Influences on Prescribing in Primary Care
Matthew Kirkman discusses the influence of the pharmaceutical industry on drug prescription practices.
Of the total NHS budget in England (£78 billion), over £7 billion is spent on drugs alone. (1) 80% is spent on branded drugs, which make up the minority of prescriptions by volume. (2) General practitioners (GPs) in the UK write approximately 650 million of the total 678 million prescriptions every year and, as such, are a big target for pharmaceutical companies hoping to push their products onto the market. (2) (3) At a time when minimising cost has become a national priority for the NHS (and indeed other healthcare systems across the world), it is necessary to ask what exactly can be done to reduce the expenditure on drugs, which account for the second largest chunk of NHS expenditure after staff costs. Whilst the primary focus of this article is the UK, many of the ideas have a wider relevance. Since generic drugs are in most cases significantly cheaper than their branded counterparts, this is primarily an issue of increasing generic prescribing. So, what exactly are generic drugs?
A generic drug has the same active pharmaceutical ingredient, but not necessarily the same inactive ingredients, as a branded drug. They are usually bioequivalent to their branded counterpart; that is, identical in clinical effectiveness. Generic drugs are usually produced when a branded drug loses its patent, approximately twenty years after the drug patent application was registered. With the significant expenditure on research and development by pharmaceutical companies, the patent period gives the discovering company a limited ‘window of opportunity’ in which to recoup their initial expenditure quickly and without competition. This limited time period is characterised by heavy marketing of these drugs to doctors.
There are many factors which influence the choice of drug that a GP prescribes. A major influence is that of the pharmaceutical companies who market to GPs via many channels, mainly through discussions with sales representatives and sales drives disguised as ‘medical education’. (4) Whilst such marketing can often provide useful information about drugs on the market, especially for new and inexperienced prescribers, it is often inaccurate. (5) The frequency of use of information provided by drug representatives in the GP setting is linked with increased prescribing costs in primary care. (6)
Pharmaceutical companies spend a significant amount of money on marketing their products; not surprising when one considers that in 1996, 1.2% of GDP in industrialised countries was spent on pharmaceutical products. (7) Gift-giving is a common marketing method used by the pharmaceutical industry and, in the UK, Clause 18.2 of the Association of the British Pharmaceutical Industry’s Code of Practice emphasises that promotional aids must be “inexpensive and relevant to the recipients’ work” (inexpensive is classed as no more than £6 in value). (8) In developing countries, luxuries such as cars and school tuition fees have been reported. (9) In surveying doctors’ attitudes towards the ‘gift relationship’ between US pharmaceutical companies and doctors, one study found that the doctors in a practice with a large number of patients, who see a larger number of patients per day, or write a large number of prescriptions per day, were more likely to receive gifts and condone the process of giving and receiving gifts. The ethics of such behaviour is extremely controversial.
Further detrimental effects of the doctor-industry relationship have been identified. A countrywide study of GPs in Britain found frequent contact with a drug representative to be significantly associated with GP willingness to prescribe new drugs and to agree to patients’ request for a drug that is not clinically indicated, dissatisfaction with consultations ending in advice only; and receptiveness to drug advertisements and promotional literature from pharmaceutical companies. (10)
Current Primary Care Trust guidelines encourage generic prescribing, and many countries have regulations in place to facilitate the development of the generic drug market. In the US, for example, the 1984 Hatch-Waxman Act was introduced to aid generic drug production and competition through subsidies and mandating the prescribing of generics where possible, among other things. The pharmaceutical industry in the developing world, by contrast, is extremely loosely regulated. In most cases, it is self-regulated by the pharmaceutical companies who, in the face of falling revenues from drugs going off-patent in industrialized nations, are now beginning to focus their energies there. (9) Of all the ethical dilemmas this brings, the most worrying is patient safety. The COX-2 inhibitor Rofecoxib (Vioxx) has been associated with thousands of deaths and even more cases of heart failure. In India, Rofecoxib was banned in October 2004, one month after being officially banned by its manufacturer Merck. One year later, it was still available in the domestic market. (9)
There has been a major uprising against the pharmaceutical companies throughout the world. The website No Free Lunch (for more information, see: http://www.nofreelunch.org) was started by a New York doctor in 1999 with the intention of changing the culture of doctors from practising medicine using biased pharmaceutical promotion to the use of unbiased evidence - encouraging doctors “to ‘just say no’ to the industry hospitality that damages patient care and the profession”. On the website, doctors can join by making the following pledge:
“I, __________________, am committed to practising medicine in the best interest of my patients and on the basis of the best available evidence, rather than on the basis of advertising or promotion.
I therefore pledge to accept no money, gifts, or hospitality from the pharmaceutical industry; to seek unbiased sources of information and not rely on information disseminated by drug companies; and to avoid conflicts of interest in my practice, teaching, and/or research”
(Source: http://www.nofreelunch.org/pledge.htm).
The Institute for OneWorld Health, a US-based non-profit pharmaceutical company, is aiding the supply of generic drugs for people with neglected infectious diseases in the developing world (see: http://www.oneworldhealth.org/). Activities such as this should ensure improved access to life-saving drugs for those most in need.
The number of lives saved and quality of life improvements brought about by the discovery of drugs goes without saying. The ethical problems brought about by pharmaceutical marketing, however, are widespread. One possible solution is tighter regulation by the government in both developed and developing countries of the promotional literature used by pharmaceutical companies, with a more stringent process of validating marketing claims. Since marketing can often have an informative, educational effect for doctors, a complete marketing ban could adversely affect patient outcomes. (11) Funding the establishment of an independent body of advice on pharmaceuticals would likely be costly to an already-overstretched health service. From the GPs’ point of view, the main priority when deciding on treatment should be the patient (patient choice and side effects, for example) with importance also given to the cost of the drug. Through ethical prescribing, the costs of medicines can be contained and generic prescribing encouraged, leading to a more efficient health service and improved health outcomes for its people.
Matthew A. Kirkman
Fourth year medical student
Newcastle University
matthew.kirkman@gmail.com
(1) House of Commons Health Committee. 2005. The influence of the pharmaceutical industry. Fourth report of session 2004-2005: Volume I. London: The House of Commons. Available: http://www.publications.parliament.uk/pa/cm200405/cmselect/cmhealth/42/42.pdf (accessed Jan 12 2008)
(2) Department of Health. 2007. Introduction to pharmaceutical price regulation. London: Department of Health. Available: http://www.dh.gov.uk/en/Policyandguidance/Medicinespharmacyandindustry/Pharmaceuticalpriceregulationscheme/DH_4071841 (accessed 12 Jan 2008).
(3) Prescription Pricing Authority. 2007. Prescription Pricing Division: Information Systems. Newcastle upon Tyne: Prescription Pricing Authority. Available: http://www.ppa.org.uk/ppa/info_sys/info_sys_support.htm (accessed 12 Jan 2008).
(4) Abbasi K, Smith R. 2003. No More Free Lunches. BMJ; 326: 1155-1156.
(5) Caudill TS, Johnson MS, Rich EC, McKinney WP. 1996. Physicians, pharmaceutical sales representatives, and the cost of prescribing. Arch Fam Med.; 5: 201-206.
(6) Ziegler MG, Lew P, Singer BC. 1995. The accuracy of drug information from pharmaceutical sales representatives. JAMA; 273(16): 1296-1298.
(7) OECD. 2000. OECD Health Data 2000. A Comparative Analysis of 29 Countries. Paris: OECD/CREDES.
(8) The Association for the British Pharmaceutical Industry. 2006. Code of Practice for the Pharmaceutical Industry 2006. London: The ABPI. Available: www.abpi.org.uk/publications/pdfs/pmpca_code2006.pdf (accessed 12 Jan 2008).
(9) Consumers International. 2007. Drugs, doctors and dinners: How drug companies influence health in the developing world. London: Consumers International. Available: http://marketingoverdose.org/documents/ci_pharma_2007.pdf (accessed 12 January 2008).
(10) Watkins C, Moore L, Harvey I, Carthy P, Robinson E, Brawn R. 2003. Characteristics of general practitioners who frequently see drug industry representatives: national cross sectional survey. BMJ; 326: 1178-9.
(11) Gönül F, Carter F, Petrova E, Srinivasan K. 2001. Promotion of Prescription Drugs and its Impact on Physicians’ Choice Behavior. Journal of Marketing; 65: 79-90.
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