Feature Commercial interests

Product placement in the waiting room

BMJ 2008; 336 doi: http://dx.doi.org/10.1136/bmj.39589.491030.BD (Published 05 June 2008) Cite this as: BMJ 2008;336:1274
  1. Leo Hickman, journalist
  1. leo.hickman{at}guardian.co.uk

    Are “health” leaflets displayed in the waiting room just a Trojan horse allowing private companies direct access to patients? Leo Hickman reports

    It is clear that the NHS is under increasing pressure from commercial interests. A handful of hospitals across the United Kingdom now have Burger King or McDonald’s operating fast food franchises on site.

    But one area that has so far been largely ignored is the way commercial interests are able to advertise in waiting rooms without any vetting. Currently few safeguards exist within the NHS to protect against such infiltration.

    I recently undertook a six month investigation into how companies are allowed to pay considerable amounts of money so that they can target patients in waiting rooms, knowing that patients are likely to think that any advertising is endorsed by their general practitioner.

    Advice or advertising?

    More worrying, perhaps, some companies, via their trade associations, are producing health “advice” leaflets with information about their products. Shouldn’t the NHS, not the companies, disseminate such information?

    My investigation began when I picked up a leaflet at my local general practice, called Coffee and Your Health. It is distributed by the British Coffee Association, a trade association representing major coffee sellers such as Nestlé, Kraft Foods, and Douwe Egberts. The leaflet aims to tackle “the confusion about whether coffee and caffeine is good for you.”

    The leaflet says: “It is recommended that women who are pregnant or trying to conceive stick to 300 mg of caffeine a day—approximately three to four cups of coffee.”

    Caffeine consumption and pregnancy is a controversial area. The Food Standards Agency (FSA) is funding a study of 2500 women on the subject that is due to be published later this year. It was commissioned after a review by the FSA’s committee on toxicity that looked at the possible effects of caffeine on unborn babies. “High caffeine intake was associated with an increased risk of low birth weight and miscarriage—high caffeine intake being 300 mg of caffeine per day, equivalent to four mugs of instant coffee, three single espressos or six cups of tea,” Andrew Wadge, the agency’s chief scientist, said last year.

    Whose advice is correct?

    Is it the advice of the FSA’s chief scientist, or the British Coffee Association, that is correct? And regardless of whom is promoting the best advice, is it appropriate that a trade association should be paying to place advice about their product in general practicewaiting rooms? If so, shouldn’t the material at least be vetted and authorised by the Department of Health? I discovered that the British Coffee Association was paying a leaflet distribution company called Waiting Room Information Services to place its leaflets in waiting rooms across the country.

    Product placement

    Waiting Room Information Services is doing good business, it seems, acting as middleman between product manufacturers and the waiting rooms—its accounts registered at Companies House record a turnover of £1.6m (€2m; $3.2m) in 2005. The company boasts that the leaflets, posters, and samples it distributes can reach 38 million patients in 6000 surgeries and pharmacies across the UK:

    “Research showed that 72% of patients took more notice of healthcare information received within a healthcare establishment . . . and 44% felt the health professional was endorsing the message . . . 74.5% of patients attach more importance to leaflets displayed within their doctors’ waiting room,” says the website of its parent company, IDS International.

    A spokesman for the company confirmed that the material it distributes on behalf of its clients is not vetted by an official health organisation. “We approach surgeries and ask them if they would like our leaflets. They can say no,” he told me. “We have on numerous occasions declined to distribute leaflets based on our own vetting. It is our understanding when we accept a leaflet from the pharmaceutical industry or the food industry that they have undertaken the necessary checks and comply with any rules and regulations that apply to their industry.”

    The British Coffee Association said it “continually reviews and updates its recommendations on coffee consumption in line with scientific evidence.” “Highly regarded independent healthcare professionals” advised the association on health matters, it said, adding: “The FSA currently advises pregnant women that ‘it is important not to have more than 300 mg of caffeine a day’. This level of consumption is in line with advice given by the Centre for Pregnancy Nutrition. The BCA upholds these recommendations in Coffee and Your Health.”

    Code of conduct

    Clare Gerada, chair of ethics at the Royal College of General Practitioners, said a code of conduct was needed: “GPs should be mindful that we can be putting information out to the public that we don’t realise is largely for promotional purposes. While we are very aware of the ethics of accepting ‘freebies’ from the pharmaceutical industry, we might be inadvertently accepting them from these companies.”

    It’s not just through leaflets that companies are able to reach patients in waiting rooms. For example, a booklet called The NHS Guide to Healthy Living , said by its publisher to have a readership of 500 000, is produced by the NHS Trusts Association (NHSTA), an organisation one would imagine is linked to the NHS. But the Department of Health, which launched an inquiry into the association as a result of my investigation, says it does not represent the NHS or the Department of Health.

    The guide goes to considerable lengths to distance itself from the NHS in the small print— “This publication has been produced by the NHSTA . . . It is not an official publication of the British National Health Service”—but it still uses “NHS” in its title. Why is it allowed to do this?

    The association’s website says it is entirely funded through a “services contract” with the publisher of the booklets, Scorpio Publishing, based in south London. The association’s honorary secretary and Scorpio Publishing’s chief executive are the same person.

    The company charges clients between £6000 and £15 000 to place a full page advertisement in its guide. The dozens of companies who have taken up this option include Iceland, Asda, Morrisons, Marks & Spencer, Wall’s Sausages, the British Potato Council, the British Toy & Hobby Association, Kellogg’s, and Allied Bakeries.

    Most of the advertisements seem to have been positioned next to editorial articles that speak positively about the type of products being offered. An article about the benefits of using an electric toothbrush (“power toothbrushes with an oscillating rotating action are more effective than manual toothbrushes in reducing plaque and gingivitis”) sits next to an advertisement for an Oral-B oscillating toothbrush.

    I showed the booklet to Muir Gray, the NHS’s “chief knowledge officer” in charge of improving the quality and distribution of information for patients. He was in no doubt that something had to be done:

    “Public health decisions are complex enough without the input of advertising. The NHS shouldn’t need to carry advertising. Clean, clear information for patients is better than any drug. People should be able to trust the information they receive, like they can expect clear, clean water to come from a tap. We need to clarify who has responsibility for information. The NHS should always give information that is unbiased,” he said.

    In response to a written parliamentary question, Ann Keen, parliamentary undersecretary for health services, responded by saying that the Department of Health was considering an “information accreditation scheme” that would “kitemark” organisations producing health and social care information, to ensure that health information comes from a reliable source.

    The NHS Trust Association said it rejected “any suggestion that the use of the term NHS in the guide misleads the public” and said it had “liaised extensively with the Department of Health regarding the use of the term.” The guide was sent to public health directors of all the primary care trusts: “Ultimately it is their decision as to whether they wish to distribute it to the GP practices in their area.” On the matter of the blurring between the guide’s editorial and advertising content, the association said it rejected articles that were too commercial or labelled them “advertisement feature.”

    “The NHSTA does not accept that there is a conflict of interest in the way it is run or in the roles of its officers in relation to the guide it produces with the assistance of Scorpio Publishing; and it firmly rejects any suggestion that the guide misleads the public.”

    It is hard to tell sometimes who is responsible for any given problem or issue. This seems to be the nub with regard to advertising in waiting rooms—each stakeholder, whether it be the Department of Health, the local primary care trust or general practitioners, believes another is responsible.


    • Competing interests: None declared.