Captured by design: the drug industry and UK healthcare

Open doors

In 2003, The BMJ heavily criticised the drug industry for using “back door” routes to wine and dine professionals.7 Today, the front door is open wide. For example, the National Screening Committee advises against screening for atrial fibrillation.8 Yet screening, organised and funded by Academic Health Science Networks, was pushed into the NHS.9 Industry, which funded it, stood to benefit. Government justified this by saying, “we need an entirely new relationship with industry based on partnership, not just transactions.”10 Health professionals and patients, informed of the evidence, may beg to differ.

Similarly, a recent BMJ investigation found that the UK health minister was in contact with the Office for Life Sciences, which in turn pressed NICE to approve inclisiran, a cholesterol lowering drug of uncertain long term effectiveness.5 The health minister’s office asked NICE to nudge approval of inclisiran “over the line” and sought a recommendation for earlier use in clinical guidelines. Rollout of inclisiran was announced at a JP Morgan summit in advance of official NICE approval. Patient targets in primary care were then aligned with prescription of the drug. In another example, Novo Nordisk, which makes semaglutide for treatment of obesity, is part funding the weight management pathway in Mid and South Essex.11 Joint working arrangements between pharma and the NHS are now commonplace, where industry part funds staff salaries and contributes to organisational decisions without public scrutiny.12

How can conflicts of interest be removed when they are embedded by design? Industry funding for core services veils NHS underfunding and establishes a damaging dependency. In primary care, “interface pharmacists” funded by industry offer free medication reviews but focus on medication changes in the industry’s interests instead of local, independent, prescribing guidelines.13 Another route to influence is through industry funding of patient organisations that operate “in therapeutic areas relevant to companies’ portfolio or drug development pipeline.”14

It is incongruous that the UK has independent processes to decide which interventions should be approved for the NHS but also industry sponsored processes, created by government, that over-ride this scrutiny and independence. Even a process for fast track patient access to “cutting edge” medical products, announced by the MHRA last year, ignored international experience. When US companies were offered fast track review “in an effort to enable breakthrough technology to reach market faster,” this was associated with a higher risk of product recall.15

In 2016, the Association of the British Pharmaceutical Industry (ABPI) created Disclosure UK in response to the health select committee’s demand for improved transparency. The database lists industry payments and benefits in kind to health professionals and healthcare organisations, but it is criticised for being only “partially transparent.”16 Information on conflicts of interest is often missing or of poor quality,1718 creating a fig leaf of superficial transparency that is ineffective.1920 The General Medical Council adds to the problem by advising that professionals “should” cooperate with disclosure schemes rather than insisting on full declaration of industry payments and other benefits.21

The current relationship between the pharmaceutical industry and healthcare in the UK is broken. Patients and the viability of the NHS are being placed at risk by choices made by successive governments. Decision making is conflicted by commercial interests and value impaired through a system that rewards industry innovation but leaves taxpayers to pick up the bill for interventions that are prematurely approved or don’t meet expected thresholds for cost effectiveness. Now, the MHRA and ABPI are allowing unacceptable delays in the industry’s already disputed process of self-regulation.22 A regulatory system that was once internationally acclaimed and highly trusted is a redesigned inside track for pharma profiteering. The UK is not alone in these missteps.

We call for an urgent, robust, and independent review of the links between the pharmaceutical industry and the NHS. We call for a system that does what was demanded by the health committee two decades ago: “ensure that industry’s activities are more clearly allied to the interests of patients and the NHS.” We call for an end to industry’s capture of government and the health service. A system that supports evidence based, cost effective interventions will benefit taxpayers over vested interests. As a general election looms, is there any political party brave enough to commit to such a review and act on its findings in the public interest?