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Big Pharma’s Little Helpers

Posted on 10 November 2012

bad pharmaThe idea the there is gold in them thar pills is, one might say, as old as the hills: the book on the left was published in 1975. But it sure is a rum old business. Dr No’s last post highlighted the paradox that, even for drugs that do work, for most patients, most drugs don’t work. This naturally enough in today’s world of evidence based medicine begs the question: why do doctors prescribe, on the industrial scale they do, when the evidence shows most of the time, most drugs don’t work? The answer, Dr No suspects, not necessarily quite so straight forward as at first it may seem, and may even have more to do with blind faith than scientific evidence.

Whatever the possible reasons for prescribing on such a scale, which Dr No will come to shortly, the bulk of it is done in primary care. GPs account for around two thirds of the NHS medicines bill, covering an eye-watering 961.5 million items – which works out at 18.3 items per person per year - in England in 2011. Given that GPs account for two thirds of the bill, and average individual item costs are mostly lower in primary care, the proportion of all prescriptions issued by GPs will be even greater – let us guesstimate three quarters. In numerical and cost terms, it is overwhelmingly GPs who are Big Pharma’s little helpers. Indeed, Big Pharma wouldn’t be anything like as Big as it is without its little helpers – which is all the more reason to ask: why do the little helpers help so willingly when, most of the time, most drugs don’t work?

The first possibility is simply that GPs, in the round, are not the brightest crayons in the box. The nice lady drug rep with high heels and rocket bra gives the doctor a sharp new pencil with Viagra written on it; and so the doctor prescribes Viagra (the NNT for which, as it happens, isn’t too bad at all, at around two: only a couple of men need take it for one to get a bigger handle back on his pan). Be that as it may, in the past, sexy repettes – Dr No has known surgeries where one couldn’t move for drug reps, not to mention panhandles – and bribes were used to sell drugs, but today, tighter rules on how drug companies peddle their wares mean this influence on prescribing peaked some time ago, and is now in decline.

The second possible reason, which Dr No has touched on in previous posts, is that GPs prescribe as much as they do because that is what they have always done, in that today’s GP in the lineal descendant of yesterday’s apothecary, or corner-shop chemist. The shopper/patient expects a pill, and the shop-keeper/doctor provides. All that caring and sharing mumbo-jumbo is so much window-dressing: behind the closed shop door, the majority of transaction remain, as they always have done, shopper-provider transactions. As Maslow might have said, when all you have is a prescription pad, everyone looks like a patient. But is this enough to explain nearly one thousand million prescriptions per year in England alone? Dr No suspects not: something stronger must be at play to generate that colossal number.

The third possible reason – and Dr No mentions it largely to rule it out – is that GPs really do understand NNTs, and so know they must, to use an example from the last post, give sixty patients a statin for one heart attack to be averted. They understand that while evidence based medicine tells us what works for some patients, it also tells us that, for most patients, most drugs don’t work; yet the only way to get any benefit at all is to prescribe on an industrial scale. But most doctors, let alone GPs, even when they do understand an NNT - many do not - don’t routinely incorporate it into their practice. Instead, the doctor believes (as indeed, to be fair, do most patients who take medication) that this drug particular works, for this particular patient; even when, as we know, most of the time, it doesn’t.

To believe in something in the absence of evidence has a name: faith. Most doctors, especially those who reach for the pen rather than the knife, Dr No suggests, believe in medicines in much the same way that priests believe in God. For each, the entity, be it a medicine or deity, is so core to the enterprise that not to have faith in it is unthinkable. Doubts maybe, but at the end of each day, the faithful return to their faith; and as is the way with faith, it can removeth all mountains, not to mention launcheth a thousand million prescriptions, for with faith comes drive. Doctors can’t help but prescribe. As the Talmud has it, more than the calf desires to suckle, the cow desires to nurse.

In Bad Pharma, Ben Goldacre paints a picture of an evil industry running rings round well-intentioned but gullible doctors. Dr No is not so sure it is as simple as that. The distorting effect of publication bias – burying bad news – has been recognised for decades, such that the scandal is not that it happens, but that it is still happening. Could it be, Dr No wonders, that doctors’ blind faith in drugs means they cannot help but be Big Pharma’s willing little helpers? They simply don’t want to know that most of the time, most drugs don’t work. As patients, we might well want to ask: when does blind faith becomes inadvertent complicity?


In giving Doctors 'wriggle room' when describing their dilemma you seem to discount the power of 'QOF'. This places a staightjacket of sorts on the prescriber (the Doctor)to ensure the Medical Politborough's edicts are followed to the letter: in other words the guidelines are followed. This is of course an added incentive to GP's to peddle 'Pharma's' wares even, as I know to be the case, many do so with little belief in what they are doing has little, or even no real evidence base to support it.

In fact, as Ben Goldacre posit's and many before him, the whole concept of 'evidence-based' medicine has been degraded by the missing data, distorted promotions and advocacy articles 'ghost wriiten' by pharma in even the most prestigious of medical journals. Briffa, Kendrick and Healy et al have all put their necks on the block to expose this but little heed has been taken of their writing's or indeed of my pathetic utterings.

As your post was written even, we see that the NHS has sanctioned the vaccination of babies for the roto-virus; a usually mild and endemic problem that is unrelated to any lack of hygiene, that does little harm except in those with co-morbidities.I posted about this some time ago. And yet more wealth is now to be bestowed upon Primary Carers to promote a somewhat dubious protocol to ignorant punters, as being essential to their babies health. If GP's and the DH stopped the promotion of low fat baby foods and milk substitutes that are bordering on toxic, babies would likely have robust enough immune systems to ward off such ailments without recourse to such protocols.

It isn't just the drugs Doc' its the whole philosphy that has become slanted and debased. Low fat this and low cholesterol that. Thin your blood, lower your BP, heighten your mood, eat this toxic extract of soy to lower your (essential) cholesterol. Even quite intelligent people, who are gaurdians of our health have either been sucked unknowingly into the mire of preventative medicine or are completely without any moral integrity. And yes it's probably a mixture of both but that is no excuse.

The conspiracy between Charities, Pharma, Doctors and the many State organs is now almost complete and we can all look forward to taking a pill for every possible ailmant for which a surrogate marker can be invented. Of course we won't be any healthier, or live any longer, lose any weight, or not have Diabete's, because the drug's generally don't work (except for the side effects). We have been doing the same things now for in excess of thirty years and the position worsens by the year. Yet we continue down the same pathways with the belief that if we keep doing the same things long enough it will improve. That's why I think that Doctor's are dillusional, but what the hell there's a drug for that isn't there?

Well I'll take the bait you threw down. As a mere thick GP I find most of my day is spent fending of the new drugs and decrees for statins for old ladies in their 90s as prescribed by the "Clever Docs" up at the hospital.
Indeed the clever hospital docs get quite upset when I refuse to prescribe the latest bling based on one paper sponsored by the Pharma company in question - ultimateyly they follow protocols slavishly, especially their juniors who prescribe unsupervised - but that's OK because the "thick GP" will follow up.

Apologies for ranting a tad, but in the round, I am not the brightest crayon in the box :-P

At last, someone willing to shine a light on GPs. As you identify, it is GPs as a group that contribute significantly towards the rise in NHS costs. And again, as you identify, a big problem is the huge amount of over-prescribing that goes on. Here are some stark figures:

In 2010, nearly 927 million prescription items were dispensed; this is a 4.6 per cent rise on 2009 AND A 67.9 PER CENT RISE ON 2000.

An average of 17.8 prescription items were dispensed per head of the population in 2010; compared to 17.1 in 2009 and 11.2 in 2000.

These figures have risen again for 2011 and no doubt 2012 will continue the upward trajectory. So what does this tell us? I think it tells us two things:

1. The uncomfortable truth is that people these days want a pill for every ill and are prepared to ship up at the surgery at the drop of a hat to get what they want. In turn, GPs dole out what their patients want because it is very often less hassle to them than standing by what is clinically correct.

2. This practice of giving the patient what they want creates a reliance on the system (and in particular the GP) that to me is unhealthy (excuse the pun!) but seems to be positively welcomed (nay, encouraged) by GPs. After all, if the punters are getting what they want and GPs (and their union) retain their powerful central role in the system then nothing changes.

And it costs us all a great deal of money. For example, prescription charge exemption means that nearly 90% of all prescribed medicines are dispensed free due to condition-specific and low income exemptions, which obviously affects the yield that goes towards offsetting the drugs bill.

Furthermore, pharmacists are paid per item on a script so in a world where GPs over-prescribe, pharmacists dispense what they are told and the state picks up the tab for nearly 90% of prescriptions, there will always be a serious funding issue.

Blackdog - Dr No had in mind a trilogy of posts (this one being the middle one) and now that the third is published you may see why QOF wasn't mentioned in this (second) post, for the third post is all about QOF (although it doesn't it doesn't use the term), and how it has distorted - some might say destroyed - traditional general practice.

SFD - it is well known that your house colour is bright purple and on that basis alone we must assume you are the unassailable brightest crayon in any box. Dr No does recognise that flippant prescribing by hospital juniors (and it must be said many seniors as well) is a nuisance for GPs (and Dr No is old fashioned enough to deplore the practice of hospital doctors recommending but not prescribing drugs - the doc who recommends should write the (first - if it is going to become a repeat then the GP can take over) prescription), but he focused on GPs in this post simply because they account for the lion's share of prescribing.

DoH PP - it is a pleasure to note that on this, the DoH and DN are on the same song sheet! Conscientious GPs will be all too familiar with the sinking feeling that arises (if a sinking feeling can be said to arise) when it becomes obvious that the patient expects say an antibiotic for a viral infection. GPs use various rationalisations to justify prescribing (eg do I really know it isn't a bacterial infection?) but Dr No suspects (and has written about this before) that the main reason for the patient's expectations and the GP's prescribing in these situations lies in the cultural roots of general practice, as apothecaries. The punter/patient is a shopper who has gone to his or her corner shop chemist to obtain a remedy and has no intention of coming away empty handed. The shop-owner/GP knows that the customer is king, and must be satisfied, whatever the cost. The outcome is all too often inevitable.

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