A short article in the BMJ reported a document apparently agreed by the BMA, the RCP, DOH and the RCGP among other signatories. It is called “Guidance on collaboration between health care professionals and the pharmaceutical industry". We have waited before commenting to see if any of the signatories are prepared to comment on this document but no response appears to be forth-coming. This is an extremely flawed document containing a number of assertions not backed up by evidence. These include:- “Healthcare and industry professionals are able to manage their relationships with each other without compromising clinical decision making" There is a considerable body of evidence shows the more contact a clinician with drug reps the less evidence based their prescribing1,2. "Industry plays a valid and important role in the provision of medical education", This directly contradicts the recent RCP report on medical education and is also in conflict with the 2005 House of Commons report on the relationship between the pharmaceutical industry and medical education3. “Information about industry-sponsored trials is publically available” There have been numerous cases over recent years where this had patently not been the case, eg rosiglitazoneand tamiflu4. We call on those who have signed this document, in particular the BMA, RCP, DOH and RCGP to explain their reasons for endorsing this document and to disassociate themselves from it. 1.Spurling GK, Mansfield PR, Montgomery BD, Lexchin J, Doust J, Othman N, Vitry AI. Information from pharmaceutical companies and the quality, quantity, and cost of physicians' prescribing: a systematic review. PLoS Med 2010; 7(10): e1000352. 2. Lexchin J, Bero LA, Djulbegovic B, Clark O. Pharmaceutical industry sponsorship and research outcome and quality: systematic review. BMJ 2003; 326(7400): 1167-70. 3. "The Influence of the Pharmaceutical Industry". Report of the House of Commons Health Committee. 5 April 2005 4. Rosiglitazone: What went wrong. 2010, BMJ, 341, pp530-4.

Competing interests: JM and MK and founding members of Healthy Skepticism UK.

Dear Editor,
Like our Australian colleagues, we were puzzled by the “neutral” reporting on the Ethical Standards in Health and Life Sciences Group’s “Guidance on collaboration between healthcare professionals and the pharmaceutical industry” by the BMJ.1 This was a very unexpected uncritical report by the journal we all associate with the “Who pays for the pizza?” and “How to dance with porcupines” articles and covers.2-4 Possible explanations:
• The wind is blowing in favour of the industry, as shown by other episodes of the same kind under the current UK government?5
• The same neoliberal wind shakes the WHO flag, and apparently finds little resistance; why should it not hit the BMJ?6
• That’s the way things are going even at the United Nations?7
• The Guidance carries the BMA logo, and it’s difficult to be critical towards one’s own mother?
We have no answer, but would expect one from the BMJ, not necessarily one of those listed above. Meanwhile, we agree with the arguments put forward by our Australian colleagues.

Adriano Cattaneo, on behalf of No Grazie Pago Io (www.nograziepagoio.it), the Italian equivalent of No Free Lunch
Maria Font, on behalf of Dialogo sui Farmaci*
Daniela Zanfi, on behalf of Informazioni sui Farmaci*
Nicola Magrini, on behalf of Pacchetti Informativi sui Farmaci*
* Italian drug bulletins belonging to the International Society of Drug Bulletins (ISDB)

1. Dyer C. Collaboration with drug industry won’t affect clinical decisions, says new guide. BMJ 2012;344:e2489
2. Moynihan R. Who pays for the pizza? Redefining the relationships between doctors and drug companies. 1: entanglement. BMJ 2003;326:1189-92
3. Moynihan R. Who pays for the pizza? Redefining the relationships between doctors and drug companies. 2: disentanglement. BMJ 2003;326:1193-6
4. Wager E. How to dance with porcupines: rules and guidelines on doctors' relations with drug companies. BMJ 2003;326:1196-8
5. Mayor S. Specialists condemn government’s obesity plan as too simplistic. BMJ 2011;343:d6688
6. Richter J. WHO Reform and Public Interest Safeguards: An Historical Perspective. Social Med 2012;6:141-50
7. Heath I. Seeming virtuous on chronic diseases. BMJ 2011;343:d4239

Competing interests: The authors of this letter are members of associations that promote a progressive disentanglement of health professionals from industry, or members of the editorial committees of independent Drug Bulletins

It is disappointing to see [1] so many reputable organisations join the Association of the British Pharmaceutical Industry in endorsing such a damaging and ill conceived document [2]. Unreferenced statements such as 'Healthcare and industry professionals are able to manage their relationships with each other without compromising clinical decision making' [2], at odds with a growing body of evidence [3], are unhelpful.

We would like to suggest an alternative set of principles for consideration:

1) Despite its flaws [4], we are probably stuck with the current model of pharmaceutical R&D, at least in the short to medium term.

2) If industry wish to make information on their products available, they can publish in a peer reviewed journals like the rest of us. Clinicians should treat this data with caution, as funding source is strongly associated with reported outcome in published trials [5].

3) It is difficult to assess how others' conflicts of interest might affect their account of the evidence base. For this reason, we should demand review articles and medical education be delivered, in almost all cases, by people with no industry links [6]. The presence of people with significant industry links on guideline committees [7] is totally unacceptable.

4) Industry codes of conduct usually have limited impact – the ABPI code is a good example of this [8].

5) Patients would be shocked if they realised the extent to which our profession is dependent on industry. Blanket bans on contact with industry reps, of the kind imposed in several American medical schools [9], are a step in the right direction.

1. Dyer C. Collaboration with drug industry won’t affect clinical decisions, says new guide. BMJ 2012; 344: e2489.
2. Ethical Standards in Health & Life Sciences Group. Guidance on collaboration between healthcare professionals and the pharmaceutical industry. Available from http://www.abpi.org.uk/our-work/library/guidelines/Documents/Guidance%20... (accessed 18 April 2012).
3. Spurling GK, Mansfield PR, Montgomery BD, Lexchin J, Doust J, Othman N, Vitry AI. Information from pharmaceutical companies and the quality, quantity, and cost of physicians' prescribing: a systematic review. PLoS Med 2010; 7(10): e1000352.
4. Trouiller P, Olliaro P, Torreele E, Orbinski J, Laing R, Ford N. Drug development for neglected diseases: a deficient market and a public-health policy failure. Lancet 2002; 359(9324): 2188-94.
5. Lexchin J, Bero LA, Djulbegovic B, Clark O. Pharmaceutical industry sponsorship and research outcome and quality: systematic review. BMJ 2003; 326(7400): 1167-70.
6. See http://www.conflictfreeconferences.com (accessed 18 April 2012).
7. Neuman J, Korenstein D, Ross JS, Keyhani S. Prevalence of financial conflicts of interest among panel members producing clinical practice guidelines in Canada and United States: cross sectional study. BMJ 2011; 343: d5621.
8. Herxheimer A, Collier J. Promotion by the British pharmaceutical industry, 1983-8: a critical analysis of self regulation. BMJ 1990; 300: 307-11.
9. For an up to date summary of regulations, see http://www.amsascorecard.org (accessed 18 April 2012).

Competing interests: TAY and CJR recently set up a scheme (see www.conflictfreeconferences.com) to accredit medical education which is independent of industry. We are have no financial conflict of interest. In 2009, TAY assisted with a study which used point of care HIV tests provided free of charge by Pasante. In 2010-11, TAY worked as a research fellow on a study part funded by GSK.

Rogers et al [1] are right, this is indeed disappointing, and equally it is disappointing that the only comment so far is from a group of Australian academics: no thunderous editorial from the BMJ despite its avowed commitment to academic independence and journal ethics. And, moreover, it all comes endorsed by the BMJ's parent organisation the BMA. It also reminds me of the initiative undertaken by the editor the Lancet at the beginning of 2008 [2], and I seem to remember that that did not fare well. However, that was an initiative to consult the medical profession, whereas this seems to be an attempt to change culture from the top. Why bother to ask after all: you might have to listen to well reasoned answers?

Not only is this very unwise but with barely a word being said it has now become official ideology, and we can only expect as a result a further excess of grief. It will be ordinary citizens who will pay both from their pockets and with their lives. As JK Galbraith warned in 1999 [3]:

"Take the common outcry about corporate welfare. Here the private firm, as it is called, receives a public subsidy for its product or service. But what is called corporate welfare is a minor detail. Far more important is the full-fledged takeover by private industry of public decision-making and government spending."

In 13 years we ought to have learnt many lessons, but instead we seem to have surrendered any kind of scepticism whatsoever. And, of course, what we have is not a fee market but a captive one.

[1] Rogers et al 'Re: Collaboration with drug industry won’t affect clinical decisions, says new guide'BMJ Rapid Responses 16 April 2012 http://www.bmj.com/content/344/bmj.e2489?tab=responses

[2] Annabel Ferriman 'Royal college sets up working party to improve relations between doctors and drug industry'BMJ2008;336doi: 10.1136/bmj.39428.617431.DB(Published 3 January 2008)

[3] JK Galbraith 'Free Market Fraud', The Progressive, January 1999 http://www.progressive.org/mag_galbraith0199

Competing interests: None declared