Conflicts of interest in healthcare - where are we now?

Abstract

Conflicts of interest in healthcare - where are we now?

This research aims to describe current practice in the declaration of interests in UK healthcare, in order to identify potential means to reduce the negative impacts of conflicts of interest.

Three studies are presented as published works: 1) a cross sectional study assessing current declaration practice in Scotland and England 2) a cross sectional study assessing recommendations of a non-NHS approved intervention in lay media, online, and NHS material, and associated financial conflicts of interest and 3) a mixed methods study, set in the UK, assessing peoples’ ability to locate a health professionals’ declaration of interest, and citizen understanding of what such declarations mean and their potential impact.

Clinical Commissioning Groups, NHS Trusts, NHS Scotland Health Boards, and private healthcare organisations; articles making recommendations about screening for atrial fibrillation from the UK (lay press, online and social media), and citizens, lay people, professionals and students in the UK were studied.

Measured outcomes included 1) Adherence to NHS England guidelines on declarations of interests, and comparison of declaration registers in Scotland, 2) Proportion of references advocating for, against and presenting balanced/neutral views on screening for atrial fibrillation (AF), and proportion of references citing commentators/organisations with financial conflicts of interest 3) a) Participants’ level of trust in professionals with variable conflicts of interest, as expressed in vignettes, b) participants’ ability to locate the declarations of interest of a given well-known healthcare professional, c) laypeople’s understanding of healthcare professionals declarations and conflicts of interest.

The research found that 1) 76% of registers published by Trusts did not routinely include all declarations of interest categories recommended by NHS England. In NHS Scotland 86% of Boards did not publish staff registers of interest. Trusts and Clinical Commissioning Groups in England have low levels of compliance with NHSE guidance on declarations of interest and in Scotland, few staff registers are public and transparency is overall lower. 2) 185/217 (85.3%) media articles were in favour of screening for AF. 194 commentators were identified; 44 were quoted more than once. 41/44 of these (93.2%) were in favour of screening. Of these 41, 37 (90.2%) had a direct or indirect financial conflict of interest, including that due to a work role. In 187 articles (85.7%) these were not disclosed. Of 23 NHS organisations holding information about funding and promoting AF screening online, 22 (96%) had industry funding. The top 10 patient information websites promoting AF screening were analysed: 9 (90%) had industry funding. 3) 85% of participants thought that knowing about professional declarations was definitely or probably important, but 76.8% were not confident they had found all relevant information after searching. Fictional scenarios found that increasing financial conflicts of interest were associated with decreased trust in professional advice. 297 participants agreed to search for a healthcare professionals’ ‘gold standard’ declaration of interest, and 169 reported some data. 5 (3%) of participants found all the information contained in the ‘gold standard’. Qualitative interviews with 21 citizens highlighted the importance of transparency but raised serious concerns about how useful declarations were in their current format, and whether they could improve patient care.

In conclusion, current practice in declaring interests in England is not congruent with NHS England guidelines. Comparatively, in Scotland, there is less public information about health professionals’ interests. Most media coverage on screening for atrial fibrillation is favourable, but conflicts of interest held by supporters are mainly not declared. Most commentators recommending screening had a financial conflict of interest in doing so. Study participants consider professionals conflicts of interest important and want to know about them, but cannot effectively locate them. In qualitative interview, participants raise multiple questions about how effectively declarations can manage conflicts.

This body of research describes contemporary practice and raises concerns that 1) current systems of declarations do not effectively achieve transparency and 2) the role of transparency in reducing conflicts of interests requires to be delineated to ensure that the intended purpose is met.

The potential benefits from transparency as well as the risks, unintended consequences, burden and evidence gaps in current declaration systems is discussed, with questions raised as to whether transparency can reduce bias or, counter-intuitively, worsen it.