Examination of Witnesses (Questions 203
- 219)
THURSDAY 11 NOVEMBER 2004
DR IONA
HEATH, DR
TIM KENDALL,
MR MATT
GRIFFITHS, MR
JOHN D'ARCY,
MR ROB
DARRACOTT AND
DR RICHARD
NICHOLSON
Q203 Chairman: Can we make a start?
I will begin by welcoming our witnesses and thanking you for your
co-operation with our inquiry. Could I now ask each of the witnesses
briefly to introduce themselves to the Committee, starting with
you, Mr Darracott?
Mr Darracott: Good Morning. My
name is Robert Darracott, I am the director of corporate and strategic
development at the Royal Pharmaceutical Society and my responsibilities
include support for policy developments across the organisation
and the Society's research and development programme.
Q204 Chairman: Was there any particular
reason why you did not submit any evidence to the Committee other
than some old papers? Was a particular decision taken not to submit
evidence? All the other witnesses have actually submitted fairly
detailed evidence upon which we can ask questions this morning.
Was there a reason for that?
Mr Darracott: No, there was no
particular reason.
Mr Griffiths: I am Mike Griffiths
and I am the joint prescribing and medicines management adviser
at the Royal College of Nursing. We support our members; we have
370,000 members and support them on anything to do with prescribing
or medicines management.
Dr Heath: I am Iona Heath. I have
been a GP in Kentish Town since 1975 and I am a member of the
Council of the Royal College of GPs. Currently, until tomorrow,
I chair their ethics committee; my six-year term finishes tomorrow.
Mr D'Arcy: I am John D'Arcy. I
am chief executive of the National Pharmaceutical Association.
We represent community pharmacy owners and we have a membership
of about 4,300 owners who collectively own 11,000 pharmacies in
the UK. To put it into perspective, that is just about everybody
except Boots. We provide a range of services to support members,
act as a voice for members, provide services and also provide
professional indemnity.
Dr Kendall: I am Dr Tim Kendall,
I am a consultant psychiatrist and medical director at Sheffield
Care Trust, but I am also deputy director of the Royal College
of Psychiatry's research unit and co-director of the National
Collaborating Centre for Mental Health, within which we do most
of NICE's mental health guidelines.
Dr Nicholson: I am Dr Richard
Nicholson. I trained as a physician, but for the last 20 years
I have been working in medical ethics, editing the Bulletin
of Medical Ethics and specialising in research ethics. I also
set up the Association of Research Ethics Committees seven years
ago.
Q205 Chairman: May I begin by asking
a general point about the mechanisms the organisation you represent
have to deal with what might be regarded by some as undesirable
influence from the pharmaceutical industry on the work that your
members do and any conflicts of interest that there may be? How
are these declared, how do you actually take account of the possible
difficulties which might arise where such a conflict could occur?
Obviously all of you represent different areas of work and I should
be interested, briefly, in how you fully address some of the concerns
that you will be aware we have picked up as a Committee so far
in this inquiry. Who wants to begin?
Dr Heath: We face a problem in
that every major national and international conference for general
practice is financially dependent upon pharmaceutical company
sponsorship, which is a deeply regrettable situation and it is
one in which a lot of people have colluded really to create unrealistic
expectations of how much post-graduate education will cost. That
is a whole area.
Q206 Chairman: One of the questions
I asked at our last session was on continuing education and the
answer I received, I cannot remember which witness it was, was
that 90% of the sourcing of continuing education for people such
as you is funded by the industry. Would that accord with your
own views?
Dr Heath: No, that would not accord
with my idea.
Q207 Chairman: What would your view
be?
Dr Heath: I think it is very individually
variable. A minute proportion of my own post-graduate education
is pharmaceutically sponsored and the whole range is there. The
only time in which I personally am in that situation is when I
attend major national/international conferences. I cannot not
do that.
Q208 Chairman: Yes, but are you unusual?
Dr Heath: No, I am not unusual.
Q209 Chairman: I am trying to get
a picture overall of your members.
Dr Heath: There is still a lot
of sponsorship of small educational meetings, but the changes
in the way general practice post-graduate education is organised,
now much more based on the appraisal system and on personal development
plans, means that you can structure your own learning and you
can do study from the internet, you can do study from books and
it counts in a way that it did not before. You used to have to
collect a whole load of events, the vast majority of which were
sponsored, but I do think that the situation has changed with
this new way of looking at post-graduate education. I do think
that it has improved at the level of day-to-day continuing education.
There is still a real, big problem about major meetings and about
a minority of the profession whose entire education comes from
attending meetings that are pharmaceutically sponsored.
Q210 Chairman: You would challenge
the evidence of 90% that was given to the Committee but another
witness.
Dr Heath: That would certainly
not accord with my experience.
Q211 Chairman: You would also perhaps
challenge the suggestion that new GPs are dining out every lunchtime
with the drug reps, which was one point that came over from one
witness. What is the extent to which GPs, your members, might
accept hospitality with a drug rep? Is it common practice when
they are marketing at a local level?
Dr Heath: It is very difficult
for me to have a grasp of exactly how much my colleagues . . .
I should be amazed if my colleagues had the time to dine out every
lunchtime. It is very hard to find the time to grab a sandwich,
let alone accept extensive hospitality. Again, there is undoubtedly
a minority which makes the most of the offers available. For that
sort of caricature picture, it is a very small minority. It is
like the GPs spending all their time on the golf course; that
was the previous caricature. I think that caricature is in that
league. Just to go back to answer the question, the College has
created a series of ethical guidelines about the sponsorship of
their own meetings, so that we try to make sure that there is
no direct linkage between the educational content and the sponsorship.
You have to try to do that and I think to an extent, we succeed.
We also have a register of interest for all our council members
and try to make things explicit in that way and expect people
to declare conflicts of interests, if they have them, when we
are debating issues.
Q212 Chairman: So you feel that system
works reasonably well.
Dr Heath: Up to a point. I still
think, and the College's view is that it is regrettable that we
are dependent on this financial support for the highest status
meetings. It is regrettable.
Q213 Mr Jones: You say that the College
tries to ensure there is not a conflict of interest in the sponsor
and the type of event. What is the point for the sponsor then,
if there is no influence?
Dr Heath: Precisely. It has to
be said that since we have been taking a firmer ethical stance
and trying very hard to make sure that there is no linkage and
making very clear, if there are sessions within, that those are
directly sponsored sessions, it has been more difficult for us
to get sponsorship. It is also extremely difficult to get sponsorship
for topics such as learning disabilities, just to grab one out
of the air, for obvious reasons. That is just one of a whole range.
Mr Griffiths: There is sponsorship
in major conferences that the RCN are involved with from pharmaceutical
companies, particularly as far as exhibitions go, and that does
obviously help generate income to make educational conferences
accessible. There are 370,000 members of the RCN and about half
million nurses in the UK and a lot of nurses, including myself,
pay for continuing professional development (CPD) out of their
money and do it in their own time. Now, obviously an awful lot
of commitment comes with nursing and making sure that you get
the best education, so that you can deliver the best care to your
patients, but there is a need for continuing professional development
to be helped out. Now as far as continuing professional development
and the split of what is paid for is concerned, I do not know,
but higher education institutions do develop some continuing professional
development which is paid for the workforce development confederations
and the strategic health authorities. We do work in conjunction
with some pharmaceutical companies and the reason that we work
in conjunction with them is to ensure that when they are putting
education out to our members it is validated, it is non-promotional,
there is a certain quality element to the education and to make
sure obviously that our members are getting decent information
across at the same time.
Q214 Chairman: Obviously nurse prescribing
is a relatively recent development. Has the relationship between
your organisation and the industry changed as a consequence in
recent times and if so, how?
Mr Griffiths: We have probably
had more interest in the nursing profession since we have become
prescribers and since the formulary has been opened up. Nurses
can now prescribe as supplementary prescribers from virtually
the entire British national formulary. There has been an increase
in interest. There has also been an increase in the debates within
the nursing press and within several publications which I edit
we have had several articles written on the influence of the pharmaceutical
industry to make sure that we are not going down the line of influencing
our clinical practice. There is some evidence that yes, we may
be influenced as well by marketing, by a whole host of different
tactics, but we try to ensure that our patient care is not compromised
and we are discussing and debating the issues with the profession.
Q215 Chairman: Do any other witnesses
want to come in on this general point?
Dr Kendall: The Royal College
of Psychiatrists has taken an increasingly tough stance about
the influence of drug companies and less than 5% of the income
of the College is from drug companies now, so it is not dependent
on them. The membership, on the other hand, is rather divided.
There are people who are very adamantly opposed to the use of
drug company money because of the influence that it inevitably
brings, but there are others who seem to exploit it quite openly.
Q216 Chairman: And the resolution
of conflict of interest within your Royal College? You have a
register along the lines of Dr Heath's organisation.
Dr Kendall: I think there is a
registry, but I am not that familiar with it.
Q217 Mrs Calton: What is the influence
of personal contact, repeated personal contact, the development
of relationships as opposed to individual pieces of information?
Is there some tendency for strong personal relationships to develop
which, over a period of months or years, might well lead to some
influencing of prescribing?
Dr Heath: I am sure there is and
for that reason our practice has not seen a drug rep in 40 years
and will never see them, for just that reason. I think more and
more GPs take that sort of stand, but not all by any means.
Dr Kendall: I personally, as a
psychiatrist, have never seen, maybe once or twice in my youth,
a drug rep, but I am very aware that there are physiatrists whose
prescribing is obviously influenced by those relationships.
Q218 Mrs Calton: I do not mean anything
untoward in those relationships.
Dr Kendall: No, the problem in
an area like psychiatry is that it is full of me-too drugs, so
that when prescribing an anti-depressant you have a choice of
a whole range of them, but all doing much the same type of thing.
I believe whichever drug rep becomes your closest friend does
have an influence on you.
Dr Nicholson: Just to come back
to your original general point, members of research ethics committees
have to declare their interests in a register of members' interests
before they join the committee. At every meeting, we have a declaration
of interests at the beginning of the meeting, so that anybody
who has any link with any of the proposals we are reviewing withdraws
from the discussion. The association of research ethics committees
has never taken any drug company money and would not, as a matter
of policy, and the bulletin I edit has never had any advertising
from drug companies.
Q219 Chairman: You and I have talked
before about your work. In terms of local level, the ethics committees
that would operate within our NHS trusts, is that the same procedure
that you described there that if there are any conflicts of interests,
they are recorded and there are clear principles at work.
Dr Nicholson: Yes, it is a general
principle.
Mr Darracott: In response to your
general question, Chairman, I would make a number of points in
respect of pharmacists. First of all, just to clear up the point,
we have a register of interests for council members and a register
of interests for staff working at the Society and I would expect
people to declare interests in discussions.
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