Shouldn’t we be able to trust doctors to give us independent advice? Earlier this year, there was an outcry when it appeared that a doctor who often appeared on TV to speak about Covid vaccines had been paid a significant sum by the pharmaceutical company AstraZeneca. The payment was to promote a flu vaccine, not the Covid vaccine. The reaction demonstrated the discomfort many people feel when doctors take money from industry – and it is also catnip to anti-vaccine conspiracy theorists. Independence matters.
This is just one of many monetary exchanges between the pharmaceutical industry and medics. Data published by the Association of the British Pharmaceutical Industry (APBI) shows that almost £42m was paid to UK health professionals in 2023 – a mix of mainly consultancy, travel and conference fees. Pharma clearly thinks a massive spend is a good idea.
Money also flows into the NHS, often in the half light. Take screening for atrial fibrillation (AF), an irregular heartbeat that can lead to strokes. There is no controversy about checking for it in people with, say, palpitations or breathlessness. But testing people who have no symptoms is quite different. It may help, or it could be harmful, leading to overuse of drugs to control heart rhythm in patients who might not need it. Quite rightly, a large trial is being run to find out.
In the meantime, the independent National Screening Committee does not recommend screening for AF. However, my research team analysed media coverage of atrial fibrillation screening. We found that it was almost always supportive, and rarely mentioned that it wasn’t evidence-based. When we analysed the sources of those positive recommendations, they almost always had direct or indirect financial conflict of interest – which wasn’t usually obvious. In effect, it meant that the NHS was doing tests, funded by pharma, which its own independent advisers recommended against.
This is an architectural feat – making the NHS bow to the wants of pharma, not the rigour of evidence-based medicine. Medical royal colleges – which exist to promote high standards in the profession – received about £9m from drugs and medical device companies in the UK between 2015 and 2022. Much of this is used for “educational programmes”. A repeated argument is that it doesn’t matter where the money comes from, because the colleges maintain “editorial control”. But it still means the company is able to provide input and information to college programmes.
And, in 2020 alone, almost £23m was paid to UK patient groups from pharma industry sources – mainly where they were “aligned with their portfolio or pipeline”. Obviously, many groups do great work for patients. Patient groups normally comment on the National Institute for Health and Care Excellence’s (Nice’s) reviews of new drugs, and research in 2019 found that the majority accepted funding from either the technology, or a competitor product, the same year they reported to Nice. This is a “back door” to influence – the worry is that groups whose survival is dependent on pharma funding may be loth to criticise it. The result is a lack of independence.
This is concerning because doctors often have little insight into how they might be influenced. One of my favourite studies asked doctors whether they were influenced by the small gifts – pens and lunches – delivered by drug reps. Most said no. But when asked whether their colleagues were influenced by the same small gifts? Most said yes. Both statements obviously cannot be true.
Generally, in the UK, the principle of transparency has been used to deal with conflicts – which I’ve argued for repeatedly. We now have a voluntary scheme, run by the APBI, that publishes pharma payments made to professionals who allow it, and to healthcare organisations and patient organisations. The Cumberlege review examined how conflicts of interest caused harm to patients via poorly tested surgical mesh resulting in life-changing chronic pain, and recommended a Sunshine Act for the UK, where publication of industry payments to professionals would be mandated. But this may be limited in what it can achieve.
I’m not arguing against transparency, but even with guidelines and an immense amount of effort, it is hard to be effectively transparent. I worked on a study that showed many NHS transparency submissions were incomplete, incorrect and difficult to make sense of. And how useful is this knowledge to average citizens? As one patient said about medical professionals declaring potential conflicts of interest: “It’s so very difficult to know how relevant it is and whether it’s really something that is swaying their judgment or not.”
The risk is that doctors think they have absolved their conflict via transparency, despite the conflict persisting. Rather than professionals taking responsibility for not having an avoidable financial conflict, the work shifts to patients, who may not have the time, health and resources to decide what to do with that information – if they know it exists at all. The result is “baked-in” conflicts without impetus to stop them, because we think that somehow transparency will make them magically go away. Indeed, in the US, Sunshine Acts have not stopped a rise in money flowing to medical professionals. In fact, one senior doctor told me that open publication of payments resulted in “willy-waving” – and competition for bigger fees.
But there is good news. Earlier this year, the Irish College of General Practitioners voted to phase out pharma sponsorship of educational events “to ensure that patient care is guided by best practices and evidence, rather than influenced by the pharmaceutical industry”. This follows the College of Psychiatrists of Ireland, which has stated: “While psychiatrists aim to improve the lives of patients and their families the pharmaceutical industry’s aims are primarily commercial in nature. These aims do not always coincide.” We in the UK are behind – and need to catch up.
The health secretary, Wes Streeting, has made clear that he wants closer working with pharma, saying the life sciences industry is integral to the UK economy. Sure, the pharmaceutical industry does a huge amount of good – but marketing prowess is no substitute for the checks and balances needed to ensure we don’t waste money and harm people. Almost 20 years ago, the health select committee reviewed the workings of the pharmaceutical industry and, in a damning report, said that the “secretary of state for health cannot serve two masters. The department seems unable to prioritise the interests of patients and public health over the interests of the pharmaceutical industry.” It’s still true, for them and for everyone else. We need transparency – but that is only the beginning of disentangling ourselves from industry influence, not the end.
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Margaret McCartney is a GP who writes about evidence-based medicine. She is the author of The State of Medicine: keeping the promise of the NHS
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