Confronting medicine’s flawsBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h3995 (Published 23 July 2015) Cite this as: BMJ 2015;351:h3995
- Trevor Jackson, deputy editor, The BMJ
The BMJ this week brings together several of the themes that we have campaigned on in recent years: competing interests and the hidden hand of the drug industry in clinical decision making; the quest for open trial data; and overdiagnosis and overtreatment.
Our GP columnist Margaret McCartney has long been a cheerleader for rational and evidence based decision making, free from the influence of pharma and politicking. This week, in addition to her regular No Holds Barred slot—in which she lambasts England’s health secretary, Jeremy Hunt, for wanting drugs costing more than £20 (€29; $31) to display the price (doi:10.1136/bmj.h3929)—she investigates so called partnerships between the drug industry and primary care (doi:10.1136/bmj.h3688).
After filing 186 requests under the Freedom of Information Act, McCartney found that 36 English clinical commissioning groups were involved in drug management programmes paid for, either directly or indirectly, by the drug and devices industry. In some areas she found that industry staff were working in general practices to review patients. In Portsmouth, writes McCartney, general practices wrote to patients with stomas and offered them an appointment with a nurse employed by a stoma company to “optimise stoma care.” In other areas pharmacists who were paid indirectly by a company making calcium and vitamin D products for osteoporosis had access to patients’ records. The practices, however, did not seek permission from individual patients.
McCartney describes a range of models for joint working between the industry and the NHS, including intermediate companies and pharma sponsored nurses and pharmacists in general practices. Although the UK government has been open about its support for closer collaboration, concerns abound about patients giving fully informed consent and the risk of drug switches that are profitable to the industry. “Are we sure we are getting a fair exchange for this intelligence gathering?” asks McCartney.
This week’s Analysis article looks beyond the NHS to shed a much wider light on the web of influence surrounding the management of osteoporosis and the diagnostic criteria for it (doi:10.1136/bmj.h3170). Andrew Grey and Mark Bolland unpick the ties between advocacy organisations, academics, and companies making calcium and vitamin D supplements. Although there is evidence that such supplements do not reduce the risk of fracture and may result in harm, they are highly profitable. And the companies that manufacture and market them are closely bound, through sponsorship and research grants, with patients’ and education groups and academics in specialist societies. “Each party benefits,” write Grey and Bolland, though “the party that may lose, and be harmed, is the public.”
A year ago The BMJ convened an expert panel that called for anonymised individual patient data from trials of statins to be made available for independent scrutiny (bmj.com/statins). This followed a highly public episode in which the journal came under criticism from Rory Collins of the Cholesterol Treatment Trialists collaboration in Oxford for its handling of two papers that made mistakes concerning the evidence on rates of adverse events from statins. An editorial by The BMJ’s editor in chief, Fiona Godlee, and colleagues Emma Parish and Theodora Bloom gives the history of The BMJ’s statins debate and subsequent attempt to see a full independent review of the patient level data on adverse events (doi:10.1136/bmj.h3908). Though there have been some encouraging signs, the overall outcome of this initiative “falls well short of current notions of data sharing,” write Godlee and colleagues. They conclude, “The statins saga forces us to confront the deep flaws in our current system for evaluating medicines and guiding clinical decisions.”
Cite this as: BMJ 2015;351:h3995