A tall, slightly stooping, gaunt figure

Dr Robert Hutchison died in 1960, seven years before I was born. However, his appearance as depicted in the portrait (above) reminds me of Roald Dahl. One of his closest friends and colleagues described him in this way:

Dr Robert Hutchison, like Roald Dahl, is recalled for his wonderful way with language. One of my favourite quotes – about the profession in which we have shared across centuries – is by Hutchison. I still find it extraordinary that he wrote this in 1897:

Robert Hutchison was born at Carlowrie Castle, Kirkliston, in 1871.

In the early 1990s I lived with Sian in Kirkliston, at Humbie farm cottages. I was then studying Landscape Architecture at the University of Aberdeen and Sian was completing her GP training in Livingston:

In 1893 Robert Hutchison graduated in Medicine and Surgery at the University of Edinburgh. Like me, he was a very young medical student, but unlike me he was far more promising.

Robert Hutchison delivered his first baby in 1894 at the Simpson Memorial Hospital Edinburgh. I was born in this same hospital 70 years later.

1897, aged just 26 years of age Robert Hutchison co-authored: Clinical Methods: A Guide to the Practical Study of Medicine:

This is still used and is now in its 23rd Edition!

Robert’s sister Isobel Wylie Hutchison was quite amazing. She was a poet, polyglot, painter, botanist and Arctic traveller. She could speak Italian, Gaelic, Greek, Hebrew, Danish, Icelandic, Greenlandic and some Inuit.  Carlowrie remained a home for her to return to from travels, although the upkeep was hard and the castle did not have electricity until 1951. Isobel died at Carlowrie in 1982, aged 92.

I was delighted to see Dr Robert Hutchison quoted in a recent BMJ response by Dr Amr K H  Gohar. This was in response to this BMJ Analysis:

Dr Gohar titled his response: Primum non nocere (first, do no harm). He summarised the potential harms from early detection which he said may include: overdiagnosis and overtreatment, false positive findings, additional invasive procedures, negative psychosocial consequences, and harmful effects on bodily function.

Dr Gohar confirmed his view [that]: “This does not mean that such early detection should be ignored but it means, as this article stresses, that early detection should be balanced. Critical assessment of early detection including early detection technologies and strategies in clinical practice is indispensable to avoid the persisting bias that early detection is only beneficial.”

This returned my thoughts to communications that I have had with Healthcare Improvement Scotland an NHS Board that is primarily guided by the American organisation: the Institute of Healthcare Improvement.

I have in Hole Ousia expressed my concerns about the approach taken to detection by Healthcare Improvement Scotland. My concerns have related to the lack of consideration of harms of  “National Improvement” drives and the continued marginalisation of consent.

Robert Hutchison may have died seven years before I was born. But in 1897 he wrote words that I consider to be most prescient:

"From inability to let well alone;

from too much zeal for the new and contempt for what is old;

from putting knowledge before wisdom, 
science before art, 
and cleverness before common sense;

from treating patients as cases;

and from making the cure of the disease more grievous than 
the endurance of the same,

Good Lord, deliver us."

 

 

 

 

‘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.”

 

Yellow socks and handstands

There is a lot of effort in NHS Scotland to raise awareness amongst healthcare staff about delirium, using statements like this:

am1

Delirium is a very complex state and it is a shame that awareness is not always accompanied by understanding of this complexity. This is not surprising as delirium is poorly understood. It remains unclear to what extent delirium is itself a risk factor for mortality, rather than simply reflecting a multi-morbid state where each condition carries its own risks:

yellow socks and handstands

[the above is an excerpt from Inside Health last week]

The following slides come from recent awareness-raising events in NHS Scotland:

Resource into OPAC THINK delirium across scotland

These “busy slides” perhaps do reflect some appreciation of the complexity of delirium. What appears to be lacking is meaningful and informed involvement of patients:

Informed choice

Margaret McCartney stated in this:

Rather than submission

In her book “The Patient Paradox” Margaret McCartney said:

awareness

All awareness campaigns can suffer from the difficulty of communicating complexity and recognising gaps in understanding. Oversimplified approaches to what is undoubtedly a serious condition could have unintended consequences and this has to be given serious consideration.

Re-labelling (and a bit)

I read this book recently [below].

I am approaching fifty. With age-related sight changes I find that my arms need to be longer!. So if I have misread “Sixty and a bit”  please do forgive me:

Now we are sixty and a bit

This book reminded my of a protocol issued by an NHS Board in Scotland:

4 april 2014 all over 65 MUST

As a doctor who tries his best to follow evidence-based medicine, I argued against this approach. I found that neither this NHS Board nor indeed NHS Scotland shared my concerns:

Brian Robson

With the recent publication of the Care Standards for Older People, the Chair of Healthcare Improvement Scotland confirmed:

Letter4b

It would appear to me that this “screening instrument” has been re-labelled by Healthcare Improvement Scotland

The 4AT was developed and promoted as:

010Tools

Recently the 4AT has been re-labelled as:

4AT validated UK Gov

The authors  4AT describe its key features:

(1) “brevity” (takes less than 2 minutes”), and

(2) that “no special training is required”

I should confirm that I use rating scales with patients as part of my daily professional life.

However I would never start out with a rating scale. To me, that would seem most disrespectful.

Rating scales can add to wider medical understanding. This is why, despite my awareness of any intrinsic shortcomings, that I continue to feel that they can be helpful.

The 4AT has recently been re-branded an “assessment test”. The 4AT was promoted for several years, with the support of Healthcare Improvement Scotland, as a “screening tool”. The validation studies, still underway, describe the 4AT as a “screening” tool.

Given that there has been no change to the test itself, I would suggest that this is re-labelling (and a  bit.)

Haloperidol prescribing to Scotland’s elders

In a previous post the FOI returns on Haloperidol prescribing in NHS Scotland were shared.  This followed on from my consideration of a BMJ report regarding the scale and potential harms of  such “off-label” prescribing to our elderly in hospital.

Since that time I have had a response from Professor Jason Leitch, National Clinical Director, Healthcare Quality, Scottish Government:

Letter from Prof Leitch

Today I have sent this reply to Professor Leitch:

To: Professor J. Leitch,
National Clinical Director, Healthcare Quality,
Healthcare Quality and Strategy Directorate
Planning and Quality Division
St Andrew’s House,
Regent Road,
Edinburgh EH1 3DG

8th June 2015

Dear Professor Leitch,
I was most grateful to receive your letter of reply dated 2nd June 2015.

I thought it best to reply to you to clarify the focus of my concerns. I wish to try and keep my reply short and focussed on the points you raise.

Point ONE:
You state that the Scottish Clinical Advisor for Dementia informed you that the “off-label use of Haloperidol for dementia is not especially unusual”. This would seem to diverge from  this BMJ change page made by NHS England’s National Clinical Director for Dementia, Professor Alastair Burns (I attach the full paper)

Dont use

You cite SIGN 86 guidelines on Dementia. These guidelines were issued 9 years ago when it was stated that “they will be considered for review in three years.” SIGN 86 is specifically for dementia and not delirium. The SIGN website indicates that there is no current plan to update SIGN 86 nor to introduce a Guideline on Delirium:

SIGN 86 was criticised in this research: Knűppel H, Mertz M, Schmidhuber M, Neitzke G, Strech D (2013) Inclusion of Ethical Issues in Dementia Guidelines: A Thematic Text Analysis. PLoS Med 10(8): e1001498. doi:10.1371/journal.pmed.1001498. I find it disappointing that an outdated and flawed guideline is still the basis for prescribing in dementia.

Ethical issues

Point TWO:
Haloperidol prescribing is part of the “Comprehensive Delirium pathway” introduced across NHS Scotland by the Scottish Delirium Association (SDA) and Healthcare Improvement Scotland (OPAC). You will be aware of this as I note that you are giving the key-note talk this week at the conference: Transforming delirium care in the real world”. Over a year ago the Secretary of the Scottish Delirium Association asked me to summarise my views on delirium improvements happening in Scotland. I did so and shared these with the SDA and with OPAC. I am disappointed to note that no reply has been forthcoming. I attach this summary for you with this letter.

Transforming delirium care in the real world

Conclusion:
It is welcome to hear that the Scottish Government are taking actions here. It is the case, by Scottish Government figures, that antipsychotic prescribing is increasing year-on-year in NHS Scotland. I seek improved care for individuals with delirium and dementia. I am concerned that current approaches, along with staff shortages and increased demands on staff time, are making it more rather than less likely that our elders may receive antipsychotic medication that can result in significant harms.

Yours sincerely,
Dr Peter J. Gordon

Included with letter:

Update, 5th October 2016. The following was published on the 
front page of the Scotsman newspaper: 

"Mental health prescriptions hit ten-year high"

prescriptions-for-mental-health-drugs-10-year-high-nhs-scotland-2016-a prescriptions-for-mental-health-drugs-10-year-high-nhs-scotland-2016-b

The figures are from the Scottish Government and can be accessed here.

“OPAC tools are working”

It is over a year since I last wrote about delirium. Being aware that the new Care Standards for older people in hospital were to be published this month I had a look on the Healthcare Improvement Scotland web platform for these new standards. As yet these standards have not been published, but I did notice the news that “OPAC tools are working”. I followed the links, read the supporting material, and watched all the associated films:

[The costs of films commissioned from the private sector by NHS 
Healthcare Improvement Scotland has been over £51,000 from 
January 2014 to February 2015]

027Tools

A lot has happened in acute care settings for Scotland’s elders since I last wrote. It is wonderful to see in these films such compassion and dedication to care amongst the healthcare teams: from allied health professionals, nurses and doctors. I agree with Professor Jason Leitch that this demonstrates a caring culture.

It was some years ago that I heard Professor MacLullich give a talk about delirium. I was inspired by his thoughtful presentation which outlined the distressing symptoms that can come with states of delirium and the associated increased risk of mortality.

In this post I will not be considering improvement work undertaken on “frailty”. In what follows I intend to further explore the Healthcare Improvement Scotland strapline: “OPAC tools are working” with particular reference to delirium.

In terms of “working”, only two key figures are given by Healthcare Improvement Scotland. The first confirms that there has been 95% “compliance” with “assessment tools” for delirium.

025Tools

The other key figure demonstrates that length of hospital stay in orthopaedics for older people has been reduced since the introduction of “frailty and delirium assessment tools”:

043Tools

In what follows the OPAC tools currently being used in hospitals across Scotland to “identify” delirium will be considered. Two specific issues continue to concern me:

(1) the risk of too great a reliance on any “brief” “tool” rather than this being part of an overall assessment; and
(2) the marginalisation of consent.

(1) Reliance on a “brief” “tool”:032Tools

The 4AT has been revised since I last wrote. It was previously described by its developers as “a new screening tool for delirium and cognitive impairment” (see below):

006Tools

The latest version (at time of writing) is version 1.2. The developers “have decided to describe” the 4AT now as an “assessment test”:

Version 1.2 4AT

As an “assessment test” the 4AT requires:

011tools

The 4AT “assessment test” is also noted for its:

009Tools

The 4AT:

008tools

The four questions that comprise the AMT4 are as follows:

052Tools

It is important to appreciate that the 4AT test is different from other tools for delirium as it incorporates the AMT4. The AMT4 is a screening tool for cognitive impairment alone. To explain further this test is in effect used to screen for dementia. This is an important point because there has been very wide debate about cognitive screening. Cognitive screening is recommended by neither the UK National Screening Committee nor NICE. Another point is that using brief tests for delirium and cognitive impairment at the same time is an approach novel to the 4AT.

Given that the 4AT test incorporates a test of cognition it is relevant to consider whether our cognitive function can so easily be encapsulated in a “very brief” test. The 95 year old philosopher, Mary Midgley, has said this about “tests”:

031Tools

Mary Midgley then goes on to say:

022Tools

Cognitive ageing has become an area of great interest since Professor Lawrence Whalley of Aberdeen University began research in this area and some of his findings are summarised in his book, the Ageing Brain.

Professor Whalley reminds us that the brain is such an incredible biological wonder. Each of us have 100 billion neurons in our brains, and whilst this may change with ageing, it is still the case that our neurons, even on our last day in life, amount to:

The shock of the fall (9)

Recently this lead Editorial was published in the Lancet:

004Tools

It repeats the reminder of Professor Whalley that:

003Tools

To many it appears counter-intuitive that something so complex as human brain function can be reliably assessed in a test that takes less than 2 minutes. In a follow-up post I will look at the work currently being undertaken to evaluate the 4AT.

(2) Marginalisation of consent:
“Compliance” with the 4AT “assessment test” is being measured in Scotland by Healthcare Improvement Scotland. My concern here, that I have expressed before, is that such an approach marginalises the right of the individual to consent or otherwise to this assessment.

I have become aware through my own clinical practice that even brief cognitive tests can be distressing to patients and can leave them fearful (the following quote is from a patient undergoing a short cognitive screening test but not the 4AT):

039Tools

Another reason to be concerned about consent is that our cognitive abilities tend to follow a parabolic distribution through life. It would be a mistake to disregard this when undertaking complex diagnostic considerations.

In March of this year the UK Supreme Court judged that it was for patients to decide whether the risks, benefits and alternative options of assessments or medical interventions have been adequately communicated:

014Tools

Treatments may bring harms as well as benefits. This is why explanation of risk should be an ethical underpinning in our interactions with a patient.

The Scottish Delirium Association (SDA)  has issued delirium pathways for use across NHS Scotland. The “OPAC tools” are generally the starting point in these pathways. The SDA Comprehensive pathway states very clearly:

040tools

This pathway outlines environmental and general measures, alongside medical and nursing approaches to manage delirium which has been identified using the 4AT test. If these measures are not in themselves sufficient to improve the state of delirium, the Comprehensive Pathway outlines further interventions:

041Tools

A recent audit of Haloperidol prescribing in NHS Scotland has confirmed the findings of the Scottish Government that in our acute hospitals prescribing of antipsychotics has been rising year on year.

To try to identify how much of this rise comes from prescribing for those aged 65 years and over, the 0.5mg capsules and 1mg/ml liquid haloperidol are likely to be indicative.

In one Scottish NHS Board (see table below), we find that haloperidol prescribing in those aged 65 years and over in the acute hospital has nearly doubled since cognitive screening was introduced and monitored at NHS Board level.

042Tools

This is a recent study published in the Lancet:

045Tools

The authors of this study argued that:044Tools

Summary:
In these films Healthcare Improvement Scotland outlines that “OPAC assessment tools work, and are working in hospitals across Scotland”. There is no doubt that delirium is a condition associated with significant morbidity and mortality. It is also clear that we have a long way to go in understanding such a complex condition. Given this, my concerns about the over-reliance on brief tools used at outset and the marginalisation of consent are unchanged.

In a follow-up post I will look at the work currently being undertaken to evaluate the 4AT.

Update, 5th October 2016. The following was published on the 
front page of the Scotsman newspaper: 

"Mental health prescriptions hit ten-year high"

prescriptions-for-mental-health-drugs-10-year-high-nhs-scotland-2016-a prescriptions-for-mental-health-drugs-10-year-high-nhs-scotland-2016-b

The figures are from the Scottish Government and can be accessed here.

“two-thirds of diagnoses would be given to healthy people”

This Scottish report “Adding Life to Years” is now rather old. It once asked about ageism:Ageism in NHS ScotlandcThis week the UK National Screening Committee has expressed significant concerns about screening tests for cognition:Awful & inaccurate 8 April 2015In NHS Scotland if you are 65 and over and need to be in hospital, you will be “screened” for “cognitive impairment”. All NHS Boards in Scotland are being measured, in terms of “compliance” for such “screening”.Increased-screeningWithout consent, and the explanation of what these simple and “brief” “screening tools” can and cannot determine, and further explanation of the potential consequences, I would argue that NHS Scotland is taking an experimental leap, where any reasonable effort to give informed consent has been marginalised.

I have huge trouble with the prevailing idea that “identification” is somehow completely distinct from “screening”. The World Health Organisation covered this matter very clearly a few years after I was born. That work, in my view, is just as relevant today.

The Scottish Government has recently issued this reassurance:aa

The Mental Welfare Commission has confirmed that they support the approach of both the Scottish Government and Healthcare Improvement Scotland.

The Scottish Government lead for Dementia has said this (behind closed doors) to his Scottish Government colleagues about my advocacy of ethical issues relating to dementia :
geoff-huggins-acting-director-for-health-and-social-care-2-dec-2015

Such a statement is perversely back-to-front. It was Geoff Huggins who proudly addressed Westminster Parliament to say that any “saboteurs” to HEAT Target 4 would be addressed by taking them “behind the bike shed”.

As of  November 2016, those who across Europe who support timely diagnosis of dementia as opposed to screening or early diagnosis:
glasgow-declarationas-of-5-nov-2016

 

British Medical Journal, 24 January 2015

This week’s BMJ provides a useful overview of the thorny issue of seeking an earlier diagnosis in dementia. I have always argued that a push for “early” diagnosis, using what are in effect screening tools for cognitive impairment, carries with it risks of mis-diagnosis and over-diagnosis. I have found it very difficult to make my voice heard in raising these concerns about potential harm to patients. Several years down the line, following significant personal consequences of persistently arguing this point, I find that the UK National Screening Committee has come to exactly the same conclusion:

Evidence-for-screening-for-

In the section highlighted above the Committee identifies twice as many false-positive as genuine diagnoses of dementia using current tests.

Industry's-interest-in-deme

Dr McCartney raises one possible explanation of why the UK National Screening Committee’s advice regarding dementia, which is no different from its advice of 2010, was effectively ignored by governments, charities and healthcare professionals. My concerns about conflicts of interest influencing policy developments led me to petition the Scottish Government for a Sunshine Act.

Undiagnosing-dementia,-BMJ,

I have a continuing concern that the figures quoted by the UK National Screening Committee refer to people aged 65 years and over. A considerable proportion of the people that I see are over 80 years. Given the parabolic distribution of cognition with age it is possible that the rates of false-positive diagnosis could be higher in this age group.

Evidence to back dementia screening is still lacking, committee says

This report has just been published in the BMJ:Evidence lacks, dementia screening Jan 2015

It has attracted this response from a “free spirit” and “old man”:J K Anand 17 Jan 2015

The article begins:

“GPs have again raised the question of why NHS England persists in promoting dementia ‘case finding’ after the UK advisory body on screening reiterated its view that the current test for dementia was not accurate enough to recommend it for routine use.”

My view, having studied the subject of “case-finding” is that it is one-and-the-same as screening:

One and the same from omphalos on Vimeo.

Dr Martin Brunet stated in this BMJ article: “Unfortunately, despite the fact that there has never been a recommendation to screen for dementia, NHS England policy has been to introduce screening programmes in primary and secondary care by using the term ‘case finding,’ to circumvent [National Screening Committee] guidance.”

The article continues: “After reviewing the evidence on screening people aged over 65 for dementia, the UK National Screening Committee concluded that none of the tests currently used in practice distinguished well enough between people with dementia and those without.”

I have just had the following submission accepted for publication by the BMJ:ethics not just for xmas

Dr Margaret McCartney stated in this BMJ article: “I hope that the architects of screening for dementia in the UK take heed of this reiteration that screening for dementia is ineffective and harmful. Who will be held to account for the harm that the dementia screening policy has done?”

Scotland’s approach to dementia diagnosis can be read here.

This film covers the evidence that Scotland gave to the All party Parliamentary Group in Westminster. The meeting was entitled “How to improve dementia diagnosis rates in the UK”

How to improve dementia diagnosis rates in the UK from omphalos on Vimeo.

The article confirms the potentially high rate of false-positives: “The committee said that current tests showed that between seven and 17 in every 100 people over the age of 65 had mild cognitive impairment but that each year only about 5-10% of these would develop dementia. With use of current tests, 18 in 100 people would test positive for dementia, the committee said, but only six would actually have dementia, leaving 12 receiving a positive result when they didn’t have dementia, while one other person who did have dementia would be missed and be falsely reassured.”

I have long argued these concerns:

The diseased Other from omphalos on Vimeo.

The parabolic pattern can be read here.

Primum non forgetful from omphalos on Vimeo.

Care of older people in hospital: Draft standards

Below is the letter I have sent to Healthcare Improvement Scotland on the recently published Draft Standards for Care of Older People in Hospital. You can submit comments to James Smith, Project Officer hcis.OP-AC@nhs.net The closing date for comments is  Wednesday 17 December 2014.

Dear James,
Thank you for inviting us all to “help to shape” the final Standards for Care of Older People in Hospital which were released in draft this November. It is also welcome to note that “at the end of the consultation period, all comments will be collated and the project group will respond to each comment received on the draft standards.”

I am writing to you in letter form as this is my preferred way of offering my thoughts on the draft standards. I hope that my letter can be published in full in terms of the consultation that Healthcare Improvement Scotland have set out.

I am aware that the new standards will form an “integral part of inspection programmes into the care of older people in acute hospitals.” I think here we should note that the previous standards were in place for 12 years without revision and so we should consider that these new draft standards might be in place for a similar period of time.

I would also suggest that the draft Standards need to be considered in the context of all the “progress reports” issued since February 2012.[1]

In general, the Standards are clearly written, free of jargon terms and largely well-referenced. These standards will help support further progress in improving hospital care for older adults in Scotland.

However, included in the 2002 Care Standards were definitions of all terms used. I note that no definitions, other than defining what is meant by a “standard”, have been included in the new draft Standards. This is a matter of concern to me.

It is my view that the new standards need to define what is meant by terms such as “detection”, “routine”, “validation”, “tool”, “cognitive impairment”, “capacity”, “consent”.

The following are areas where I think specific criteria can be improved upon:

It is welcome that the new draft standards now include Standard 5: Skills mix and staffing levels: [that]“older people are cared for by knowledgeable and skilled staff, with care provided at a safe staffing level.” Specifically, Criterion 5.5 states “There are clear processes in place for staff to escalate any concerns about staffing levels with associated plans to mitigate safety risk. There are robust processes for the monitoring of staffing levels.” The term “processes” is not defined. As an NHS Consultant I recently expressed my concerns about staffing levels. Unfortunately I found that my concerns were not being listened to by my employers. After following all “processes” available to me, I felt that I had no other option but to resign. I would urge the Project Group to be much more specific in their recommendations here.

I also have specific concerns regarding cognitive screening. The three extant Progress Reports for older people in acute hospitals contain terms such as: “screening”, “tools”, “toolkits”, “dashboards”, “pathways”, “protocols”, “tracers”, and “targets”. It is notable that these terms generally do not appear in the draft Standards. Given that these terms are used to measure and monitor progress by Healthcare Improvement Scotland, and that all NHS Boards are expected to follow the recommendations based on Inspections, it is concerning that the draft standards make almost no mention of them. I had expected to find clear guidance on screening in the new draft standards.  In fact the draft Standards, in contrast to the current 2002 Standards, do not use the term “screening” at all.  In terms of patient safety it would appear that “screening” has been re-branded as “detection”. The draft standards would thereby appear to side-step the ten criteria set out by Wilson & Jungner for the World Health Organisation[2].

The latest Progress Report states this:
“We are working together with healthcare teams from across acute hospitals in Scotland to test and introduce new tools with the aim of improving screening for frailty and improving early management of delirium”. The Report continues “National guidance states that every patient aged 65 years and over is assessed for cognitive impairment when admitted to hospital”. The Inspectors concluded: “In 12 inspections, we found that screening for cognitive impairment was not routinely carried out or recorded for patients when admitted to hospital.”

It is abundantly clear from all Healthcare Improvement documentation that current improvement methodology in Scotland’s acute hospitals is based on screening where “all patients over the age of 65” are to be assessed by a “screening tool”. The unintended consequences of such approaches may include any of the following: mis-diagnosis, heightened stigma, heightened fear of hospital, mistaken removal of autonomy, and increased prescribing of medications like Haloperidol[3],[4]. In terms of “pathways” the risk is that such harm may begin with a “screening tool”[5].  It is notable that the NICE guideline on delirium[6] does not endorse screening. It would also be helpful if the standards could confirm the view of the UK National Screening Committee.

There are also two specific areas where the use of references should be re-considered:

(1) There is a mistake in the draft Standards where it is referenced “Alzheimer Scotland. Assessing cognition in older people: a practical toolkit for health professionals. 2013”. This is actually not a publication by Alzheimer Scotland. This “Toolkit” by the Alzheimer Society recommends assessment “when cognitive impairment is suspected” (not screening). In Acute Care they recommend use of any of the three following tests: Abbreviated mental test score (AMTS), 6-Item cognitive impairment test (6CIT), General practitioner assessment of cognition (GPCOG). In terms of the draft care Standards it is necessary to define what “tools” or “tests” are being recommended, as well as the evidence behind their use.

(2) Scottish Intercollegiate Guideline Network (SIGN) Guideline 86 – Management of Patients with Dementia. This guideline is now 6 years beyond the review date set by SIGN and as a national guideline it has compared very poorly when compared to 12 other national guidelines. SIGN 86 was particularly criticised for narrowness of approach and lack of ethical considerations[7]. As such better documents on which to base the standards need to be sought.

This brings us to Draft Standard 2 – Consent and decision-making; “Older people are involved in every decision about their care and treatment.” It is my certain view that Consent Standard (Standard 2) needs developing and more meaningful inclusion in each of the 16 proposed standards. My fundamental concern is that the approach subsequently described in the criteria as currently worded appears to ignore consent. An up-to-date and comprehensive systematic review of this important area is presented in this paper: The full spectrum of ethical issues in dementia care: systematic qualitative review [8].

We must be wary of treating broad concepts such as delirium or “cognitive impairment” as identical to specific diseases (which they are not). We must remember that cognition has a parabolic distribution through life and age related cognitive changes are actually more common than dementia or delirium. This is particularly true of the age group most commonly admitted to acute care in NHS Hospitals today. This does not mean that delirium or dementia should be considered any less lightly.

I wish to conclude with this consideration: the exercise of compiling standards must be immensely difficult. The range of issues is very broad and the standards have to apply fairly to all of Scotland’s elders. For this reason, I would argue that a development group would be best served by a wider distribution of inputs: including a GP, a public health representative, an ethicist, and an older person! I would argue that at the “drawing up stage” of standards that it is important to have direct involvement of those with experience. In my view it is not sufficient for an organisation to collect views and then to chose which views are most important.

I am very grateful to have had the opportunity to offer my considerations on the Draft Standards. I hope my comments are received as well-intended comments from a dedicated NHS clinician. Thank you again for inviting responses. I hope that you will receive helpful feedback from all quarters.

Yours sincerely,
Dr Peter J Gordon

[1] Care for older people in acute hospital (Progress Report, May 2013 – July 2014) Healthcare Improvement Scotland http://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/opah_overview_reports/opah_overview_report.aspx

[2] J. M. G. Wilson, G. Jungner Principles and practice of screening for disease. World Health Organisation http://whqlibdoc.who.int/php/who_php_34.pdf

[3] Gordon, P.J. Delirium Screening https://holeousia.wordpress.com/2014/03/26/delirium-screening/ 26 March 2014

[4] Prescribing & Medicines: Medicines for Mental Health, Financial Years 2002/03 to 2011/12. A National Statistics Publication for Scotland http://www.isdscotland.org/Health-Topics/Prescribing-and-Medicines/Publications/2012-09-25/2012-09-25-PrescribingMentalHealth-report.pdf#

[5] King, G. Speak Up! The Mini Mental State Examination a tool or a weapon? Mental Health Lecturer, University of Dundee. Mental Health Nursing. Oct/Nov2013, Vol. 33 Issue 5, p14

[6] National Institute for Health and Care Excellence. Delirium: diagnosis, prevention and management. 2010 [Cited 2014 November 7]; Available from: https://www.nice.org.uk/guidance/cg103/resources/guidance-delirium-pdf

[7] Gordon, P. J.  Dementia Guidelines: research and clinical criteria are not simply “interchangeable” http://www.bmj.com/content/347/bmj.f7282/rr/676567

[8] The full spectrum of ethical issues in dementia care: systematic qualitative review. The British Journal of Psychiatry (2013)202: 400-406 http://bjp.rcpsych.org/content/202/6/400.full

Below is page one of my letter to Healthcare Improvement Scotland. Previous correspondence is here.

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