‘The medical untouchables’

The following is a recent opinion piece by Dr Des Spence published in the British Journal of General Practice.

I had been lined up to do the media interviews on BBC Scotland in relation to petition PE1651. However, on the day, due to changed travel arrangements, I was not available. Dr Des Spence was interviewed instead and did a better job than I could have done.

As an NHS doctor and specialist, I fully support this petition (PE1651) which calls on the Scottish parliament “to urge the Scottish Government to take action to appropriately recognise and effectively support individuals affected and harmed by prescribed drug dependence and withdrawal.”

I have submitted my response.

I feel it would be helpful to hear the views of the Chief Medical Officer for Scotland and in particular, how this matter might be considered as part of Realistic Medicine.

Three recent posts by me demonstrate the scale of competing financial interests in medical education in the UK. If you have a moment, you should have a look. Perhaps you might then share the worry that I have about this matter:

I have previously raised my own petition, PE1493, which the Scottish Public has supported. This was a petition for a Sunshine Act for Scotland, to make it mandatory for all financial conflicts of interest to be declared by healthcare professionals and academics.

My petition, supported by the public, had no support from “Realistic Medicine”. The public has had no update from the Scottish Government on my petition in 18 months. My view is that this is a shocking failure of governance and would seem to demonstrate a lack of respect for democracy.

Psychiatry Without Borders

The International Congress of the Royal College of Psychiatrists took place in Edinburgh, the city of my birth, between the 26 – 29 June 2017. This International Congress was called “Psychiatry Without Borders”.

As a psychiatrist who has worked in NHS Scotland for 25 years I made a peaceful protest outside the International Congress.

I have previously petitioned the Scottish Parliament to consider a Sunshine Act for Scotland which would make it mandatory for healthcare workers and academics to declare potential financial conflicts of interest on an open public register.

The pharmaceutical Industry has this year increased payments to healthcare workers and academics for ‘promotional activities’ –  from £109 million up to £116.5 million today.

The Association of the British Pharmaceutical Industry (ABPI) has, from 2015, established a voluntary disclosure system with searchable database. It remains the case that 65% of those who have received payments have opted out – and this accounts for 60% of the total payments (as reported in the British Medical Journal (BMJ 2017;357:j3195)

What follows here are the ABPI disclosures made by some of the speakers at the 2017 Royal College of Psychiatrists International Congress.

It is important to note that it is my understanding that no speaker 
was paid for giving presentations at this International Congress. 

These declarations relate simply to the voluntary declarations
for the years 2015 and 2016 respectively.

If you click on each declaration you will get a closer view.

In previous posts I have provided as much public transparency as there is currently available  relating to the potential financial conflicts of interest of those involved with the British Association of Psychopharmacology (BAP). This Association works closely with the Royal College of Psychiatrists in providing Continuing Medical Education.

A number of those involved in BAP have chosen not to declare on the ABPI Register. For this reason, I attach the declarations given along with the new BAP Guidelines for treating dementia as Professor John O’Brien was giving a talk about these guidelines at the 2017 International Congress:

A few personal thoughts:

Well done to those who have declared on the ABPI Register.

However, it remains the case that we cannot scientifically consider the scale of potential biases that financial incentives may bring to the prescribing of medications in the UK. This is because we have an incomplete dataset. This is surprising given that we do have longstanding evidence that exposure to industry promotional activity can lead to doctors recommending worse treatments for patients.

I would like to see the College, of which I am a member, support the public’s request for sunshine legislation.

 

 

Statements made by senior Psychiatrists working in the British Isles

“you are either abstinent or promiscuous when it comes to industry. Well you can see which side I am on”.

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

“Who would have thought that Pharma Hospitality could cause excessive weight gain and type II diabetes? They kept that quiet”, I replied, ruefully patting my stomach.”

“this latest non-problem”

“it is time we all grew up”

 

How mechanical should healthcare be?

These two fliers are currently being shared by the Royal College of Psychiatrists:

The following words, it seems to me, are appearing more frequently in healthcare:

ToolsTraffic Lights Dashboards toolkits

It is my view that all those involved in healthcare need to consider the potential consequences of the widespread use of such mechanical language.

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 lawn was white with doctors









For patients only

This is a film about leucotomies undertaken for mental illness in the United Kingdom.

This film is not about psychosurgery after 1970.

Were we asleep at the wheel?

At the beginning of June 2008 I sent an e-mail to Dr Leon Eisenberg, a former child psychiatrist, and a man of philosophy and science:
leon-eisenberg
Dr Eisenberg was then 89 years old and I wanted to convey how important his writings had been to me:mindlessness-and-brainlessness-in-psychiatry-1986
I did not expect a reply:
leon-eisenberg-to-peter-gordon-8-june-2016

A year later Leon Eisenberg died.

were-we-asleep-at-the-switch

After his death a memoir was discovered: which Eisenberg had named “Were We Asleep at the Switch?”.

Eisenberg suggested that a switch from ‘mind’ to ‘body’ has taken place in psychiatry as a discipline, which has led to overuse of medication.

He also argued that “monied interests” had been making de facto decisions on behalf of us all about the “science” of things that might affect us.

Eisenberg was worried that the overwhelming impact of economic considerations may have rendered, and might continue to render futile, the professional contributions of many brilliant, timely, and concerned working scientists.

leon-eisenberg-1987b