Psychiatry without borders

This week the International Congress for the Royal College of Psychiatrists is taking place in Edinburgh. It is titled “Psychiatry without Borders”.

Given my concerns about the harms associated with over-medicalisation I decided to make a peaceful protest outside.

I was born in Edinburgh in 1967.

This was a home-made protest.

I have no associations with Critical Psychiatry, Anti-Psychiatry, Scientologists, the Citizens Commission on Human Rights.

I am simply a doctor who is interested in ethics.

I am of the view that critical thinking is an essential part of science.

I understand that biases come in all forms. However there is longstanding evidence that exposure to industry promotional activity can lead to doctors recommending worse treatments for patients.

Thank you to all who came to talk to me on the day. Particular thanks to Chrys Muirhead and her son Daniel for all their support

I waited the full day as I wanted to meet the Cabinet Minister for Health (Scottish Government) outside the International Congress. This was my experience:

More details about a Sunshine Act for Scotland can be found here and here.

The public consultation can be found here.

 

Transparency at the Top

I wrote “Transparency at the Top: British Psychiatry” in April 2015 but did not share it publically as I wanted to give the Royal College of Psychiatrists time to improve the governance of financial conflicts of interest. Over the last 2 years improvements have been made by the Royal College of Psychiatrists however the system in place is unsearchable, costly, and bureaucratic. It also does not help determine how much of the £340 million that the pharmaceutical industry pays each year for “promotional activities” goes to the “top” educators (key opinion leaders) in UK psychiatry.

Sir Professor Simon Wessely has been an outstanding President and has carefully listened to the concerns that I have kept raising on this issue. This week he hands over the Presidency of the Royal College of Psychiatrists to Wendy Burn.

Tomorrow, the International Congress: Psychiatry without Borders begins in Edinburgh. I will be protesting outside because I remain concerned about the considerable reach (to the many) of a handful of educators: “The Law of the Few”.

  Here follows my original transcript, dated 25 April 2015:

The Chief Executive of the GMC recently confirmed in the BMJ:

To ensure public transparency of financial payments to healthcare workers and academics both France and America have introduced a Sunshine Act. In the UK we do not have such statutory basis to transparency. Royal colleges rely on Guidance such as this guidance, CR148, by the Royal College of Psychiatrists*:

The Royal College of Psychiatrists Guidance, like The GMC, gives clear and unambiguous guidance*:

The Royal College of Psychiatrists has recently expressed that, in addition to such clear and unambiguous College guidance (CR148), that the Association of the British Pharmaceutical Industry (ABPI) “central platform” to be introduced in 2016, will ensure transparency that will “so avoid some of the criticisms of yesteryear”:

The ABPI “Central Register” has no statutory underpinning and any healthcare worker or academic can choose to opt out of revealing any financial payments made from industry.

It is perhaps then an opportune time to consider whether the Royal College of Psychiatrists is correct to express confidence that we may be able to “avoid some of the criticisms of yesteryear” in regards to transparency in regards to the relationship between industry and psychiatrists. To consider this, we might do well to look at some of the key College leads. So to start at the top this should include the current President of the Royal College of Psychiatrists. Such a consideration should also include the current Chair of the College Psychopharmacology Committee. To be properly representative of College leads, this consideration should also include a Psychiatrist who is today widely considered as a ‘key opinion leader’ in British psychiatry.

The only purpose of this consideration is to attempt to examine if our College leads are exemplars in transparency and to attempt to establish if they have followed College guidance CR148.

Sir Professor Simon Wessely was elected last year as President of the Royal College of Psychiatrists and took presidential office on the 26th June 2014. The week after his appointment, Professor Wessely was interviewed on BBC Radio 4 and, as part of this public broadcast, was part of a discussion with James Davies, University of Oxford:

This is an emphatic statement made publicly by the President of the Royal College of Psychiatrists.

In fact Wessely has been transparent about “Financial Disclosures” as given here following a co-authored review paper published in JAMA in 2014: “Dr Wessely has received financial support from Pierre Fabry Pharmaceuticals and from Eli Lilly and Co to attend academic meetings and for Speaking engagements.”

This full transparency helped Joel Kauffman consider the 2004 JAMA Editorial and this can be read in full here. But meantime, here is the relevant extract:

Those at the top of British psychiatry would appear to have a range of definitions of “transparency”? It is certainly very clear that Sir Professor Wessely does not have anywhere like the volume of working relationships with industry as some of the other current College leads. Last year Wessely gave the keynote lecture “Psychiatry under fire” at the following conference. This was not a sponsored talk as the programme makes clear. The Conference was organised by Professor Allan Young who confirms that the “objective” of this symposium is to provide “independent” education to help “achieve personal CPD objectives and in your everyday clinical practice”.

Professor Allan Young is also Chair of the Psychopharmacology Committee of the Royal College of Psychiatrists and his declarations are publicly available here where he confirms that he is paid for “lectures and Advisory Boards for all major pharmaceutical companies with drugs used in affective and related disorders”. Professor Allan Young may well be one of the most influential ‘key opinion leaders’ in British psychiatry. In this role, as a most influential educator Professor Allan Young has recently been considered here and here.

Also giving a talk at this 2014 “Latest Advances in Psychiatry Symposium” is Professor Guy Goodwin who is also considered to be a “key opinion leader” and who is undoubtedly one of those at the “top” of the hierarchy of British Psychiatry.

Professor Guy Goodwin featured centrally on the BBC Panorama programme in the following month. This programme was titled “who is paying your doctor” and Dr Goodwin came under considerable scrutiny. However it should be the case, that such scrutiny should include not just a single, individual “key opinion leader” but those like the Chair of Psychopharmacology Committee and the President of the Royal College of Psychiatrists. For patients to have trust in the medical profession it should be the case that such leads are exemplars when it comes to transparency of financial interests.

Following the Panorama programme in which Professor Guy Goodwin featured, the Head of Professor Goodwin’s University Department, had an article published in the BMJ where he expressed the view that the media harm caused by raising the subject of transparency “may outweigh any good”. An alternative view is given here. As a result, Dr David Healy, Director of the North Wales Department of Psychological Medicine offered a proposal to ensure wider consideration of transparency in British Psychiatry. This proposal for a “proper and open debate” was copied to a wide range of individuals including Professor Goodwin and had previously been discussed with Sir Simon Wessely. The correspondence can be read here .

As President of the Royal College of Psychiatrists, it is clear that speaking proportionally, most of the research Professor Wessely has been involved in has not involved working with the pharmaceutical Industry. Wessely is after all a professor of psychological medicine at the Institute of Psychiatry, King’s College London and head of its department of psychological medicine. Compared to some of the psychiatrist colleagues around him, and in particular “key opinion leaders” it is no doubt the case that Wessely has worked less with industry. However, it is not the case that he has “never worked with industry” as he emphatically stated on Radio just after becoming President of the Royal College of Psychiatrists.

In the past, Professor Wessely has helped prepare review articles through “educational grants” from the pharmaceutical industry. It perhaps may be argued that this is not “working” with industry. Though College guidance CR148 does seem to be much clearer in what it expects in terms of transparency. This was one such article involving Wessely and another one can be accessed here.

A few years before College Guidance CR148 was introduced, and long before Wessely was elected President of the Royal College of Psychiatrists, he gave his personal view on ‘working’ relationships with industry and insisted that it was “time we doctors grew up”. At the time, the BMJ published a range of views, and one of these has been included alongside Wessely’s to demonstrate this range. Professor Wessely’s personal view is now over a decade old and it would be helpful to know if his views have changed over this period of time.

Summary:
Is it the case that calling for transparency regarding financial payments may cause more harm than good? Some of those at the top of British psychiatry would appear to have put forward this view, arguing that such will damage public trust. Yet the GMC are clear what they expect of their professional group, namely doctors. Is it not time that we had an open public debate about this involving more than those just at the top?

*Since writing this CR148 was replaced in March 2017 by CR202

       Update of 11 June 2017: "The Law of the Few"

 

 

“The Law of the Few”

Malcolm Gladwell in his book ‘The Tipping Point’ describes what he terms “The Law of the Few”: namely that the influence of a few people can result in change in behaviour across a wider population.

This Hole Ousia post is about the education of psychiatrists and takes all its material from publically available sources. This post hopes to demonstrate the considerable reach (to the many) of a handful of educators.

This post follows on from the evidence that was gathered for my petition to the Scottish Parliament to consider introducing a Sunshine Act for Scotland. That petition closed 16 months ago following a consultation with the Scottish public who, in majority, asked that payments made to healthcare workers and academics be declared on a mandatory basis. I have argued the reasons why I am of the view that such mandatory declarations should be registered on a single, open, central, searchable, independent database.

Evidence has demonstrated that when a doctor has a financial “conflict of interest”, this can affect the treatment decisions they make, or recommend. There is longstanding evidence that exposure to industry promotional activity can lead to doctors recommending worse treatments for patients.

The post has come about following my invitations in the last month to Continuing Medical Education (CME) provided in my place of employment (NHS Scotland). I do not knowingly  attend sponsored medical education and so declined these two talks. The first was by Dr Peter Haddad (sponsored by Lundbeck) and the next one, just two weeks later, was by Professor McAllister Williams (sponsored by Lundbeck).

I am an ordinary psychiatrist working in a provincial NHS general hospital and to find such prominent individuals visiting our wee corner of Scotland left me to reflect upon the wide influence of a few key individuals.


The British Association for Psychopharmacology (BAP) describes itself as “a learned society and registered charity. It promotes research and education in Psychopharmacology and related areas, and brings together people in academia, health services, and industry.”

Professor Hamish McAllister-Williams is an Ex-Officio Member of BAP and is currently the BAP Director of Education.  Dr Peter Haddad, former Honorary General Secretary of BAP, has been involved over a number of years with BAP education providing articles and masterclasses.

Over the course of my career as a psychiatrist I have frequently heard colleagues say that BAP “is the place to go” for CME.  It is now a requirement for General Medical Council Appraisal and Revalidation to demonstrate with our College that we have participated in CME. Once this has been demonstrated the Royal College of Psychiatrists will issue a Certificate of “Good medical standing”.

As BAP Director of Education, Professor McAllister Williams recently shared this offer to trainee psychiatrists. Following the dissemination of this I took the opportunity to look more closely at the current BAP calendar for Continuing Medical Education. This again demonstrates the wide influence of a small number of individuals, some of whom would appear (within the limits of the current voluntary disclosure regime) to have potential financial conflicts of interest.

In the remaining part of this post I have included a few examples

As BAP Director of Education, Professor McAllister Williams chaired this BAP 2015 Summer Meeting: “Expert Seminar in Psychopharmacology”. The key-note speaker was Professor Stephen Stahl who many consider as one of the most influential key opinion leaders in world psychiatry.

In the USA, pharmaceutical and medical device companies are required by law to release details of their payments to doctors and teaching hospitals for promotional talks, research and consulting. This was the return for Professor Stahl at the time of his contribution to BAP as an educator of UK psychiatrists:

In the UK disclosure of payments is on a voluntary basis.

Professor David Nutt, former BAP President, has declared financial interests on the voluntary ABPI Register. Over the ABPI “disclosure period”, Professor Nutt has declared just short of £46,000 that he has received from Janssen-Cilag Ltd and Lundbeck Ltd.

There are strong links between BAP and the Royal College of Psychiatrists. The President Elect for BAP is Professor Allan Young.  Professor Allan Young is Chair of the Psychopharmacology Committee of the Royal College of Psychiatrists. Dr McAllister Williams, the BAP Director of Education is an appointed member of this Committee. Some years ago I wrote this post about the Royal College of Psychiatrists Psychopharmacology Committee.

Some years ago I put together this Hole Ousia post on Professor Allan Young and also this post. It is clear that Professor Allan Young remains a very active educator and opinion leader in the UK and beyond:

Professor Guy Goodwin was President of BAP between 2004 and 2005. In April 2014 he featured prominently on  BBC Panorama:

On the 40th anniversary of BAP, Professor Peter J Cowen was given the Lifetime Achievement award:

Professor Philip J Cowen featured in this post of Hole Ousia of some years back: All in the past? Well no. Definitely not.

Conclusion:
The recently retired CEO of the Royal College of Psychiatrists, Vanessa Cameron, who had been with the College for 36 years was interviewed for the Psychiatric Bulletin in December 2016. This was the view that she expressed:

Each time I reconsider this subject I do not find evidence to support this view. My worry is that the Royal College of Psychiatrists is being complacent in facilitating the education of the many by such a small group of individuals. The Law of the Few.

Footnote:

If you click on each invite below you will access what is available 
in the public domain regarding the educational activities of the 
recent speakers. I apologise if this is in any way an incomplete 
record.

 

Continuing Medical “Education”

To be revalidated by the General Medical Council all UK doctors have to evidence participation in Continuing Medical Education (CME). This is based upon an accredited system of Continuing Professional Development (CPD).

CPD is mandatory.

This Hole Ousia post considers CPD for UK psychiatrists.

This week I was included in a circular e-mail that ‘sign-posted’ this free CPD educational opportunity for trainee psychiatrists. I was asked to share this with trainees.

BAP is acronym for the British Association of Psychopharmacology. I frequently hear colleagues describe it as “the place to go to” for CPD.

This is the current Calendar:

I have written on a number of occasions over the last few years to BAP about transparency of financial conflicts of interest:

BAP have now significantly improved on transparency and each speaker now has a link to any declared financial interests. This is available to professionals and public alike.

The declarations however give no details of amounts paid for any particular service.

BAP educational events are regularly advertised in the British Journal of Psychiatry

The Chief Executive of the Royal College of Psychiatrists recently offered this reassurance (Psychiatric Bulletin, December 2016):

Last year £340 million was paid by the Pharmaceutical Industry to UK healthcare workers for “promotional activities”.

There is currently a voluntary register (ABPI).

The BMJ reported this in March 2017:

As it stands, professionals, patients and public alike can have no clear understanding of where this £340 million went to in the UK for “promotional activities”.

However we do have evidence that promotional activity can lead to doctors recommending worse treatments for patients.

Returning to the Continuing Professional Development (CPD) calendar that the British Association of Psychopharmacology (BAP) is currently providing. It took me a full day to go through the declarations. These follow below, in alphabetical order of  educator:





In summary it is encouraging to see these declarations of financial interests for BAP educators. This is a group of professionals who have a position of significant influence over the prescribing patterns of current and future psychiatrists. This means that even those doctors who regard themselves as not being subject to conflicts of interest may be indirectly influenced.

It is my concern that this potential influence is not always recognised by colleagues attending CPD in good faith and this is my reason for compiling this post.

“All in the past”: well, no.

All in the past from omphalos on Vimeo.

Seven years ago this Editorial was published in the BMJ:KOL

Eleven years ago, all NHS Chief Executives in Scotland were asked to implement and govern this Scottish Government circular: HDL 62. This has not happened.HDL-62

The General Medical Council published nine years ago:  “Good Medical Practice”, which makes very clear:Annexe A, GMC

General Medical Council on conflicts of interest from omphalos on Vimeo.

Seven years ago the Royal College of Psychiatrists issued its own guidance, CR148:CR148 says (3)

Given these multiple levels of failing in governance, and in the pursuit of scientific objectivity, I have petitioned the Scottish Government to consider implementing a Sunshine Act. The research behind this can be accessed here.

I am employed as an NHS psychiatrist and have been an NHS Consultant for 13 years.

Over this time, the key opinion leaders in UK psychiatry (though I have never met) have become known to me.

Continuing Medical Education invites (generally “CME-accredited”) come to my NHS e-mail address on a weekly basis.

As an NHS employee I have had regular invites to attend “CME-accredited” conferences that include educational talks by distinguished speakers such as:

  • Professor Allan Young
  • Professor Peter Passmore
  • Professor Guy Goodwin
  • Professor Philip J Cowen
  • Professor David Nutt
  • Professor J Chick
  • Professor David Taylor (pharmacist)
  • Professor Clive Ballard
  • Professor Nick Fox

It is the case that (in 2015) we still have no way of knowing how much may be paid to any individual to educate professionals like myself

The ABPI “central platform”, which will be operational next year, allows individuals to “opt out” of revealing any payments.

Dr McCartney has long argued that the medical profession should take the lead on transparency. I agree.

009b

The Royal College of Psychiatrists guidance CR148 has not been followed since it was introduced seven years ago. The updated system (following my dogged persistence) still fails to require details of monetary exchange or for specific dates of (any such) payments.

The USA have introduced a Sunshine Act and so in recent years, drug companies have started releasing details of the payments they make to doctors and other health professionals for promotional talks, research and consulting:

CropperCapture[1]

Over a decade ago, I noted this letter of reply by Professor Philip J Cowen. A reply that troubled me.

Cowen, P J - Constructionism 24-5-2011Professor Philip J Cowen

A straightforward internet search would indicate that Professor Cowen has followed extant guidance regarding transparency. Here follows some of the material on Professor Cowen to be found in the public domain:Cowen, P. J,CINP, 2016 Cowen, P J - 3-3-2014 Cowen, P J - 17-11-2014 Cowen, P J - 19-5-2011  Cowen, P J - 2011 2011, RCSPsych Int CongressCowen, P J - 2014 b Cowen, P J - 2014 Cowen, P J - 2015 Cowen, P J - April 2014 Cowen, P J - April, 2012 Cowen, P J - Aug 2010 Cowen, P J - Aug 2013 Cowen, P J - Dec 2012 Cowen, P J - ECNP Cowen, P J - Jan 2015 Cowen, P J - May 2012 Cowen, P J - Nov 2012 Cowen, P J - Nov 2012b Cowen, P J - Nov 2013From “Our own window” published in BMJ rapid responses:Soft rebuttal, 2001

Progress on transparency: Royal College of Psychiatrists

It is most welcome to be able to report that the Royal College of Psychiatrists have been considering my recent feedback, as a College member, on its governance of “relationships with pharmaceutical and other commercial organisations“.The College have now made publicly available the declarations of interest from the  Faculty of Old Age Psychiatry Annual Scientific Meeting held in Glasgow in March 2015. These can be accessed here (they are included in the “Final Programme“)Old Age March 2015 RCPsychI also understand from the President of the Royal College of Psychiatrists that they “will have an e-system in place by the next international congress” and that all of those on the Organising Committee will add any declarations of interest to their committee biographies.Forefront 2015I want to thank Professor Sir Simon Wessely who has been most helpful and taken time out of his busy schedule to communicate with me personally and has promised to keep me updated on the progress of the College in revising its guidance CR148. I very much admire and appreciate that our current College President listens carefully, engages widely and responds personally when he can. I should say that I have not had similar experience before.

One final point. The Royal College has admitted that “we were at fault for not being ahead of the game”. I am not sure this is entirely the best summary of where the College were before my recent communications on transparency of financial interests. I say this as the College published its guidance on this matter exactly seven years ago now. CR148 is very clear on what it expects in terms of “good psychiatric practice” and “relationships with pharmaceutical and other commercial organisations”. The research involved for my petition to the Scottish Government for a Sunshine Act has revealed that the Royal College of Psychiatrists is far from alone in having failed over many years in the governance of existing guidance in this area.

It may be that similar experience of failings in governance of transparency, across a number of organisations, was instrumental in the decision for the USA and France to introduce a Sunshine Act.

Psychopharmacology Committee: Royal College of Psychiatrists

Psychpharmacology Committee

This is the current membership of the Psychopharmacology Committee of the Royal College of Psychiatrists. It has eleven members and is chaired by Professor Allan Young.

I had expected that all members of this Committee would have ensured full declarations of interest. Along with the biographies 2/3rds of the Committee have given declarations. It is worth having a look at these.

Dr Ben Goldacre, on social media recently said this “I really wish the Royal College of Psychiatrists would show some leadership and do Conflict of Interest declaration properly. Not hard, happy to help. It’s unnecessary and embarrassing to be resistant on this issue, we need to be seen to be clean by our patients.”

I would like to see a wider variety of experience in the membership of such an influential committee. I note the committee includes an individual with “lived experience” and welcome this. Perhaps the Committee could also include a public health expert and an ethicist. I would like to see Committees such as these have the resources to be more critical of prevailing approaches.

 

 

“Believe me, that is not the way to get things done”

This post is about medical education in NHS healthcare: this is called “Continuing Professional Development” (“CPD”).

In this post I will explore the current relationship between medical education with commerce.

The title of this post is taken from a quote by the current Director of Medical Education for NHS Forth Valley in a communication to me on this matter. The Director of Medical Education was scolding me for asking about transparency.

As I get older I find that I see more patterns.

How we “see” such patterns will differ for us all!  My previous post was about a pattern that I had noticed regarding ageing and memory: The parabolic pattern

The pattern in this post is not one of light. It is a dark pattern. A pattern not easily seen.

Before trying to shed some light on this pattern, I want you to know that I am a scientist (as well as an artist) who supports innovation, scientific realism and progression. This is why the Scottish physicist, and poet, James Clerk Maxwell has long been my guide.

The pattern of images that follow (where I will try to keep my words spare) represent my very real concern that science today (and not just “in the past”) has rather too readily become the pocket of industry.

It was Alexander McCall Smith who wrote to me recommending this book:

026

This week I faced a repeating pattern with this “educational” circular from my new NHS employers:

014

Professor David Taylor is an Academic Pharmacist and so not registered with the General Medical Council. Prof Taylor has had significant input into the development of UK-wide guidelines on prescribing in mental health. He has been open about his significant financial conflicts of interest

018

Professor David Taylor, paid by the Pharmaceutical Company Janssen, had earlier this year, given an “educational” talk to CPD teaching with my former employers:

008

I refused to go to this. Why? Well through much of the previous 6 months, my NHS e-mail in-box had received e-mails (not at my request) from the makers of Asenapine. Several “key opinion leaders” featured in these promotions, including Professor Alan Young (whom more of later) and Prof David Taylor. The following slide comes from this online powerpoint:002

The next in this slide demonstrates good practice as in it Professor David Taylor outlines his comprehensive, and well-spread, financial conflicts of interest:

003

Even though not a doctor, after I wrote to him, Prof David Taylor submitted his declarations to whopaysthisdoctor.com . We should commend this openness, as here Professor Taylor is a leading example of necessary transparency. It is important however that we consider that in “offering” “education”  Professor Taylor has significant financial under-writing. Professor Taylor has had a significant role in the development of UK-wide guidelines on prescribing in mental health.

Three years back: On the 17th May 2011 I wrote to NHS Forth Valley to say that I found that the link to the “Hospitality Register” was non-functioning. It took two years of polite inquiry for NHS Forth Valley to finally confirm that as an NHS Board it had NO register of interests for ALL staff. I was later to discover (through Freedom of Information requests) that this was a pattern spread across ALL twenty-two of NHS Boards in Scotland:

007

Eleven years back: in circular HDL(2003) 62 The Scottish Government stated that “Chief Executives are asked to establish a register of interest for ALL NHS employees and primary care contractors”: 

027

This year: The Director of Medical Education for NHS Forth Valley, said (25 February 2014) “Traditionally we have not registered the various meetings on the list as it was not required of us”. 

I will post some recent examples of sponsored education involving NHS Forth Valley employees. I do so without wishing to focus on any individual. It is important that what I present is understood only as part of a wider pattern.

It may be my error, but I cannot find any declarations made, by those involved in these sponsored educational meetings in any NHS Forth Valley Register. I wrote to the CHP General Manager of NHS Forth Valley on the 20th March 2014, where I included ALL the following examples of employees involved in what would appear to be sponsored meetings.

[the coloured highlights in the following promotions are mine (they are only part of my much wider effort to bring transparency). My endeavour is not to single any individual out.]

[I recognise that the sample I present (based on my much wider pinterest page) is simply the promotions for “education” which have come my way.]

023

024

022020

Patterns appear at all levels and not just “local”. For the governance of conflicts of interest, at a UK level, we follow the General Medical Council.  At annual appraisal and at five-yearly revalidation all doctors are asked to sign a probity section where each individual doctor confirms (or not) the following (this screenshot is from my recent Revalidation):

012

Before closing: the following example of an “educational” “CPD” event reveals a pattern that does not just involve those employed by the NHS such as charities and third-sector organisations:

021

The pattern is broad. I have no doubt. I recently debated with Professor Clive Ballard at a Royal College of Psychiatry Conference in Durham. I suggested to the organisers, well in advance of the conference, that all those involved might consider that they declared any financial interests in the programme. The organisers agreed that this was a good suggestion. As it turned out I was the only one to declare.

011

Professor Clive Ballard chose not to reveal in the RCPsych programme, or in his presentation, any potential financial conflicts of interest.

Another speaker at this RCPsych Conference was Professor Allan Young. Like Professor David Taylor he had given hearty support to the promotion of Asenapine (my NHS email in-box was frequent witness to all of the promotions).

At the RCPsych conference, where I was a fellow speaker, Professor Allan Young started out by mocking any need for transparency: “for those of you who watch panorama, I do not give my consent for you to film this”. Professor Allan Young then presented his “Conflict of Interest Statement”. He did not talk his interests through (unlike the rest of his presentation) and my image is thus blurry. Professor Allan Young presented his multiple financial interests in a blink of an eye but also fortunately in a camera click.

In my camera click, I resisted Professor Allan Young’s wishes. Light is important to all patterns.

015

Following my advocacy, NHS Forth Valley, would seem to be the only NHS Board, out of Scotland’s twenty-two NHS Boards to have an open access register for all employees.

From the evidence I have gathered it seems clear to me that Scottish Health Boards continue to fall very far short of complying with HDL 62. Yet this guidance delivered to ALL NHS Board Chief Executives is now 11 years old!

I am not legally minded. Senior Health Board Managers in Scotland are signing off annual Appraisals and five yearly Revalidation that staff are individually following their employers Guidance (including Scottish Government HDL 62 guidance: guidance issued to all Chief Executives in 2003) . The GMC are clear on what is expected regarding “probity”

It is for this reason that I submitted a petition to the Scottish Parliament suggesting that they might consider a Sunshine Act. Other countries have instituted such legislation. Like John Betjeman, I do not welcome bureaucracy, however a central, open access register, enshrined-in-law, should be neither difficult nor burdensome to implement.

Early detection of dementia: RCPsych result

“This House supports the early detection of dementia”

Following on from my previous post which outlined my opposing argument, I can now share the result of this RCPsych debate:the result 26 Sept 2014

The narrowness of the result is undeniable. Yet the motion was defeated.

It seems that my fellow professionals were not fully swayed by the determination of a “Key Opinion Leader” such as Professor Clive Ballard.

I neither wish nor am I able to analyse this result, I only wish to record the result: that the motion that “this house supports the early detection of dementia” was defeated.

The forum of this debate is though worth reiterating:  Royal College of Psychiatry, members, for Continuing Professional Development (CPD) Conference.

I might speculate that this result is indicative of a growing concern regarding the difficult to establish boundaries between ageing and disease.

What follows are the slides that I gave in riposte to Prof Ballard’s initial argument. An argument in which he advocated the pre-diagnosis of dementia.

At this point it may be worth noting that this CPD-accredited Conference (unknown to me until arrival at the conference) was sponsored by Eli Lilly UK and the Medical Protection Society.

I did not have lunch at the conference but it still could not escape my notice promotions made by bill-board and representative of Eli Lilly. This was to promote AMYVID “Cognitive Impairment: Do you have the evidence you need to  reach a diagnosis?”P1030870

This promotion is rather extraordinary in that after boldly outlining encouraging statistics LILLY states that “Beta-amyloid disposition is BELIEVED to be a biomarker for Alzheimer’s disease”.

AMYVID--sponsored-Durham-Co

I do not know about you, but my approach to science has not been one of “belief” (scientism) but rather seeking evidence based on systematic analysis and using this as a guide to professional and ethically based practice.

As stated, I had suggested to Dr Tom Hughes, the organisers and my opposing debater, before the Conference in Durham that all speakers might like to consider declaring any interests in the programme. As it turned out I was the only speaker to do so. One speaker, Prof Allan Hughes did presented his interests in a slide, but in the time it took my camera to click, the slide was gone. Prof Allan Young did not talk through his declarations but said before his FLASH presentation of them that:

“For those of you who watch panorama, I do not give my consent for you to film this”

Given extant GMC guidance I have ignored Prof Allan Young’s request and so here follows his interests as captured on my camera in Durham, at this RCPsych, CPD sponsored event, dated 26th September 2014:

Prof-Allan-Young-26-9-14

Returning to my riposte to Prof Clive Ballard. These were the slides on which I based my reply:

I started with one of my published letters in the British Medical Journal:

Untitled-1 copy

Confusion abounds. The recent BMJ discussion about the screening for dementia has highlighted that it is both incorrect and potentially stigmatising to consider such confusion as the preserve of our older generation.

At least six areas of confusion do seem prevalent when it comes to our understanding and collective approach to memory loss in old age:

(1) General confusion:
The general population is increasingly using the word “Alzheimer’s” instead of “dementia.” This is hardly surprising when you consider:

(2) Professional confusion:
NICE and SIGN Guidelines for Dementia both contain definitions of dementia and of Alzheimer’s disease, yet in the body of the guidelines, the terms are frequently used interchangeably.

(3) Confused ‘education’:
Much post-graduate medical “education” is sponsored by the Pharmaceutical Industry. Much awareness raising by charities is also backed by the Pharmaceutical Industry. Many political imperatives are influenced by lobbyists for the Pharmaceutical Industry. We are certainly confused about where the line lies between these activities and “marketing”?

(4) Confusion between research and clinical agendas:
Advances in research are too often extrapolated prematurely into a general clinical setting by well intentioned clinicians who may also be responding to the clamour of the latest press-release.

(5) Confused about risk:
The communication of risk is fundamental to medical practice but is undoubtedly difficult. Every intervention has the potential for benefit and for harm. We are so keen to see the former that we sometimes forget to look for the latter.

(6) Confusion about science:
Scientific evidence must be taken in context. Many universities are responding to this by making the Medical Humanities an integral part of their under-graduate medical curriculum.

The dictionary definition of confusion is: “a feeling that you do not understand something or cannot decide what to do.” We must resist the temptation to respond to confusion with over-simplification and instead find a way to acknowledge complexity.

SLIDE 1:
This is a screenshot of the latest Alzheimer’s Society film on research. The Alzheimer’s Society state that “current treatments only help with the symptoms for a short while” Alz Society 14 Jan 2014

SLIDE 2:
The Alzheimer’s Society continue “they don’t stop dementia from progressing”Alz Society 14 Jan 2014b

SLIDE 3:
In June 2010, an outcome of a judicial review for  NICE guidance on drugs for Alzheimer’s disease was published.NICE-June-2010

The Judge found that NICE “was not irrational in concluding that there is no cumulative benefit to patients after 6 months treatment with these drugs”

SLIDE 4:
At last year’s national Conference, in a talk sponsored by Lundbeck, Professor Ballard presented a talk entitled “Clearing the fog: what are the barriers to evidence based prescribing in Alzheimer’s disease”Three-KOL's-2013-in-UK's-Na

SLIDE 5:
This talk would appear to have been  based on this publication of the same year in the British Journal of Mental Health Nursing.

It is worth noting that Prof Ballard, like most research academics, refers to Alzheimer’s disease and not Dementia of an Alzheimer’s type.Barriers-ballard

SLIDE 6:
In this paper Prof Ballard states “However, despite evidence of significant benefits of pharmacological treatment only 10% of dementia patients receive Acetylcholinesterase inhibitors or Memantine – this figure remaining much the same since 2008. In addition to the beneficial clinical outcomes of these treatments in the slowing of cognitive and functional decline, health economic analyses also indicate that they are cost effective”

SLIDE 7:
This article written by the CEO of Alzheimer’s Society in The Journal of Dementia Care has Jeremy Hughes stating the opposite to what his own organisation have said in recent media “Although drug treatments aren’t effective for all people with Alzheimer’s disease, they can slow down the progression of the condition for many”CEO-of-Alz-Society-July-201

SLIDE 8:
The current Alzheimer’s Society film however states “they don’t stop dementia from progressing”Alz-Society-14-Jan-2014b

SLIDE 9:
This report in the PULSE journal from January 2014 concluded that ”the analysis of data from 2012 found prescribing rates of Donepezil, Galantamine, Rivastigmine and Memantine were 50% higher than expected when compared with prevalence rates of Alzheimer’s disease.”26-Jan-2014-AD-drugs3er 

SLIDE 10:
In a “Think tank” Report sponsored by LILLY it was concluded in 2012 that “doctors should be rewarded for the early diagnosis of dementia” and they also “suggested targeted screening”CropperCapture[2]

SLIDE 11:
Just recently, the Editor of the BMJ called Pre-dementia (in other words early diagnosis) as “another government policy, which based on this paper, might be summarised as daft and damaging”CropperCapture[3]

SLIDE 12:
Dr Clare Gerada, former Chair of the Royal College of general Practitioners has openly stated, and copied to Professor Alastair Burns, our Dementia Tsar, that “screening for minor memory loss risks medicalising normal ageing”CropperCapture[4]

SLIDE 13:
Dr Margaret McCartney in Chapter 9 of her book “The patient Paradox”  explores “Who decides what doctors do: pharma, politicians or patients?”CropperCapture[5]

SLIDE 14:
I remember this BBC News Report from January 2012. It featured my fellow debater who now advocates for the early detection of dementia. In this report, Prof Ballard described how brain function can start declining as early as age 45.CropperCapture[6]

SLIDE 15:
The doctor and entrepreneur, Prof Claude Wischik, of Tau Therapeutics has expanded this finding in the following way: “one in five adults over 40 are impaired by Alzheimer’s”CropperCapture[7]

SLIDE 16:
There are many types of dementia such that there is a risk that “Alzheimer’s” has become synonymously misunderstood as dementia. One of the first questions I am generally asked at the clinic “what is the difference between Alzheimer’s and dementia”

This is a quote I have used many times in my publications and films on early diagnosis. It is from the Lancet in 2011 in an article by my colleague Prof Ballard:

CropperCapture[8]