An open letter to the incoming President of the Royal College of Psychiatrists

To: Dr Lade Smith, President of the Royal College of Psychiatrists
From: Dr Peter J Gordon [Retired NHS psychiatrist]
Date: Monday 17 July 2023

Dear Dr Lade Smith,

I wanted to write to wish you all the best in your Presidency of the Royal College of Psychiatrists. Though I am now several years retired I still take an interest in matters related to well-being. I watched the husting films and thought that all the candidates spoke very well. I really wish you well in the workforce issues which continue to be a serious concern across healthcare in the UK.

When your predecessors started in office I also wrote to them to wish them well. My interest has primarily focussed on ethics and how we might best approach well-being.

I resigned from the College nearly 5 years ago. I explained the reasons behind this decision in a letter of the 24^th July 2018 to Dr Adrian James, who was then Registrar. The two principle reasons were [as per my letter]:

Letter to the Royal College of Psychiatrists, 24 July 2018:

[1] Evidence does not support the conclusion of the Royal College of Psychiatrists that “the relationship between the College and Pharma is distant” [Vanessa Cameron, previous CEO, December 2016] and that “College policies and procedures around declarations of interest are sufficiently robust” [Paul Rees, current CEO, June 2018]. As a direct consequence informed consent and realistic psychiatry are compromised.

[2]I am concerned that the core values of the Royal College of Psychiatrists are not always being upheld. It is my view that this has been revealed through the College approach taken to those who have shared less than positive, and sometimes harmful, effects of psychiatric interventions including prescribed medications.

I had no reply to this letter other than an automated response from the College confirming that my direct debit had been cancelled and that I was no longer a member of the College.

A year later I took the decision to fully retire from Medicine at the age of 51 years. I informed the College of my decision, in a letter to the President, dated 25th October 2019. Again, I had no reply.

Letter to the Royal College of Psychiatrists, 25 October 2019:

I was dismayed that the Royal College of Psychiatrists deliberately chose not to respond to my letter of resignation of the 25th September 2018. I felt that to completely ignore this letter was disrespectful, but more worryingly the public can have no indication whether the two issues that I raised in my letter are of any concern to the Royal College of Psychiatrists. This puts our shared goals of “fully informed consent” and patient safety at risk.

I would urge the College to restore ethics to the very heart of all that we do. I will continue to urge all Royal Colleges to support Sunshine legislation. I wish you every success in encouraging doctors to Choose Psychiatry - and indeed not to leave psychiatry early as I have. Any loss of experienced doctors will be to the detriment of patients and the profession alike.

In the same period of time that I sent the October 2019 letter to the College, Professor Wendy Burn, President, publicly offered the following reassurance: “Despite what some people think, most clinicians in the UK are not influenced by the pharmaceutical industry”. Unfortunately no evidence was provided to support this statement. The key word in this statement is “influence”. In my 25 years working as a psychiatrist my experience was that the majority of my colleagues did not work, in any way, for the pharmaceutical industry. However, my research for a Sunshine Act, revealed that, in terms of influence on prescribing, the pharmaceutical industry relies on a group of academics and doctors [and sometimes allied professionals such as pharmacists]. This group has been described as “Key Opinion Leaders”, and perhaps more accurately as “Paid Opinion Leaders”.  My experience as an NHS doctor was that my colleagues were generally unaware that they were being educated [for mandatory Continuing Medical Education] by influential professionals who have received payments from the Pharmaceutical Industry. It is my understanding that, generally speaking, the pharmaceutical industry spends more of its revenue on marketing than it does on research and innovation. This fact, I would suggest, is evidence in itself.

President Burn’s reassurance reminded me of an exchange on the influence of the pharmaceutical industry between her predecessor, Professor Simon Wessely [President of the Royal College of Psychiatrists 2014-2017] and Dr Ben Goldacre [author of Bad Science and Bad Pharma]. Dr Goldacre concluded this exchange: “I’m very concerned about the reputational consequences for the profession of casual false reassurance on these issues”.

The year before I retired from medicine the college ‘reissued’ it’s Core Values for Psychiatrists: Communication, Dignity, Empathy, Fairness, Honesty, Humility, Respect and Trust. In the ‘reissue’ these values were framed within a new acronym, the opening ‘C’ standing for courage.  In terms of ethical considerations it concerned me that an organisation would put its own “courage” ahead of that of patients. The Cumberlege Review: First Do No Harm has evidenced the harmful consequences of such a one-sided approach which can encourage a culture of institutional defensiveness. This, I believe, has been demonstrated at the recent 2023 Royal College of Psychiatrists International Congress. I am not on social media but many have been in touch with me to say that some of what was shared from the Congress revealed a defensiveness that risked being blind to the reality of lived experience of ever so many.

The Royal College of Psychiatrists has always been determined to address stigma.  Although there is no generally accepted specific theory of stigma, it can be defined as ‘an attribute that is deeply discrediting and that reduces the bearer from a whole and usual person to a tainted, discounted one’ (Goffman, 1963). One of the College initiatives set up  to address stigma is a module that in its introduction states: “Attitudes held by health professionals, including those who work in and outside of mental health, can have positive and negative impacts upon patient quality of care.” A whole section of this module explores this question: What can people including psychiatrists do to reduce stigma? 

The advent of social media has created a new environment where health professionals are at risk of increasing rather than reducing stigma. The balance of power between psychiatrists and patients [members of the public] has always been unequal because of the legal authority to detain. This imbalance also includes the application of diagnostic categories to others. It is disappointing to see any misuse of this power, for this will only perpetuate stigma. It is a real challenge for the College to ensure that the values that the organisation has set out are followed by its members in all settings, including social media.

In this letter which I have made open because the College has not responded to previous communications, I have tried to demonstrate that the two issues raised in my original resignation letter have still not been openly addressed by the College. A position statement by the Royal College of Psychiatrists on the Cumberlege Review is long overdue. I would also suggest that the College needs to be seen to stand up for professional values rather than turning a blind eye to behaviour by members and fellows of the College that departs from professional values expected of healthcare professionals. The reputation of Psychiatry and ongoing trust in the profession may be dependent on strong moral leadership. There will be many, myself included, who will steadfastly support you in this.

Yours sincerely,

Peter J Gordon.