‘It was odd being dead’

This is a fictional film. It is about a teddy bear, Dr Hale Bopp and a day of two halves. In the morning Dr Hale Bopp goes exploring in the Scottish Borders and he comes across the ruin of the Monteath mausoleum on Gersit Law. The oak door of the mausoleum has been breached and one can get inside and be with Monteath and the two angels that guard this forgotten statesman. Above him the dome has beautiful window stars to the universe beyond.

Dr Hale Bopp is a well-travelled bear and is constantly exploring, enjoying and reflecting upon the world in which he lives. The guid doctor has come to the view that life is complex, diverse and sometimes “messy”. He leaves the Monteath mausoleum with paws that were muddy and heads for a different afternoon. An afternoon of Appraisal to ensure that as a fictional bear and doctor that he is providing Good Medical Practice.

So that was the day of two halves. This film is about that.

Dr Hale Bopp is getting on a bit now and is at the end of his fictional medical career. One day soon he will retire from being a doctor but meantime he is of the view that his wanderings, philosophical and creative between the arts and sciences, has been nothing but to the benefit of the patients that he cares for.

Important note:
None of the words used in this film are those of the filmmaker. They are “borrowed” from C.P. Snow’s “Corridors of Power”; Evelyn Waugh’s “Decline and Fall”; and Jessie Burton’s novel “The Muse”.

‘It was odd being dead’ from omphalos on Vimeo.

Source material:
(1) Physicians of the future: Renaissance of Polymaths? By B F Piko and W E Stempsey. Published in The Journal of the Royal Society for the Promotion of Health. December 2002, 122(4), pp. 233-237
(2) Time to rethink on appraisal and revalidation for older doctors. By Dr Jonathan D Sleath. Letter published in the BMJ, 30 December 2016, BMJ2016;355:i6749
(3) Career Focus: Appraising Appraisal. Published in the BMJ 21st November 1988, BMJ1988;317:S2-7170
(4) Revalidation: What you need to know. Summary advice for Regulators. General medical Council.
(5) The Good Medical Practice Framework for Appraisal and Revalidation. General medical Council.
(6) Taking Revalidation Forward: Sir Keith Pearson’s Review of Medical Revalidation. January 2017.
(7) GMC response to Sir Keith Pearson’s report on Taking Revalidation Forward.

Music credits (under common license, thank you Dexter Britain):

(1) Perfect I am not – by Dexter Britain
(2) Telling stories – by Dexter Britain


“This most unusual request”

In August 2013 I read an article published in the BMJ which was entitled Three quarters of guideline panellists have ties to the drug industry”.

Majority-of-Guideline-panel

I have petitioned the Scottish parliament for a Sunshine Act. My petition seeks a single, searchable register of payments made to healthcare workers and academics. My petition has now been considered 6 times by a parliamentary committee. The committee would appear to be coming to the view that such a register would need to have statutory underpinning (just as they have in France and the USA). However, before any decision is made by parliament, the Scottish Government have asked for wider public consultation.

Update, March 2016: 
The public consultation concluded, by majority, that it should be 
mandatory for all financial transactions to be publically declared.

Peter-Sunshine,-Jan-2015

The Scottish Government and the Cabinet Secretary for Health, Wellbeing and Sport, have made comment “that apart from the petitioner” the issue of transparency has not been raised by other NHS healthcare professionals. This brings me to this blog-post which might explain why this has been the case.

we-can-find-no-record

In an entirely anonymised way I shall briefly present the narrative behind a senior healthcare professional who served as a key individual in a panel developing a national guideline. Unfortunately no records of financial interests for this guideline exist and so, as part of my research for a Sunshine Act, I wrote politely to this senior healthcare professional asking for the details of any financial conflicts of interest. I was grateful to receive responses but unfortunately found that they were uninformative and defensive. It was however clear from research publications that this individual had received payments from the pharmaceutical industry.

HDL-62

In Scotland, all NHS Chief Executives were written to by the Scottish Government in 2003 asking that they established registers of interests for all employees including GPs. However, across Scotland, for more than 12 years, this guidance has not been followed. In the hope that this senior healthcare worker had declared to his employers, I wrote to the Health Board involved. In doing so they breached my polite request for anonymity. I asked the Health Board if they could forward the evidence of this senior healthcare worker’s declaration to his employers, as expected in HDL 62 and also for GMC Annual Appraisal.

After many months, I received a reply from the NHS Board. This is the relevant section of the reply which confirms there are no entries for this senior healthcare worker who was involved in developing a national guideline which advises on prescribing.

One a

The NHS Board reply encouraged me to consider confidentiality of this senior healthcare worker but made no apology for my anonymity being broken.

The final paragraph of the NHS Board reply apologised for the time taken to look into this but asked me to “appreciate that this is a most unusual request”.

One b

The GMC does not consider it “unusual” to maintain transparency regarding financial conflicts of interest:

GMC on CoI

My experience for researching whether GMC guidance and extant NHS Scotland guidance on transparency have been followed has been most difficult. It has had negative consequences for me and I have felt as if I have been regarded as “unusual” to be concerned about transparency. Robert Francis in his two recent reviews relating to the NHS has talked of ‘a culture of fear’ where healthcare workers are fearful of the consequences of putting patients first. Perhaps then, this is why, other healthcare workers have not raised concerns about transparency of payments made by industry to colleagues.

Freedom to speak up

It would appear from this example that it is possible that authors of prescribing guidelines may have previously been paid by industry. As things stand there is reasonable chance, as a Scottish patient, that the medication you receive has been informed by such a process. And you will have no way of finding out if this is the case.

Update, September 2016:

SIGN 86, Management of patients with Dementia, has now been withdrawn, 
so is historical. 

I therefore feel that it is entirely reasonable to identify it.

sign-86-guideline-chair-dr-peter-connelly-guideline-now-withdrawn

sign-86-guideline-healthcare-improvement-scotland

 

“Trust is generally being eroded”

Last week I watched with much interest the 52nd Maudsley debate. The motion debated was: “This house believes that the use of long term psychiatric medications is causing more harm than good”.

52nd Maudsley debate

The Maudsley debate was covered in a head-to-head BMJ article.

Long-term-use-of-psychiatri

Given that I have petitioned the Scottish Government for a Sunshine Act I was interested in what this Maudsley Debate might say about our approach to transparency of financial conflicts of interest:

Transparency: hold the applause (British Psychiatry) from omphalos on Vimeo.

This particular aspect of the 52nd Maudsley Debate reminded me of a series of letters published in the BMJ a decade ago. It is interesting to consider what has, and what hasn’t changed, in the intervening ten years. The letters were in response to the following 2003 editorial:

No more free lunches (2003)

In a letter of response Dr K S Madhaven argued that “the market has us all in its grip”:

001 Madhaven

Whereas Professor Simon Wessely, in his letter of response, was of a view that “It is time we all grew up”:

001 Simon Wessely

Simon Wessely

Professor Wessely began his letter of 2003:

002 Simon Wessely

and continued:

005 Simon Wessely

It is interesting to reflect on changes that have occurred in the United Kingdom since 2003:

  1. Continuing Professional Development (CPD) has become a requirement of GMC Revalidation:
  2. the pharmaceutical industry now has to follow the ABPI code and healthcare professionals no longer receive branded products such as pens 
  3. “Sandwich lunches” (sponsored Continuing Medical Education – CME) remain core to continuing education. In NHS Scotland, at least two NHS Boards rely entirely on industry sponsorship to support the education of their staff
  4. It remains the case that, at any educational conference, neither the audience nor the public have any idea of how much speakers may have received from the pharmaceutical industry or commercial enterprises in the past three years. The proposed 2016 ABPI register is unlikely to help as any individual can opt out of disclosing payments received. Going by the experience in America, in some cases considerable sums may be routinely involved.

Professor Wessely, in 2003, was concerned about over-regulation, a concern that many of us, including myself have some sympathy with:

006-simon-wessely

Watching the Maudsley debate, in 2015, I was reminded of Professor Wessely’s 2003 fear that “trust [was] gradually being eroded” . It would seem to me that the audience of 2015 would agree with Professor Wessely that this may indeed have happened. However such erosion of trust would seem to be for exactly the opposite reason given by Professor Wessely. It would appear to be the lack of transparency rather than an “Orwellian world of prohibitions” that has contributed to this.

007-simon-wessely

Following the 52nd Maudsley Debate I have written to Professor Wessely, as President of the Royal College of Psychiatrists, to ask if the College might support a single, central, open, searchable database where all payments to healthcare workers, academics and researchers must be disclosed.

Royal College of Psychiatrists: relationships with pharmaceutical and other commercial organisations

In response to my letter to the Royal College of Psychiatrists regarding relationships with pharmaceutical and other commercial organisations I received this e-mail from Professor Nick Craddock, Treasurer of the Royal College of Psychiatrists:

From: Nicholas Craddock
Sent: 13 March 2015 15:17

Dr Gordon
Thank you for your letter of 15th February concerning the revision of CR148 “Good Psychiatric Practice: Relationships with pharmaceutical and other commercial relationships”. The current report along with all other College reports is available on the College’s website.

This report has been reviewed initially by the Committee on Professional Practice and Ethics. Their draft has been sent for comment to the Psychopharmacology Committee and to representatives from the Academic Faculty including myself. The document will then be further revised in the light of comments received before being finally approved by the Policy and Public Affairs Committee. If you would like to submit any written comments perhaps you could send these to the Chair of the Policy and Public Affairs Committee as soon as possible.

The declarations of interests for speakers at the forthcoming International Congress will appear on the Congress App which is available to all delegates. If you are not able to come to Birmingham I can arrange for this to be sent to you. Declarations are currently being collected.

The declarations of interests for speakers at the Old Age Conference will be available to all conference delegates. I can also make these available to you if you are not intending to attend this conference.

Yours sincerely
Nick Craddock

Professor Nick Craddock
Treasurer
Royal College of Psychiatrists
21 Prescot Street
London E1 8BB

Here is the reply I have sent to the Royal College of Psychiatrists dated 14th March 2015:

Dear Professor Craddock
Thank you very much for your e-mail of the 13th March 2015 which is most helpful. It is particularly welcome to hear that, in terms of the forthcoming CPD-approved Royal College of Psychiatrists Conference that “the declarations of interests for speakers at the forthcoming International Congress will  appear on the Congress App which is available to all delegates.”  As I am not coming to this conference I would be most grateful to accept your offer to arrange for this to be sent to me.

Forefront 2015

I would also like to accept this further offer: “the declarations of interests for speakers at the Old Age Conference will be available to all conference delegates.  I can also make these available to you if you are not intending to attend this conference.”

Old Age March 2015 RCPsych

I remain of the view, as articulated in my letter of the 14th February 2015, that The College should have no more difficulty in having a tab on the homepage of these Conferences with declarations of all involved than they do in having a tab on the homepage for “Exhibition opportunities.”

exhibition-opportunities

I am also most grateful to be appraised about the process and timescale of the revision of CR148 “Good Psychiatric Practice: Relationships with pharmaceutical and other commercial relationships” which was first approved in January 2008. I note that CR148 contained a “due for review: 2011”.

CR148 cover

You have invited me to make comments on this revision to CR148 and to forward these “as soon as possible” to the Chair of the Policy and Public Affairs Committee. I hope this letter will suffice and I will forward it to the Acting Head of Policy as you suggest. I have not been party to any of the considerations to date and for this reason I would like to comment on the existing guidance, CR148, issued January 2008.

The research that I have undertaken across the UK over the last few years, in preparation for advocating a Sunshine Act to the Scottish Parliament, has led me to conclude that this guidance is not being fully followed.

CR148 principles

The “principles” of CR148 have a basis on “transparency” and “full declaration of relationships with commercial organisations”.  When I was a speaker at the RCPsych Autumn Conference in Durham I was the only speaker to declare my interests in the programme.  At the Conference itself, Professor Clive Ballard, one of the other speakers, did not declare any interests at all. Another speaker, Professor Allan Young, a key Opinion Leader in Affective disorders, appeared to belittle transparency regarding the need to declare financial  interests. There was no declaration of his extensive financial interests in the programme.

debate-as-set-out (2)

This leads me to my FIRST QUESTION in relation to the proposed revisions of CR148: What consequences will there be for an individual who does not follow the guidance?

CR148 guidance

CR148 states “psychiatrists should avoid accepting inducements that might compromise the independence of their professional judgement and practice”. We know from ABPI figures that in a calendar year at least £40 million has been paid to UK health professionals by the pharmaceutical industry.

40 million

The ABPI have recently introduced a “Central Platform” which will form a central register of individual financial payments to healthcare workers. This will not start reporting till 2016. However the main problem with this register is that individual healthcare workers can opt-out of disclosing payments. Given that the Royal College of Psychiatry is not alone in having struggled to govern its own existing guidance, it is reasonable to have concern that this ABPI “Central Platform” will share such difficulties.

Thus, my SECOND QUESTION: What role, if any, will the ABPI “Central Platform” have in the revised CR148?

CR148 Registers of members interests

The research I have undertaken in NHS Scotland has confirmed that local registers are generally not being maintained and are generally not open to the public.

The Scottish Government has confirmed that the guidance issued on this in 2003, HDL 62, has not been followed. HDL 62 asked the following of Chief Executives:

HDL-62

At annual appraisal all doctors are asked to sign a Probity statement similar to the screenshot below. In this, each doctor confirms that he or she has followed paragraphs 56-76 of Good Medical Practice and complied with local mechanisms of declaring interests. In Scotland, I have evidence that in terms of “transparency” that there are widespread discrepancies here and I fear that public trust in our profession may suffer if we do not take action.

Probity statement SOAR Appraisal (Jan 2014)

To conclude, my view is that the simplest, most effective, consistent and evidence-based way to ensure transparency regarding financial conflicts of interest would be to have UK legislation that seeks a central, single, open, searchable register that is updated on a regular basis and which is tied to professional accountability and GMC governance. Ideally this would include not just psychiatrists, but pharmacists, academics, allied health professionals and indeed charities. My final question then is what discussions have taken place between the Royal College of Psychiatrists and the GMC on revisions to CR148

Yours sincerely

Peter signature
Dr Peter J. Gordon

Copied to:

  1. Professor Sir Simon Wessely, President Royal College of Psychiatrists, 21 Prescot Street, London, E1 8BB
  2. Vanessa Cameron, Chief Executive, Royal College of Psychiatrists, 21 Prescot Street, London, E1 8BB
  3. Chris Fitch, Acting Head of Policy, Royal College of Psychiatrists, 21 Prescot Street, London, E1 8BB
  4. Niall Dickson, Chief Executive and Registrar, GMC, Regent’s Place, 350 Euston Road, London NW1 3JN.

Royal College of Psychiatrists and conflicts of interest

The Chief Executive of the General Medical Council (GMC) recently confirmed, in response to a recent BMJ article, that it “takes very seriously the issue of conflicts of interest”:start-with-GMC

We know that in the course of a year, in the United Kingdom:40 million

Currently, it is almost impossible to find out anything other than the overall figure.

NHS registers of interest are not functioning. Yet doctors are asked to sign this at annual Appraisal:Probity-statement-SOAR-ApprAll Appraisals are then scrutinised by senior NHS managers to be “signed off”:

The BMJ make this charge:failure of regulation

However should we be asking if our Royal Colleges are also failing?

For several years I have written to the Royal College of Psychiatrists about conflicts of interest. This post is based on the latest correspondence which was prompted by the recent announcement of this International Conference:

change-my-practice

The Co-chairs give this welcome note:welcome-by-co-chairs

It is almost certain that a significant proportion of the £40 million goes to: KOLs2

The Conference organisers have made it clear of the “exhibition opportunities” provided at this event:exhibition-opportunities

What is less clear is whether the speakers or those involved in workshops or seminars have any conflicts of interest.

This is why I have written to:Board-RCPsych

My most recent letter to the above, copied to the Chief Executive of the GMC, asks for transparency ahead of the Conference in this important area:Craddock-letter

 

 

 

 

 

 

“A probity issue and may lead to a failure to revalidate”

Here is a submission to the BMJ by S. Musheer Hussain, Consultant & Hon Professor of Otolaryngology, Ninewells Hospital & University of Dundee Medical School:
CropperCapture[1]
Here is relevant communication with NHS Tayside on a register of interests