Abstract
Key vested interests that affect the practice of medicine and the medications and treatments paid for by the NHS, and private care institutions in Britain and elsewhere in the world are held by ‘ethical’ pharmaceutical companies (so named apparently because they do their own research). Their aims are to sell as many of their products as possible at the highest price achievable while in patent. Many of these companies are international and charge different prices for the same products to different countries which can lead to ‘grey imports’ of drugs that they have sold to another country and that were never intended for the UK.
Other vested interests are held by the manufacturers of medical equipment, devices and/or substances and the suppliers of medical services (there is some overlap). Their incomes (and/or their shareholders’ dividends) will depend directly on persuading hospital managers, clinicians and at times politicians responsible for providing and paying for medical care to buy their products rather than others (which may be equally good and cheaper). The same companies may well manufacture very similar products or equipment, some of which are cheaper than others. Branding will be a very important factor in their marketing and trying to persuade their professional and lay customers that their brand is the cheapest or best and most effective albeit perhaps more expensive. Companies can advertise to the lay public when the products can be bought over the counter in the UK.
In the UK, the National Institute for Health Care and Excellence (NICE) was set up to guard the NHS purse strings to make sure that products bought by the NHS offer value for money and may be prescribed by clinicians in the NHS. However, whether a health authority buys some and not others will end up as a post code lottery for patients.
GPs are the traditional gatekeepers of routine prescribing and managing most hospital admissions so they are a prime target of the pharmaceutical industry and its skilled marketing teams with inducements to offer. Many years ago, I was asked to give a medico-legal talk that was being funded by a drug company to a group of GPs in a county town. When I arrived, I was met by one of the doctors: I asked how I would know who the company’s reps were. He replied: ‘They are the good looking ones who are well dressed and smile a lot.’ They were easily identified.
While some GPs are inclined to be cautious and tend to prescribe drugs that are most familiar to them, others are keen to try new drugs: their names will be noted eagerly by drug companies’ sales reps. Whether they use the hard or soft sell, pharmaceutical companies promote their products and have generous budgets for this purpose. In the past, doctors were offered lavish entertainments and a range of gifts which ranged from modest pens, pads and mugs with their logos to expensive executive toys. The companies and their reps had vested interests in making sales, and many clinicians benefited in a variety of ways which may have affected their independent judgment – though few would admit this.
Drug companies fund what is often very long term and expensive research; many compounds and drugs and formulae that looked promising have to be discarded along the way, as they come under scrutiny and are found to be too toxic or ineffective. To maximise their profits, companies argue that they must be able to recoup the research costs and make a profit so they need to manufacture products that will be bought by or for as many people as possible which means in the rich or richer world with developed health care systems. It also means that they will research for products that can cure or suppress or limit common conditions even when there are already many products on the market. They are usually reluctant to fund expensive research for rare illnesses (Cinderella conditions) and/or illnesses that are generally confined to the Third World, and poor countries where governments have no adequate health budgets and only a handful of people would be able to pay for expensive new drugs. A deal was done on the AIDS virus – but there was in addition to altruism, anxiety about the need to try to control the spread of the disease.
The reluctance to pay for the research and development of medicinal drugs intended primarily or almost exclusively for Africa and other poor countries is the reason there is no vaccination or cure for Ebola at all notwithstanding this virus was first detected and studied nearly 40 years ago. I suspect that had the current outbreak in West Africa remained contained with deaths maximising in the low thousands that there would have been no panic and desperate seeking of a vaccination and cure.
However, Ebola is no longer just a terrible disaster for the people of Liberia, Guinea and Sierra Leone with (at the time of writing) over 4,500 deaths with horrifyingly rapid rates of infection and the numbers of cases doubling each week there are estimates that there could be 10,000 new cases a week in West Africa by December. Only a handful of infected people have travelled to Britain, the USA, Spain and Germany but there are fears it could spread as healthcare workers nursing infected patients in Spain and the USA working in high-tech hospitals are now infected and may have infected others without realising they were potential victims or carriers. Accordingly, there is fear that if not contained in West Africa, Ebola could spread to Europe, the USA and beyond. The true numbers of deaths are quite probably far more than have been formally reported in Africa. The survival rates are around 70% with the disposal of dead bodies posing the greatest risk and challenge to local conditions.
British and American healthcare workers and service personnel are being sent to West Africa to help train local people and help them to treat those infected and isolate those who are at risk. Doctors and scientists around the world are working desperately and cooperating more than usual, to find a cure and a vaccination to curtail the spread of the disease. It is now in the world’s interest to do so – thus the vested interests have shifted and so have the treatment aims. In Britain, the government, after dismissing this as impractical and ineffective, has now set up screening for passengers who arrive in the UK to key airports from the three infected countries by testing for the presence of fever. This is the scientific equivalent to wheeling World War I artillery into Hyde Park to fend off the Luftwaffe during the Blitz – largely ineffective but it makes the public feel something is being done. Meantime, the emergency is dispensing with much regulatory red tape and processes are being accelerated in the dash to find a cure and to increase the amount available for treatment of the only known product ZMapp which may reduce the impact of the disease and allow survival. The risk of dying from Ebola, once a person is infected, is so high that no trial of this medication will include a placebo (as is normal in a randomised controlled trial of a new substance) as this would deprive a patient of the potential benefits of the drug under review which in these circumstances would be unethical.
But to return to other perhaps shifting vested interests. For some clinicians, health-workers, service providers and manufacturers a major change in their field may not be altogether welcome if they lack the skills and expertise or capital to deal with it and there is morbidity (and sometimes mortality) in training. Some surgeons used only to open surgery struggled initially when minimally invasive techniques were being pioneered and patients died in consequence. A hospital unit may lack the money needed to buy best and most diagnostic equipment but continue to offer services that are less good than they could be. Some clinicians will refer patients on to units that have better equipment (and this may create undesirable delays) while others will offer the less than state of the art treatment that they have available.
Then, there is the issue of screening: government and private institutions will have invested very heavily to set up and run universal screening programmes and having persuaded the public that the results must be beneficial as it will enable a cancer to be diagnosed earlier than would otherwise be the case and so treatment is likely to be more effective and survival longer. Imagine the disappointment when the benefits are far less greater than expected and there is a serious downside in terms of misdiagnosis and over-diagnosis with the consequence that people undergo unnecessary procedures, are made very anxious without due cause and some are harmed significantly, lose days at work and suffer other adverse effects. And universal screening programmes are expensive and many might argue that a more restricted programme would be a much better option and release much needed funds to be spent more usefully. It is likely that any such plan would result in screams of protest from pressure groups, some clinicians involved in it and others with contracts and premises that depend on the programme continuing and even expanding. See the Letter from Professor Susan Bewley on page xxx. Professor Bewley and many other academics and clinicians take the view that it would be difficult to justify a programme for universal screening for breast cancer now given the most recent evidence that it is counter-productive in many instances; this evidence was not available when the project was set up with the highest hopes and best of intentions. The House of Commons Science and Technology committee has recently published its report – http://www.publications.parliament.uk/pa/cm201415/cmselect/cmsctech/244/244.pdf.
The aim of trying to detect common (and other) cancers as early as possible is in itself laudable provided that once these are detected you can cure or contain them with an improved survival rate and quality of life. Many millions of pounds have been poured into these programmes and the public induced to believe that they are beneficial and will reveal cancers earlier enabling more effective treatment. But arguably, some of this money could be better spent on different health projects. The most recent evidence indicates that there is a lot of over diagnosis and over treatment of relatively harmless growths and very early cancerous changes which result in avoidable morbidity and anxiety.
Lobbying is also a major factor in influencing which drugs or treatments should be favoured by the NHS and other health care institutions. In the Times of 1 October 2014 (p. 18) there is an article headed: ‘Pharmaceutical giants donate to charities that back their brands’ and discusses a report from the BMJ which names ‘the Multiple Sclerois Trust’ as receiving funding from Bayer which markets Sativex, a drug that NICE does not support as giving value for money. The Chief Executive of the MS Trust said it did not endorse any specific products or services and industry contributions accounted for less than 10% of the charity’s income. However, while drug companies must disclose relationships with patient groups and charities on their websites, the requirement does not work in the other direction, but it should now do so. Some charities limit or refuse industry support or donations from only one company, and MIND refuses support from all pharmaceutical companies.
As already discussed, pharmaceutical companies have a vested interest in expanding their range of effective drugs when patents are still running. They may, depending on their research practices, be regarded favourably as medical pioneers and life savers when a drug is successful and with anger when they fail and their products cause harm and most particularly if it can be proved that adverse effects were concealed. With such heavy investment, it is easy to see why companies may be tempted to try to suppress negative results – which may not show the drug causes actual harm but simply that it is not effective. What impact the so-called Saachi Bill would have with its aim of ‘freeing’ doctors from regulation and fear of litigation to try new methods of treatment if passed is very uncertain. Given the Bolam test doctors are already able to innovate and indeed do so and its critics fear that it will provide quacks with a charter to do great harm notwithstanding amendments put in place to try to avoid this.
Vested interests in medical treatments are cash-based and/or rest on reputations and practices that are or have been built on them even where there is little evidence to support them. In the case of homeopathy and many other complementary therapies, there is no scientific basis whatever for effective healing and much to suggest that they are no better than a placebo – and yet there are many patients willing to pay for them.