Why I resigned from NHS Forth Valley

I resigned from work on the 6th June 2014. Some folk have been wondering why. Below I offer briefly the background to my decision to resign and why it was a matter of more than just principle.

I have worked for NHS Forth Valley as a Consultant in older adults in Clackmannanshire for nearly 13 years. This has been hugely rewarding for me and indeed a privilege to share in the lives of the wonderful elders of Clackmannanshire often in a time of need. The team of which I was part worked with dedication, compassion and professionalism even though at times we had to make difficult decisions due to the demands placed on our service. The support from colleagues in primary care, social work and third sector was greatly valued and our joint-working a source of satisfaction long before integration of services was ever considered.

I also wish to thank my employers for their support, particularly as I faced the steep-learning curve of the non-clinical aspects of today’s medicine and the shifting sands of political mandates and targets.

What follows is a brief account. It is to help explain and perhaps allow wider reflection, including my own. It seems to me that finding the words to express complex matters in writing helps me to “see” better. I am aware that this will be one account, open to challenge as none of us (thank goodness) will have the same view on life.

The factors involved in my resignation were complex. Life is complex after all. The beginnings of all this go back many years when I was faced with a difficult situation. I was concerned that our most elderly were more at risk of mis-diagnosis of dementia. This was at a time of incentivised targets for the early diagnosis of dementia (HEAT target 4 in Scotland) and increasingly I found that elderly patients were being diagnosed with “early Alzheimer’s disease” but in fact did not fulfil internationally accepted clinical definitions of dementia. My concern was that in the late stages of life individuals who would never develop dementia were being told they had it. What was in truth an increased risk of developing dementia was being expressed to patients, families and carers as a definitive diagnosis. My dilemma in speaking out about this was that very few others seemed to share my concerns. This seemed to me to be the case across a range of professions and jurisdictions.

My approach was first to discuss this with colleagues, which only confirmed that my view was that of the minority. I then raised the matter through the appropriate channels of line-management. Initially I was supported in raising my concerns. However this did not last: the most likely reason for support being withdrawn was that I was diverging from the majority.

From that time on my professional life got tough. I wrote an account of my concerns called “Peter’s Lost Marbles” the transcript of which I turned into a short film. This transcript and film were praised by the then Chief Executive of the Mental Welfare Commission and by the then Lead Policy Officer for Alzheimer Scotland. Both these National leads suggested that the transcript should be published in a journal and that the film version be used to encourage wider understandings of the complexities involved in the early diagnosis of dementia.

Dr Peter has one or two marbles left, and written on one of the more brightly coloured ones is the oath he took on graduation: primum non nocere (above all, first do no harm). Yet Dr Peter has found that his medical colleagues, Alzheimer associations and indeed politicians show little inclination to look at this singular marble.

NHS Forth Valley decided that an “External Review” would be held. It was documented ahead of this  External Review, by the Medical Director at the time:  “but the main concern is with PG [Peter Gordon]”. Increasingly isolated, and not included in strategic meetings to improve “joint working” it was difficult to know how to proceed. Through stress I was signed off by my GP and was off for 6 months. Interestingly having been off once before in 2004 (my only severe depression caused by discontinuation of Seroxat) I found that I was re-defined by some as a case of “recurrent illness”.  I have found it very difficult to escape this stigma and my experience has been that my profession is just as likely as any other to see “illness” before the person.

I have always taken a pluralistic approach to science and have been a lecturer in Medical Humanities. I am interested in ethics, professionalism, philosophy and their crucial contribution to the evidence-based medicine that I aspire to follow. It was my interest in professionalism and my concern that medical education was inextricably linked to marketing that led me to advocate greater transparency in financial conflicts of interest. I have pursued this with some determination. I have petitioned the Scottish Government for ‘A Sunshine Act’ and have argued that we should at least have transparency of financial interests equivalent to that which we expect of our parlimentarians.

My experience has been that it is not easy to pursue transparency in the health service. If anybody is interested much of this can be followed here.

The final straw for me was that I no longer felt that my concerns about staffing levels in the team of which I was part were being taken seriously.

I am deeply sad to have left NHS Forth Valley an institution I hold dear. I leave behind many friends, colleagues and special people. My career is now in limbo. But the main reason I write is in the hope of wider reflection and perhaps even a change of culture.  I have been honoured and privileged to be part of the lives of the wonderful and inspirational elders of Clackmannanshire. I have learned so much from them all.

Below is the last formal letter I received from Dr Peter Murdoch, Interim Medical Director of NHS Forth Valley. It is dated 21st May 2014. Dr Murdoch has kindly agreed that I can share this letter in its entirety on my blog. I have taken perhaps unusual route of making this open to all as I passionately believe that transparency is better even if the portrayal of me is not one that I recognise.  I accept any errors of judgment and frailties on my part (but these are not illness).

Letter-Peter-Murdoch-21-May

Link to letter to Dr Peter Murdoch, Interim Medical Director of NHS Forth Valley, from Dr Brian Robson, Executive Clinical Director for Healthcare Improvement Scotland, dated 22 May 2014

Update on NHS registers of interest (Scotland)

From: Gordon Clark
Scottish Government Health Directorates
Pharmacy and Medicines Division
St Andrew’s House
Regent Road
Edinburgh, EH1 3DG

Our ref:2014/23079

5 August 2014

Dear Dr Gordon
Thank you for your email of 7 July to Alex Neil MSP, Cabinet Secretary for Health and Wellbeing about NHS registers of interest. You have also copied correspondence between yourself and Dr Iain Wallace, Medical Director, NHS Lanarkshire. In your email, you state that you have not had a reply from the Scottish Government since 15 May. I have searched our records, however, I’m sorry to say that I have found no record of correspondence from you on this issue since March. If you would like to send copies of the correspondence you had in mind we would be very happy to receive it.

As stated in my letter to you of 17 April, we are aware of your interest in these important matters and also that you are the author of a petition for a Sunshine Act which is currently being considered by the Scottish Parliament. The Scottish Government remains happy to consider any recommendations from the Public Petitions Committee on this issue.

We are aware that there are a range of issues that have led to the creation of registers of interest not being implemented in full and we consider that national collaboration is important to address these issues and challenges and to consider how the Scottish Government can support NHS Boards in implementation for what is needed in 2014 and beyond. To facilitate this, the Scottish Government is undertaking work with NHS Boards with a view to supporting consistent implementation across Scotland in a way fit for 2014 and beyond.

We are aware from your evidence to the Public Petitions Committee that you would support registers being in place for “healthcare workers” however you do not think that this would include pharmacists at this stage, and possibly not GPs. If you wish to provide us with further information on your views on this and your view on where best practice exists we would, of course, be happy to receive them.

I hope you find this helpful.
Yours sincerely,
GORDON CLARK

5-Aug-2014-Scot-Gov-on-Regi

Below is a reminder of HDL(2003) 62, issued 12 December 2003 to all NHS Boards and what action it asked of all Chief Executives:

HDL 62

“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 http://holeousia.wordpress.com/2014/01/01/the-forgetfulness-of-others/

[20] Merton, R.K The changing production system of scientific knowledge from Hole Ousia http://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

Why the GMC should set up a central registry of doctors’ competing interests

Open Letter to the General Medical Council
Why the GMC should set up a central registry of doctors’ competing interests

Published 15 January 2014

Margaret McCartney, general practitioner, Glasgow,
Ben Goldacre, Wellcome research fellow in epidemiology,
Iain Chalmers, coordinator, James Lind Library,
Carl Reynolds, NIHR academic clinical fellow in occupational lung disease, Imperial College London,
Jonathan Mendel, social geographer,
Sam Smith, freelance transparency consultant (formerly of the campaigning group Privacy International),
Susan Bewley, professor of complex obstetrics, King’s College London,
Martin Brunet, GP, Binscombe Practice
Peter Gordon, consultant psychiatrist, NHSForthValley,
David Carroll, medical student, Queen’s University, Belfast,
Ben J F Dean, orthopaedic research fellow, University of Oxford,
Trish Greenhalgh, professor of primary healthcare and dean for research impact, Barts and the London School of Medicine and Dentistry,
Iona Heath, retired general practitioner,
Martin McKee, professor of European public health, London School of Hygiene and Tropical Medicine,
Allyson Pollock, professor of public health research and policy, Queen Mary University of London,
Sian Gordon, GP and GP appraiser, Falkirk

Correspondence to: M McCartney margaret@margaretmccartney.com


This transparency can only be good for medical practice

Dear sir
Trust between patients and doctors is critical to good medical practice, and doctors are still highly trusted by the public.[1] But we should ensure that we deserve it. The Association of the British Pharmaceutical Industry has estimated that the drug industry pays £40m (€48m; $65m) a year to doctors for speaking fees, flights, hotels, and other travel expenses[2]. Yet who is being paid what is opaque. It is clear that exposure to pharmaceutical advertising adversely affects future prescribing.[3] [4] There is also evidence that if doctors accept gifts from the drug industry, patients trust doctors less.[5]  Citizens can access MPs’ central register of their financial conflicts of interest,[6] yet patients cannot find out whether their doctor has a financial conflict of interest. The vast majority of doctors will be receiving no payments from any organisation other than their employer or the NHS. Some will receive fees for their expertise from NHS or non-NHS organisations. Others will be receiving some pharmaceutically sponsored education. A few will be receiving large amounts for assisting pharmaceutical or other companies with their profile and sales of their products.

The General Medical Council (GMC) says, “You must be honest in financial and commercial dealings with patients, employers, insurers and other organisations or individuals . . . If you are faced with a conflict of interest, you must be open about the conflict, declaring your interest formally, and you should be prepared to exclude yourself from decision making.”[7] Yet there is no formal way to declare such interests, especially when conflicts may subtly influence a doctor’s practice—such as small gifts from the drug industry. The lack of a system to document payments means that patients cannot routinely be informed whether their doctor receives benefits from companies that may affect their prescribing.

Given the evidence, patients should be able to know when drug companies are influencing and paying their doctors. Nor is promotion by the industry the only concern. A burgeoning public relations and media relations industry pays doctors to promote products from hand creams to foodstuffs. Surely the financial transactions that underpin these promotions should be made obvious to potential customers and patients? Similarly, the Advertising Standards Authority has admonished many clinics for unfair advertising of products and unfair practices. Yet the monetary relations concerning the doctors promoting these products have not been made explicit.

There is a need for change. The current system of self declaration is variable, opaque, and unreliable. Investigations into the “hospitality registers” of Scottish hospitals have found a paucity of information about payments to doctors.[8] Although the Association of the British Pharmaceutical Industry has said, in personal communications, that it proposes to make details about payments to doctors available, with their consent, this would not force doctors to disclose payments. The industry’s proposals for declaring payments have the disadvantage of not taking account of monies arising from other commercial transactions. Although academics and journals have led on declarations of competing interest, they are inconsistent (some interests are mentioned on some papers and not on others). It is unrealistic to expect that patients, or indeed colleagues, will have access to this information or should be responsible for gathering and interpreting it.

All doctors already reflect on their probity when undergoing annual appraisal. It would serve the interests of transparency to share these conclusions easily with peers and patients.

We would discourage the long and potentially irresolvable discussion about what does or does not represent a conflict or interest (membership of a political party, board membership of a charity, ownership of a nursing home, or ownership of a primary care service while working as a commissioner of care). Rather, we suggest that patients may be good judges of this. Moving from the notion of an academic conflict of interest being something “that would embarrass you if it were to emerge after publication and you had not declared it”[9] the question should become, “Is there anything that would embarrass your relationship with your patients or the public if you do not declare it now?” Although having an interest is not necessarily by itself a problem, failure to disclose some declarations might be. It is likely that doctors’ professionalism would lead to more over-declaration than under-declaration. However, patients are most likely to be concerned about payments from the industry, PR companies, and declarations of interest over commissioning of services.

Some of us have already met representatives of your organisation to consider whether the GMC is the most appropriate body to hold a list of declarations of interest, updated annually, alongside details of our qualifications and registration status. Although we urge the GMC to consult on this, we appreciate that this step change may cause concerns for some. For most doctors a declaration of interests would be simple and straightforward, containing little or nothing of particular concern. For a few it would make it clear to patients and colleagues who the paid opinion leaders are and whose advice on health interventions may be influenced by payments from the manufacturer. This transparency can only be good for medical practice. It may cause discomfort for a few but would enhance trust in the profession as a whole.

To enable doctors to register their declarations of interests publicly, we have meanwhile created a pilot website, http://www.whopaysthisdoctor.org, designed to allow a simple download for the probity section of our annual appraisals. We invite doctors to use the website and hope that they and their patients will find it useful. We anticipate that, in time, a public declaration of interests will be seen as the right thing for all professionals to make.

Competing interests: All the signatories’ declarations of interests can be found at http://www.whopaysthisdoctor.org.


[2] Drug companies pay doctors £40m for travel and expenses. Guardian 5 Apr 2013. http://www.theguardian.com/society/2013/apr/05/drug-companies-pay-doctors-40m.

[3] King M, Essick C, Bearman P, Ross JS. Medical school gift restriction policies and physician prescribing of newly marketed psychotropic medications: difference-in-differences analysis. BMJ 2013;346:f264.

[4] Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA2000;283:373-80.

[5] Green MJ, Masters R, James B, Simmons B, Lehman E. Do gifts from the pharmaceutical industry affect trust in physicians? Fam Med2012;44:325-31.

[6] House of Commons. Register of members’ financial interests. http://www.ipsos-mori.com/researchpublications/researcharchive/15/Trust-in-Professions.aspx.

[7] GMC. Financial and commercial arrangements and conflicts of interest. http://www.gmc-uk.org/guidance/ethical_guidance/21161.asp.

[8] Gordon P. NHS Scotland: register of interests. http://holeousia.wordpress.com/tag/hospitality-register.

[9] Horton R. A statement by the editors of the Lancet. Lancet2004;363:820-1.

The GMC: “The differences between our guidance and a compulsory register”

This is the General Medical Council’s response to my Petition for a Sunshine Act to the Scottish Government:

PE1493/I

9 January 2014
To: petitions@scottish.parliament.uk
Andrew Howlett
Assistant Clerk
Public Petitions Committee
The Scottish Parliament

Dear Mr Howlett,
Scottish Parliament Public Petition PE1493 on a Sunshine Act for Scotland

Thank you for giving us the opportunity to submit our views on the proposed introduction of a ‘Sunshine Act’ for Scotland, creating a searchable record of all  payments (including payments in kind) to NHS Scotland healthcare workers from Industry and Commerce.

I have set out below how our guidance to doctors applies in this area, as well as some work that we will be taking forward which is relevant to the issues raised in the petition.

The status of GMC guidance
The standards we expect doctors to abide by are set out in our ethical guidance. Good medical practice and all its explanatory guidance, including that on Financial and commercial arrangements and conflicts of interest, describes what doctors must do when faced with a conflict of interest, including offers of payment or hospitality made by pharmaceutical or other healthcare companies.

Doctors must demonstrate, through the revalidation process, that they practise in line with the principles and values set out in our guidance. Serious or persistent failure to follow the guidance will put their registration at risk, because these are the standards they’ll be judged by if their fitness to practise is called into question.

The differences between our guidance and a compulsory register
Our guidance for doctors1 makes clear that they must be open and honest about  any financial and commercial interests, and they must not allow these to affect the  way they treat or care for patients. The guidance also sets out that doctors must  be open about any conflict, declaring interests formally, and should be prepared to  exclude themselves from decision-making.

This guidance on conflicts of interest is not limited to payments (including payments in kind) from Industry and Commerce as proposed in the Petition. Nor is  it restricted to doctors working in the NHS. Rather our guidance:

• applies to all doctors, regardless of their grade, specialty and whether they work in the NHS or the independent sector;

• relates to any conflict of interest, not just payments or payments in kind;

• says doctors must not accept any inducement, gift or hospitality that may affect or be seen to affectthe way they care for patients, ie it covers perceived, potential conflicts as well as those that are recognised and current.

Publishing research results
In the Official Report of 12 November 2013 Dr Gordon made reference to the failure to publish trial data. Our guidance on research1 makes clear that:

• we expect doctors to be open and honest about their research;

• financial interests must not affect completion of research;

• doctors should publish research results, including adverse findings, through peer review journals.

We also state that, as well as reporting adverse findings to the affected participants, and those responsible for their medical care, doctors must report adverse findings to the research ethics committee, and bodies – such as the Medicines and Healthcare products Regulatory Agency – responsible for protecting the public.

Fitness to practise cases relating to conflicts of interest
We can confirm that over the past seven years (since April 2006) over 200 (240) doctors were referred to us with allegations about conflicts of interest (from a total of over 25,000 cases). In 33 cases the doctors were referred to panel hearings. Of those doctors who were referred to panel hearings, 5 were erased, 6 suspended and 4 had conditions put on their licence. As at 21 November 2013, there were also a number of doctors (14) with open cases relating to conflict of interest allegations.

A compulsory register would require legislative change
We do not currently have any powers in the Medical Act 1983 to require doctors to disclose financial interests to us, and any scheme to publish details of doctor’s financial interests would need to be voluntary.

A change in legislation would be needed to establish a compulsory register of doctors’ interests. If this were not implemented across the UK simultaneously, it is not clear whether and how a change in legislation in Scotland – as proposed in this Petition – might impact on our regulation of doctors across all four UK countries. As it happens, in the light of a recent review of professional regulatory legislation undertaken by the Law Commission, we understand that a Bill is likely to be brought before the UK Parliament during the course of 2014 which would replace the 1983 Act with a new Act applicable to all the professional regulators.

Next steps
We recognise that there is scope for us to promote our guidance on good practice, to continue to raise awareness of it and do what we can to ensure compliance with it. Throughout 2014 we will continue to look for ways to embed the principles in doctors’ day to day practice.

We will also assess conflicts of interest and the practicality of keeping a list of doctors’ interests attached to the Register. Through our Corporate Strategy for 2014-2017 we are committing to considering if there are any changes that we could make to the medical register to make it as relevant, accessible and useful as possible. This review will provide a timely opportunity to address this important matter.

We would welcome information about the progress of this Petition and would be glad to offer a meeting if that would be helpful.

Yours sincerely
Paul Buckley

Director of Strategy & Communication

Annex A: Extracts from GMC guidance

Annexe A, GMC

The GMC say “If you are in doubt about whether there is a conflict of interest, act as though there is. “

I sent the letter below to the GMC after reading their Guidance on declarations of interest:

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From: Gordon Peter (NHSFORTHVALLEY)
Sent: 27 November 2013 13:09
To: standards@gmc-uk.org
Subject: Declarations of Interest and doctors

27th November 2013,

Dear GMC,
Each year I sign my annual appraisal form, including the probity section, to confirm that I have followed my NHS Board policy on conflicts of interest. I have never had any such declarations to make so I have always signed with probity: http://holeousia.wordpress.com/declarationof-interests/

However FOI research to all 22 Scottish NHS Boards has demonstrated that Boards universally lack – either with no policy, or no register, and not infrequently without both:

http://holeousia.wordpress.com/category/medical-writings/pharmaceutical-industry-and-medical-education/nhs-hospitality-registers/

So my question is:

How many doctors are signing off annual appraisal but have not registered COI with their NHS Board or Trust? And thus have the GMC had any reports of doctors who have not declared COI?

In terms of “regulating doctors, ensuring good medical practice” this surely is a legitimate and very real concern. Last year £40 million was paid by Pharmaceutical industry to healthcare workers for Continuing Medical “Education” and recent reports have evidenced that up to 3/4s of Guideline Panellists have “ties to industry”

I would be grateful for your thoughts on this.

Yours sincerely,
 Peter Gordon

GMC

On the 14th January 2014, I had this most helpful reply from the GMC:

From: GMC
Sent: 14 January 2014 14:59
To: Gordon Peter (NHS FORTH VALLEY)
Subject: RE: FOI query

Our ref: F13/5915/EH

Dear Dr Gordon
Thank you for your email below. Our Standards Team forwarded your email to us to look into whether we could provide the information you request. I apologise for the delay in responding to you.

I’m afraid we don’t hold the necessary data to be able to tell you how many doctors are signing off annual appraisal but have not registered conflicts of interest with their NHS Board or Trust. However, in relation to whether the GMC have had any reports of doctors who have not declared conflicts of interest more generally, we can provide some information which I hope will be helpful.

When we investigate a case against a doctor we record some information concerning the allegations made in an electronically searchable way. We also record a very brief description of the allegations made in a ‘free text’ field.

We have looked at cases opened since 2007 (the first full year for which we have this facility) for those with allegations falling within the following groups – ‘fail to declare interests’, ‘interests affect patient care’, ‘undeclared interest – other’, ‘undeclared interest in home’ and ‘undeclared interest in hospital’. We have located 201 cases opened since 2007, relating to 199 doctors, where there is an allegation falling within any of these categories.

However, we cannot extract the specific figure you require from this search. I have therefore used the ‘allegation description’ field to assist in identifying any cases where a Health Board/Trust alleges a failure to declare a conflict of interest to them, as per your email. I have located six such cases. I should stress that this figure results from a limited manual search of the description field and not a review of all information held on all 201 cases.

Of these six cases, two are on-going, one was closed with advice and the remaining three were heard by a Fitness to Practise Panel.

I should explain at this point that as allegation categories are selected by the Investigation Officer when we begin to investigate a case, it often happens that, if the doctor is referred to a hearing, they are not referred on the basis of all allegations originally recorded. For example, allegations may not progress to this stage due to a lack of evidence.

Therefore, of the three cases heard by a panel, in only one case was an allegation concerning non-declaration of a conflict of interest to the Trust considered by the Panel. I have attached the public minutes for your information.

I hope this is helpful. If you have any concerns regarding the handling of this request please contact Julian Graves, Information Access Manager, at jgraves@gmc-uk.org.

Kind regards
Redacted

Information Access Officer
Tel no: 0161 923 6314