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Shining a light into dark corners
The Chairman of NHS England explains what is being done to tackle conflicts of interest:
Earlier this month I chaired the first meeting of a task and finish group charged with improving the management of conflicts of interest across the NHS.
The group’s membership and terms of reference are now available.
The issue is a topical one; several recent stories in the press have highlighted examples where the conduct of NHS employees in receiving payments from pharmaceutical companies has been open to question, and has raised legitimate public concern.
This is a complex area. Conflicts of interest can occur in a multiplicity of different situations within healthcare, however their management is fundamentally a question of good judgement supported by due process.
I am clear that we have a responsibility to use the £110bn healthcare budget provided by the taxpayer to the best effect possible for patients, with integrity and free from undue influence. If we do not, we have failed in our duty and will lose the public’s trust.
I’m very pleased that we have convened a group of capable individuals who are committed to addressing this issue.
Our group will meet four times over the summer in order to develop an approach that we hope will make it easier for individuals and organisations to understand and appropriately manage conflicts of interest.
At our first session there was a good discussion on the variation in the current system and the need to learn from the best to create greater consistency and a levelling up of practice. There are many local and national organisations that do this well. NICE, for instance, have a comprehensive policy and approach which addresses the specific conflicts that arise in the context of advisory groups. There are also lessons we can learn from other countries – such as the physician payments or Sunshine Act in the USA.
There was a valuable consensus among the group about the need to have a common definition of conflicts of interest. We felt it important to stress the possibility for a person’s judgement in regard to a primary interest or duty to be affected by a secondary interest they hold. This could be a conflict between a public role and a private investment but could just as easily be a conflict between two public duties.
We recognised that conflicts can be actual i.e. real and present, potential ,i.e. likely to arise unless action is taken. We also agreed on the importance of avoiding perceived conflicts of interest even where no actual conflict is present, since we need to maintain public trust.
We will need to carefully consider how we will maximise the impact of our work; our worst fear is that we produce a report which gathers dust on a desk. Our ambition, therefore, is to engage with the system through our call to evidence and consultation to produce a set of usable tools which facilitate and reinforce the ethical culture of the NHS.
At the next meeting on 4 July we will focus on both the appropriate principles and rules needed to manage conflicts of interest and also the approach to identification and management of interests when they arise.
Dear NHS England,
Below is a copy of a BMJ rapid response on this subject:
Self-regulation is an oxymoron
Re: Drug company is suspended from UK industry body after “deception on a grand scale” Adrian O’Dowd. 353:doi 10.1136/bmj.i3574
Braillon, Noble and Bewley have summarised perfectly the current situation with regard to partnership working with industry (1).
It just so happens that today the ABPI has published its voluntary register (2). It has been reported that “Up to half of medics and other health service staff working for pharmaceutical companies alongside their day jobs have refused permission for their names to be included in a new online database.” (3)
The Scottish Parliament commissioned a consultation with the Scottish public regarding the need for a Sunshine Act (4). The response was that the majority of those consulted considered that financial declarations had to be mandatory (5).
NHS England has set up a task and finish group to look at setting rules to manage conflicts of interest. It is not clear whether these rules will be voluntary or mandatory (6).
It will be interesting to see what progress is made over the months ahead but it is worth noting that other countries have moved on from voluntary to mandatory requirements because the former have been ineffective..
(1) Braillon, Noble and Bewley http://www.bmj.com/content/353/bmj.i3574/rr
(5) Scotland’s NHS needs a Sunshine Act to make pharma links transparent: https://www.theguardian.com/healthcare-network/2016/jun/28/scotlands-nhs…
(6) NHS England: Shining a light into dark corners: https://www.england.nhs.uk/2016/06/malcolm-grant-3a/
Competing interests: Dr Peter J Gordon raised a petition with the Scottish Government to consider introducing a Sunshine Act for Scotland: http://www.parliament.scot/GettingInvolved/Petitions/sunshineact . Dr Sian Gordon is a partner with Graeme Medical Centre, Falkirk which appears in the voluntary ABPI Register: http://www.abpi.org.uk/our-work/disclosure/Pages/DocumentLibrary.aspx
01 July 2016
P.J. & S.F. Gordon
Psychiatrist for Older Adults and General Practitioner
Bridge of Allan
Still no sign of my comment.
Perhaps I am being unreasonably impatient.
If so forgive me.
Hi Dr Gordon,
Thank you for you comments
I apologise for the delay in publishing your comments. We try and make sure comments are published with 24hrs, but during busy periods this can be slightly longer.
I submitted a response to this but as yet it has not appeared? Can you please let me know if my response is to be posted?
The task Group may be interested in developments in Scotland.
The full details are collected here:https://holeousia.wordpress.com/about-me/a-sunshine-act-for-scotland/
And here is a short up-to-date summary:
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.
Warrington CCG has a members spouse being paid employed by Spire – is this right ?
Thank you for your comment.
If you have concerns relating to an individual organisation please can we ask you to raise these directly with the organisation concerned in the first instance so that they can be investigated.