A general practitioner in Glasgow unpacks how the hand-in-glove relationship between the pharmaceutical industry and the NHS has changed – for the worse.
Junior doctors are overworked, underslept, abused by the healthcare system and generally downtrodden. So, a few decades ago, when a kindly lady knocked upon the hospital office door (a cupboard, really) to offer us juniors an educational session with free dinner, I felt momentarily loved. ‘You have a tough time,’ she said, soothingly, and ‘by the way, I’m organising an education session – what sort of meal do you fancy: French, Italian, Thai? You can have anything you want. Here’s some chocolate in the meantime.’
I still remember the restaurant, which had fairy lights in the ceiling, a civilised ambience and unlimited alcohol. Coffee came and the kindly lady said, ‘I just need your name, pet,’ before passing around a piece of paper and a pen. ‘Okay,’ I said, scribbling, and she gave me a leaflet about some drug I’ve long forgotten, saying, ‘That’s the education bit done.’ We both laughed.
Today, it’s a different matter. Dinners on a drug company’s dime are rare events. Rather, the pharmaceutical industry works on the inside of the NHS, with complex, often opaque deals which can fund staff, education or medical devices. The result is an invisible but complex dependency – and an NHS which can’t profess to be independent.
But back in the 1990s, when I was a struggling junior doctor, drug dinners were a fact of medical life. They were a blessed relief from the cruelty of the wards and it didn’t occur to me for some time that perhaps they were a bad idea. Pharmaceutical companies make products. They want them to be prescribed. So they take doctors out for dinner, make them feel good and grateful, and then tell them about whatever new and fantastic medication they’re happening to manufacture. As doctors have to prove they are keeping up to date, making ‘education’ a minimal effort keeps everyone happy.
Some doctors could even be promoted by the pharmaceutical industry to be a ‘key opinion leader’ – selected perhaps for their charisma, academic standing or personal reputation. The offers would start to arrive: an invitation to lecture peers on the best treatment for diabetes, anaemia or chronic bronchitis. A keen company might request your presence at international conferences and ask that you consult for them, all with generous remuneration.
In 2005, the Health Select Committee decided that things should change and published a dynamite report into the workings of the pharmaceutical industry in the UK. They described the insidious, widespread marketing of drugs at professionals, misleading advertising, the suppression of unfavourable trial results and a trend for ‘overmedicalisation’ – diagnosing and treating conditions that were likely to get better just as well by themselves. They discussed how diazepam had been marketed and prescribed widely for patients with anxiety or insomnia, but left them addicted for years afterwards. They wrote about how ‘aggressive’ marketing and ‘promotional hospitality masquerading as education’ contributed to the ‘inappropriate prescription of medicines’, with doctors ‘sometimes too willing to accept hospitality from drug companies’.
They called for change: for doctors to openly declare their financial conflicts and for drug companies to reduce their marketing. They wrote that ‘the interests of patients, the NHS and industry can be at odds’ – obvious, but ignored. Since then, almost none of the committee recommendations have been fulfilled. And rather than individual doctors having quiet dinners with drug representatives, we have wholesale ‘industry partnerships’ driving past the checks and balances that are meant to keep the good ship NHS safely afloat.
Here’s an example of how the NHS has marched to the drug industry’s beat, rather than followed its own, independent, advice. Atrial fibrillation (AF) is a cardiac condition where the heart beats erratically. It has multiple causes: high thyroid hormone levels, pneumonia, heart attacks or just bad luck. People may notice something wrong: breathlessness or fatigue, for example. It can cause a stroke and can also be symptomless. A massive study is being held to work out whether screening, then, does more good than harm. The UK National Screening Committee, who make evidence-based judgement calls on what screenings the NHS should do, say ‘screening is not currently recommended for this condition’. And yet, the trusted NHS has been ignoring that instruction and doing exactly that.
Why? The pharmaceutical industry. In 2013, organisations called Academic Health Science Networks (AHSNs) were launched by the Cameron government. Their stated aim was ‘innovation’. There’s nothing wrong with that, particularly in the NHS, where innovation is lacking, IT departments’ fax machines still rattle around and computer systems crash several times a day. But this wasn’t the sort of innovation they meant. Instead, ‘partnerships’ with pharma companies would ‘deliver the productivity savings we need… and it will also support our role as a major investor and wealth creator in the UK.’ In practice, what this meant was that the companies making the blood thinners – who stood to benefit from increased prescribing – paid for staff to screen people for AF.
In return for this funding, the AHSNs got NHS data, created targets for numbers of people to be diagnosed and paid for nurses and pharmacists to screen people. There were even schemes where firefighters got involved. They were given the kit for cardiac screening and told to check patients when they visited for home safety checks. I’ve spoken to dozens of doctors and pharmacists who didn’t know that the official NHS advice was different. That’s unsurprising: the AHSN, who had industry funding, paid for staff training.
When I was a junior doctor, and decided to avoid drug company influence, I just stopped accepting the invitations to dinners. Now it’s almost impossible to avoid. Drug companies give the NHS millions every year for ‘joint working’, education and sponsorship arrangements. This money can fund staff, including nurses and pharmacists, and includes ‘education’ for professionals working in clinics – typically in areas where new, profitable drugs could be prescribed. For example, recently, near me, an ‘optimisation clinic’ for patients with chronic bronchitis has opened, where the deal explicitly states that an ‘intended benefit’ would be an increase in prescribing GSK products (‘if clinically appropriate’). It’s funded by GSK, a multinational pharmaceutical company who manufacture a lot of drugs for this condition.
Another example: in England, NHS obesity clinics are being jointly designed with Novo Nordisk, a Danish multinational company who make the new weight loss drug semaglutide, better known as Wegovy, to ‘combine financial and non-financial resources to redesign the weight management pathway’. To a beleaguered hospital accountant, financing clinics with help from pharma might look attractive. In return, companies get access to NHS data, relationships with prescribers and the ‘expansion of an eligible patient population’. In other words, more prescribing opportunities.
This might sound very reasonable. You might argue, in a post-Brexit world, that the life sciences should be buttressed. You might argue that a mature relationship between the NHS and the pharmaceutical industry is possible, one that avoids conflicts of interest and inappropriate prescribing. I disagree. Allowing an external industry to shape the NHS means giving away its independence. The NHS becomes reliant on pharma income, targeted at areas of practice where the drugs are profitable and prescribing is the aim, ignoring all the less sexy, less lucrative areas of practice.
Nor should we claim to be un-influenceable. It is remarkably easy to be swayed by sales pitches – especially when the salespeople are likeable and especially when they do not appear to be salespeople. We want to please others, even more so when we depend on them for funding. A research study once asked junior doctors whether pharmaceutical promotions influenced their prescribing. The majority thought it didn’t. But they also thought that most other doctors succumbed. We are naive.
What they really are paying for, here, is influence. Take patient organisations – these could be charities or support organisations for patients with a particular disease or condition – which have now become prime territory for pharma funding. Drug companies focus their sponsorship where it is likely to pay dividends: funding patient groups who might use the products they make or are developing. Of course, many patient groups do a huge amount of good. The National Institute for Health and Care Excellence (NICE), who make decisions about what NHS treatments to fund, routinely ask patient groups for their views. But almost three quarters of the groups that contributed to NICE’s appraisal process had accepted money from a manufacturer in the product area in the year or two prior – yet NICE were aware of this only a minority of the time. In other words, industry influence still manages to get inside a decision-making process that was meant to be independent.
Back in 1999, when the newly established NICE decided not to approve an anti-flu drug made by Glaxo Wellcome because it didn’t work very well, the chair of the company, Sir Richard Sykes, stormed into 10 Downing Street calling the decision ‘ludicrous’. He said the choice not to fund his drug ‘calls into question the suitability of the UK as a base for multinational pharmaceutical operations’. This kind of threat has now been subsumed into the fabric of the NHS. Dinner dates are no longer the gateway drug into the beating heart of the NHS. The system has been rigged, and we are all the worse off for it.
