Examination of Witnesses (Questions 300
- 315)
THURSDAY 11 NOVEMBER 2004
DR IONA
HEATH, DR
TIM KENDALL,
MR MATT
GRIFFITHS, MR
JOHN D'ARCY,
MR ROB
DARRACOTT AND
DR RICHARD
NICHOLSON
Q300 Mr Jones: Are there any examples
of nurses being struck off for inappropriately advising the use
of a particular pharmaceutical?
Mr Griffiths: I could not tell
you whether any have been struck off recently; that is for the
Nursing and Midwifery Council. Nurses do get struck off.
Q301 Mr Jones: I know that. I have
asked a similar question of several professional bodies in this
inquiry so far and so far nobody has come up with a single example
of any of their professional organisations being deregulated,
unlicensed, struck off or whatever for inappropriate prescription
or advice on prescriptions. Either it does not happen and there
is no problem with a big chunk of what this inquiry is about,
or the regulatory system organised by the professionals is inadequate.
Mr Griffiths: I do not think it
is inadequate. I think that nurses are going up in front of disciplinary
councils and they are being called to answer for what they are
actually doing. A recent case was a nurse who gave a prescription-only
medicine without it being prescribed and I believe they were struck
off by the Nursing and Midwifery Council.
Q302 Mr Jones: That is a different
sort of thing. Since the nurses are employed by the pharmaceutical
company, there is an inherent conflict of interest if they are
conducting an audit within the practice.
Mr Griffiths: I do not believe
so. I believe that at the end of the day you need to have people
there with some clinical skills.
Q303 Mr Jones: You do not think that
he who pays the piper calls the tune.
Mr Griffiths: At the end of the
day if you are auditing, you are auditing. If you are changing
a prescription, that is a different, but even then under supplementary
prescribing by nurses, for example, the supplementary prescribing
takes place in a partnership. It has to be backed up with an evidence
base which is basically supporting your prescribing decision.
It is not as though people are just going in and changing people's
scripts, it has to be evidence based. If it is not evidence based,
they would have to answer why it was not evidence based.
Mr Jones: You are satisfied. Thank you.
Q304 Siobhain McDonagh: GSK told
us that it funded the diplomas in respiratory disease management
of 235 nurses and 199 nurses in diabetic management in 2003. How
did the deal come about? Could funding mean that training in some
areas is done at the expense of training in others and thereby
distort the overall output of specially trained nurses?
Mr Griffiths: I do not know how
the deal came about, because I have never had any dealings with
GSK to tell you the honest truth. As far as the amount of training
which has gone on is concerned, it is actually worthwhile and
thank you very much to GSK for actually providing that sponsorship.
If they had not provided the sponsorship, then the nurses probably
would not have got the actual training. As long as there is some
sort of quality indicator in there and somebody actually making
sure it was independent and not biased only towards their drugs,
but giving them education around the disease process, I do not
see a problem with that as long as it is the case. I am sorry,
what was your last question?
Q305 Siobhain McDonagh: Could funding
mean that training in some areas is done at the expense of training
in others and thereby distort the overall output of specially
trained nurses?
Mr Griffiths: Not necessarily.
Obviously they were picking up diabetes and asthma and there are
national service frameworks around diabetes and asthma. The new
GMC contract which pays GPs on quality has diabetes and asthma
in it as quality indicators. So they are not only targeting areas
which are of interest to them as a company commercially, but also
areas which are important to clinicians in ensuring that quality
care is delivered and making sure that national service frameworks
are also delivered.
Dr Heath: May I come in because
I am astonished by that figure and it makes a lot of sense of
my local experience. We now all have local respiratory nurses
and local diabetic nurses and it is very interesting how much
of their recommendation is proprietary rather than generic and
how often they suggest changing to a different glucose measurer,
how often they suggest a different pen system. I think it is having
more of an influence and it is very worrying for a practice like
ours which tries very hard not to have a direct . . . We were
all rather uncomfortable after one of our sessions with the respiratory
nurse which was all around different gadgets. That just throws
light on that experience, which is interesting.
Mr Griffiths: Most diabetic nurses
I have come across have actually not come through with any pharmaceutical
company qualification, they have come through with a higher education
institute qualification; they are coming through with the Warwick
diabetic diploma or the Warwick asthma diploma. It is usually
a higher education institution which has validated a course and
it is a degree or master's level course, as opposed to the pharmaceutical
company.
Q306 Siobhain McDonagh: This is not
picking on nurses in any sense but the next question is about
the whole area which we have dealt with in other inquiries, not
just in the pharmaceutical industry but in terms of work done
on obesity and the relationship of sponsorship from good companies
and stuff. Has the RCN any real concerns about safeguarding its
own independence as its relationship with the pharmaceutical industry
develops? Has the RCN developed any formal policy, defining how
that relationship should and should not be pursued?
Mr Griffiths: We do and any sponsorship
which comes in, anything commercial which comes into the Royal
College of Nursing—and there are things which do come in,
we do work in partnership where possible—goes through a
sponsorship manager, it goes through committees within the Royal
College of Nursing which is a member-led organisation and at the
end of the day we will represent our members, but our members
are involved in the running of the organisation. We are looking
out for them and obviously to make sure that patient care is kept
to a high quality. Our independence is important to us and I know
we cannot be truly independent if they are validating something
on behalf of a pharmaceutical company, but we do have to look
at working partnerships to make sure that we can get the education
out of our nurses.
Q307 Chairman: Do you know overall
how much you are receiving directly from the industry?
Mr Griffiths: I could not tell
you.
Q308 Chairman: Is there any way of
getting back to us?
Mr Griffiths: We could get back
to you.
Q309 Chairman: Could I put that question
to the other organisations here today who have some relationship?
Is it possible for you to give us some feedback on the full financial
support which is received and the various ways in which it is
received? That would be very, very helpful.
Dr Kendall: The drug industry's
relationship throughout all of medical education is a constant
presence, even down to the Wednesday morning case conference.
You will have a pharmaceutical company stand there and it is all
around you.
Q310 Dr Naysmith: We had some evidence
a couple of weeks ago about clinical trials and the publication
of the results of clinical trials and we have dealt with quite
a lot of that already today. One of the things which was suggested
was that there existed something called ghost writing in terms
of pulling together the results of a number of clinical trials
in various areas and that prominent academics would then put their
names to a paper summarising this result and publish it. That
struck me as most amazing. Have any of you ever come across that
sort of thing happening: having clinical academics, usually in
medical schools, who have not actually participated in the trials
but only given their name to something done by somebody else,
then putting their names on a scientific paper and publishing
it as though they had been one of the main contributors to it?
Mr Griffiths: I edit five publications
and I know that all of the work we commission from authors comes
from those authors. I am sure that ghost writing does happen.
Q311 Dr Naysmith: Why are you sure
that it does happen?
Mr Griffiths: I am sure that it
happens because at the end of the day academics are obviously
judged on the amount of research they get out, the quality of
the research.
Q312 Dr Naysmith: That is the driving
force behind it.
Mr Griffiths: And there is a funding
issue behind it. I do not think it happens to any extent in the
nursing profession or at least not very widely. For most of the
publications I edit I know the authors personally and I know that
it comes in from them.
Dr Nicholson: I do not have personal
experience, but I know that two years ago there was a paper in
the journal called Pharmaceutical Physician, which goes
round to physicians working in the pharmaceutical industry, on
the importance of choosing your ghost writer early and getting
them well briefed on what the trials was supposed to be showing
and how to make sure that your ghost writer handles the academics
whose names are going to go onto the paper in a proper manner
to keep them on side.
Q313 Dr Naysmith: Did you say this
was a published article?
Dr Nicholson: Yes.
Q314 Dr Naysmith: It would be nice
to have a look at that.
Dr Nicholson: Yes.
Q315 Chairman: May I conclude with
one question? All of you have made some critical comments about
the industry in a variety of ways. I think we are all conscious
that the industry plays a very important role in our economy and
we are also conscious of concerns about increasing movement of
the industry out of the UK, for a variety of reasons which I do
not want to go into, but you will be aware of some of them. Do
you have any fears that if we cannot act or recommend action on
some of the issues you have pinpointed as concerns from your organisations,
we may add to that process even further of losing the industry
within the UK? Could a balance be struck without us losing the
industry, addressing some of the areas you have raised?
Dr Kendall: I suspect that you
would need to have at least a Europe-wide approach to it. At the
moment the different regulatory agencies are not properly synchronised,
but they do all talk and they do share some regulations. Unless
you did it Europe-wide there might be a risk. If a new regulatory
framework could be agreed throughout Europe, it is an industry
which is in need of pressures on what amount to massive profits.
I am sure they could sustain better regulation and still make
profit.
Mr D'Arcy: We are the end of the
supply chain and I made the point earlier that a key part of the
tools of our trade are medicines which come from the industry.
So a relationship with the industry is very, very important to
us and critical to us. You are quite right that the industry on
the one hand does do a lot of good. It provides medicines and
Dr Heath gave the example of a peptic ulcer, which is a good example
of how medicine has contributed to healthcare, made patients'
lives better and reduced healthcare expenditure in secondary care.
There are issues which face industry: no doubt tax regimes, animal
rights issues are a big one which is a growing concern, the regulatory
burden is there. The regulatory burden has to be there and we
have to work within that. It is a difficult job balancing the
commercial role and a healthcare contribution role and a balance
does have to be struck. It is possible to draft this and make
recommendations where the two can co-exist, to say that we do
need the industry and we do need to recognise the good that the
industry brings and certainly from a pharmacy perspective we need
to work with industry, but we need to work with industry in a
way which is credible, in a way which is objective. I think therefore
that within the regulatory burden, or within ethical codes or
code of practice, controls over there, we need to make sure that
they are there to deal with these issues of probity. It would
be a great shame if we took all of these issues. It is easy to
go through a session like this and be very, very negative about
everything and ignore the positive. It is about getting a balance
and it would be a great shame indeed if we came to a conclusion
and said that because there are loads of problems we need to diss
the industry or rubbish the industry. What we need to do is to
find a balance and one that works and deals with that effectively
through controls.
Dr Heath: The relative proportions
that companies spend on PR and promotion and that they spend on
original research seem to have got out of kilter. That must be
something to do with the incentives which we are offering the
industry and that seems to me where there is room for shift.
Dr Nicholson: Two quick points.
One is that the Department of Health has failed to help the pharmaceutical
industry in terms of running clinical trials in this country.
In particular the Central Office for Research Ethics Committees
and what it has been doing and its failure to get hold of the
R&D departments has meant that a lot of research is now going
to other parts of Europe, which is why the Europe-wide approach
may not work well because it is much cheaper to do the research
in Poland or Hungary or even Croatia, countries like that, than
it is in this country. The second point is that I wonder whether
there is any way that one can produce some sort of moral pressure
on the pharmaceutical industry to spend some of its time looking
towards long-term interests rather than short-term profits. I
suspect the pharmaceutical industry would look a great deal more
pleasant in many people's eyes if they started making serious
efforts to address that 90% of the global disease burden which
they do not address at the moment.
Mr Darracott: You have had the
King's Fund paper which I think is called Getting the Right
Medicines. This is a personal view but there is a positive
contribution in there for what might be done. It seemed to me
that what the King's Fund was suggesting was that there was an
opportunity for a grouping within the Department of Health or
within government to look systematically at the whole disease
burden. We recognise that at the moment there is investment in
specific areas and that there are some neglected areas which are
not being looked at which from society's point of view might be
more appropriate to be looked at and we might want to look at
them. The other thing the King's Fund did point out in that paper
was that that sort of group could be a place where the public
voice could be a serious part of what needs to be done as well.
That paper does have some merits and could certainly be looked
at.
Chairman: On behalf of the Committee
may I thank you for what has been an excellent session. We have
learned a great deal and a number of you indicated that you would
come back to us with further information on certain issues. I
should like to thank you all for your co-operation with this inquiry.
Thank you very much.
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