If NHS Scotland has been genetically-modified with QI

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

 

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”:

“Freedom to speak up” and a “Stronger voice”

Last week Sir Robert Francis, QC, published this reviewFreedom to speak up

I was interested in this review given my recent experiences.

In putting patients first I have always supported an open and honest culture.

Recently I was fortunate to meet Richard Norris, Director of The Scottish Health Council:

Stronger voice

I fully support a stronger voice for all. A strong voice may also be a critical voice.

These two separate reviews remind me of a rewarding partnership I have with Chrys Muirhead. I am a doctor and so the first review applies most to me. Chrys Muirhead is a carer and activist, and the second review applies most to her.

Our shared experience has been of the considerable difficulties we have each had in raising critical questions. In sharing our knowledge and experience we have, together, found greater empowerment. This has been an enlightening experience for me.

Empowerment and enlightenment

 

 

 

 

 

 

“A public register of UK doctors’ financial interests is long overdue”

Below is my latest submission to the BMJ:

Fiona Godlee, Editor of the BMJ, has concluded that: “The profession must take the lead to protect patients and maintain public trust. The GMC should act, and a public register of UK doctors’ financial interests is long overdue.”(1)75854084_Godlee_62719j

Godlee,-29-Jan-2015

In response, Niall Dickson, Chief Executive of the GMC, has stated that: “Our guidance is comprehensive and clear in respect of the responsibilities of individual doctors and we have taken appropriate action against individual doctors in the past where there has been evidence that our guidance has been breached”. (2)A3DD946F-9966-E522-E48690C05D7C7B5F

I have petitioned the Scottish Government for a Sunshine Act regarding health professionals’ financial conflicts of interest. (3) This was considered most recently at the meeting of the Petitions Committee on 27th January. The evidence accumulated so far demonstrates that existing Scottish Government guidance, in place since 2003, has never been followed in NHS Scotland. FOI response from the GMC confirms that no doctor has been formally investigated in Scotland for breaching guidance on financial interests. (4)

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Niall Dickson has stated on behalf of the GMC that “Parliament has not given us powers”. It would seem that Fiona Godlee has correctly identified what needs to be done, and it is clear that governments will need to act.

References:
(1) Godlee, F. Medical corruption in the UK. 29 Jan 2015 http://www.bmj.com/content/350/bmj.h506

(2) Dickson, N. The GMC responds to the special report in the BMJ on regulating doctors’ financial and commercial interests; 29 Jan 2015 http://www.bmj.com/content/350/bmj.h396/rr

(3) Gordon, P.J. PE01493: A Sunshine Act for Scotland  http://www.scottish.parliament.uk/GettingInvolved/Petitions/sunshineact

(4) General Medical Council response to Dr Peter J Gordon. F13/5915/EH; dated14 Jan 2014