A letter that the Scottish Parliament felt unable to publish

With careful thought, and backed with full supporting evidence,  I sent the following letter of the 2nd February 2016 to support my petition for a Sunshine Act for Scotland.

The Senior Clerk of the Parliamentary Committee was of the view that this letter did not comply with the Scottish Parliament’s policy on the treatment of written evidence. I was therefore asked to redact significant sections of the letter.

After considerable communications to and fro, I replied as per this e-mail of the 3rd March 2016:

I fully respect the right of the Scottish Parliament to determine 
what it publishes.

I feel very strongly that my letter without the highlighted text 
merely reiterates what I have already said, and fails to provide 
the evidence that I have repeatedly been asked for.

So my position is that I do not wish to amend my letter of the 
1st February on PE1493.

My petition has since been closed. I therefore have decided to publish my letter to the Scottish Parliament in full along with supporting evidence. I have had professional advice that what is contained in this letter is not defamatory as it is based on veritas and has full supporting evidence:

Dear Mr McMahon
Petition PE01493: A Sunshine Act for Scotland

I realise that the Committee must receive a great amount of correspondence however I hope that the committee might agree that what follows is extremely important when considering PE1493.

Since I last wrote to the committee I attended, for accredited continuing medical education, the Royal College of Psychiatrists in Scotland Winter Meeting held on the 29th January 2016. It is this that has compelled me to write this update as it demonstrates beyond doubt that lack of transparency around financial conflicts of interest remains a serious issue. An issue with implications for both patient safety and healthcare budgets. It also demonstrates that Government action is the only way to address this.

The full powerpoint presentations of this Accredited meeting for 
Continuing Professional Development can be accessed here - but only
for members of the Royal College of Psychiatrists. 

I am a member of the Royal College of Psychiatrists and I am of the 
view, as a scientist, that these lectures should be available to all 
and not just to members.

One speaker highlighted the increase in prescribing costs in her health board area which was due to the high prescribing rate of a new antipsychotic injection, palperidone depot (XEPLION®). The next speaker demonstrated both the inferior effectiveness of this drug when compared to existing (far cheaper) depot medications and the perception amongst Scottish psychiatrists that it was more effective. Below you will see the flyer sent to mental health professionals in Scotland when this drug was launched:

002 Financial Conflicts of Interest, Scottish Psychiatry

I have highlighted one of the paid speakers, Dr Mark Taylor, because he also spoke at this week’s meeting where he reminded us that he was Chair of SIGN Guideline 131: The Management of Schizophrenia, which was published in March 2013.

At this week’s meeting Dr Taylor presented his declarations as follows: “Fees/hospitality: Lundbeck; Janssen, Otsuka; Roche; Sunovion”.

Dr Taylor commented on these declarations with the statement that “you are either abstinent or promiscuous when it comes to industry. Well you can see which side I am on”. Audience laughter followed.

The general question that arises is whether an influential professional such as a Chair of National Guidelines might earn more from the pharmaceutical industry than in his or her role as a healthcare professional? At present it is impossible for anyone to establish the scale of competing financial interests. To remind the committee the following avenues are not illuminating:

1. Royal College of Psychiatrists. This week’s meeting did not appear on the college database. In any case this database is neither searchable nor does it include specific details of payments and dates

2. NHS Boards. The committee has already established that, across Scotland, HDL62 is not being followed.

3. SIGN guidelines. The committee is aware of significant governance failings particularly in comparison with NICE which includes details of financial sums paid and associated dates.

4. Discussions with Senior Managers in NHS Scotland relating to the General Medical Council’s expected level of transparency has brought forth written responses describing my interest as “highly unusual” and “offensive and unprofessional”

5. The forthcoming ABPI register allows any professional to opt out of inclusion.

It is also worth repeating that the information provided to the public consultation on this petition failed to highlight most of the issues identified in points 1 to 5 above.

In terms of cost both to the public purse and the individual patient the Government’s stated wish for a “robust, transparent and proportionate” response would be fulfilled if a single, searchable, open register of financial conflicts of interest that has a statutory basis were to be introduced

“Unprofessional”

My view is that we all have conflicts of interest.

Science however cannot ignore financial conflicts of interest.

We can find no record

The above was a recent statement by the Scottish Government in response to my petition for a Sunshine Act.

This statement by the Scottish Government reminded me of why so many of my healthcare colleagues would choose not to express any concern about lack of transparency

My experience in asking, as fairly and politely as I can, about the governance of: Good Medical Practice” (General Medical Council); NHS Scotland (HDL62) and Royal College of Psychiatrists (CR148) has met with calls of being “unprofessional”.

Annexe A, GMCHDL-62CR148 cover

It was disappointing how many colleagues used the term “unprofessional” when asked about governance of the declarations of financial conflicts of interest.

NHS Forth Valley – Hospitality Register 2013/2014

As petitioner for the Sunshine Act I undertook Freedom of Information Requests to all 22 NHS Boards in Scotland to establish if Boards had  Registers of Interest for ALL staff. The findings revealed that most Boards did not.

NHS Forth Valley has kept Registers of Interest from 2010 to current date. Following persistent enquiries by myself regarding public transparency these have recently been made available on-line.

This accords with the guidance in HDL 62, issued 2003: “Chief Executives are asked to establish a register of interest for all NHS employees and Primary Care contractors”. For this, and for taking the extra step of ensuring public access to the registers, NHS Forth Valley are to be congratulated.

This blog post encourages you to consider the contents of NHS Forth Valley’s Hospitality Register for 2013 to 2014 as an illustration of the involvement of sponsorship of Continuing Professional Development (“CPD”).

There is now robust research evidence that sponsorship influences clinical practice, no matter how much individual healthcare workers claim to be immune from such influence.

BMJ-cover-19-July-2014---me

We are all aware of straightened public sector budgets and so it is perhaps not surprising that external sources of finance are welcomed. In fact it would appear that:

“Yes, you’re correct – there is no NHS Forth Valley budget that pays for educational meetings held in the Centre.” Director of Medical Education for NHS Forth Valley, 25th February 2014

I would argue that this is a false economy adding to the risk of over-medicalisation and subsequent harm.

(the following is an example, showing just one page out of seven, from NHS Forth Valley’s Hospitality Register 2013-2014)

*Note, as of last time of checking, 10 December 2014, the current Register has not been updated since I left employment with NHS Forth Valley. This means that there has had no entries in 4 months.

CropperCapture[1]

“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.