Intended for healthcare professionals

Observations Reality Check

Forget sponsorship and free trips—welcome to Pharmacare

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.d8316 (Published 04 January 2012) Cite this as: BMJ 2012;344:d8316
  1. Ray Moynihan, author, journalist and conjoint lecturer, University of Newcastle, Australia
  1. Ray.Moynihan{at}newcastle.edu.au

Drug companies are now helping prescribe how healthcare is designed and delivered

In matters medical, among the most salacious stories in Australia last year were revelations about healthcare officials being flown around the world, business class, courtesy of the global drug giants.1 Conferences in Paris, Milan, London, and Stockholm were among the destinations for the antipodean decision makers, who were also generously provided with accommodation. The practice was defended by the government but horrified consumer groups. The health economist Gavin Mooney described it as a “culture of bribery that needs to be stopped.”1

To those with quaint notions of independent policy making in the public interest it seemed bizarre that health department officials were accepting largesse from companies that were simultaneously negotiating sales with the same department. Government acceptance of this corporate influence peddling seemed stranger than fiction. But a recent warming of relations between the drug industry and the NHS in England well and truly eclipses the sponsored trips for jet setting colonials.

Forget sponsorship: those charged with running the health system have started collaborating with drug makers to manage the way that care is designed and delivered. No longer simply suppliers of one component of care, the drug industry is moving into the co-pilot’s seat, helping run the very system itself, at the same time as selling drugs to it. And the fox hasn’t had to dig a hole under the chicken coop fence—he has been invited to walk straight through the front door.

Taking conflict of interest to a whole new level, a company that profits from selling drugs for mental illness is now officially working to help doctors commission mental health services. In November Janssen, the maker of the antipsychotic risperidone, entered a joint working relationship with the mental health network of the NHS Confederation, which represents most organisations that make up the NHS.2 3 The plan is to build a social networking site as part of a “whole programme of work” with the drug company, which also sponsored the network’s recent annual conference. A Janssen spokesperson describes the new “partnership” as a “fantastic opportunity” to help doctors “optimise” the way mental illness is managed. And as the company’s public relations people reliably informed me, this was just one example of a new trend explicitly encouraged by the government.

“Moving beyond sponsorship—joint working between the NHS and pharmaceutical industry”4 is a toolkit produced in 2010 by the Department of Health for England and the Association of the British Pharmaceutical Industry. It says that the NHS and drug companies “share a common agenda to improve patient care outcomes,” using a range of strategies that include “healthy living,” identifying “appropriate patients,” and optimising the numbers of those patients receiving treatment. Potential benefits for patients and the system are claimed to include better care and improved health. Benefits for companies, according to industry documents, are “more and/or better use of medicines, including the company’s medicine(s),” better understanding of customers’ needs, and “improved reputation.”5

The notion that public health systems and drug companies share a “common agenda” is a public relations fantasy. At best, agendas sometimes overlap; at worst, they’re in direct conflict. Companies aim to maximise profits from drugs sales; the health system aims to maximise population health. To confuse these aims is as dangerous as it is disingenuous.

After many years in denial, clinical medicine is finally facing up to the distorting effects of financial entanglement with pharmaceutical marketing. The evidence is impossible to ignore: sponsored trials favour the sponsor’s drug; and doctors who expose themselves to company promotion tend to prescribe more, with higher costs and lower quality.6 7 Yet as doctors move towards greater independence from drug companies, health system managers seem to be jumping into the still warm bed. Food, flattery, friendship, and funding make for a powerful aphrodisiac.

In the case involving Janssen, although the project doesn’t deal with specific drugs, it will touch on how mental illness is understood and treated in the new commissioning environment—subjects in which the company has direct interests. Concerns about over-medicalisation and diagnostic creep in mental healthcare are a direct threat to the size of medication markets,8 making it more important for drug companies to maximise their influence on those running the system. In fact, better access to key decision makers is another industry benefit highlighted by those pushing the new “joint working” model.

Along with improving access, the partnership will certainly offer reputational benefits at a time when Janssen is facing major legal action in the United States. Its parent company, Johnson & Johnson, says that government authorities are “continuing to actively pursue both criminal and civil actions” relating to the marketing of risperidone.9 Attorneys general in at least 10 states have legal action pending against Janssen, with many more states indicating potential interest in litigation. Already in the past two years the company has been forced to pay penalties and compensation totalling almost $600m (£390m; €460m) in relation to drug promotion in 2003, though it’s confident of ultimately winning those cases on appeal.

It’s abundantly clear why companies want to buy improved reputations and access to influential decision makers. For the health system, however, there’s an obvious danger that these new arrangements will see healthcare become progressively even more like “Pharmacare,” where drug-centric decision making maintains over-medicalisation and continues to divert attention away from finding effective prescriptions to fight the social and environmental determinants of ill health.

Notes

Cite this as: BMJ 2012;344:d8316

References

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