It’s common for doctors to take money from pharmaceutical companies. Occasionally, to be sure, this is lurid corruption, but that’s rare. More common is the banal, day-to-day reality of doctors who have some kind of financial conflict of interest. Maybe they accept money from a drug company for travel to a conference. Maybe they’re presenting the results of a trial about that company’s drug. Maybe they take money to give educational lectures to local doctors about a particular medical condition, and they happen to have a pre-existing preference for that company’s drug.
None of this is criminal. But it does all need to be openly declared, just like MPs declare their own conflicts. I’m a doctor, and I run the DataLab at the University of Oxford. This month we launched a new research paper, and accompanying website, describing what happened when we sent a Freedom of Information Act request to every NHS trust in the country, asking for all the conflict of interest data they hold. You can see the results for each individual trust at: coi.theycareforyou.org. They’re not pretty.
As with most problems, the issue is mostly chaos, rather than corruption. The General Medical Council (GMC) asks all doctors to declare their conflicts, but nobody specifies where, or how. NHS trusts are supposed to collect it for their own purposes, but none had a public disclosure register. Dozens sent nothing in response to our request. And nearly all the registers we did get were missing key information. They simply disclosed that company “blank” gave £400 to doctor “blank”. This reads very oddly, in 2018.
Why is disclosure being done so badly? It’s a low priority. But these priorities are set by policy, and leadership. Many of us in medicine have advocated for a simple, central, mandatory database, managed by the GMC. Industry and the Royal Colleges have promoted voluntary disclosure instead but this has failed, as we said it would. The UK pharmaceutical industry body has a disclosure register where doctors are allowed to censor themselves: and literally half those payments are censored.
I know that many in pharma have been frustrated by this. Secrecy undermines public trust in the industry as well as the medical profession. And this is where the elder statespeople of my profession are most out of touch. Royal Colleges and Academies make sweeping statements about “building public trust” in medicine, and in doctors. But they always point to “better PR” as the solution. That might have been true in the 1980s. In the 21st century, we earn trust through transparency.
In particular, we get progress by making transparency banal. A financial conflict of interest is not a moral curse. It’s a simple fact of life that needs to be disclosed, so that everyone can see it, and judge the impact for themselves. Conflicts are not always trivial, of course. As we discuss in our paper, there’s good evidence to show that doctors, overall, tend to hold favourable views about treatments where they have a financial conflict of interest. But that doesn’t mean any single doctor is untrustworthy, and there are many good reasons to accept money from industry. It’s simple: this must always be declared, so that colleagues, researchers, patients and policymakers can come to an informed and fair view about the impact of each doctor’s financial conflict.
What happens elsewhere? In the United States, since the Sunshine Act came into force, everything is disclosed. The sky has not caved in, doctors simply got on with their lives. It has increased transparency. It has also created a single, simple disclosure system, and made it easy for doctors to be transparent, taking anxiety and uncertainty off the table. It has also facilitated important research. Last month a widely reported analysis found that the biggest prescribers of highly addictive opioids were also receiving large sums of money from the companies that market these drugs.
I hope there are not similar stories to be found in the UK. There may be uncomfortable isolated cases, but I hope we are less financially driven, as doctors, in the UK. And disclosure itself, of course, can help prevent shady practices. If any tiny number of doctors are tempted, then transparent disclosure might help them to think twice.
But until that happens, we will put all the disclosures we can get into the public domain, on theycareforyou.org. And we will spotlight the gaps. Trusts with room to improve can use our site to find those Trusts doing disclosure well, and learn from them. Local people, patients, journalists, hospital staff, and local campaigners can also help drive up standards, by examining the data and bringing accountability.
What’s next? I have two predictions. Firstly, NHS England has a new vague policy on disclosure. From long experience, I can promise you this won’t be competently implemented, unless trusts are publicly held to account. Secondly, I truly believe that policymakers will act. Transparency is cheap. It’s more important than ever before, because doctors are increasingly selling private services to local NHS commissioners. And it’s something that the government can do to improve standards in the NHS without spending any money.
So I’m optimistic. My only sadness is this: we could have led the way. Instead, transparency will be imposed on my honourable profession, by politicians, because the current generation of medical leaders are living in the 1980s. So be it.
Ben Goldacre is a doctor, policy expert and author of Bad Science.
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