Kings Fund breakfast debate, 20 October 1999

"Pharmaceutical companies should be allowed to advertise their prescription products to the public"


Proposer: Margot James, Chief Executive, Shire Hall International

Good morning, ladies and gentlemen. In proposing the motion that pharmaceutical companies be allowed to advertise their products direct to consumers, I would like first to acknowledge and then dispense with some of the commonly heard arguments from my side of the fence. Yes, of course, we're all in favour, I'm sure, of better informed patients, of patients taking more responsibility for their own health, and for them to have the right to information about the products that they are prescribed. But I would be the first to agree that, just by allowing pharmaceutical companies the right to advertise to the public, does not necessarily mean that we will get more of those good things, to a greater extent. Likewise I've often heard it said that there is something inevitable about DTC - that with the availability of information from American websites and the globalisation of the media generally, that the law eventually in Europe will become an ass and will be forced to change. Well that may be true, but that does not necessarily mean that it is right.

The key question, as far as I see it, is, can the allowance of DTC advertising help solve some of the critical problems that we are all agreed exist. As Alan Milburn said, when he was Minister of Health: at its best the NHS leads the world, but the degree of local variation means that patients cannot be sure of receiving the best. How true.

We all know about the variation in care, the difficulty of getting research into practice, the middle classes having disproportionate access to better treatments and services and the cases of bad medicine, albeit practised by a minority, but in the name of clinical freedom. And the waste of money and the poorer health outcomes that can directly be attributed to people not complying with their medication.

These are big problems which I believe can be significantly reduced by allowing companies greater freedom to communicate. At the very least, DTC will help raise awareness of diseases that are poorly understood, or taboo, in some way. Commenting on the Pharmacia and Upjohn incontinence campaign, Clare Rayner, who I'm delighted to say is with us this morning, said that the job is to help people who have a very real symptom, that they often feel that they cannot possibly talk to their doctor about. They think they are unique; they don't think other people have the problem, and it is very comforting to know that it is common and treatable.

Many patients don't even know certain treatments exist that might help them over some of the most uncomfortable symptoms, that they live with day in and day out. Just as advantageous I believe DTC would be to patients who suffer from a long-term chronic condition and for whatever reason - say, they're suffering from epilepsy - whatever reason, they're stuck on a polypharmacy regime of old medicines that were invested before I was even born.

Some of the saddest stories I hear when I attend consumer focus groups are from people who are on this kind of medication, who for years have believed erroneously that the problems they suffer are caused by their disease - when in fact they are caused by the medication they are on. Properly balanced pharmaceutical advertising, reaching those people, would provide them with a glimmer of hope.

And there's something about equity in all this, as well. We all know that one of the government's top priorities at the moment - we all know that people in poorer areas, with less educational opportunity, have access only to the poorer treatments and poorer services and their non-compliance with medication goes unnoticed and unchecked - or is more likely to - and they are more likely to die prematurely

The restrictions, I think, on DTC only exacerbate this inequality - and I think it's important that we understand the reasons for that. Most communication around healthcare, when it doesn't come from a healthcare professional, comes via editorial in newspapers and magazines, and off of a myriad of websites. Relying on those channels increases inequality, because people from lower socio-economic groups tend to have to get their information needs met by television, and tabloid newspapers. They read the quality press less, and they have less access to electronic media. Yet it is in those channels that we see most balanced healthcare information. They are more likely to be on the receiving end of the sensationalist health coverage that we see in the tabloid press.

A well constructed advert that meets all the regulatory requirements, placed in say the middle of, say, Coronation Street would offer an information lifeline to groups who are only operating the margins of our health service today

And that brings me to the difficult issue of rationing. There's two opposing views here on the subject of DTC. On the other side, we hear that in a service which we all know is struggling to meet expectations, as of now, it is said to be a bad thing to allow anything that might inflate those already high expectations - the implication being that demand can be more easily controlled for products like Taxol or Orlistat, for example, if companies are censored in the information that they can provide to consumers.

But I think that, by going down that line, we are confusing two things. We are confusing peoples rights to have information about treatments that are available with peoples' right to have those treatments free at the point of delivery. And those are two different things. And in most cases, there won't be a simple "yes, the NHS will pay - no, the NHS won't", as was implied in the recent NICE ruling on Relenza. For the most part, medicines will start to become available according to certain criteria - and why should consumers not have information from manufacturers about those treatments and the criteria. Surely that would enable them to have a better and more informed dialogue with their doctor about the suitability of the treatment for them and about their eligibility for it.

And that brings me on to the doctor-patient relationship. Critics are very concerned that DTC will somehow undermine that very important relationship between the doctor and the patient. Doctors fear that DTC will bring in its wake a host of semi-informed and demanding patients, and that gets tied up with the whole subject of workload. Dr George Chisholm, Chair of the GPC prescribing committee commenting on the same incontinence campaign said: GPs are under a lot of pressure as it is, and I think the majority of GPs will not find it helpful for patients to come in with coupons from papers and magazines.

I'd make two comments on this. First of all, I can just as easily envisage as to how the relationship between GP and patient could be improved by DTC, rather than reduced. Compliance could be much improved and that could only be of benefit to both doctor and patient, and secondly, the information provided does not negate the fact that it is still the GP who prescribes the product. And anecdotal evidence that I've picked up when reading the GP press at the time of the Viagra decision, was overwhelmingly on the side of the fact that most patients to whom Viagra was denied on the NHS actually found the decision quite acceptable when it was communicated to them by their doctor.

And finally, I think we should touch on compliance. The US experience, I think it's very important to remember, is not just about television advertising. All the branded commercials are backed up by an array of written information, free-phone telephone lines, websites and so forth. And much of that back-up information involves well proven methods of improving patient compliance. As an example, I would cite a campaign run by Parke Davis in the States, supporting patients with Alzheimers, on their product, Cognex. They developed a family care plan for the whole family and they measured the success of this in terms of keeping patients with the product and, after six months, twice as many patients on Cognex, with the Family Care Plan support were still on the product, as compared with the people who were just on the product without the support programme.

Furthermore there's evidence to show that, in the States, patients, when they see an ad are often reminded to continue taking their medication. So, I believe that, if companies have more freedom to communicate directly with patients, and can see a fair rate of return on that investment, then we would see the benefits of improved compliance translated into improved outcomes and a better doctor-patient relationship.

What is most important in all of this is to ensure that the information put out by companies is subject to strict and effective regulation. There can be justification for allowing advertising that distorts a product's potential, that raises false expectations. The regulations are working well in the US and there is no reason why we could not make them work equally well over here.

It's time for this debate to move on. It should no longer be focusing on whether to allow DTC. It should be focusing now on how to control DTC, such that it becomes a greater force for improved health awareness, an aid to alleviating health inequalities and a counter to poor medical prescribing and postcode prescribing, where that exists. I shall now be delighted to hear from Joe Collier the arguments against. Thank you very much."

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