Exposing drug industry funding of UK patient organisationsBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1806 (Published 22 May 2019) Cite this as: BMJ 2019;365:l1806
- Piotr Ozieranski, assistant professor1,
- Emily Rickard, research assistant1,
- Shai Mulinari,, associate professor2
- 1Department of Social and Policy Sciences, University of Bath, Claverton Down, Bath, UK
- 2Department of Sociology, Lund University, Lund, Sweden
- Correspondence to: P Ozieranski
From 2012 to 2016 the drug industry donated over £57m (€65m; $73m) to UK patient organisations, with the annual sum more than doubling over the period
The funding benefited a small number of organisations and activities related to research and public involvement
The industry gave priority to commercially high profile conditions
Industry payment disclosures had limited transparency
Patient organisations—third sector entities comprising patients, carers, or both, that provide support and advocate for people with specific conditions12—are increasingly involved in policy and research.13 But their contributions have been questioned when they receive funding from drug companies.45 With few exceptions,67 existing research underscores that financial ties to an industry driven by profit risk turning patient organisations into seemingly independent “third parties”8910 that promote novel medicines, often with problematic clinical profiles, cost, or cost effectiveness.1112
These concerns are crucial in the UK, where drug development, appraisals, and commissioning rely extensively on input from patient organisations.13 Notably, patient organisations contributing to appraisals by the National Institute for Health and Care Excellence (NICE) have widespread, and often not entirely transparent, financial relationships with drug companies,14 which is consistent with findings from other countries.4515
We know little about the scale of industry funding, its main providers and recipients, and the nature of funded activities.16 These questions have not been answered by case studies of policy decisions or patient organisations17 or by cross sectional analyses of industry sponsorship using patient organisations’ websites,15 tax records,5 and surveys.4 But new sources of data generated by the industry offer new opportunities for anlaysis.114 We use one such source, disclosure reports published on company websites,1618 combined with patient organisation websites and charity regulator records to examine the big picture of industry funding of UK patient organisations.
Forming a new payment database
Since 2012 corporate members of the European Federation of Pharmaceutical Industries and Associations (EFPIA) and the Association of the British Pharmaceutical Industry (ABPI) must disclose their payments to patient organisations. Unlike healthcare professionals, patient organisations cannot decline the publication of data on their payments.19 As in the US,1 the disclosure reports are dispersed on company websites, so establishing the scope of industry involvement for any patient organisation, let alone the overall pattern, is difficult.
During June 2017 to July 2018 we searched online for disclosures of payments to “patient organis(z)ations” or “patient groups” made by companies participating in the ABPI’s Disclosure UK database in 201520(see web supplements 1 and 4)—the database covers payments to healthcare professionals and organisations.21 Overall, we identified 220 disclosure reports covering payments from 2012 to 2016, excluding 27 duplicates (see web supplement 5).
The number of disclosing companies rose from 30 in 2012 to 54 in 2015, then dropped to 46 in 2016 (web supplement 2). The proportion of ABPI companies (as of January 2018) that disclosed rose from 45% (24/53) in 2012 to 66% (35/53) in 2016. Overall, 66 companies published at least one disclosure report over the five years, but only 21 did it every year; these figures were 43 and 19, respectively, for members of ABPI. A missing report may indicate no payments or a failure to disclose.
We extracted data to a single database, converting all 5232 identified payments to 2016 pounds (see web supplement 6). After reading the payment descriptions and carrying out additional web searches using recipient names, we excluded four payments that were not made in 2012-16 (worth £10 040 out of a total £61 874 269 (0.02%)) and 656 (worth £4 558 976), that were not made to UK organisations meeting EFPIA’s definition of a patient organisation (box 1; see web supplements 3 and 4). These payments might signify problems in defining patient organisations,2 possibly combined with precautionary over-reporting of payments.
Definition of patient organisation by the EFPIA16
Patient organisations are defined as not-for-profit organisations (including the umbrella organisations to which they belong), mainly composed of patients or caregivers that represent and/or support the needs of patients or caregiversRETURN TO TEXT
The challenges we encountered in building our database are similar to earlier concerns about the low transparency of reporting of industry payments by patient organisations.45152223 They also coincide with deficiencies in the transparency of payments to healthcare professionals24 and organisations from Disclosure UK.202425
We coded the condition areas of 444 out of 508 identified patient organisations (87%) using ICD-10 (International Classification of Diseases, 10th revision); the remaining 64 organisations focused on diseases or issues not included in ICD-10. We also coded payment goals based on iterative reading and aggregating of semantically similar payment descriptions. We coded the characteristics of patient organisations using their website data and records held by the Charity Commission for England and Wales, the Scottish Charity Regulator, or the Charity Commission for Northern Ireland. Two researchers conducted the coding, resolving differences through discussion.
Little and large: trends in industry payments
Overall, industry disclosed 4572 payments worth £57 305 253 during 2012-16. This represented only a sixth of its funding for healthcare professionals and organisations (£340.3m) in 2015 alone.26 Patient organisations, however, seemed increasingly important for drug companies. From 2012 to 2016, the yearly number and value of payments rose (table 1). For the 21 companies that disclosed consistently over the five years, the number of payments increased slightly (738 versus 772), but their value was 1.4 times higher (£10 838 391 versus £7 634 493).
The top five payments represented 20% of the total value (table 2). The value of the largest payments rose over time, with the share of the top 5% almost doubling from 33% (2014) to 65% (2016). But small payments were most common, with 50% being no larger than roughly £5000 annually. Small payments are potentially important, as findings from the US show that even smaller amounts might affect physicians’ prescribing.27
Dominance of big pharma
A few companies dominated the funding landscape, with the top 10 providing 69.2% of all funding (table 3). Most of the top 10 showed a shared understanding of what constitutes acceptable payment values, with similar interquartile ranges (except for Pfizer and Astellas, representing the low and high extremes) and maximum payments (except for Pfizer, Takeda, and Astellas, which had considerably larger highest payments). As with payments to healthcare professionals, the largest donors were “big pharma” companies.20
Who received funding?
Out of all 508 identified patient organisations, 434 (85%), receiving £53 467 424 (93%), had a clear organisational form. Associations formed the largest proportion of these (173, 40%), followed by foundations or funds (61, 14%), trusts (58, 13%), and forums, groups, and networks (51, 10%). The corresponding funding shares were 35%, 29%, 8%, and 4%.
Furthermore, 444 of the patient organisations (87%), receiving £54 071 418 (94.4%), were registered charities, so they had to follow minimum transparency requirements, including publishing their financial accounts.28 Consistent with the EFPIA’s definition of patient organisations as “mainly composed of patients and/or caregivers,”16 482 organisations (95%), receiving £56 666 334.8 (98.9%), had members (including support groups or online forums) or supporters (including volunteers or friends).
Most funding (£47 466 806, 82.8%) went to 31 multipurpose organisations combining patient support with advocacy, policy involvement, awareness raising, or research. Conversely, the organisations focusing on just one of the two activities highlighted in EFPIA’s definition16—“support” (87 organisations) and “representation,” here understood as “advocacy,” (69)—received just £2 732 019.0 (4.8%) and £5 467 917.0 (9.5%), respectively.
What activities got funded?
The top funding priority was supporting patient organisations’ engagement with outside audiences. Notably, public involvement, including “advocacy, campaigning, and disease awareness,” “communication,” and “policy engagement” attracted £17 860 574 (31.2%) (table 4). Similarly, engagement in research totalled £14 085 520 (24.6%), mainly because of two large grants received by Myeloma UK and Breast Cancer Now (see table 2). By contrast, support for patients attracted £3 381 030 (5.9%) and organisational maintenance and development, £1 613 061 (2.8%).
This hierarchy of funding goals might indicate that patient organisations have matured organisationally, so outside engagement is the key area of their empowerment.7 An alternative interpretation would focus on the risks associated with the underinvestment of core organisational functions and using patients as “third parties” leveraging industry influence in areas like drug development and approvals,29 health technology assessment,12 and commissioning.11
In drug discovery, the industry prioritises investing in some conditions over others based on their commercial viability.30 Cancer in particular has a privileged place.31 Our data show a similar pattern: of the 30 condition areas (or their combinations), the top five accumulated £39 423 529 (68.8%), with neoplasms alone attracting 36.4% (table 5). The second category—endocrine, nutritional, and metabolic diseases—received 11.3%, and infectious and parasitic diseases 8.0%.
The hierarchy of funding within each condition area also reflected the industry’s commercial priorities. In neoplasms, multiple myeloma attracted £7 495 729 (35.9%), followed by breast cancer (19.6%); 26 other types of cancer attracted less than 10% of funding. Diabetes received £3 741 181 (57.6%), the most of any endocrine, nutritional, and metabolic disease. The bulk of funding for certain infectious and parasitic diseases went to HIV (37.4%) and viral hepatitis (23.6%). Importantly, the biggest donors in these condition areas have recently launched several high priced drugs. Key examples include Pfizer (palbociclib for breast cancer32), Takeda (ixazomib for myeloma33), Lilly (dulaglutide for diabetes34), Gilead (emtricitabine/tenofovir for HIV35 and sofosbuvir/ledipasvir for hepatitis C36).
As in the US,4 funding was concentrated on a few patient organisations within each condition area. Crucially, across all 30 condition areas the top recipient accumulated an average share of 65.6% of funding.
Clearing the fog
The emerging picture of industry funding shows that companies might seek to use some patient organisations as “third parties” in reaching other audiences. Without necessarily determining the content of the funded activities, firms could shape the profiles of patient organisations through heavy investment in their external activities. This could then influence the public’s and policy makers’ perceptions, consistent with other industry marketing practices.29 Importantly, both tiers of the industry’s payment strategy have demonstrable effect on clinical “key opinion leaders” (large payments)37 and prescribers (small payments).38
The concentration of funding on certain types of organisations, activities, and conditions might reinforce inequalities between organisations with different budget sizes,2 advocacy potential,39 or representing conditions ascribed varying levels of “social value.”40 Furthermore, given the weakness of public funding,41 limited industry investment in patient organisations’ internal work, could affect their long term sustainability.
Nevertheless, following patterns identified elsewhere, financial relationships between many companies (especially non-big pharma) and patient organisations are sparse.415 In any case, answering questions about the extent of industry influence requires examining how open different patient organisations are to accepting funding15 or how much their priorities match those promoted by industry funding.10
But the picture is not fully clear, given the transparency shortcomings, which are similar to those found in other areas with industry self regulation.42 Tackling them would require an integrated, regularly updated payment database with robust quality assurance policies. The ABPI is not currently considering such a database,43 but it should at least introduce a standardised disclosure template, perhaps modelled on the one used for Disclosure UK.44 A space to report that no payments were made would enable identification of those breaching their disclosure obligations.16 Furthermore, a precise definition of patient organisations would help distinguish them from healthcare organisations, which should be reported separately in Disclosure UK.43
Responding to risks posed by the concentration of industry funding requires structural solutions,45 such as a shared corporate funding pool detached from current commercial objectives or treatment areas or a programme of public grants including, for example, the expansion of the Health and Wellbeing Programme run by the Department of Health and Social Care, NHS England, and Public Health England. This would make for a more level playing field for patient organisations that cover currently underfunded condition areas or have weak industry links. Achieving this objective, however, might face barriers related to a long term decline in public funding available to patient groups, which, depending on specific Brexit arrangements, might be further exacerbated by loss of access to EU funding; the increasingly complex institutional environment in which patient organisations operate; and a widening scope of patient organisations’ activity.41
We thank Anne Sauviat (University of Cambridge) for her help in conducting web searches. Thanks also to Marcell Csanadi (Eotvos Lorand University), Courtney Davis (King’s College London), and Luisa Enria (University of Bath) for their helpful comments and suggestions. Special thanks go to Olga Loblova (University of Cambridge) for the inspiring discussions about the big picture of our data.
Competing interest: We have read and understood BMJ policy on declaration of interests and declare the following: SM and PO’s work on the study reported in this paper was supported by the grant “What can be learnt from the new pharmaceutical industry payment disclosures?” awarded by the Swedish Research Council for Health, Working Life and Welfare (FORTE #2016-00875). ER’s work was funded through the above grant. The funding body has played no part in the design or conduct of this analysis. We have no other competing interests to declare.
Contributors and sources: PO is an assistant professor at the Department of Social and Policy Sciences, University of Bath. PO conceived and drafted the paper, collected, coded, and analysed the data. SM is an associate professor at the Department of Sociology, Lund University. SM contributed to concept development, data analysis and writing. ER is a research assistant and doctoral student at the Department of Social and Policy Sciences, University of Bath. ER collected and coded the data and contributed to writing the paper. PO is the guarantor of the article. This article draws on the following primary data sources: 220 annual payments reports comprising drug company payments to UK patient organisations; websites of 508 UK based patient organisations; online databases of the Charity Commission for England and Wales, Scottish Charity Regulator, and The Charity Commission for Northern Ireland; and the WHO ICD-10 (version 2010) website.
Provenance and peer review: Not commissioned; externally peer reviewed.
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