Intended for healthcare professionals

Editorials

Doctors’ conflicts of interest

BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3247 (Published 21 August 2020) Cite this as: BMJ 2020;370:m3247
  1. Helen Macdonald, UK research editor1,
  2. Margaret McCartney, honorary fellow2,
  3. Carl Heneghan, director2,
  4. Fiona Godlee, editor in chief1
  1. 1The BMJ, London, UK
  2. 2Centre for Evidence Based Medicine, University of Oxford, Oxford, UK
  1. Correspondence to: F Godlee fgodlee{at}bmj.com

The mesh scandal has shown that a register is now essential

The report of the Independent Medicines and Medical Devices Safety Review,1 chaired by Julia Cumberlege, examines how England’s health system responded to reports of harm linked to the hormone pregnancy test Primodos, the anti-epileptic drug sodium valproate taken in pregnancy, and pelvic mesh. One of the report’s nine recommendations is that the General Medical Council’s register “should be expanded to include a list of financial and non-pecuniary interests for all doctors. The public has a right to know.” The review team listened to the views of a wide range of patients, one of whom said: “We should be aware of clinicians’ allegiances or involvements whether they be financial or other so we too can reach informed decisions about who is best to treat us, and how they should treat us.”

Moral arguments for transparency aside, there is little debate that relevant financial or other professional and intellectual interests can, and have, distorted medical research, education, guidelines, and practice.2 The idea of transparency of interests is far from new. Cumberledge writes that “we have found ourselves in the position of recommending, encouraging and urging the system to take action that should have been taken long ago.” The House of Commons Health Select Committee recommended a GMC declaration register in 2013,3 with similar registers to be run by other professional bodies such as the Royal College of Nursing and Royal Pharmaceutical Society of Great Britain.

The BMJ has reported on how the original evidence on vaginal mesh was “mired in a multimillion pound deal, industry funded research, and undisclosed conflicts of interest.”4The BMJ has called for greater transparency and independence from commercial financial interests in particular because bias in these cases is predictable and arguably simpler to identify, record, and judge than other interests.2

The UK currently lacks legislation, lagging behind other countries (table 1 summarises international approaches). It therefore has no robust system to ensure that industry declares payments to doctors, other decision makers, and institutions and no robust self-declaration of interests by those groups; both are needed. The Association of British Pharmaceutical Industries has a voluntary register, but most money is unaccounted for, partly because healthcare professionals can decline to have their names listed.5 The UK’s few existing mechanisms for self-declaration by clinicians or other decision makers are fragmented, incomplete, and inconsistent. There is no single place where someone can enter their interests and where employers, colleagues, patients, and members of the public can access them. NHS trusts in England are required to collate their employees’ financial interests annually and publish the interests of decision making staff prominently on their websites,6 but few do this well. Journals and conferences each require their own forms to be filled in.

Table 1

International legislative approaches to disclosure

View this table:

Not a breed apart

Why has progress in the UK been so slow? Could it be that Britain’s doctors are still seen as a breed apart from the rest of humanity? The GMC’s guidance on financial interests states that clinicians should be honest, open, prepared to exclude themselves, and avoid situations that may affect or be seen to affect their decision making.7 But it then goes on to say: “You must not allow any interests you have to affect the way you prescribe for, treat, refer or commission services for patients.” This seems to reinforce the notion that doctors can self manage interests in a way that others cannot.8 Judges and politicians are expected to declare relevant interests.

The GMC hints at consequences for registration if there are “serious or persistent failures” and does pursue egregious cases. But the onus is still on patients and colleagues to uncover problematic interests rather than on professionals to declare them. In 2019 the Royal College of General Practitioners voted to campaign for a mandatory declaration of financial and non-financial interests through the GMC, with the costs being met by central government.9 To our knowledge, no other royal college has taken this position.

Need for central register

Annual declarations of doctors’ interests should now be established. A publicly accessible central register held by the GMC seems a reasonable and feasible approach. If this requires changes to the GMC’s legal framework, the government should enact the necessary legislation. In our view, the register should allow comprehensive declarations of interest without judgment of their relevance, display both contemporaneous and historical information, and be searchable, auditable, easy to locate, and freely available. There will be important issues to resolve about how data should be electronically collected and held, and the register will need wide consultation with clinicians and patients. The process should be minimally burdensome for those entering information while being sufficiently comprehensive and reliable for those seeking information. We anticipate that few doctors will have substantial declarations to make. Systems and processes will need to be tested and piloted before becoming mandatory to reduce unintended harms.

The establishment of such a register for doctors is just a start. It does not obviate the need for a UK equivalent to the US Sunshine Act, which requires drug and device manufacturers to report all payments to doctors. There are also many healthcare decision makers who are not doctors, including allied health professions, hospital managers, patients in advisory roles, and researchers, most of whom have no regulator or professional body to hold information centrally.

Once a register exists, it will be the job of healthcare providers, guideline committees, employers, journals, patients, and the public to define which declared interests they consider to be conflicts of interest and to evolve our understanding on how such conflicts should be managed. As the Cumberlege review says, the aim must be to “improve the lives of people who have been harmed and make the system safer in the future.” A proper system for declaration of doctors’ interests is a necessary step towards this goal.

Acknowledgments

Attendees at EBM Live 2019 contributed ideas on the characteristics of a centralised register.

Footnotes

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare that The BMJ has taken a strong position on the need for declaration of interests and excludes those with relevant financial interests from authoring content that directs clinical practice. HM and FG lead The BMJ’s campaign for research, education, and practice that is independent of commercial interests (www.bmj.com/commercial-influence ). The BMJ declares its revenues from commercial sources annually and editors declare interests annually which are displayed. MM is a RCGP council member and a member [?]of its trustee board. She receives income from freelance writing and broadcasting and royalties for published books and helped to set up whopaysthisdoctor.org. CH is an NIHR senior investigator and editor in chief of BMJ Evidence-Based Medicine, and has received payments for his media work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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