Examination of Witnesses (Questions 87
- 99)
THURSDAY 14 OCTOBER 2004
DR DES
SPENCE, MR
GRAHAM VIDLER,
DR IKE
IHEANACHO DR
PETER WILMSHURST
Q87 Chairman: Can I welcome our witnesses
to this session of the Committee and express our thanks for your
written evidence and your willingness to come and speak to us
today. Could I ask you briefly to introduce yourselves to the
Committee.
Dr Wilmshurst: I am Peter Wilmshurst.
I am a consultant cardiologist at the Royal Shrewsbury Hospital.
Dr Iheanacho: My name is Ike Iheanacho.
I am Editor of Drug and Therapeutics Bulletin, which is
published by Which?
Mr Vidler: I am Graham Vidler,
Head of Policy at Which? For the sake of clarity, I should explain
to the Committee that since we submitted written evidence, we
have changed the name we campaign under from "Consumers'
Association" to "Which?"
Dr Spence: I am Dr Des Spence.
I am a GP, and I speak for the No Free Lunch organisation in the
UK.
Q88 Chairman: Can I begin by asking
a broad, general question, probably to you, Dr Spence, and some
of the other witnesses, as to how you feel our approach to health
care in this country is shaped by the role of the pharmaceutical
industry.
Dr Spence: We certainly feel that
the industry has a major influence over health care policy and
that the influence of the industry is across the board, so it
is not just a question of impacting upon doctors and nurses but
it is the involvement with patient organisations and with government
agencies. The industry is active in all these spheres and has
a very clear agenda. Our perspective is that the agenda of the
industry, which is predominantly that of profit—and they
are responsible to their shareholders—is in some ways in
direct conflict with the responsibilities of the NHS.
Q89 Chairman: If I were to put it
to you in a different way, if we did not have the industry working
as it currently does and as you and the other witnesses have described,
and the influence it has, which comes over pretty clearly in your
evidence, how might our approach to health care be shaped differently?
Would we do things differently to the way we do them now?
Dr Spence: We probably have different
priorities, in the sense that if you have an industry that is
worth £9 billion a year, that has enormous clout over the
priority setting. We certainly feel that health care is not merely
about drugs. Health is not about what medications you take. It
is a much broader brush than that. We would seek a much broader
discussion about health in its global sense. One of the issues
that I feel very strongly about as a day-to-day general practitioner
is the amount of health anxiety and health neurosis that has been
generated, often through things like disease awareness campaigns.
We certainly feel that is undermining people's sense of health
and wellbeing. To put it bluntly, the reason for that is because
it is in the commercial interests of the pharmaceutical industry
to promote new conditions and different conditions.
Q90 Chairman: Can you give any specific
examples? What you are saying is people are being made anxious
about a condition, and we have seen examples in some of the evidence,
conditions that may not even exist.
Dr Spence: I suppose a good example
would be something like depression. I know this might be touched
upon later during the session. When I first started in general
practice, there was a campaign called Defeat Depression.
Q91 Chairman: Was this an industry
campaign?
Dr Spence: It was a campaign promoted
through the Royal College of General Practitioners and the Royal
College of Psychiatrists, but with industry backing it with money.
That led to us being told that a third of people were depressed,
that we should screen for it, that we should start using antidepressants
early, and we did. If I think back five or 10 years ago, we were
diagnosing large numbers of people with depression, and we were
prescribing many antidepressants. As time has gone on, I have
certainly begun to realise that in some ways yes, there are many
people who do have depression, but lots of people are just unhappy
and that is a part of life. So there is a whole generation of
people coming up who almost feel that being unhappy is an abnormal
state, which, of course, it is not. That is part of the backlash
against the use of antidepressants. The public as a whole are
beginning to realise that.
Dr Iheanacho: I would like to
echo a lot of what Dr Spence has said. Your question related to
how things might be different if the industry were not active
in the way that it is. The plain answer to that is that there
would be a lot more focus on things that the industry does not
do so well or is not so interested in, such as non-drug measures
and so on. It would be a mistake, I think, for anyone to equate
the activities and interests of the industry with necessarily
promoting public health.
Dr Wilmshurst: There would also
be a major impact on medical education. There is a requirement
for people to undertake a certain number of hours of medical education,
50 hours a year, and most of that is funded by industry, directly
or indirectly. Whenever I go to a lecture at the postgraduate
institute in my hospital, the room hire is paid by a drug company,
as are the meals that you get, and the NHS would have to find
the funding for that because there is inadequate funding, and
government is tied in with it. Next week there is a conference
at the Royal College of Physicians, at which the key speaker is
the Deputy Chief Medical Officer, and industry sponsors that meeting:
it is £2,000 a time to have your logo on the bag; £6,000
a time to sponsor part of the cocktail reception for the delegates.
Presumably, the NHS is happy that industry sponsors.
Chairman: We will come on to the education
aspects a bit later on.
Q92 Mr Jones: My early questions
are general. Which group of people would you say hold the reins
of control over the medicines that we take and how, if at all,
has that control changed over the last decade or two?
Mr Vidler: Obviously, as you have
already heard in evidence from the Department of Health and MHRA
and others, the Government believes that it is gaining a firmer
control on what medicines are prescribed and to whom, but in our
evidence we quite clearly set out, I think, a number of ways in
which that is not the case, areas in which the pharmaceutical
industry continues to have undue influence. We pointed out the
multi-pronged marketing approaches that the industry uses whereby
it will use disease awareness campaigns, for example, to raise
public awareness of conditions, as Dr Spence said, such as mental
illness, and what can be quite trivial conditions such as toenail
infections. What those awareness campaigns will do is encourage
the public to go and see their GP, often in quite strong terms,
saying, "Go and see your GP. Be forceful. There is something
that can be done." Simultaneously, the companies will be
advertising specific drugs to those GPs, and what our research
with GPs earlier this year showed was that GPs were aware that
all this activity was going on, but quite often it was easiest
for them to take the path of least resistance, and if they had
patients coming in and saying, "I have this condition. I
have been told you can help me treat it," they will say,
"Yes," to save themselves time, even though they may
feel it is not the most appropriate prescription in those circumstances.
Q93 Mr Jones: Has that influence
changed over time?
Dr Iheanacho: First of all, in
terms of who controls what is prescribed or what is used, which
was your original question, clearly there are multiple influences
on that, but one of the key strands that pulls it all together
is the role of the industry, because the industry is involved
in all of the key stages, whether it is the decision to make the
medicine, give it a licence, and how it is marketed, whether it
is the educational and other information that goes to doctors,
other health care professionals and patients, whether it is industry's
role with government in terms of government's championing of industry's
competitiveness or other activities, and so on. It is difficult
to see, if you take any key stage which leads to the use of a
drug, where industry does not have a rather powerful and I think
an unchanging role really. There is nothing to suggest that that
influence has weakened over time. If anything, I would say it
has become stronger.
Dr Spence: Certainly in surgeries
much of my experience about change in influence comes from the
pharmaceutical industry and from the use of drug representatives,
and their contact with the doctors can almost be on a daily basis.
Certainly my contact with the industry via pharmaceutical reps
five years ago was on a daily basis. That can lead to very wide
variations in a local area in the prescriptions of drugs. Taking
the situation of Vioxx recently, in our local area, within a very
short space of time, within three or four years, that class of
medication became 40% of the particular group of medicines that
we were using, and there was a very wide variation between different
practices on how that was conducted. That is despite the recommendations.
Q94 Mr Jones: Can I ask a naïve
question? GPs are very busy people. We hear constantly that they
have no time for more than five minutes per patient. Why are they
wasting all their time seeing pharmaceutical companies?
Dr Spence: It is not a naïve
question. The reason is that you know these people. I feel slightly
awkward about being here because I do not want to seem unkind
to the people I have known as representatives for years and years,
but I feel like I have to be. The reason we see them is because
you have a personal contact with them. Often, certainly in the
areas that I work in, they provide lunch on a daily basis to many
of the doctors and nurses in the area.
Mr Jones: So when I want an early appointment
with my GP, I am going about it the wrong way; I should offer
to take him out for dinner.
Q95 Chairman: Has the advent of primary
care trusts changed these practices in any way?
Dr Spence: No.
Q96 Chairman: That is interesting,
because obviously there is a much greater degree of monitoring
of prescribing practices of individual GPs within PCTs. What you
are saying is that the practices we have all heard of over many
years of the kind you have just described continue without any
impact?
Dr Spence: Yes.
Q97 Mr Jones: Can I move on to a
different though again a fairly general question: what is the
connection between the development of new drugs and the improvement
in therapy? How well-connected or not are these two processes?
Dr Wilmshurst: I do not know if
they are really. It relates in part to the previous question,
because I think the pharmaceutical industry also influences the
research that is published. I know from experience. One reason
I am here is that I was offered a bribe of two years' salary not
to publish research which was counter to the interests of the
company making the drug. I know other people were influenced because
of that not to publish—not because of bribes but pressure
was put on other researchers working on the same drug.
Q98 Mr Jones: I think other questions
will begin to explore that particular area but can I ask you more
generally. One might again take a naïve view that every time
a new drug comes into the marketplace, there is a new cure being
proposed. Can you broadly explain what the relationship between
new drugs and new cures is.
Dr Iheanacho: There is an uncoupling
in the relationship you have described. The advent of new drugs
often has very little to do with new cures. If you look at all
the drugs that are licensed in a particular year and critically
assess whether these actually constitute genuine innovations for
patients, you would be surprised, I think, to find that relatively
few of them do, and a decreasing proportion do. That is the important
thing. The ability of industry to produce genuine innovations
is going down—there is no secret about that—partly
because it is expensive and difficult to do. When you see a new
drug, you always have to ask yourself the question which we do:
what does this actually offer as an advantage compared to what
I have already, or what my patient has access to already? They
are not coupled at all.
Q99 Dr Naysmith: I was interested
in what Dr Spence was saying in relation to depression and how
people were being encouraged to think they are depressed and you
can have a drug treatment for it. When I discussed this matter,
as I have before, with general practitioners, they tell me that
they know that some kinds of talking therapies would be a lot
better for their patients than giving a pill, but you just do
not have the time to do that. Is it compensating really for not
having the time to talk and try and sort problems out, or is it
just a way to get patients out of the practice more quickly?
Dr Spence: It goes back to agenda
setting. It goes back to saying, "What is the priority when
it comes to treatment?" From the point of view of talk therapies,
that could come from the primary care trust. The resources that
are spent or used for, say, antidepressants, which can be up to
£80 a month worth of antidepressant medication, could be
freed up to provide talk therapies, but it is because the industry
are very effective at drilling their line of intervention. It
is treatment first. The people involved in talk therapies do not
have the same levels of influence and access to the people who
make those decisions.
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