Select Committee on Health Written Evidence


Memorandum by Dr Julian Colledge (PI 113)


  I graduated in Medicine from Bristol University in 1972 and have gained post-graduate qualifications in psychiatry, general practice and obstetrics and gynaecology. During the past 25 years as a General Practitioner I have always had an interest in cost-effective prescribing. For eight years I was a manager of an out-of-hours co-operative for 300 doctors and was responsible for managing the medicines and dealing with the complaints.


  1.  The priorities of NHS spending are distorted by overwhelming demands for medication. We are using too many drugs and too many expensive medicines with little certainty that they are benefiting our patients.

  2.  Massive financial savings could be made by cost-effective prescribing using a "Core National Formulary."

  3.  There is no doubt that the pharmaceutical industry has produced some drugs which have been of immense benefit to humanity over the past 50 years. However, also it would be reasonable to say that many drugs have not been of benefit and definitely some have been harmful. Iatrogenic illness is a significant cause of morbidity and mortality.

  4.  Of the thousands of drugs available on the NHS very few save lives.

  5.  Pharmaceutical companies generate needs and markets.


  The role of the doctor should primarily be one of health education to prevent illness, support, and encouragement of self reliance in the management of disease. All of us should remember that the title of doctor is derived from the latin docere—to teach, and that one of the basic tenets of the Hippocratic Oath is—"first do no harm". Unfortunately the provision of prescriptions has become institutionalised in modern health care—"the quick fix."

  Working at the coal face, I have seen so far, more than a quarter-of-a-million patients and yet only saved a few lives. Prompt administration of penicillin to patients with meningitis, and other inexpensive antibiotics to patients with overwhelming infections and early referral for surgery of patients who had life-threatening surgical conditions have been the main factors in saving lives in general practice. Of course, good management of chronic conditions, such as hypertension, does have an impact on morbidity and mortality, however again medication used does not have to be vastly expensive.

  From the Black Report and other research you will know that poverty and ill-health are closely linked. Clean water, sanitation, employment, reduction of poverty, vaccination programmes, avoidance of environmental pollution are all major factors in the improved health of the nation. To promote individual versus state responsibility for health and endeavouring to prioritize and achieve the right balance of spending is immensely difficult.

  The pharmaceutical industry is basically driven by the profit motive. 47% of my patients are on some form of repeat medication and 14% of my patients are on four or more repeat medicines. My Practice is fairly average for rates of prescribing. These statistics seem shocking and one has to question the health benefits (and financial implications) of such a large proportion of the population taking regular medication. My practice prescribing costs are 16% below the local average and 17% below the national average. The practice is meeting all the requirements of the new GMS Contract and is achieving the maximum number of points. The Practice makes less than average referrals to secondary care. Data confirming these figures is available upon request.


  As a junior doctor in the 1970's working for a cardiologist I prescribed Practolol, a beta-blocker that was subsequently withdrawn as it caused retro-peritoneal fibrosis and death. Also, I also prescribed Clofibrate to lower cholesterol, which subsequently was withdrawn because it caused an increased rate of bowel cancer. In November 2004 Vioxx (Rofecoxib) used in arthritis was withdrawn from the market as it caused a significant increased rate of deaths from heart problems. For many years, I was convinced by the research data, general medical opinion and the information from pharmaceutical companies that HRT was good for my menopausal female patients. In the early 90's many GPs had "Well Woman Clinics" and a very high proportion of menopausal women were put on HRT in the belief that it reduced their risk of heart disease and osteoporosis. These beliefs were supported by some very large trials from the USA. At the time, some of the media encouraged patients to think that HRT was the path to eternal youth. In an editorial article in the British Medical Journal about 18-months ago the conclusion was "That HRT is good for symptoms but bad for health".

  Initiatives such as NICE, working on evidence based medicine should reduce future risks. But serious mistakes continue to be made. Why does this still happen?


  From the general practice perspective over the past 30 years, the following categories of drugs have been major advances and made very positive impacts on health care:

    —  PPI's (proton pump inhibitors) have dramatically reduced the mortality and morbidity from peptic ulceration.

    —  The low dose combined oral contraceptive Pill is effective, safe and inexpensive.

    —  Beta-blockers, statins and ACE-inhibitors and diuretics have all made major contributions in the care of hypertension and cardiovascular disease.

    —  SSRI anti-depressants are safe in overdose and have been a major advance in the treatment of depression.

    —  Many anticancer drugs have been enormously beneficial to humanity.

  Within these categories there are now many off patent generic medicines which are inexpensive and very cost-effective. However, there are many expensive "me-too" drugs which have no real benefit over the ground breaking original drugs. All too often misleading research and advertising are used to boost drug company profits. Eso. and des. molecular variations of former drugs are blatantly misleading and a method of profiteering.

  NICE and regulatory bodies should contribute towards identifying needs and approving research at a national and international level.

  Hopefully the mapping of the human genome and other advances in human biology will inspire and enrich future unbiased research and then pharmaceutical innovation.


  Nowadays a very large amount of research is sponsored by drug companies and clearly is biased. Important negative findings are often withheld. These should be published, for example the manner in which the data was presented with regard to Cox-2 inhibitors. The British Medical Journal has expressed concerns about this over a period of several years (Abbasi K. Editors Choice. BMJ 204:329.27.11.04). Similar problems have arisen with the conduct of research and marketing of a group of drugs called A2-blockers, used in heart disease and hypertension (Verma S and Strauss M. Angiotensin Receptor Blockers and Myocardial Infarction, BMJ 329.27.11.04 Page 1248-1249). This article illustrates how confusing the research is relating to these particular drugs and how they may be positively harmful to patients. Currently the NHS spends vast sums of money on these drugs on an evidence base which is very shaky and will probably result in litigation. Twenty-five years ago the Medical Research Council undertook a large amount of pure research, the funds for the MRC were whittled down. Surely the NHS and universities should be undertaking non-sponsored pure research.


  "There is no such thing as a free lunch". Advertising works. With the best will in the world, accepting educational grants, sponsorship or hospitality will inevitably compromise the prescribing of individual doctors. My own opinions have been inappropriately swayed by pharmaceutical representatives and promotional information.

  Safe, unbiased and useful sources of information include medical journals such as the British Medical Journal, Drugs and Therapeutics Bulletin and Current Problems published by the Committee of Safety of Medicines, The Department of Health bulletins and other independent medical journals and locally produced prescribing information. Many websites, such as the British Hypertension Society, produce balanced and well-considered information about prescribing with appropriate evidence based links.


  The controversy surrounding many drugs, for example HRT (hormone replacement therapy), Cox-2 inhibitors (anti-inflammatory drugs for arthritis) and angiotensin receptor blockers (for raised blood pressure, heart disease and prevention of renal disease in diabetics), illustrates the immense difficulties for any regulatory authorities. The research is often very controversial and contradictory.

  Vested interest and immense profits hinder truth. With respect to the most recent controversy, to quote David Graham, the United States Food and Drug Administration Associate Director, "The dangers of Rofecoxib were apparent eight years ago and not acted upon, the harms suppressed. What has now unfolded may be the most serious example of regulatory failings about drug related harm since the thalidomide scandal". Please see Advisory Briefing of the Food and Drug Administration, NDA, 20-757(S-021),


  Please see a GP's perspective above and attached document entitled "Cost Effective Prescribing—Saving Millions for the NHS".


    —  Enormous financial savings to the NHS could be made by adopting an evidence based "Core National Formulary" without compromising safety or efficacy.

    —  The positive and negative influences of the pharmaceutical industry should be recognised and constantly scrutinised.

    —  Pure academic research must be encouraged and adequately funded from unbiased sources.

    —  Negative research findings should be published.

    —  Health promotion and encouragement of personal responsibility for health must be encouraged.

    —  Please see separate document entitled "Cost Effective Prescribing—Saving Millions for the NHS." for specific details of how to achieve significant financial savings.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2005
Prepared 26 April 2005