due to a number of factors: the lack of access to psychological therapies or other meaningful supports; the wide promotion of antidepressants where marketing is routinely conflated with education; and a culture of increasing medicalisation generally.

I would suggest that this petition might be considered in light of the Chief Medical Officer’s Realistic Medicine campaign. It is time for balance to be re-established between “medical paternalism” and the valued, vital and real-world experiences of patients who are taking medications like antidepressants. I am particularly disappointed in my own College, the Royal College of Psychiatrists for not making greater effort to facilitate such balance. Without such, I fear more harm will result from inappropriate and costly prescribing in NHS Scotland.

Finally, due to widespread “off-label” promotion of antidepressants in Scotland, patients may experience withdrawal syndromes which can be most severe and precipitate mental states far more serious than the mental state for which they may have originally been prescribed.

I would urge the committee to consider this petition most carefully and to seek balance in their appreciation of where expertise rests.

‘Informed consent is a fundamental principle underlying all healthcare’

A recent Independent Review for NHS Scotland stated that: “Informed consent is a fundamental principle underlying all healthcare”

The Cabinet Secretary for Health and Sport, Shona Robison stated to the Scottish Parliament (17 March 2017): “Informed consent and shared decision making are expected prior to any procedure being carried out.”

On the 20th April 2017, I wrote to Healthcare Improvement Scotland 
about Patient consent in NHS Scotland:

I have just completed my annual Appraisal which is a General Medical Council requirement as part of 5 yearly Revalidation. As part of this I was informed by my Appraiser that I must comply with all the LearnPro modules which I have now done.

The following screenshot comes from the NHS Lothian mandatory LearnPro module on Capacity and Consent:

I apologise as the text is small, so I have reproduced verbatim what it states to me as an NHS Lothian employee:

“Consent is both a legal requirement and an ethical principle and requires to be obtained by healthcare professionals, prior to the start of any examination, treatment, therapy or episode of care.”

“In Scotland, everyone over the age of 16 is an adult. The law assumes that adults can make their own decisions and can sign legal documents, such as consent to medical treatment (in some circumstances this also can apply to children under the age of 16) provided they have the capacity. This means that they are able to understand what is involved in the proposed treatment, retain the information, be able to weigh up the information needed to make the decision and then communicate that decision. Treatment might be delivered in a hospital, clinic or in someone’s home.”

In years past I have written about consent for older adults in hospital in NHS Scotland:

Do we care enough about consent?

‘OPAC tools are working’

I am writing to Healthcare Improvement Scotland as I find myself confused.

Do I follow the mandatory requirements of my employers on consent? Or do I follow the National Improvement requirements of OPAC-HIS where consent is not required for assessments such as the 4AT assessment test? (formerly called “4AT screening tool”)

I know, from the re-drafted Care Standards, that Healthcare Improvement Scotland take consent very seriously.

I should state that I am writing in my own capacity and in my own time.

12 May 2017 - I sent this update to Healthcare Improvement Scotland:

Forgive me for this further correspondence but I felt that I should update you on the learning that I received as part of my attendance for Continuing Medical Education (CME) yesterday.

This CME event was for the Royal College of Psychiatrists in Scotland – Faculty of Old Age Psychiatry and was held in Falkirk.

At this event the Chair of Old Age Psychiatry for the Royal College of Psychiatry was giving a talk and when the time came for questions I asked about the wide use of haloperidol in older adults in hospitals in NHS Scotland. Dr Thompsell replied “evidence has found that Haloperidol actually worsens the outcome of delirium”.

Another lecturer at this meeting, who was giving a talk on her area of expertise: anti-psychotics and older adults, was Dr Suzanne Reeve. She replied: “Haloperidol does increase mortality in older people compared with other antipsychotics. That message has been out for a while but has not really got across.”

The next talk was entitled “Successes of Old Age Psychiatry Liaison team” and one of the slides shown had the headline “Compliance with 4AT”. The impressive “compliance” figures then followed. The dictionary definition of compliance is “the act of yielding”.

My concern here is for patient harm and indeed increased patient mortality. National Improvement work undertaken by HIS has been instrumental in increasing “compliance” with tools such as the 4AT and it is clear that no consent is deemed necessary. I have argued that this is not ethical as these tools are often the beginning of “pathways” and “protocols” that may result in the administration of haloperidol.

I am genuinely worried that National Improvement work undertaken by Healthcare Improvement Scotland has not properly considered ethics, available evidence and the potential for unforeseen consequences. You will understand that I am also nervous about writing this letter given the consequences for me when I first “spoke up” three years ago:

I would very much value your advice. I am not sure that I can work in a profession if it loses sight of Hippocrates and “first do no harm”.

This is the response from Healthcare Improvement Scotland,
dated 17th May 2017:

“Thank you for your letter of the 20th April and your letter of 12th May, in which you raise the interesting issue of taking consent in relation to cognitive screening.

I understand from staff involved in the inspections of older people’s care in hospital that taking of written consent prior to initial assessment for frailty is not routinely undertaken. Assessment at the point of admission, or where a change in a patient’s cognitive presentation is giving cause for concern, can alert staff to possible increased risk and enables planning of care for the patient. In these circumstances staff adopt a proportionate approach such as asking, for example, if they may ask some questions.

For absolute clarity though, as an employee of NHS Lothian, the requirements set out in the Board’s policies and mandatory training are those that you should follow.”