We need a more holistic and societal view of healthcare and wellbeing…

I spent eight years serving as a member of Belfast Local Commissioning Group (LCG); the last two years in the chair. LCGs were one of those bodies that spin out from grand government shake-ups of health-care structures where the people doing the shaking up forget to close down other bodies doing more or less the same things so the new bodies lack; any clear role budget or power. There were five LCGs across N. Ireland meeting monthly from around 2008 until 31st March 2022 – they will stay on in some shadowy shadow-form until another body with perhaps a new set of ideologies takes over their reigns.

I am off course being much too cruel and cynical as the Belfast LCG did a lot of great work for the city. I was pleased to be invited, with other past Chairs, to the final LCG meeting and to say farewell to its highly talented LCG lead who was retiring. Before the kind words and the cake-cutting there was the usual monthly meeting. It was five years since I occupied the chair but the business, the issues and politics were strangely familiar and irritatingly predictable. We heard from a community-leader about a multi-disciplinary team (MDT) programme for coordinating “social prescribing” through community development organisations. This was the old challenge I knew well; trying to bring together and making use of myriad community groups allegedly providing services across the city yet with no evidence of benefit. These groups, mostly single issue organisations, vie for recognition and funding and only after that do they considered what it is they might do for the health and well-being of the good citizens of Belfast. They end up offering; Tai Chi, reflexology, aroma therapy or cups of tea to “the pissed” on a night out in Belfast City Centre. They all believe their services are transforming the health and well-being of the local population. Commissioning I was convinced must be evidence-based. For the services these groups provided that was a struggle.

Getting this point diplomatically across was difficult, frustrating and political. They were good at politics because that was the core of their being. LCG was accused of not providing services (ultimately funding the services they had to offer) and if we did provide the services we were accused of not providing proper access. When we assessed their services and found them ineffective we were accused of using the wrong methodology.

But recently my staunch ideological views on evidence based medicine have been severely challenged by a BMJ paper which opines that most evidence-based medicine is a sham as it has been corrupted by corporate interests, failed regulation, and commercialisation of academia.

Reliable data from clinical trials should be how we decide which interventions to fund. But most clinical trials are conducted by the pharmaceutical industry and then reported in the names of senior academics. More importantly the clinical trials necessary to show the most effective interventions will not be funded as Big Pharm does not see a profit.

Confidential pharmaceutical industry documents seen by the paper’s authors, give a worrying insight into the degree to which industry sponsored clinical trials are misrepresented. We have been tricked by an industry whose first priority is profit. The integrity of science and the role of science in an open, democratic society is where practitioners do not cling to cherished hypotheses and take seriously the outcome of the most stringent experiments. This ideal is, however, threatened by Big Pharma, in which financial interests trump the common good. The BMJ article is pretty direct and hard hitting.

Ownership of data and knowledge by Big Pharma suppresses negative trial results, fails to report adverse events, and does not share raw data with the academic research community. This has always been a concern and one that has not been properly addressed.

The authors claim that patients die because of the adverse impact of commercial interests on the research agenda. There is increasing evidence of this malpractice certainly in the available data to support the marketing of many medicines; SSRIs, statins, opioids and testosterone. In depression, for example, the evidence-base for the effectiveness of SSRIs in the treatment of mild to moderate depression shows these drugs to be only as good as placebo. Long-acting opioids were marketed as less addictive than immediate release versions as the evidence-base produced by the Sackler company sponsored clinical trials and promoted by their generously funded key opinion leaders, showed this but it has resulted in half a million US deaths and counting.

The BMJ authors accuse Big Pharma of having a greater responsibility to its shareholders than the common good. Universities have always been elite institutions prone to influence through endowments and the recent Sackler debacle is testimony to this. But in more recent years particularly in the face of inadequate government funding academic institutions have been forced to actively seek pharmaceutical funding. Those of us who spent any time in academic posts know all too well the pressure to get such funding. Ghost-writing of medical journal articles and continuing medical education are the means by which academics become agents for the promotion of commercial products.

I was wrong. LCG was right to support community development and I now realise that it opened up for me a more holistic and societal view of healthcare and wellbeing. We need to be more supportive of the great work all community groups do at a grassroots level. I now wonder, for example, if the football coach bringing a group of teenagers onto a cold, wet pitch on a Wednesday night for football training might be doing a lot more to reduce the suicide and drug addiction rates in the future than I have done over the last 40 years dishing out anti-depressants? This is a question that will probably never be answered with a double-blind randomised control trial.

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