On Friday the 25th of November 2016 I gave a talk for the Scottish Philosophy and Psychiatry Special Interest Group.
My subject was “Improvement Science”.
The following is based on the slides and the four short films that I presented.
My talk was entitled:
The meeting was held at the Golden Lion Hotel, Stirling:I started the day off:
I gave these declarations:
I explained to the audience that like Dr Rev I M Jolly I can be overly pessimistic:
The dictionary definition of ‘Improvement’:
The dictionary definition of ‘Science’:
My concern is any pre-determinism to science:
The Health Foundation have considered Improvement Science: this is from 2011:
Many different terms are used including “QI” for “Quality Improvement”:
This is where improvement science began, in Boston, Massachusetts:
The Founder of the Institute for Healthcare Improvement (IHI) was Don Berwick:
The first description of this movement in Britain goes back to 1992 by Dr Godlee:
Fifteen years later, Dr Godlee, Editor of the BMJ, said this:
Only last month the BMJ briefly interviewed Don Berwick:
IHI describes improvement science as being based on a “simple, effective tool”:
This tool was developed from the work of an American engineer, W. A. Deming:
The “Model for Improvement” Tool [TM] is described by IHI as a “simple, yet powerful tool”:
The current President and CEO of IHI is Derek Feeley:
Up until 2013, Derek Feeley was Chief Executive [Director General] for NHS Scotland:
In April 2013 Derek Feeley resigned from NHS Scotland:
22nd February 2015 it was reported: “The astonishing and largely hidden influence of an American private healthcare giant at the heart of Scotland’s NHS”:
Dr Brian Robson, Executive Clinical Director for Healthcare Improvement Scotland [HIS] is an “IHI Fellow”:
Professor Jason Leitch, National Clinical Director for the Scottish Government is an “IHI Fellow”:
Might we be facing the biggest change to healthcare in Scotland since the NHS began? Improvement science is moving quickly and widely across Scotland:
This “Masterclass 1” for Board members cost £146,837:
An NHS Board member commented after the Masterclass:
Healthcare Improvement Scotland is one organisation with a very wide remit over NHS Scotland and it works closely with the Scottish Government:
Nine cohorts of Safety Fellows and National Improvers have so far been trained following IHI methodology:
I was reminded of the current enthusiasm for improvement science when the Convener of a recent Scottish Parliament Committee meeting said of targets (another approach enthusiastically taken by NHS Scotland):What is the place of ethics in Improvement Science?
In 2007 the Hastings Centre, USA, looked into this in some depth:
The Hastings Centre argue that Improvement science cannot ignore ethics:
In 2011 the Health Foundation, UK, produced this “Evidence Scan”:The Health Foundation commented that “improvement science is just emerging”:
The Evidence Scan found a “real paucity of evidence about the field of improvement science”:
I would also suggest that there is a real paucity of philosophy about the field of improvement science:
The Health Foundation did find papers on the conceptual nature of Improvement Science but concluded that:
Mary Midgley is a philosopher now aged 95 years who is widely respected for her ethical considerations:
Chapter 7 of her book “Heart and Mind: The Varieties of Moral Experience” begins:
Mary Midgley is concerned about the overuse of reductionist tests in medicine stating that:
This film is about the potential consequences of inappropriate reductionism:
Leon Eisenberg has written many papers about this subject. He argues that reductionism should not be “abandoned” but that we must keep sight of where such an approach is scientifically useful and also where it is inappropriate:
In the Hastings Report, Margaret O’Kane asks:
In my view the answer to this question is YES. I am hopeful that the National Improvers recruited to NHS Scotland would agree:
As an NHS doctor I have seen unintentional harm brought about by National improvement work in Scotland. This related to a “Screening Tool” that was introduced across Scotland as part of this work. I found that the unintended consequences of the use of the following tool included implications for patients’ autonomy and the risk of over treatment:
Both the Hasting Group and the Health Foundation are of the view that improvement science cannot separate itself from the ethical requirements of research:
This article published in February 2016 argues that individual “rights transcend all aspects of Improvement science”
The following is a verbatim representation of a conversation held by National Improvers working in NHS Scotland:
In November 2016 Professor Joshi, also a psychiatrist outlined his concerns about reductionism in a published letter to the BMJ:
In this short film the mechanical language of healthcare improvers is considered:
Professor John Bruce was a Moral Philosopher in Edinburgh University in the 18th century. He built this temple, the “Temple of Decision”, in the grounds of his home by Falkland Palace so that he could consider his thesis:
Professor John Bruce did not succeed in his endeavour. His Temple however stood for many years:
But it eventually collapsed and his endeavour to “reduce the science of morals to the same certainty that attends other sciences” collapsed with it.
Any search of Healthcare Improvement Scotland for “ethics” finds this result:
This film is about more up-to-date buildings – the enthusiasm for which was based on improvement science: The Red Road flats in Glasgow:
The following is an edited clip of the evidence given to the Scottish Parliament by Healthcare Improvement Scotland (HIS) on the 31st January 2017:
The full session can be watched here
The Official Report can be accessed here
The contributions of those “retired” often prove invaluable
BMJ submission by Dr Peter J Gordon.
2nd September 2015
Yesterday I was at a consultation event held by Healthcare Improvement Scotland which sought wider views on a proposed national approach to “Scrutiny” of health and social care in Scotland. At the meeting I met a number of individuals who had been designated “retired” on their name badge. I was not surprised to find that during the course of the consultation event, the contributions of those “retired” proved to be invaluable.
Returning home on the train I thought about this a little more. Names like J K Anand, L Sam Lewis and Susanne Stevens, all regular submitters to the BMJ rapid responses came into my mind. All describe themselves as “retired” and one happily calls himself “an old man”. The contributions by retired folk have always struck me as having a different quality to those by people who are still employees of today’s NHS. In “retirement” there may be a greater freedom to ask questions of prevailing approaches. Our older generation also has great experience which should be considered as “evidence” in itself.
Yet in my job as a doctor for older adults, I see the world around me as seeming to do its best to reduce our elders. The language used in discussing our elders commonly denotes some sort of loss. For example the “guru” of Healthcare Improvement Don Berwick talks about the “Silver Tsunami”. Other healthcare leaders talk of “epidemics” and “challenges”, implying that our elders are a burden to younger generations. To address these “challenges” the healthcare improvers, it seems to me, are devising shortcuts. Today these are often termed “tools” and may be part of “toolkits”. I have even heard healthcare improvers discussing the need to “invent” a “tool” for patient centredness. I think our elders, or those “retired”, might consider this to be particularly ridiculous.
So I would like to say three cheers for the “retired” folk. To discourse they bring wisdom, to the prevailing methodologies they are more willing to ask critical questions, and when it comes to cutting through to what matters, being true to oneself, our elders are superior to many, if not most, policy makers.
The following are quotes by Raymond Tallis:
I recently noted this request:
Anybody who has read my writings on Hole Ousia will be aware that I have a dislike of the current mechanical language that would seem to be particularly favoured by healthcare improvers. So I am not convinced that a tool like a “costometer” (had it been invented) would manage to measure the outcomes that really count!
It is my impression that we seem to have many more conferences today than we once did. Sometimes it is the case that one finds that these conferences involve the same speakers covering well rehearsed topics. One such recurrent topic is “awareness”.
It often seems to me that there may be less “awareness” of interests that may lie behind such conferences. Here, please do not be tempted to think that I am referring to the pharmaceutical industry alone. It is the case that many conferences today are those organised by charities, Royal Colleges, health improvers, third sector agencies and by government bodies.
The “costometer” is an invented tool. If it did exist, could it really measure the true value of all these conferences?
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]
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.
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”:
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.
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):
The latest version (at time of writing) is version 1.2. The developers “have decided to describe” the 4AT now as an “assessment test”:
As an “assessment test” the 4AT requires:
The 4AT “assessment test” is also noted for its:
The four questions that comprise the AMT4 are as follows:
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”:
Mary Midgley then goes on to say:
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:
Recently this lead Editorial was published in the Lancet:
It repeats the reminder of Professor Whalley that:
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):
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:
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:
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:
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.
This is a recent study published in the Lancet:
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"
The figures are from the Scottish Government and can be accessed here.
What follows are the costs of films made for NHS Healthcare Improvement Scotland. The period covered is 1 Jan 2014 to 26 Feb 2015. Costs for all other photography commissioned by Healthcare Improvement Scotland are not included. The total cost is over £51,000.