Open Letter to the General Medical Council
Why the GMC should set up a central registry of doctors’ competing interests
Published 15 January 2014
Margaret McCartney, general practitioner, Glasgow,
Ben Goldacre, Wellcome research fellow in epidemiology,
Iain Chalmers, coordinator, James Lind Library,
Carl Reynolds, NIHR academic clinical fellow in occupational lung disease, Imperial College London,
Jonathan Mendel, social geographer,
Sam Smith, freelance transparency consultant (formerly of the campaigning group Privacy International),
Susan Bewley, professor of complex obstetrics, King’s College London,
Martin Brunet, GP, Binscombe Practice
Peter Gordon, consultant psychiatrist, NHS Forth Valley,
David Carroll, medical student, Queen’s University, Belfast,
Ben J F Dean, orthopaedic research fellow, University of Oxford,
Trish Greenhalgh, professor of primary healthcare and dean for research impact, Barts and the London School of Medicine and Dentistry,
Iona Heath, retired general practitioner,
Martin McKee, professor of European public health, London School of Hygiene and Tropical Medicine,
Allyson Pollock, professor of public health research and policy, Queen Mary University of London,
Sian Gordon, GP and GP appraiser, Falkirk
Correspondence to: M McCartney firstname.lastname@example.org
This transparency can only be good for medical practice
Trust between patients and doctors is critical to good medical practice, and doctors are still highly trusted by the public. But we should ensure that we deserve it. The Association of the British Pharmaceutical Industry has estimated that the drug industry pays £40m (€48m; $65m) a year to doctors for speaking fees, flights, hotels, and other travel expenses. Yet who is being paid what is opaque. It is clear that exposure to pharmaceutical advertising adversely affects future prescribing.  There is also evidence that if doctors accept gifts from the drug industry, patients trust doctors less. Citizens can access MPs’ central register of their financial conflicts of interest, yet patients cannot find out whether their doctor has a financial conflict of interest. The vast majority of doctors will be receiving no payments from any organisation other than their employer or the NHS. Some will receive fees for their expertise from NHS or non-NHS organisations. Others will be receiving some pharmaceutically sponsored education. A few will be receiving large amounts for assisting pharmaceutical or other companies with their profile and sales of their products.
The General Medical Council (GMC) says, “You must be honest in financial and commercial dealings with patients, employers, insurers and other organisations or individuals . . . If you are faced with a conflict of interest, you must be open about the conflict, declaring your interest formally, and you should be prepared to exclude yourself from decision making.” Yet there is no formal way to declare such interests, especially when conflicts may subtly influence a doctor’s practice—such as small gifts from the drug industry. The lack of a system to document payments means that patients cannot routinely be informed whether their doctor receives benefits from companies that may affect their prescribing.
Given the evidence, patients should be able to know when drug companies are influencing and paying their doctors. Nor is promotion by the industry the only concern. A burgeoning public relations and media relations industry pays doctors to promote products from hand creams to foodstuffs. Surely the financial transactions that underpin these promotions should be made obvious to potential customers and patients? Similarly, the Advertising Standards Authority has admonished many clinics for unfair advertising of products and unfair practices. Yet the monetary relations concerning the doctors promoting these products have not been made explicit.
There is a need for change. The current system of self declaration is variable, opaque, and unreliable. Investigations into the “hospitality registers” of Scottish hospitals have found a paucity of information about payments to doctors. Although the Association of the British Pharmaceutical Industry has said, in personal communications, that it proposes to make details about payments to doctors available, with their consent, this would not force doctors to disclose payments. The industry’s proposals for declaring payments have the disadvantage of not taking account of monies arising from other commercial transactions. Although academics and journals have led on declarations of competing interest, they are inconsistent (some interests are mentioned on some papers and not on others). It is unrealistic to expect that patients, or indeed colleagues, will have access to this information or should be responsible for gathering and interpreting it.
All doctors already reflect on their probity when undergoing annual appraisal. It would serve the interests of transparency to share these conclusions easily with peers and patients.
We would discourage the long and potentially irresolvable discussion about what does or does not represent a conflict or interest (membership of a political party, board membership of a charity, ownership of a nursing home, or ownership of a primary care service while working as a commissioner of care). Rather, we suggest that patients may be good judges of this. Moving from the notion of an academic conflict of interest being something “that would embarrass you if it were to emerge after publication and you had not declared it” the question should become, “Is there anything that would embarrass your relationship with your patients or the public if you do not declare it now?” Although having an interest is not necessarily by itself a problem, failure to disclose some declarations might be. It is likely that doctors’ professionalism would lead to more over-declaration than under-declaration. However, patients are most likely to be concerned about payments from the industry, PR companies, and declarations of interest over commissioning of services.
Some of us have already met representatives of your organisation to consider whether the GMC is the most appropriate body to hold a list of declarations of interest, updated annually, alongside details of our qualifications and registration status. Although we urge the GMC to consult on this, we appreciate that this step change may cause concerns for some. For most doctors a declaration of interests would be simple and straightforward, containing little or nothing of particular concern. For a few it would make it clear to patients and colleagues who the paid opinion leaders are and whose advice on health interventions may be influenced by payments from the manufacturer. This transparency can only be good for medical practice. It may cause discomfort for a few but would enhance trust in the profession as a whole.
To enable doctors to register their declarations of interests publicly, we have meanwhile created a pilot website, http://www.whopaysthisdoctor.org, designed to allow a simple download for the probity section of our annual appraisals. We invite doctors to use the website and hope that they and their patients will find it useful. We anticipate that, in time, a public declaration of interests will be seen as the right thing for all professionals to make.
Competing interests: All the signatories’ declarations of interests can be found at http://www.whopaysthisdoctor.org.
 Ipsos Mori. Trust in professions poll 2013. http://www.ipsos-mori.com/researchpublications/researcharchive/15/Trust-in-Professions.aspx.
 Drug companies pay doctors £40m for travel and expenses. Guardian 5 Apr 2013. http://www.theguardian.com/society/2013/apr/05/drug-companies-pay-doctors-40m.
 King M, Essick C, Bearman P, Ross JS. Medical school gift restriction policies and physician prescribing of newly marketed psychotropic medications: difference-in-differences analysis. BMJ 2013;346:f264.
 Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA2000;283:373-80.
 Green MJ, Masters R, James B, Simmons B, Lehman E. Do gifts from the pharmaceutical industry affect trust in physicians? Fam Med2012;44:325-31.
 House of Commons. Register of members’ financial interests. http://www.ipsos-mori.com/researchpublications/researcharchive/15/Trust-in-Professions.aspx.
 GMC. Financial and commercial arrangements and conflicts of interest. http://www.gmc-uk.org/guidance/ethical_guidance/21161.asp.
 Gordon P. NHS Scotland: register of interests. https://holeousia.wordpress.com/tag/hospitality-register.
 Horton R. A statement by the editors of the Lancet. Lancet2004;363:820-1.