“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.

 

A Sunshine Act for Scotland (parliamentary update)

007 (2)My petition was further considered by this parliamentary committee on the 31st March 2015. What follows is the full transcript:001John Pentland, MSP002HDL-62Angus MacDonald, MSP 003Jackson Carlaw, MSP 004John Wilson,  MSP 005 006 007 008 009009b003 (2) 005 (2)

Open and transparent from omphalos on Vimeo.

Kindness

I resigned from NHS Forth Valley on the 6th June 2014. This was a very sad day for me as I had worked as a Consultant in older adults in Clackmannanshire for nearly 13 years. I hugely miss the people of Clackmannanshire and wish to reaffirm my sincere gratitude to the small team that I was very lucky to be part of.

What follows are some of the kind words that I received before and after I left NHS Forth Valley:003kindness014kindnessThe following message was from a nurse in training who showed exceptional promise:001kindnessFrom a carer:004kindnessFrom a carer:005kindness copyFrom a carer:006kindnessFrom a carer:007kindnessFeedback on my presentation for local CPD:030kindnessFrom a carer:008kindness 009kindnessFrom a member of staff in NHS Forth Valley:010kindnessFrom the Consultant Trainer of Junior doctors in psychiatry in NHS Forth Valley:031kindnessFrom a member of staff in NHS Forth Valley:011kindnessFrom the organiser of the Carers Support Group:1111From a GP who works in Clackmannanshire:013kindness1From a patient:033kindnessFrom a carer who, before I was involved, had significant concerns about the care given to her loved one in NHS Forth Valley:abcFrom a GP who works in Clackmannanshire:015kindnessFrom an NHS Forth Valley Consultant colleague in Psychiatry for Older Adults:016kindnessFrom a nurse:missedFrom a member of staff in NHS Forth Valley:020kindnessFrom a nurse:wwFrom a Healthcare Assistant:022kindnessFrom my secretary:principlesFrom a number of folk with lived experience::024kindnessFrom an ethicist:transparencyFrom a patient to NHS Forth Valley:026kindnessFrom a patient to NHS Forth Valley:027kindness028kindnessThe reference that was given to NHS Forth Valley before my Consultant interview in 2002:029kindness

“Bonuses for senior doctors rise”

It was reported this week that “bonuses for senior doctors” in NHS Scotland is on “the rise”:Discretionary points4This reminded me of a range of views expressed after I offered my personal considerations about “pay awards” for NHS Consultants.

I should say that I found the ‘award panel’ to be thorough but hugely labour intensive in terms of time and resource. “Cost” should perhaps be considered a number of ways:discretionary-points1 This was one replyDiscretionary points2 This was another:Discretionary points3 This week’s report began:Discretionary points5 Consultants can get up to seven “discretionary points” before moving on to three levels of “merit awards”:Discretionary points6 Discretionary points7 Discretionary points8Discretionary points9My personal view is that such financial incentivisation risks skewing behaviour. This potential has been evidenced in other areas of healthcare where “incentivisation” has been involved.

There may be further consequences of financial incentivisation: such that professionalism may be “guided” more by managers, politicians and “improvement science” than by experience, training and knowledge.Discretionary points9cIt is many years since I was part of a discretionary award panel but I noted at the time that a number of applicants were working “jointly” with the pharmaceutical industry, particularly in research. Such research would significantly improve the chance of a senior doctor getting discretionary points or merit awards. None of these senior doctors did I ever find declaring such interests on any register of any sort.

I noticed one reply to this recent article commented that:Discretionary points9d We must also consider that:Discretionary points9eHere are the criteria for Discretionary points as part of any annual application: Discretionary-points9b

Declaration: I have one discretionary point. I no longer apply for awards. This is my personal view. I respect all other views.

Historical note: Additional payment to consultants dates back 
to 1948 when "incentive payments" were available to encourage 
consultants to join the NHS. The "merit award" system was 
nationally based and has progressed to the present mixed local 
and national awards system.

Declaration of Interest form: Royal College of Psychiatrists

The Treasurer of the Royal College of Psychiatrists recently informed me that the College are in the process of revising CR148 Good Psychiatric Practice: Relationships with pharmaceutical and other commercial relationships, and that “this report has been reviewed initially by the Committee on Professional Practice and Ethics. Their draft has been sent for comment to the Psychopharmacology Committee and to representatives from the Academic Faculty including myself.  The document will then be further revised in the light of comments received before being finally approved by the Policy and Public Affairs Committee.”Principles of RCPsychThe Treasurer kindly asked if I had any comments. In this post I wish to look specifically at the current Royal College of Psychiatrists Declaration of Interest form. blank-coi-form2

  • I am assuming that a paper form is a temporary solution: the declarations should be submitted routinely as part of the biography
  • I would suggest that the Royal College of Psychiatrists use a template similar to this voluntary register: Who Pays this Doctor?
  • “Yes” or “No” answers lack in necessary transparency (see again Who Pays this Doctor? )
  • It should not be down to the declarant to decide if he or she “perceives” if they have a conflict of interest, or if it is specifically relevant. The General Medical Council advise “If you are in doubt about whether there is a conflict of interest, act as though there is.”
  • All declarations should be openly available, on-line, ahead of any Conference with a direct link from the Conference homepage
  • All Conference programmes should be openly available and each “bio” should include full declaration of interest

 

“A mark of exceptional impact”

On the 26th March 2015, following a previous post by Hole Ousia, the Royal College of Psychiatrists stated that it “‏is committed to our Conflicts of Interest policy.” principles-of-rcpsychThis policy advises that:cr148-guidance1and that:cr148-guidance3Dr Ben Goldacre in his book “Bad Pharma” suggested that:008This is advice I have tried to follow, but have found that it is much harder than I realised. Ben Goldacre also gave this advice:007I have written to the Royal College of Psychiatrists for a number of years now as I have concerns that extant College Guidance is not being followed. Recently the President of the Royal College of Psychiatrists reassured me that “our team are on the case”. 

Here are the twenty members of the Organising Committee for the forthcoming International Congress in Birmingham. The linked biographies demonstrate that 19 out of 20 have so far not provided any declarations of interest.  At the same time there appears to have been no difficulty in offering sponsorship opportunities in advance of the conference.Organising Committtee International congress 2015Here is the view of the Editor of the BMJ this time last year. A year on and it appears that there is still a need to hold the applause.002Through research for my petition to the Scottish Government for a Sunshine Act I have collected evidence that fully supports Dr McCartney’s claim that, one way or another, “doctors’ education is paid for almost exclusively by industry”012Dr Ben Goldacre is of the same view.KONICA MINOLTA DIGITAL CAMERAThis is the Royal College of Psychiatrists response to the Association of the British Pharmaceutical Industry (ABPI) “Central Platform” which intends to set up a central, open-access register of payments. However any healthcare worker or academic can simply opt out of disclosing any payments on this registeravoid some ofIn recent social media correspondence with the President of the Royal College of Psychiatrists, Dr Ben Goldacre‏ made a series of comments:

“Surely the problem here is the College calling this a problem of the past while failing to implement basic COI transparency? It’s such a dull ancient thing to have to gripe about.”

“I’m surprised that the declarations that have been made aren’t publicly posted?”

“I am very concerned about the reputational consequences for the profession of casual false reassurance on these issues.”

“I really wish the Royal College of Psychiatrists would show some leadership and do Conflict of Interest declaration properly. Not hard, happy to help. It’s unnecessary and embarrassing to be resistant on this issue, we need to be seen to be clean by our patients.”

The President of the Royal College of Psychiatrists replied: “Give us a break Ben. We are chasing and everyone speaking will do so with a full COI. Which will largely be empty”006Unless we have transparency it is impossible for any of us to know who might be paid to educate us. We know in one year that the pharmaceutical Industry paid £40 million to healthcare workers in the UK.

Last year at a Royal College of Psychiatrists Conference, one speaker was Professor Allan Young. Professor Young’s declarations can be accessed from the webpage of the Psychopharmacology Committee of which he is currently chair.Prof Allan Young, ChairBelow is Professor Young’s “bio” as an organiser for the International Congress. As is the case for 95% of the organising committee, this does not yet include the declarations above:Prof Allan Young as organiser of RCPsych Conf

This is a post that I never wanted to write. I should not have had to. This is a governance issue. It is the Royal College of Psychiatrists who should be ensuring that their policy CR148 is being followed.

We need our College to lead on transparency otherwise we risk a dark “mark” which may be “exceptionally” difficult to rub off.

Psychopharmacology Committee: Royal College of Psychiatrists

Psychpharmacology Committee

This is the current membership of the Psychopharmacology Committee of the Royal College of Psychiatrists. It has eleven members and is chaired by Professor Allan Young.

I had expected that all members of this Committee would have ensured full declarations of interest. Along with the biographies 2/3rds of the Committee have given declarations. It is worth having a look at these.

Dr Ben Goldacre, on social media recently said this “I really wish the Royal College of Psychiatrists would show some leadership and do Conflict of Interest declaration properly. Not hard, happy to help. It’s unnecessary and embarrassing to be resistant on this issue, we need to be seen to be clean by our patients.”

I would like to see a wider variety of experience in the membership of such an influential committee. I note the committee includes an individual with “lived experience” and welcome this. Perhaps the Committee could also include a public health expert and an ethicist. I would like to see Committees such as these have the resources to be more critical of prevailing approaches.

 

 

“appropriate” and “correct” concerns in NHS Scotland

After sending an update of my petition for a Sunshine Act to the Chief Executive Officer of NHS Forth Valley I received this reply. Whilst I was employed by NHS Forth Valley I raised concerns that HDL 62, the Scottish Government Circular sent to all Chief Executives in NHS Scotland, was not being followed.Jane-Grant,-NHS-Forth-ValleTwo aspects of this letter from the Chief Executive Officer for NHS Forth Valley are worth further consideration:

(1) Transparency: when I was an employee of NHS Forth Valley I was described by Senior Managers as “unprofessional” for raising concerns that NHS Forth Valley was not following extant Scottish Government guidance on transparency regarding declarations of interest. Further enquiry established that the guidelines were not being followed in most NHS Boards in Scotland. I went on to raise a petition to the Scottish Parliament, details of which can be read here.Petitions Committee 31 march 2015At the Scottish Parliament on the 31st March 2015, John Pentland, MSP, the Committee Convener said: “what was alarming to me is that these guidelines had been completely ignored”. John Pentland, MSP suggested that the Scottish Government, in moving forward, consider that any “register is more of a statutory nature “. 

Angus Robertson, MSP, said to the parliamentary committee that he wanted to “take the opportunity to congratulate the petitioner for highlighting this issue” 

(2) Freedom to Speak Up: The Chief Executive Officer reinforces in her letter the “importance of a culture of openness and candour” in NHS Forth Valley. The Chief Executive Officer however appears to have made the following qualifications: that any concerns raised should be “appropriate” and “correct”.

To conclude: it appears to me that there are still significant barriers to raising concerns in NHS Scotland. If you click on the image below you can read the full review by Sir Robert Francis. I have selected one particular recommendation which I think will require a different mindset to that suggested in the letter above.Freedom05002

Windows

On Tuesday I attended the Scottish Parliament in Edinburgh to observe further appraisal by the Petition Committee of my request that Scotland considers introducing a statutory Sunshine Act. This post is to thank the Committee for considering the opening of a window.window012

I share John Betjeman’s disapproval of bureaucracy. However I reckon that we all share a love of sunshine: Peter-Sunshine,-Jan-2015

This post is a pattern of images of windows that I observed as I walked from Waverley station to the Scottish Parliament. It was Alexander McCall Smith who wrote to me suggesting that I read this book:051

Candia McWilliams is another acclaimed Edinburgh writer:Candia McWilliams

Candia McWilliam’s book, What to look for in winter, is about her “functional blindness”. It is a book full of light:Candia McWilliams (3)

Candia McWilliams invited me for lunch at her home. Candia McWilliams opened windows in my mind. I made a film about what I gained from her (as I tend to do). Candia McWilliams (4)

I left Bridge of Allan station reading the Herald. I noticed this cartoon. I wondered if this cartoon window might be indicative of my day?window013

As I arrived at Waverley Station the glass roof appeared clearer to me than ever before:window011

At Carubber’s Close this half-clouded window caught my eye. Carubber’s Close always turns my mind’s eye to Richard Holloway, another acclaimed Edinburgh writer. I make films (as I may have already mentioned!) and I once made a film about Richard Holloway’s wonderful narrative “leaving Alexandria”:window010

Reaching the Royal Mile. I found myself wondering (yet again) how many windows to the world do we have? window009

Through a gap I spotted St Andrew’s House and the windows of the Scottish Government:window008

Impossible to miss, these spiked piers, similar to Roseberry, but here with a window behind reflecting the passing world in the ripple of old rolled-glass:window007

Next door, the whisky shop protects its wares with mesh-reinforcement to the glass window:window006

I always stop at the Poetry Library. Andrew Greig (another acclaimed Edinburgh writer) said “In Another Light“:  “Poems appeal to the engineer in me – such great size to power output ratio, wondrous wee gleaming machines, the best of them inexhaustible.” window004

Opposite the poetry library we have arguably Edinburgh’s finest poet. Robert Fergusson often poked fun at establishment and medical pedagogy:window005

Robert Fergusson brightens my spirits. But realising my tendency to be metaphorical, I stopped to show that I had not yet been locked up!window003

At least the policeman outside parliament saw no immediate need to detain me:window001

The Scottish Parliament is a wonderful building with windows of all shapes. As I watched the Petitions Committee light came in through every shaped window.

Petition for sunshine, 31 March 2015

The Convener of the Petitions Committee, John Pentland, MSP:Petitions Committee 31 march 2015

After raising a concern …

This report was published recently:Freedom05

I was particularly interested in the following excerpt:003

In his Report, Robert Francis gives:002

I was a Consultant in one NHS Board for 13 years until I resigned in the summer of 2014. I then applied for a post in another Board. I was the only candidate but was unsuccessful. The  same post has now been readvertised:    NHS Tayside job advertised in BMJ, 27 March 2015