Examination of Witnesses (Questions 620
- 639)
THURSDAY 16 DECEMBER 2004
MS MARGOT
JAMES, MR
MIKE PALING,
MR RICHARD
HORTON, MS
JENNY HOPE
AND MS
LOIS ROGERS
Q620 Jim Dowd: If it is being contended
that the US experience is beneficial to the patient why should
British patients not benefit similarly? Why is the industry against
it? Given the fact that the people who are advertising in the
USA and New Zealand are the self-same drug companies who would
be advertising here, why do they think it is a good thing there
and they will take part in it and something they would not want
to see here?
Ms James: I think there are two
possible reasons for that. One reason is that they do not see
that it is possible for it to happen here. We have a very difficult
healthcare system in Britain compared to the US. Some of the disease
areas which people have become much more conversant with as a
result of DTC advertising and some of the under-treatment that
existed in those categories has been removed or certainly improved
so that where patients were not getting decent treatment for high
cholesterol or schizophrenia, for example, they now are because
they are informed. I think that the companies feel that that would
obviously have a cost implication because statins are more expensive
than doing nothing; atypical anti-psychotics are more expensive
than the dreadful old therapy which causes awful side effects.
I think the companies accept that there is an issue in this market
with what I have just described. The second reason I think that
some companies—not all perhaps—are reluctant is because
it is costing an awful lot of money in the United States. The
cost of consumer advertising is much more costly than representative
and professional advertising and I think quite a few of our clients
do not want it here.
Q621 Jim Dowd: That has also impacted
on driving up prices to the consumer in the US.
Ms James: There is no evidence
of that at all.
Q622 Jim Dowd: Where do all these
costs go? Do they just disappear into the ether?
Ms James: If a patient was not
on medication that he/she needed before and thanks to the advertising
and the dialogue with the doctors they now are, that is obviously
an add-on cost. That does not mean that the price of the treatment
has increased.
Q623 Jim Dowd: Presumably someone
has to pay that somewhere.
Ms James: In the States it is
a different system. It is based on insurance and co-payment. Obviously
the patient is bearing more of a brunt of that cost than the patient
is here where most people are on free prescriptions.
Q624 Jim Dowd: Is this not at heart
just an attempt by the pharmaceutical companies to recruit the
patients into their promotional campaigns by increasing pressure
on prescribers?
Ms James: I think from all the
transcripts I have read from your debates I think what I detect
is an inability to see that an action can have two consequences.
It can improve public health and be to the public good and it
can also provide a return to the shareholders of the pharmaceutical
companies. The example of patients being better treated in the
States is an example of just that point.
Q625 Jim Dowd: Is that a general
point on the work of this Committee?
Ms James: No, just some of the
transcripts I have read I have felt there was a reluctance to
accept that an action can be to the good and be also profitable.
Q626 Jim Dowd: The premise of this
whole inquiry is that the pharmaceutical industry in this country
at least are a genuine legitimate business. We do not dispute
that for a moment; they have shareholders and they have the right
to make money. Certainly one of the cases from the New Zealand
experience was a completely manufactured condition that nobody
was complaining about before: bladder incontinence. They alleged
it was incontinence; they said, "Are you going to the lavatory
too many times a day? If so, you need this drug."
Ms James: Are you suggesting that
does not exist?
Chairman: Of course incontinence exists;
I think we need to clarify this.
Q627 Jim Dowd: What I am saying is
that they introduced this problem by direct marketing to patients
telling them to go to their general practitioners and demand this
drug and even giving them a free sample. They showed the rate
of consumption of this drug; the rates of consumption went up
enormously. The effect it had on the condition was zero. People
had not even asked their general practitioner about this being
a problem before and it was done entirely to inveigle the patient
into the position of marketing on behalf of the drug company.
That is the great danger.
Mr Paling: Often patients do not
go to a doctor if they do not think there is a treatment available.
Erectile dysfunction would be a very good example of that. To
me the bigger issue is that if you take a country like the UK,
and the way we treat ,and compare it to the United States—even
to other European countries like France—there is serious
under-treating of very, very important conditions (diabetes would
be one very good example) because we do not have such a level
of contact between the patient and the doctor. Our treatment is
therefore not so early; it is not so aggressive in terms of treating
the disease and I think that whoever creates it or whoever does
it there is an important need for further information. I am not
talking about branded pharmaceuticals, but we need to get more
information to the patient to understand conditions (a) that they
might have them and (b) that they should seek medical advice.
Then the doctor can decide if they have to have treatment. The
numbers suggest that there are 300,000 diabetics in this country
at large who have never seen a doctor and never been treated.
That, to me, is a really worrying concern.
Q628 Jim Dowd: There are many things
that are very worrying; what is also worrying is if you try to
tell somebody that they are ill without them knowing it because
you have a treatment for them.
Mr Paling: If they go to the doctor
the doctor will tell them they are well.
Q629 Jim Dowd: These are people who
were not presenting with this condition before.
Ms James: I do know about that
condition in terms of this country—I do not know about the
New Zealand example that you have quote. And a great many people
over the age of 40 do suffer from incontinence and I know one
of the pharmaceutical companies did undertake research about four
years ago of a population of women over the age of 40 and also
general practitioners and they found that a large number of women—I
cannot remember the exact numbers—did have this problem,
it really did bother them and they were too embarrassed to consult
their doctor about it. When the company did the research with
the general practitioners they found that 90% of general practitioners
were too embarrassed to mention the problem as well. So this is
the role for the pharmaceutical company, to bring these things
out into the open and give patients hope.
Q630 Chairman: No-one would deny
what you have just said as being a problem. Women with childbirth
implications obviously understand that. What was a concern in
New Zealand—we have not explained it fully because it was
quite detailed—was the way in which a problem had been created
that did not really exist. It was implying that if you went to
the loo so many times a day then that was abnormal when, in view
of people objectively, most medics would say it was not abnormal.
What Jim was saying was that an apparent abnormality had been
created in the interests of a particular company when a problem
did not really exist. That was the difficulty.
Ms James: I suppose you are saying that
it was exaggerated.
Q631 Mr Jones: If there is a problem
and it is medically treatable and that sells X amount of drugs,
if you widen the market out so that you include in the range of
abnormality a large part of what would then be the normal population
you would increase the market for the drug.
Ms James: This is a very bad strategy
commercially because all you do is you get a lot of people in,
you treat them, they go away, their lives are unchanged and your
drug gets a bad name. Most of our clients would not want to do
that for that very reason.
Jim Dowd: The point was that they can
behave in this fashion because DTCA is available. That is when
they said, "Go to your GP and get a free sample" and
they used DTCA precisely to generate this. Anyway, I have gone
far enough on this point.
Q632 Dr Taylor: Can I just go back
to Ms Hope for a moment. I am afraid it highlights a paper that
I do not read for which I apologise, but do you say that statins
are being advertised with whole page advertisements?
Ms Hope: Yes. This is now appropriate
because one statin has been granted approval to go from prescription
only to pharmacy and it is just a start, really, of a whole lot
of things that are going to be rolled out.
Q633 Dr Taylor: Are these sorts of
advertisements appearing widely in other newspapers as well?
Ms Hope: Yes, it is consumer press
that we can now run these. There have been some surveys carried
out—which I am sure you are aware of—since this happened
in July showing that some pharmacists are giving inappropriate
advice and also highlighting a conflict of interest between pharmacies
offering cholesterol testing with a statin next to it. I think
there are real concerns about this and we do not really know what
led to this decision to free up the market because we do not have
access to the decision-making information that was in font of
the authority but against the advice of, for example, the RCGP,
but it also coincided—as you will be aware—with the
extension of the patent (if you like, in quotes) on the statin
concerned from six months to a year when this particular statin
cannot be challenged in the market place. A cynic like me might
think that this is a very interesting development that you can
now move your statin which is out of patent in the prescription
market into pharmacy only medicine and get a year's worth of protection.
Q634 Dr Taylor: I think we are aware
of that and are looking into it. Can I just go back to Dr Horton?
Advertising revenue: does that depend from any companies on the
publication of articles or are they completely separate? If you
refuse to publish something do they then withdraw some advertising
revenue?
Dr Horton: I do not know of any
instance of that, but what I do know is where journals have published
critical editorials of a particular company or industry and an
advertising has been withdrawn from those journals which has precipitated
a crisis within the publication where the editors have got sacked
or there has had to be some whole scale change in the way the
journal is organised. For those journals that depend upon advertising
revenue very much advertisers are key constituents for that journal
and they wield enormous power in shaping the agenda of that journal.
The example I am thinking about is the Annals of Internal Medicine
which published a few years ago an article very critical of industry
and advertisers just withdrew their advertising whole scale and
two very well respected editors were sacked.
Q635 Dr Taylor: Do you actually vet
the advertisements?
Dr Horton: Yes, we do. I think
we are very lucky here because the advertising that gets submitted
to The Lancet goes through the commercial department of
The Lancet and then it comes to the editorial department
and we apply criteria to adverts as much as one can in the same
way that you look at research articles. Actually, The Lancet
does not have a massively high circulation so we do not publish
huge numbers of adverts; it is not such a difficulty for us.
Q636 Dr Taylor: Going back to Ms
James, your website produces evidence that campaigns actually
work. I think the quote is that your work can "independently
increase sales". What is the evidence behind that? What is
the evidence that promotional campaigns work?
Ms James: It is difficult to demonstrate
a direct link with sales and we do not do so very often. The reason
it is difficult is because there is so much going on in any particular
market that to pinpoint your own activity and pull it out and
demonstrate that patients have had better treatment because of
what you have done is difficult. There was a campaign we ran last
year for increasing the uptake of flu vaccination and I think
that we did demonstrate an increase; certainly over 200,000 who
were not planning to take up the vaccination took it up as a result
of a huge publicity campaign that we ran. There was not too much
else going on in the market so we were able to demonstrate that
that was a success that was driven by our campaign. For the most
part, the way we evaluate and monitor our programmes is more to
do with benchmarking awareness levels: has our campaign increased
the awareness of a particular problem or a range of solutions
or have doctors become more aware?
Q637 Dr Taylor: How would you assess
that they have become more aware?
Ms James: We sometimes undertake
benchmarking before a campaign starts so that we might research
medical awareness and views of a particular area of medicine or
treatment or a message that we want to get across and then after
a series of activities we would undertake the research a second
time and we would monitor the difference. Again it is difficult
because you are not the only player in the communications mix.
Q638 Dr Taylor: What is the response
rate to questionnaires from general practitioners about those
sorts of activities?
Ms James: You obviously have to
provide a financial incentive and as long as that is appropriate
to the time that it takes you can usually get quite a substantial
response, probably a good 20% if it is appropriately remunerated.
Q639 Dr Taylor: Ms Rogers, in your
memorandum to us you say, "The British Medical Journal
itself is distributed free to doctors in Britain because it is
subsidised by the drugs industry." I remember paying a whacking
subscription to the BMA which included the BMJ so it is
not quite true to say that it is distributed free, is it?
Ms Rogers: I do not know whether
the subscription that you pay to the BMA would cover the production
costs of the BMJ. I do not think it does.
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