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.
