- Kate Adlington, clinical editor,
- Fiona Godlee, editor in chief
- Correspondence to: K Adlington
This week the Association of the British Pharmaceutical Industry (ABPI) launched its long awaited database of payments to doctors.1 This is a useful step towards greater transparency and public accountability, but it serves mainly to show just how far we have yet to go.
Called Disclosure UK, the database reports payments from ABPI member companies to healthcare professionals and organisations in the UK. According to this first release of data, drug companies paid out over £340m (€400m; $450m) in 2015.2 3 The average annual declared payment per named clinician was £1500 and the highest declared value was £98 000.
This is part of a Europe-wide initiative, for which the pharmaceutical industry should be congratulated.4 But as an answer to concerns about the influence of money on clinical and healthcare decisions, its limitations are all too clear. Firstly, because of EU privacy law, declaration is voluntary.5 Health professionals can exclude certain payments or opt out entirely. And there is no option for a nil return so if a doctor isn’t listed this could mean either no payments were received or the doctor declined to be identified.
In view of this, it is encouraging that 70% of recipients agreed to have their named data published, and we applaud those who did so.2 3 But the database does not record how many doctors withheld disclosure, how much they were paid, or what for. Named declarations account for only 48% of the total value paid, suggesting that the highest paid individuals were more likely to opt out.2 3
Secondly, and for obvious reasons, this database covers only drug company payments. Important though these are, they represent only part of the overall picture of financial competing interests in healthcare. There are no equivalent data on payments from medical device companies. Nor do we have information about the broad array of other financial interests that might influence clinical and procurement decisions, such as owning shares in private healthcare companies and income from private practice.
Thirdly, the data are hard to interpret. Most people are likely to find broad categories of payment such as “fees for service and consultancy” unhelpful. Research funding, responsible for two thirds of the total paid out in 2015, is declared only in aggregate, not by individuals.3 When The BMJ is deciding on a potential author for an educational article, we ask for information about payments for conferences, advisory board work, speakers bureaus, honorariums, and payments associated with named drugs.
Finally, the database is far from user friendly. Data are published in a single cumbersome spreadsheet, unsuitable as a public facing tool. Comparing drug companies is difficult, and licensing arrangements governing use by outside parties are ambiguous.
We can expect the data to improve over time and, as attitudes change, more doctors to be willing to disclose. But we should not mislead ourselves or the public into thinking we have made more progress than we have. Other countries are further along the road. The equivalent US register documents payments from both pharmaceutical and medical device companies in forensic detail.6 Public disclosure is mandatory, enshrined in the Physician Payment Sunshine Act. The US website is well funded by government and easier to navigate. Disclosure in the Netherlands is mandatory but self regulated by a professionally agreed code of conduct rather than legislation.7 8
What next for the UK? There is currently little political appetite for US-style legislation, with bigger issues likely to distract parliament for some time. But there are encouraging signs of growing commitment within the profession.
A meeting hosted by The BMJ and the Royal College of Physicians in October 20149 and a subsequent working group reached a strong consensus that the new ABPI database was a welcome start but that the medical profession should take the lead. Participants favoured the Dutch model with a national, online public platform for declaration of interests championed and funded by medical associations.
NHS leaders are now taking this seriously. NHS chair, Malcolm Grant, has launched an initiative to develop principles and guidance for managing conflicts of interest across the healthcare system, covering gifts, hospitality, sponsorship, research and educational funding, shareholdings, and private practice.10 NHS England has published guidance for clinical commissioning groups,11 12 and NHS providers will be contractually obliged to publish local registers of employees’ interests.13
As for doctors, the General Medical Council is clear about their responsibilities: “If you are faced with a conflict of interest, you must be open about the conflict, declaring your interest formally. If you are in doubt about whether there is a conflict of interest, act as though there is.”14 What is lacking is an effective mechanism for making these declarations. Prompted by parliament’s Health Committee last year, the GMC is consulting on changes to the medical register to potentially include “declarations of competing professional interests.”15 16 This would probably be voluntary in the first instance but would allow nil returns, making it clear which doctors have not taken part.
Transparency is no longer an optional extra. It is necessary for fair, effective, and accountable healthcare. The ABPI’s Disclosure UK is a welcome first step, but the public should demand and professionals should provide better. Patients deserve a comprehensive, searchable and eventually mandatory public facing database of doctors’ declarations of interests, and the GMC is best placed to deliver it.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following: KA was secretary of and FG co-chaired the jointly hosted BMJ/RCP meeting on conflict of interest in October 2014 and the subsequent working group. KA previously worked as clinical fellow at NHS England. FG is a member of the NHS "task and finish group" working to develop principles and guidance for managing conflict of interest in the NHS. The BMJ is owned by but editorially independent from the BMA. The BMJ and its parent company BMJ receive advertising, reprint, and sponsorship revenues from the pharmaceutical and devices industry. Its other revenues come from non-industry advertising, subscriptions, and open access fees. The BMJ has a long history of campaigning for greater transparency and better handling of conflicts of interest in healthcare and research.
Provenance and peer review: Commissioned; not externally peer reviewed.