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

Stephen Stahl: $3,581,159 in payments from Pharma

In my last post I considered the level of transparency provided by the British Association for Psychopharmacology (BAP) in relation to its recently published Guidelines on prescribing for depressive disorders.

This post, will very briefly look at the programme for the recent 2015 Summer Meeting and specifically the issue of transparency:

07BAP

If you download the programme and then type “declaration” into text search you get zero responses.

The programme does list these sponsors:

08BAP

I noticed that Stephen Stahl was giving several keynote educational talks on day one of this conference for the British Association for Psychopharmacology (BAP). Stephen Stahl is a world-wide “key opinion leader” who has his home in California.

09BAP

In America all payments to individual doctors and academics must be provided for the public. This being a statutory requirement of a Sunshine Act. All payments can be established by typing into a searchable database called dollars for docs.

Here is the return, as at the time for writing, for Dr Stephen Stahl:

Stephen Stahl

In the United Kingdom the public have no way of establishing if or how much individual British doctors or academics may have been paid by the pharmaceutical industry or by other commercial companies. When these individuals are involved in educating the healthcare profession or drawing up guidelines this situation needs to change. And soon.

 

 

British Association for Psychopharmacology Guidelines (BAP)

01BAP

The above Evidence-based guidelines for treating depressive disorders with antidepressants has recently been published.

The British Association for Psychopharmacology are an organisation highly regarded by my profession of psychiatry. 12% of their funds come directly from the Pharmaceutical Industry.

I have petitioned the Scottish Government to introduce a Sunshine Act. It is for this reason I am interested in transparency of financial conflicts of interest.

Some of the expert authors involved in developing these guidelines have featured in Hole Ousia before, including:

Other authors of these guidelines are well known as “key opinion leaders”. Some were part of the Royal College of Psychiatrists International Congress, 2015 and their declarations can be found here

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

This post looks only at the level of transparency provided by BAP in these Guidelines. Most academics are of the view that full transparency of financial interests is necessary if we are to make recommendations that are “explicitly evidence-based”:

02BAP

I have written to Susan Chandler, Executive Officer for BAP, on a number of occasions over the last few years about BAP’s approach to declarations of interest:

03BAP

Professor Ian Reid was a former colleague of mine 
who is sadly missed.

Here is a copy of my last communication with BAP sent at the beginning of May 2015:

12BAP

I copied this to the General Medical Council. They did not reply.

This was the reply from the Executive Officer for BAP. I have received no further communications:

13BAP

Here is what BAP provides in these Guidelines. It is worth comparing the limited amount of information provided here with the much more comprehensive information provided by NICE guidelines.

04BAP

05BAP

In conclusion:
It is not possible to find out how much doctors like these Guideline authors have been paid.

The Academy of Medical Royal Colleges are of the view that all payments to individual doctors and academics should be mandatory.

10BAP

All in the past from omphalos on Vimeo.

Update, 5th October 2016. The following was published on the 
front page of the Scotsman newspaper: 

"Mental health prescriptions hit ten-year high"

prescriptions-for-mental-health-drugs-10-year-high-nhs-scotland-2016-a prescriptions-for-mental-health-drugs-10-year-high-nhs-scotland-2016-b

The figures are from the Scottish Government and can be accessed here.

Latest Advances in Psychiatry

What follows is recent correspondence with the organisers of “Latest Advances in Psychiatry”. I can publicly share older correspondence if so wished. It is not dissimilar

From: Gordon, Peter J
Sent: 22 April 2015 11:14
To: ‘imayne@wiley.com
Subject: 14th Latest Advances in Psychiatry Symposium

Dear Izabela,
I hope you do not mind me writing. I seem to recall I contacted you before the previous LAP Symposium and you were very helpful. Though I recall only one of the sponsored talks had an identified speaker at the time we communicated and that was Professor N Farrier.

I have petitioned the Scottish Government for a Sunshine Act which if implemented would make declarations of financial interests a statutory requirement for healthcare workers and academics. I say this to explain my interest. I understand that conflicts of interest are part of life but argue that we should be fully transparent about financial conflicts of interest. I say this as an NHS doctor and psychiatrist of 20 years.

Recently I have been helping the Royal College of Psychiatrists improve transparency and the President Prof Sir Simon Wessely has been most helpful. Yet it still seems the case that College Guidance, CR148, issued 7 years ago is far from generally being followed, let alone governed over this time by the College.

I note the LAP Symposium held last month had three “satellite” symposia: one sponsored by LUNDBECK and two sponsored by SUNOVION.

I was wondering if the public can have open access to the financial basis of such sponsored symposia and where it is clarified who gave the sponsored talk and where publicly they made full declarations of interest as per CR148?

I would hope that declarations for all involved in LAP 13 and 14 have been made, are archived, and publicly available. This should include organisers and Chairman.

I do hope you can help direct me to the level of transparency that is enshrined by the Royal; College of Psychiatrists in CR148 and also, for doctors, the GMC “Good Medical Practice”.

Kind wishes
Dr Peter J Gordon
Bridge of Allan

Wiley reply

“Conservative prescribing”

This editorial, an opinion piece by Prof David Healy, was recently published in the BMJ. In this post I intend to explore the arguments made around whether “chemical imbalance” was ever part of standard medical teaching. I will also explore the suggestion, made by some experts that antidepressant prescribing in the western world is “conservative”.

024 Conservative Prescribing

Professor Healy’s editorial has attracted a number of replies. Here is one:

026 Conservative Prescribing

A psychiatrist in training gave his view that the above reply was “the cleverest” and then offered his own reply:

016 Conservative Prescribing

The psychiatrist in training then gave the following link to what he called: “the sensible reaction”:

019 Conservative Prescribing

I found that I agreed with the statement made in this “expert reaction” by the President of the Royal College of Psychiatrists:

018 Conservative Prescribing

However I found that I did not share the view of Professor David Taylor that the “idea that SSRIs correct an imbalance in the brain never really existed”:

017 Conservative Prescribing

In the 1990’s, as a psychiatrist in training, I followed the “Defeat Depression Campaign”. A central plank of this was the “chemical imbalance theory” involving serotonin. There was hardly an educational event that I went to where a “Stahl” neurotransmitter diagram was not displayed. Even up till 2007, I still found the Stahl diagrams appearing as part of my CME education:

029 Conservative Prescribing

In response to Professor Healy’s article on serotonin and depression it concerns me that experts such as Prof Philip J Cowen and Prof David Taylor are suggesting that the “chemical imbalance theory” always was “mythical”. I was there. It was a very real part of my “education” and often given by experts of the day.

Furthermore, it would seem to me that such expertise is considered as sufficient in itself rather than including experience of taking SSRIs both short and long-term.

027 Conservative Prescribing

In his BMJ editorial Professor Healy gave this stark 2015 statistic:

012 Conservative Prescribing

It has been argued that this figure indicates over-diagnosis:

028 Conservative Prescribing

“Are antidepressant overprescribed”  was the question debated between Dr Des Spence and Professor Ian Reid  published in a BMJ Head-to-Head in January 2013.

Are antidepressants overprescribed, BMJ, 2013

A few years before this debate I gave a view on antidepressant prescribing from “my own window” which I submitted as a rapid-response in the BMJ. As I journey through life I often find my views change, but the view from the window I looked out from in 2011 seems still to be very much the same to me.

I was very sad when Professor Ian C Reid died last year, prematurely, as the result of cancer. I trained with Ian Reid in Aberdeen and he was an inspirational speaker and a most committed scientist. His loss is significant.

This research study was published in the British Journal of General Practice in September 2009:

020 Conservative Prescribing

The study gave a conclusion that I agreed with:

Conservatively

The study supported my view that GPs do not indiscriminately prescribe antidepressants. Here, I should be clear, I am talking about newly diagnosed depression, in a time more than a decade on from the likes of the “Defeat Depression Campaign”. However it remains true that access to psychological therapies, in NHS Scotland, remains a very real “challenge”.

Professor Ian Reid went on to say:

014 Conservative Prescribing

And gave his view that:

015 Conservative Prescribing

It is here I depart from sharing Ian Reid’s view. My view is that we need pluralistic evidence, rather than expert opinion alone, that chronic prescribing of antidepressants represents an “improvement in practice”.

The medical profession are generally of the view that long-term antidepressant prescribing is “appropriate” because it is likely that most individuals taking antidepressants have a “recurrent illness” and that such is often demonstrated when they stop taking their antidepressants.

011 Conservative Prescribing

The problem is that most studies into antidepressants, on which prescribing is based, have been short-term studies, often only 6 weeks. Without longer-term studies and the evidence of experience, we simply cannot be sure why so many individuals receive long-term antidepressant treatment.

004 Conservative Prescribing

In summary: It is certainly the case that antidepressants are widely prescribed in the Western world.  In my view we need to see more evidence that prescribing of antidepressants, particularly chronic prescribing, is “appropriate” and “conservative”.

Note to reader:
I am not a "Critical Psychiatrist" as I prescribe psychoactive 
medications including antidepressants. I try to do so only if 
indicated, and if this is the patient's preference. To prescribe 
"appropriately" I do my best to share the knowns and unknowns of 
antidepressant prescribing along with explaining potential harms 
and potential benefits. One potential unknown is the optimal 
duration of prescribing. Professor Reid's evidence would 
appear to demonstrate that long-term prescribing is common 
practice.

“PULSE Live is heading to Scotland”: the Corn Exchange

My wife is a GP working in NHS Scotland and was recently invited to the “PULSE LIVE 2015″ educational conference to be held in Edinburgh on the 19 May 2015:Pulse Live 1

This educational conference is to be held in Edinburgh’s Italianate and historical CORN EXCHANGE. General Practitioners can register for a free place and 7 CPD hours are accredited:Pulse Live 2

In my earlier career I trained as a Landscape Architect at Edinburgh University and was awarded the Scottish Chapter prize. This will explain to you why old buildings and designed landscapes interest me. The Corn Exchange was where traders brought grain to sell. It was a place of barter: where goods were exchanged for money:Former corn exchange

With this in mind it is worth looking at the PULSE LIVE 2015 programme and noting that a significant number of the educational talks are sponsored by the pharmaceutical industry or other commercial enterprises. The speakers are mostly from NHS Scotland and it is fair to reasonably conclude that they will receive honoraria for giving their talks:Dr Douglas Elder, Bayer HealthCare, 2015 Dr Paul Newman, Johnson & Johnson, 2015 Dr Richard Watson, Lundbeck, 2015 Dr Tom Fardon, Pfizer, 2015 LUTS, 2015, Pulse Live, Astellas

My interest in this area relates to my wish to consider the ethics of medical practice. In this instance, my interest is in public transparency of any financial transactions between healthcare workers/academics and wider commerce.

I should make it very clear: I understand that conflicts of interest are part of life.

Over a few years I have collected the invites to NHS doctors to attend pharmaceutical sponsored education. These invites are collected here and demonstrate that financial sponsorship by the pharmaceutical industry (or commercial enterprises), as included in PULSE Live 2015, is generally the norm. Dr McCartney has considered this in her BMJ Column of last week: Forever indebted to pharma—doctors must take control of our own education:009b

My petition to the Scottish Government for A Sunshine Act is a request that transparency surrounding (non NHS) financial payments made to all those involved in healthcare (including academics and all those involved in medical education) to be a requirement by statute. In terms of the United Kingdom, I have suggested that Scotland might lead the way on this. America and France have introduced a Sunshine Act.

Open and transparent from omphalos on Vimeo.

NHS Scotland has failed (in my view, most miserably) to follow Scottish Government guidance HDL 62. This Government Circular was issued to all NHS Scotland Chief Executives over a decade ago. The Scottish Government has, since my petition which was based on my research, accepted widespread failure across NHS Scotland to follow HDL 62.

HDL-62

The Cabinet Secretary for Health, Wellbeing and Sport, Shona Robison MSP, wrote recently to the Convener of the Scottish Parliament Petitions Committee. Shona Robison, 24-4-2015

The Cabinet Secretary for Health, Wellbeing and Sport, asks for a “broader view” on an issue that the Scottish Government agree is “important”. The Cabinet Minister will be attending PULSE Live 2015 for the “Big Interview”:Pulse Live, Cabinet Minister for Health, May 2015

Perhaps the Cabinet Secretary for Health, Wellbeing and Sport, will look upwards to the roof of the Corn Exchange which is celebrated for its “massive single-span”. Sponsored Medical Education also celebrates a massive span across NHS Scotland. Please do not be fooled into thinking that this, like the Corn Exchange and the bartering it once housed, may be a thing of the past.Former corn exchange

So go on, if you dare, be like me and shout about this from the roof-top! If we reach for the sunshine perhaps we might all be a little healthier. Sunshine on Leith!0094638392057_600

Dumfries and Galloway NHS – Register of Interests

Dumfries and Galloway NHS

31 May 2013

“Attached are a redacted Gifts and Hospital Register and Pharmaceutical Interests for 2008, 2009, 2011 and 2012. There is no pharmaceutical interests register for 2010”

Chief Executive’s Office
Freedom of Information
Mid North Crichton Hall
Bankend Road
Dumfries
DG1 4TG

After some further communication, Dumfries and Galloway NHS, supplied on the 28 June 2013 the above registers free of redacted names of employees.

Dumfries and Galloway NHS Registers and all communications with Dumfries and Galloway NHS can be accessed here: https://www.whatdotheyknow.com/request/register_of_payments_from_pharma_155#outgoing-283202

Note: NHS Dumfies & Galloway Register for 2008 is unspecified: “Lilly. Astra Zeneca, Lundbeck, Janssen-Cilag, BMS, Pfizer, Wyeth and Servier – Sponsorship for various meetings” and “Lilly, Astra Zeneca Cilag- occasional honoraria for lecturing, meetings, consultancy and sponsorship to educational events/meetings”

NHS Dumfies & Galloway Register for 2009 is unspecified: 19 departments listed and multiple Pharmaceutical Companies involved

For summary of Registers (due to the heterogeneity of the returns from across Scotland) this is a rough guide at best:: https://docs.google.com/spreadsheet/ccc?key=0ApF86-MCSbZzdGlVd2ZPYWhyN1ZUbkliNlFpTGxtMFE&pli=1#gid=0

Sunlight, tears and disinfection

“Sunlight is the best disinfectant,” a well-known quote from U.S. Supreme Court Justice Louis Brandeis, refers to the benefits of openness and transparency.

Sunshine, tears and disinfection

Sunshine, tears and disinfection: https://vimeo.com/74513757

This film carries the suggestions of Dr Ben Goldacre from his latest book “Bad Pharma”: amazon.co.uk/Bad-Pharma-companies-mislead-patients/dp/0007350740 At the end of this very short film, Dr Goldacre, in his appreciation of transparency that the American Medical Students Association have brought to conflicts-of-interest and healthcare, stated that he felt almost weepy.

Tears, like sunlight, it occurs to me are also disenfectants. Both sunlight and tears bring clearer vision.

CREDITS:
(1) To Dr Ben Goldacre of course

(2) To Ruth Jarman and Joe Gerhardt the prize winning filmmakers of “Brilliant Noise” by Semiconductor: vimeo.com/1284717

“Brilliant Noise takes us into the data vaults of solar astronomy. After sifting through hundreds of thousands of computer files, made accessible via open access archives, Semiconductor have brought together some of the sun’s finest unseen moments. These images have been kept in their most raw form, revealing the energetic particles and solar wind as a rain of white noise. This grainy black and white quality is routinely cleaned up by NASA, hiding the processes and mechanics in action behind the capturing procedure.”

(3) “Slow Motion Strut Version Two” is the background music track by the awesome Dexter Britain (dexterbritain.co.uk)

DISCLAIMER:
I have tried to acknowledge all source material. If any copyright is breeched please let me know and I will address such failings on my part. Also this film is an artistic work and does NOT represent the views of any organisation.

The AMBITION behind this FILM:
To see the UK develop and implement a SUNSHINE ACT as soon as possible. The filmmaker has petitioned the Scottish Parliament for a Sunshine Act: holeousia.wordpress.com/category/medical-writings/pharmaceutical-industry-and-medical-education/sunshine-act-for-scotland/