Rising stars: British Association of Psychopharmacology

I submitted a rapid response to the BMJ last September after viewing galleries of photographs of the British Association of Psychopharmacology (BAP) Summer Meeting of 2016. The BMJ did not publish my post. This year’s galleries of the British Association of Psychopharmacology (BAP) Summer Meeting have now been shared. This is an amended version of what I sent last summer:

I was recently shared the published photographs of the British Association of Psychopharmacology 2016 Summer Conference.

At this BAP conference, an accredited CPD conference, the rising stars are seen to mix with today’s key opinion leaders. We all welcome the sharing of experience between generations and I have repeatedly stated how important I believe this to be. Some of the BAP key opinion leaders have declared significant financial interests with the Pharmaceutical Industry.

Up-to-date declarations of BAP speakers can be viewed here

I support transparency.  I have understood that this can only ever be a means to an end.

Robert K Merton once insisted that science should be based not on interest but ‘disinterest’. Merton’s star rose long ago and he is now dead. I do hope that all generations of scientists might be able to see his ‘disinterested’ star, still in the sky that we all share.

 

Unrealistic Medicine

This BMJ Editorial of the 30th June 2017 has had a number of responses:

The Editorial was a consideration of Academy of Medical Sciences report ‘Enhancing the use of scientific evidence to judge the potential harms and benefits of medicines’.

The President of the Academy of Medical Sciences and the Chair of the Report, Professor Sir John Tooke, has submitted this reply:

It is most welcome for Professor Sir John Tooke to set out his further thoughts but I found that what he said did not reassure me about the future of science and so submitted this response:

Unrealistic Medicine
Written by Peter, 15 July 2017
Submitted as BMJ Rapid Response.

The further thoughts of Professor Sir John Tooke, Chair of the Academy of Medical Sciences report ‘Enhancing the use of scientific evidence to judge the potential harms and benefits of medicines’ are most welcome.

Professor Sir John Tooke does not reassure me that an era of unrealistic medicine and the business of science will change anytime soon. Meantime the NHS is struggling across the United Kingdom and this may be in part due to the promotion of medical interventions whose evidence base lacks the objectivity that we all surely seek.

I would suggest that most of us fully understand the “reminder” from the Academy of Medical Sciences that potential conflicts of interest can come in all forms and not just financial. But like the public I share the view that we should start with potential financial conflicts of interest as evidence has determined that exposure to industry promotional activity can lead to doctors recommending worse treatments for patients  Godlee and Freer remind us that we expect this from our elected politicians and in other areas of public life.

The voluntary ABPI Register is not working. Its database is only a little more than half complete. This really does challenge the “E” in EBM.

The pharmaceutical Industry has, over the preceding year, increased payments to healthcare workers for “promotional activities” from £109 million to £116.5 million.  This is a major part of Industry budget. Furthermore, we do not know how much may be being paid by device makers and other forms of industry for promotion of their products.

It is welcome, but somewhat “after the bell has rung”, that Professor Sir John Tooke confirms that the Academy of Medical Sciences intends to “review” its approach to public transparency. But one wonders how many “houses” do we need to “get in order” to address this issue effectively? I find myself worrying that it could be like a game of Monopoly that never seems to end.

The most effective and cheapest way to address this matter would be Sunshine legislation. This would avoid multiple, overlapping and generally unsearchable databases of interests.

I would suggest that the reputation of science is at stake as is the balance between benefits and harms for us all

Roy Porter, who sadly died prematurely was considered as one of the United Kingdom’s finest historians of science and health. He ends “Madness: A Brief History “ with a teasing question: ‘Is folly jingling its bells again?’

 

Reductionism – truly, madly, deeply

On Friday the 25th of November 2016 I gave a talk for the Scottish Philosophy and Psychiatry Special Interest Group.

My subject was “Improvement Science”.

The following is based on the slides and the four short films that I presented.

My talk was entitled:
001-improvement-science The meeting was held at the Golden Lion Hotel, Stirling:golden-lion-hotel-stirling-25-nov-2016-1golden-lion-hotel-stirling-25-nov-2016-2I started the day off:
002-improvement-scienceI gave these declarations:
003-improvement-science
I explained to the audience that like Dr Rev I M Jolly I can be overly pessimistic:


005-improvement-scienceThe dictionary definition of ‘Improvement’:
006-improvement-scienceThe dictionary definition of ‘Science’:
007-improvement-scienceMy concern is any pre-determinism to science:
008-improvement-scienceThe Health Foundation have considered Improvement Science: this is from 2011:
009-improvement-scienceMany different terms are used including “QI” for “Quality Improvement”:
010-improvement-scienceThis is where improvement science began, in Boston, Massachusetts:
011-improvement-scienceThe Founder of the Institute for Healthcare Improvement (IHI) was Don Berwick:
013-improvement-scienceThe first description of this movement in Britain goes back to 1992 by Dr Godlee:
014-improvement-scienceFifteen years later, Dr Godlee, Editor of the BMJ, said this:
015-improvement-scienceOnly last month the BMJ briefly interviewed Don Berwick:
016-improvement-scienceIHI describes improvement science as being based on a “simple, effective tool”:
017-improvement-scienceThis tool was developed from the work of an American engineer, W. A. Deming:
018-improvement-scienceThe “Model for Improvement” Tool [TM] is described by IHI as a “simple, yet powerful tool”:
019-improvement-scienceThe current President and CEO of IHI is Derek Feeley:
024-improvement-scienceUp until 2013, Derek Feeley was Chief Executive [Director General] for NHS Scotland:
021-improvement-scienceIn April 2013 Derek Feeley resigned from NHS Scotland:
022-improvement-science22nd February 2015 it was reported: “The astonishing and largely hidden influence of an American private healthcare giant at the heart of Scotland’s NHS”:
023-improvement-scienceDr Brian Robson, Executive Clinical Director for Healthcare Improvement Scotland [HIS] is an “IHI Fellow”:
dr-brian-robsonProfessor Jason Leitch, National Clinical Director for the Scottish Government is an “IHI Fellow”:
026-improvement-scienceMight we be facing the biggest change to healthcare in Scotland since the NHS began?nhs-scotland-1947 Improvement science is moving quickly and widely across Scotland:
027-improvement-scienceThis “Masterclass 1” for Board members cost  £146,837:
028-improvement-scienceAn NHS Board member commented after the Masterclass:
029-improvement-scienceHealthcare Improvement Scotland is one organisation with a very wide remit over NHS Scotland and it works closely with the Scottish Government:
031-improvement-scienceNine cohorts of Safety Fellows and National Improvers have so far been trained following IHI methodology:
032-improvement-scienceI was reminded of the current enthusiasm for improvement science when the Convener of a recent Scottish Parliament Committee meeting said of targets (another approach enthusiastically taken by NHS Scotland):033-improvement-scienceWhat is the place of ethics in Improvement Science?
034-improvement-scienceIn 2007 the Hastings Centre, USA, looked into this in some depth:
035-improvement-scienceThe Hastings Centre argue that Improvement science cannot ignore ethics:
036-improvement-scienceIn 2011 the Health Foundation, UK, produced this “Evidence Scan”:improvement-science-2011a2The Health Foundation commented that “improvement science is just emerging”:
037-improvement-science
The Evidence Scan found a “real paucity of evidence about the field of improvement science”:
038-improvement-scienceI would also suggest that there is a real paucity of philosophy about the field of improvement science:
039-improvement-scienceThe Health Foundation did find papers on the conceptual nature of Improvement Science but concluded that:
040-improvement-scienceMary Midgley is a philosopher now aged 95 years who is widely respected for her ethical considerations:
041-improvement-scienceChapter 7 of her book “Heart and Mind: The Varieties of Moral Experience” begins:
042-improvement-scienceMary Midgley is concerned about the overuse of reductionist tests in medicine stating that:
043-improvement-science
This film is about the potential consequences of inappropriate reductionism:

Leon Eisenberg has written many papers about this subject. He argues that reductionism should not be “abandoned” but that we must keep sight of where such an approach is scientifically useful and also where it is inappropriate:
045-improvement-scienceIn the Hastings Report, Margaret O’Kane asks:
046-improvement-scienceIn my view the answer to this question is YES. I am hopeful that the National Improvers recruited to NHS Scotland would agree:
047-improvement-scienceAs an NHS doctor I have seen unintentional harm brought about by National improvement work in Scotland. This related to a “Screening Tool” that was introduced across Scotland as part of this work. I found that the unintended consequences of the use of the following tool included implications for patients’ autonomy and the risk of over treatment:
048-improvement-scienceBoth the Hasting Group and the Health Foundation are of the view that improvement science cannot separate itself from the ethical requirements of research:
049-improvement-scienceThis article published in February 2016 argues that individual “rights transcend all aspects of Improvement science”
050-improvement-scienceThe following is a verbatim representation of a conversation held by National Improvers working in NHS Scotland:
051-improvement-scienceIn November 2016 Professor Joshi, also a psychiatrist outlined his concerns about reductionism in a published letter to the BMJ:
052-improvement-science
In this short film the mechanical language of healthcare improvers is considered:

Professor John Bruce was a Moral Philosopher in Edinburgh University in the 18th century. He built this temple, the “Temple of Decision”, in the grounds of his home by Falkland Palace so that he could consider his thesis:
054-improvement-scienceProfessor John Bruce did not succeed in his endeavour. His Temple however stood for many years:
055-improvement-scienceBut it eventually collapsed and his endeavour to “reduce the science of morals to the same certainty that attends other sciences” collapsed with it.
057-improvement-scienceAny search of Healthcare Improvement Scotland for “ethics” finds this result:
056-improvement-science
This film is about more up-to-date buildings – the enthusiasm for which was based on improvement science: The Red Road flats in Glasgow:

 

                         Post-script:

The following is an edited clip of the evidence given to the Scottish Parliament by Healthcare Improvement Scotland (HIS) on the 31st January 2017:

The full session can be watched here

The Official Report can be accessed here

The Scottish Public Want Sunshine

There is a long standing joke about the lack of sunshine in Scotland.

Three years ago I began the process of raising a petition with the Scottish Parliament to urge the Scottish Government to introduce a Sunshine Act.

A Sunshine Act makes it a statutory requirement for all payments from commercial interests made to healthcare workers and academics to be declared publically. The metaphor is that sunshine brings full light. Both the United States of America and France have introduced a sunshine act.

The doctor in Gabriel García Marquez’   ‘Living to tell the tale’ says “Here I am not knowing how many of my patients have died by the Will of God and how many because of my medications”. Márquez often returns to the theme of medical ethics in his writings and reminds us that all interventions have the potential for benefit and harm.  In ‘No one writes to the Colonel’, “a man [who] came to town selling medicines with a snake around his neck”. Here Márquez is reminding us of the long history of the financial opportunities open to healthcare professionals.

As a junior doctor in around 2000, I was handed by a Consultant a several hundred page document entitled “Behavioural and Psychological Symptoms of dementia”. The Consultant told me “this is the way forward!” Some years on I came to realise that this document had been developed, funded and disseminated by the Pharmaceutical Industry whose first loyalty, as a business, is to its share-holders.

In the wake of the dissemination of this document, prescribing of antipsychotics, sedatives and antidepressants in Scotland has been rising year on year. This has been described as mass prescribing, and is often long-term. Yet the evidence to support such prescribing is poor.

There is much promotion of “partnership working” between industry and healthcare. Yet we must remember that these two partners have different aims, and it is the responsibility of healthcare workers to follow the ethical approaches central to their professions. For example, the General Medical Council is clear about what is expected of doctors in their code “Good Medical Practice”. The potential for conflicts of interest is recognised and doctors are advised “you must be open about the conflict, declaring your interest formally”.

Since 2003, Scottish Government guidance has been in place to allow the declaration of financial interests of NHS staff, to their employing health boards. As a result of my petition, the Scottish Government has confirmed that this guidance is not being followed.

One key area of concern is the continuing professional education of healthcare professionals, another requirement of professional bodies. In at least two Boards in NHS Scotland, continuing medical education relies entirely on the financial support of commercial interests.

National and international conferences may also form part of continuing professional education. Because of the Sunshine Act in the USA, we know that a key-note speaker at a recent UK conference has been paid more than £3 million dollars by the pharmaceutical industry since the Sunshine Act was introduced. There is currently no way of knowing the scale of any payment made to a UK speaker sharing the same platform.

My experience of trying to clarify if there is transparency about financial payments in Scotland has been revealing. I have encountered significant defensive reactions from individuals and organisations. There has long been a body of evidence that, for example, prescribing behaviour is influenced by commercial interests, yet doctors find it hard to accept this. This collective denial would suggest that the forthcoming (voluntary) ABPI Register is unlikely to work as many will regard it as not applying to them and will therefore opt out.

As part of their consideration of my petition, the Scottish Government commissioned a public consultation exercise on a need or not for a Sunshine Act. The majority of participants expressed their view that all financial payments should be declared on a single, central, searchable register and that this should be a mandatory requirement.

The forecast for Scotland looks good: sunshine.

 

“In pursuit of marketing approval” [antidepressants for anxiety]

This is a report in the current BMJ:  Publication bias01This was the result of the pursuit of the market:Publication bias02The US Food and Drug Administration failed to ensure scientific objectivity:Publication bias03Robert K Merton would weep at this.

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.

“Alzheimerisation”: wandering, wondering and worrying

28th January 2014

Data published this week demonstrated that in 2012 prescribing of “dementia drugs in Alzheimer’s disease” was “50% higher than expected.”[1] In a published commentary about this, it is stated that “experts say that the discrepancy may be because of rising prevalence rates, and an underestimation by analysts of the number of people with Alzheimer’s disease”.[2]

Of course, it is just as feasible that there could be other explanations for this dramatic increase in prescribing. Here, I am going to share with you some of my thoughts against the potential backdrop that some sociologists have chosen to term as “Alzheimerisation”.[3]

(1) Wandering
It is not just our elderly who may wander. Recently I got lost in our new ward designed for those with dementia! I also want to suggest that our “experts” have wandered and may still be wandering. Between 1962 and 2013, roughly the duration of my life so far, we have had twelve different categories for mild cognitive change in the later years of our life.[4]

The wandering of our experts has been between ageing and disease. On expert “maps” they have generally been placed in separate spaces.[5]

Alzheimer’s disease is a pathological diagnosis based on post-mortem microscopic pathological changes in the brain. This is a definition based on the understandings of 1908 and which subsequent research has established as limited. Professor Clive Ballard, one of today’s leading experts in Alzheimer’s disease summarised this in the Lancet in 2011 “The paradigmatic brain pathology of Alzheimer’s Disease – plaques and tangles – is only a post-mortem finding of limited explanatory value in the expression of dementia in the population.”[6] Forty years of research on amyloid deposition has found that it has no simple causative role[7] and indeed post-mortem studies have established that amyloid deposition is generally also found in the post-mortem brains of those who have lived long lives without any cognitive or memory loss.[8]

(2) Wondering
We all wonder[9]. Even with dementia, despite all the bleak reporting, we generally still have much capacity to wonder. The day that science stops wondering is a day that should worry us all.

Using data from 2011 (the year before we find this 50% increase in prescribing of dementia drugs1) it has been established that the prevalence of dementia has actually significantly reduced.[10] Professor Sube Banerjee recently gave commentary to this in the Lancet and stated that “The CFAS data point to substantial added value from existing healthy lifestyle messages. They suggest that lifestyle changes – e.g., in diet, exercise, and smoking – might reduce the risk of dementia and promote more general health and wellbeing. This notion should be incorporated into health promotion messaging. Inclusion of the potential benefit of dementia prevention in communications could drive greater adoption of healthy life-styles with resulting benefits for individuals and society.[11] I would agree. It thus interested me, that in this report, Professor Banerjee never once used the word “Alzheimer’s”. So I am left wondering about a mismatch of language between Professor Banerjee’s report11 and the latest statement that the prescribing for “Alzheimer’s” has increased by 50% in one year.1

Our Prime Minister has talked a lot about the myths that have added to the stigma of dementia.[12] I agree with our Prime Minister that myths should not be part of medical science. I wonder then why the prevailing “understanding” has been that for the four licensed drugs for dementia that they can potentially improve the outcome especially if instituted early. No robust evidence has ever supported such conclusions.[13] The prevailing early diagnosis strategies and targets, promoted by dementia experts, political and charity leads, made very little effort to correct this understanding.[14]

(3) Worrying
I admit that I worry quite a lot. Given my determination to pursue science that is pluralistic and that heeds the lessons of history and cultural change, I have in recent years, started to worry that we have “re-branded” too much of memory loss in old age, and generally, as “Alzheimer’s disease” or even just “Alzheimer’s”.

In the 1990’s the pharmaceutical industry, hopeful that anti-amyloid drugs would be efficacious, employed branding firms, such as Complete Clarity to “build” a “future-focussed market landscape.” [15] At the same time key opinion leaders were employed to “educate” the medical profession on this newly “built” “market landscape”. Many of these Key Opinion Leaders are today still being well paid for educating us all.[16] Perhaps I worry too much about this? Perhaps we should all be reassured that such experts have greater ability to be objective and so are uninfluenced by potential biases that evidence has demonstrated influence the rest of us.[17] Last year for example, Ballard, who had confirmed that “the paradigmatic brain pathology of Alzheimer’s Disease – plaques and tangles – is only a post-mortem finding of limited explanatory value in the expression of dementia in the population”6 published a paper, sponsored by Lundbeck, in which he outlined the “barriers to evidence-based prescribing in Alzheimer’s disease”. In this paper Ballard made a “key point” that “only about 10% of dementia patients receive an acetyl-cholinesterase inhibitor or Memantine”[18]

As I recently described in my blog (the Forgetfulness of others[19]) I am a full supporter of all research and innovation that aims to improve the outcome and the lives of those living with dementia, of whatever stage. I would urge that the approach to such research has a pluralistic base and is led by science that Robert K Merton insisted should be disinterested i.e. not for personal advantage but for the progression of science alone.[20] In this respect, I personally found the big-business framing of the G8 Dementia Summit as an opportunity that actually risked the sort of imbalance that the BMJ have considered as “too much medicine too little care”.[21]

I also was left worried after the G8 Dementia Summit that the recurrent use of military and plague metaphors used by many of the dementia experts and politicians, in effect actually risked heightening the stigma that, in the same breath, they urged us to address.[22]

Nearly two years ago, I made a film called The diseased Other[23] in which I sought to outline my concern that we risk mislabelling one-in-two of our most elderly as “suffering” from “Alzheimer’s disease”. If my worry is valid, then we must consider if we have truthfully explained the scientific uncertainties of the diagnosis of Alzheimer’s disease in this age group. Most of the dementia experts I ask today cannot easily answer this seemingly straightforward question: “What do we mean by Alzheimer’s disease?”[24] Our elders deserve full engagement with both our certainties and uncertainties even if Banerjee considers the latter as “toxic”.[25] Both false-negative and false-positive diagnoses should concern us equally. To worry about one and not the other is simply unethical.

I also worry that our elders are today more fearful than previous generations about dementia, or as “Alzheimer’s” as it now almost seems synonymously misunderstood. I would like to see more research in this area.[26] I have certainly found a disproportionate level of fear in many of those who come to my clinic or who have been discharged from hospital (this is increasingly the case now that cognitive screening is mandatory for any individual 65 or over admitted to hospital.)[27] The controversial Dementia DES has now been well debated, and is based on the view that our elderly need not be asked for consent for memory-testing and that dementia should be “case-found” regardless of patient wishes.[28]

So in summary, I close with three questions:

  1. Do  we risk, through policy approaches and “healthcare improvement”, re-labelling many of our oldest citizens as “suffering” from “Alzheimer’s disease”?
  2. Might this latest report of a 50% increase in prescribing of dementia drugs be indicative of this?
  3. Should the “Alzheimerisation” neologism be confined to room 101 or should it have full light of day?

I proudly sign off as a wanderer, wonderer and worrier.


[1] Health & Social Care Information Centre: Use of NICE appraised medicines in the NHS in England – 2012, experimental statistics,21 Jan 2014 http://www.hscic.gov.uk/catalogue/PUB13413/use-nice-app-med-nhs-exp-stat-eng-12-rep.pdf

[2] Duffin, C. Alzheimer’s dugs ‘overprescribed’ suggest NHS figures. PULSE magazine, 24 January 2014 http://www.pulsetoday.co.uk/clinical/therapy-areas/neurology/alzheimers-drugs-overprescribed-suggest-nhs-figures/20005654.article#.UuoCwOWontx

[3] Giggs, P. and Rees Jones, I Medical Sociology and Old Age – Towards a sociology of health in later life. From Chapter 5 Chapter 5: The death of old age, critical approaches as undertakers. Routledge. 2008

[4] Le Couteur, D.G, Brayne, c. et al Political drive to screen for pre-dementia: not evidence based and ignores the harms of diagnosis. Published 9 Sept 2013. BMJ2013;347:f5125

[5] George, D. R., Whitehouse, P & Ballenger J. The Evolving classification of dementia: placing the DSM-V in a meaningful historical and cultural context and pondering the future of “Alzheimers” Cult Med Psychiatry. 2011 Sep;35(3):417-35.

[6] Ballard, C et al Alzheimer’s disease, Lancet 2011 Mar 19;377(9770):1019-31

[7] George, D.R., Whitehouse,P.J., D’Alton,S and Ballenger, J. Through the amyloid gateway. The Lancet, Vol 380 December 8, 2012

[8] Reisa A. Sperlinga et al Toward defining the preclinical stages of Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease Alzheimer’s & Dementia 7 (2011) 280–292.

[9] Tallis. R. In Defence of Wonder and other Philosophical Reflections. Published 2012. Acumen

[10] The Cognitive Function and Ageing Study (CFAS) I and II http://www.cfas.ac.uk/

[11] Banerjee, S Good news on dementia prevalence – we can make a difference. The Lancet. 26 Oct 2013

[12] Cameron, D. The Prime Minister’s Challenge on Dementia. Policy paper Published 26 March 2012 https://www.gov.uk/government/publications/prime-ministers-challenge-on-dementia

[13] Drug Discovery Programme – Alzheimer’s Society Dementia Research 14 Jan 2014 http://www.youtube.com/watch?v=F2clNGdQRWs

[14] Midgley, Mary. The Myths we live by. Routledge. 2004

[15] Mapping the Future of Alzheimer’s Disease: The Business Problem http://www.completeclarity.com/see-our-work/case-study-the-future-of-alzheimers-disease/

[16] Moynihan, R. Key opinion leaders: independent experts or drug representatives in disguise? Published 19 June 2008 BMJ2008;336:1402

[17] Spurling, G. M et al Information from Pharmaceutical Companies and the Quality, Quantity, and Cost of Physicians’ Prescribing: A Systematic Review. Published: October 19, 2010. 10.1371/journal.pmed.1000352

[18] Ballard, C. Barriers to evidence-based prescribing in Alzheimer’s disease. March 2013. British Journal of Mental Health Nursing, Vol2 No1

[19] Gordon P., The forgetfulness of others.1 January 2014 https://holeousia.wordpress.com/2014/01/01/the-forgetfulness-of-others/

[20] Merton, R.K The changing production system of scientific knowledge from Hole Ousia https://holeousia.wordpress.com/2013/05/11/the-changing-production-system-of-scientific-knowledge/

[21] British Medical Journal: Too much medicine campaign http://www.bmj.com/too-much-medicine

[22] Ashcroft, R. Why I feel angry, not grateful, after Cameron’s dementia summit. The Guardian. 12 December 2013 http://www.theguardian.com/commentisfree/2013/dec/12/angry-not-grateful-cameron-dementia

[24] Richards, M and Brayne C. What do we mean by Alzheimer’s disease? Published 12 October 2010 BMJ2010;341:c4670

[25] Burns, A and Buckman, L. Timely Diagnosis of Dementia: Integrating Perspectives, Achieving Consensus  Meeting London, June 2013 http://www.dementiaaction.org.uk/assets/0000/3808/NHS_England_BMA_Diagnosis_Consensus.pdf

[26] Manthorpe, J. From forgetfulness to dementia: clinical and commissioning implications of diagnostic experiences. British Journal of General Practice. 2013;63: 30-31

[28] Haynes, J Dementia DES will result in widespread misdiagnosis, expert claims 12 Sept 2013 PULSE

Scottish Parliament Public Petition PE01493 (update)

On the 28th January 2014 the Public Petitions Committee of The Scottish Parliament are to consider the gathered responses to my Petition for a Sunshine Act. This is a letter I have sent today to the Committee with some of my reflections on the various responses to the petition

Saturday, 18th January 2014

To:
Andrew Howlett
Assistant Clerk
Public Petitions Committee
The Scottish Parliament

Dear Mr Howlett,
Scottish Parliament Public Petition PE01493 on a Sunshine Act for Scotland
I understand from Chris Hynd, Committee assistant that my petition is to be considered by the Public Petitions Committee at its meeting on Tuesday 28th January 2014. I also have been made aware that there will be no oral evidence heard at the meeting. I therefore thought it might be helpful to offer some thoughts in writing ahead of your meeting.

I will keep this short as you already have much evidence to consider.

Before I make two main points I would like to thank the Public Petitions Committee, Chrys Hynd, and Andrew Howlett for the huge amount of work that has gone into researching for this petition and for ensuring that all has happened in a most efficient way. The communication from Chrys Hynd has been so helpful and absolutely faultless. I have been very impressed with the Public Petitions Committee processes and my personal experience of involvement has been wholly positive.

As of today, 18th January, I have read all nine written submissions to the Petitions Committee offering thoughts on PE1493/I. In general it seems to me that there is agreement that a single, publicly open, searchable register of interests would be a good way forward in the interests of objectivity, patient well-being and general probity. I believe that this is a fundamental basis to science otherwise we will be blind to potential biases. Evidence has repeatedly found that treatments marketed through “education” where commercial success is a most significant determining factor, has resulted not just in the loss of scientific objectivity, but also significant harm. Transparency here would at least allow patients to weigh up if the treatment they are being offered might be vulnerable to anything short of scientific objectivity. I would argue that this is important to us all.

I want to make just two further points, the first is based on the most helpful response to this petition from the General Medical Council (GMC), and the second considers updates on the Association of the British Pharmaceutical Industry (ABPI) letter to the Committee before the Petition was heard on 12th November 2013:

  • The GMC confirm that a “compulsory register would require legislative change.”  I share the view of the GMC that if such legislative change is to take place that we need to consider that such should be part of regulation of doctors across all four UK countries. Perhaps this petition needs to evolve so that the Scottish Government, with legal advice, can consider this UK-wide dimension. Scotland could be a constructive and helpful lead on the need for legislation such as a Sunshine Clause as Part of the Medical Act.
  • The Committee may be interested to know that the GMC, through a Freedom of Information Request by myself have now confirmed that no Scottish doctor between 2011 and 2012 was referred to GMC for non-declaration of competing interests. For that calendar year, ABPI have confirmed that on aggregate, £40million was paid to UK doctors by the Pharmaceutical Industry. Estimating that £4million was paid to Scottish doctors it is concerning that this does not appear on Scottish Registers of interest for this year. I would suggest to the Committee that this evidence is most concerning and should serve as call for action. Trust in the medical profession is crucial to good healthcare. Somewhere here, trust is being broken.
  • I have,in the time since presenting evidence to the Committee, met with Andrew Powrie-Smith of the ABPI. This was a most helpful meeting and it is very clear to me that the ABPI are committed to improving transparency. I understand from Andrew Powrie-Smith that last year, ABPI member companies agreed, as part of amendments to the ABPI Code of Practice, to disclose payments to individually named healthcare professionals, including consultancy services such as speaking and sponsorship to attend medical education meetings. It is proposed to come into effect in 2016, and is “enshrined in the EFPIA Disclosure Code” which the ABPI confirm has been “adopted across 33 European countries.”
  • However, if I understand correctly, any doctor who does not wish his or her payments revealed can simply opt-out. Such payments would then only be recorded in aggregate. This, I would suggest is a reason why legislation, as has happened in other Countries across the world, is necessary.

Some very good questions were put to me when I presented my petition to the Committee on the 12th November 2013. It is still the case that the practicalities of who keeps and maintains this register need to be discussed. Key players will be the GMC and ABPI but I also think that there needs to be a political overview given the likely need for legislation. The cost of keeping this register and excessive bureaucracy were raised as concerns. These are very legitimate concerns which I share. However I am of the view that the cost could be offset completely by medical practice which follows objective science where benefits and harms are given equal weight and therefore where costs of harm and over-medicalisation are minimised. I am of the view that this is an ethical, scientific as well as cost-effective approach to the health of our nation.

I hope these reflections are of some assistance to the Committee in their further considerations.

I am grateful to each and every one of you.

Yours sincerely,
Dr Peter J. Gordon

The changing production system of scientific knowledge

This is an extract about the work of Robert K Merton as outlined on “Genes, Cells and Brains” by Hilary Rose & Steven RoseChanging-system-of-producin