Select Committee on Health Written Evidence



Memorandum by IMS HEALTH (PI 6)


  1.  IMS has been at the forefront of the collection and analysis of healthcare data for more than 50 years. Its complex databases, sourced from thousands of hospitals, pharmacies and GP practices around the world are used widely by Governments, industry, universities and patient organisations to help deliver change in healthcare policy and delivery. In recent months IMS UK data have been used to help:

    —  the NHS Prescribing Support Unit to cost out the implications of the new General Practice Contract[1] and to help understand why NHS prescribing for controlled drugs in London is low;

    —  the Department of Health Cancer Team to analyse the variation of NICE approved cancer drugs;[2]

    —  the National Institute of Clinical Excellence to examine adherence to its published appraisals;[3]

    —  the Medicines and Healthcare Products Regulatory Agency to assess the extent of usage of hospital and OTC medicines in children.

  2.  IMS is uniquely positioned to help this Inquiry. IMS collects and processes electronic information on prescriptions extracted from about half the pharmacies in the UK. This information has been combined on a confidential, and anonymised, basis with industry promotional information.

  3.  In addition IMS collects information on the overall volume of industry promotion in three key areas—representative calls, direct mail and advertising.

  4.  This information gives IMS a deep understanding of the patterns of prescribing in primary care and the impact of pharmaceutical representative promotion.


  5.  This response to the Inquiry focuses on the provision of drug information and promotion, the third point raised by the Committee in its Terms of Reference. Within this area IMS' response deals primarily with the effect of representative promotion.

  6.  Given the importance of drugs approved by the National Institute for Clinical Excellence, this response focuses specifically on the impact of representative promotion on those products that have both been analysed by IMS and which at that point in time had received a favourable review from NICE. The product areas that form the basis of this review are thus:

    —  Proton pump inhibitors—used in the treatment of gastro-oesophogeal reflux disease.

    —  Atypical antipsychotics—used in the treatment of schizophrenia.

    —  Cox II inhibitors—used in the treatment of osteo and rheumatoid arthritis.

    —  Glitazones—used in the treatment of Type II diabetes.


  7.  As measured by IMS[4], the overall number of representative calls has fallen in recent years (-6% over five years). This level of effort has also been concentrated on fewer products, in part due to fewer new products being launched and corporate mergers. In 1999 16.3% of details were for the top 10 most detailed products. In 2003 this figure had risen to 22.4%.


  8.  Variation in the costs and volume of GP prescribing is often put down to industry promotion. Certainly studies have long shown that industry representatives are a primary source of information on new products. The causes of prescribing variation cannot, however, be so simply explained.

  9.  A recent study found that about a third of the variation in prescribing can be explained by differences in the breakdown of a practice's list by age, sex and temporary resident status.[5] More than a third of the remainder can be explained by the differences in the proportion of patients on low incomes.[6] NHS Scotland's Information Services Division also point out in their report on the allocation of resources to English regions[7] that other factors such as the number of GP partners, and the distance the patient must travel to surgery or hospital also have a part to play.

  10.  Nonetheless it is clear from the IMS analysis of the three examples set out in the table below that representative promotion of NICE approved products can have a supportive effect. The growth of prescriptions in those doctors who received calls from representatives was larger than in those doctors who had not received any calls. Significantly, moreover, in a separate analysis done for NICE by an independent health economics agency using another of IMS databases, there was no evidence that, in the example common to both analyses, the increase in prescriptions was inappropriate. The increase in prescribing occurred in patients with the relevant risk factors.[8] From these analyses it can be seen, therefore, that representative promotion has the ability to counter any tendency to under use appropriate medicines.

Average growth in number of prescriptions per GP in study period

GPs receiving no calls by representatives
GPs called on by representatives
Product 1—GPs thought to be interested
Product 1—GPs thought to be less interested
Product 2
Product 3

  11.  The IMS evidence below also indicates that the influence of the representative can be an effective support for NHS' decisions. At the same time it is clear from the same analysis that it can be difficult for representatives to have an effect where local opinion is not favourable.

Market share (%) at end of study period for Product A where Hospital opinion was:

No endorsement
Low endorsement
High endorsement
GPs not seen by rep
GPs seen by rep

Market share (%) at end of study period for Product A where PCT opinion was:

GPs not seen by rep
GPs seen by rep

  12.  It is also clear that doctors exercise their own judgement. In all the cases of NICE approved products where the prescribing of competitor products was examined by IMS, representative promotion was supportive of the therapeutic class, not just the brand.

  13.  In the case described in more detail below, moreover, representative promotion also appeared to be associated with an increased level of use of older, and the less expensive, products. This phenomenon may be due to one of three factors, or a combination of all three:

    —  a "halo" effect whereby discussions about the therapy area encourages doctors to pursue new treatment patterns;

    —  doctors receive information from other representatives to ensure a balanced view;

    —  representatives focus mainly on those doctors with the highest opportunity, or interest, to prescribe or treat particular diseases.

Average volume of prescribing per GP at end of study period
GPs not seen by representative
GPs seen by representative

Product Z
Closest competitor
All other drugs in same class


  14. Based upon the evidence analysed above, representatives do have an effect on doctors' prescribing in general practice but this is by no means the whole story. Doctors exercise discretion. Hospitals and PCTs can constrain or promote representative impact. At the same time, within the subset of products examined here, it is clear that representative promotion has acted to support the uptake of NICE approved products or classes of drug.

1   The Prescribing Support Unit, January 2004: National Prescribing Cost Implications of the GMS contract. Back

2   Variations in usage of cancer drugs approved by NICE: Report of the review undertaken by the National Cancer Director Back

3 Back

4   Representative details are measured using a panel of 200 doctors per quarter who record the number of representative details they receive and the messages communicated. This is projected to a national total. Back

5   Rice et al. Derivation of a needs based capitation formula for allocating prescribing budgets to health authorities and PCGs in England: regression analysis BMJ 2000;320:284-8. Back

6   Prescribing Support Unit: Personal communication. Back

7   Allocation of Resources to English Areas. ISD Consultancy Services 2002. Back

8   8 Back

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Prepared 26 April 2005