This post is based on an Editorial published in the BMJ on 27 September 2017: Identifying frailty in primary care.
The full article can be read here.
This post is based on an Editorial published in the BMJ on 27 September 2017: Identifying frailty in primary care.
The full article can be read here.
It is most welcome to hear from Philippa Whitford about positive outcomes of NHS Scotland’s collaborative approach to quality improvement and the learning that this might provide for the rest of the UK. I share Philippa Whitford’s concerns about the potential consequences of competitive systems such as occurs more in NHS England with providers, commissioners and contracts and the inevitable fragmentation that this brings. The integrated approach taken in Scotland along with the engagement of patients and frontline practitioners is indeed something to be most positive about.
However, NHS Scotland’s approach to Quality Improvement is based on what is known as “improvement science”. This is a relatively new approach to science introduced from the USA and based on methodologies from the engineering and airline industries. The Health Foundation, in its ‘Evidence Scan’ found a “real paucity of evidence about the field of improvement science” . The Health Foundation found papers on the conceptual nature of Improvement Science but concluded that: “none of these could be said to be seminal pieces of research acting as building blocks for the field as a whole”.
As far back as 2007 Brent et al identified that “ethical issues arise in QI because attempts to improve quality may inadvertently cause harm, waste scarce resources, or affect some patients unfairly.”
Scotland has two key National Improvement initiatives for older people in acute hospital care. One is for Delirium and the other is for Frailty.
The QI initiative on Delirium was reliant upon “screening tools” that were effectively made mandatory for all those aged 65 years and over admitted to hospital. Healthcare Improvement Scotland measured the “compliance” with the use of these “screening tools” across Scotland. On the wards I was finding that these tools were not infrequently being interpreted as diagnostic and that older people were sometimes considered as lacking in “capacity” on this basis. I was also concerned that this approach could lead to greater use of antipsychotic medication.
The QI initiative on Frailty is currently being implemented across NHS Scotland. This is despite the fact that there is no internationally accepted clinical definition for Frailty. More “screening tools” have been developed by Healthcare Improvement Scotland and “Frailty Hubs” are now being set up in most NHS Boards. It may be worth noting recent high-level disagreement amongst British Geriatricians about the validity of the “Frailty Industry” as one senior Geriatrician described it.
The experience of these national initiatives perhaps highlights the limitations of approaches which work best in mechanical settings. The same success cannot be guaranteed when applied to more complex presentations such as delirium and frailty.
It has recently been stated that “ethical approval is less burdensome” for QI. However I suggest that we must be wary of taking shortcuts that may result in potential harm as well as potential good. This is why ethics and philosophy have an established role in science.
Another risk is that if science is pre-determined as “improvement”, this may limit the acceptance of critical thinking.
Philippa Whitford concludes that in NHS Scotland “Quality improvement has made its way into the DNA of frontline staff”. I share the view that Quality Improvement has much to offer. However, if NHS Scotland has been genetically-modified with QI let us hope that the wider considerations necessary for science are included in the base-code.
Dr Peter J Gordon Psychiatrist for Older Adults NHS Scotland
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
The following analysis: “Surge in publications on early detection” was recently published in the BMJ. The authors concluded that “we need more critical thinking and more studies that specifically target both benefits and harms of early detection”:
The authors of this analysis will no doubt welcome the following response as a good example of critical thinking. This reply was submitted by Robert Steele (Independent Chair of the UK National Screening Committee); Anne Mackie (Director of Screening, Public Health England); John Marshall and Zeenat Mauthoor (both PHE Screening)
Submissions such as this reinforce my view that the criteria and principles that apply to screening must also be applied to early detection and “case finding”.
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.
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.
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."
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:
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.”
There is a lot of effort in NHS Scotland to raise awareness amongst healthcare staff about delirium, using statements like this:
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:
[the above is an excerpt from Inside Health last week]
The following slides come from recent awareness-raising events in NHS 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:
Margaret McCartney stated in this:
In her book “The Patient Paradox” Margaret McCartney said:
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.
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:
This book reminded my of a protocol issued by an NHS Board in Scotland:
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:
With the recent publication of the Care Standards for Older People, the Chair of Healthcare Improvement Scotland confirmed:
It would appear to me that this “screening instrument” has been re-labelled by Healthcare Improvement Scotland
The 4AT was developed and promoted as:
Recently the 4AT has been re-labelled as:
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.)
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:
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,
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.
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)
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.
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.
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.
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"
The figures are from the Scottish Government and can be accessed here.