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Why is it that in most areas of modern life I am treated as an adult with choices that I can make, except when it comes to the medicines I might take?

Locked doorWhy is it that in most areas of modern life I am treated as an adult with choices that I can make, except when it comes to the medicines I might take?

If I take out a mortgage, a life policy, buy a car or book a holiday, I am in the driving seat. If I smoke or drink, both potentially hazardous to my health, I am still left with choice. Yet, when it comes to pharma products, I am reliant on others to make choices for me. This is paternalistic and way out of touch with the real world,which is changing fast.

I was in New York recently and watching television. I was interested to see that Pfizer runs prime time adverts on many channels informing the American public about their place in the economy and wider society. The ad plugged no product, but put the Pfizer brand centre stage. On many other channels, I witnessed direct-to-consumer (DTC) advertising promoting panoply of drugs covering many disease areas, including statins, products for erectile dysfunction and respiratory problems.

The ads were slick, attractive and not frightening, suggesting that I might like to discuss a particular product with my doctor or other health professional. In America, I sense that this is a reflection of a totally free market where the consumer expects to be informed of choices. In India, where I spend a good deal of time, the choice agenda is different because of necessity.

In rural parts of India, where doctors may be less available or too expensive, I can buy a whole range of products over-the-counter (OTC) from a pharmacist that in England would require the blessing of a doctor. I should add that the advice Indian pharmacists offer is excellent and sensible, they do not dispense without care and professionalism. The other area that is rapidly changing the pattern of medicines is the internet. It is now perfectly possible for well-informed and some not so well informed citizens to buy virtually any medications via the web.

For and against
Simple technology is allowing greater freedom and choice to millions, yet in the UK and most of Europe we remain wedded to archaic models to govern who can take what. Why are pharma companies and doctors so against the expansion of OTC products and DTC marketing? For doctors, the monopoly on the control of the use of medicines is partly linked to their income. GPs who prescribe and dispense are also on a nice little earner. The GP, in particular, has immense control.

In hospital practice the power is as great but the personal financial incentives less so. There is a risk, however, that a financially pressed hospital may lean on doctors to prescribe the cheapest options to contain the drugs budget, hence a hidden conspiracy that might lead to the patient not getting the best option. The very nature of the funding of the NHS through general taxation makes us different from the US, but should that stop the patient from having the best information available to ask appropriate questions of prescribers?

The doctor monopoly on prescribing in the UK is being eroded. The implementation of non-doctor prescribing certainly has the potential to alter prescribing patterns over time, especially in long-term conditions, but progress is slow.  While the government has proposed to increase the number and range of OTC products, with the community pharmacist taking a greater role in medicines management, progress is slow and the expansion of OTC preparations remains under the control of the health professional and not the patient. Conservatism and paternalism lie at the heart of the health professions in the UK when it comes to prescribing.

Pharma companies seem quite happy to see their products put before the American public, yet are reluctant to let other citizens in other countries enjoy the same access to information. Why? Some argue that it is simply a matter of differing legislation and that they abide by the law of each country in which they do business. Could it be that they are frightened by the costs of DTC marketing?

Advertising, especially on television and through mass media, is not cheap but what companies now spend on limited product advertising in the UK to doctors and others is not cheap either. If the public knew more about what is available it might also improve the quality of medicines management in the UK. We waste millions on inappropriate prescribing or poor patient compliance in the UK. Could this improve with a better informed public? I suspect it could.

Better advice
Drug labelling and patient information has improved in recent years, but as a patient I only access that information when a product is actually prescribed. Would it not be better if I could freely access as much information as possible about all options in a more equal discussion with a health professional, before a prescribing decision is actually made? As a nurse and someone with knowledge of pharma products I am often called upon by family and friends for informal advice.

It is staggering how often I have to suggest that a different product or dose range might help. I always suggest that people check out products for themselves and then seek a discussion with their prescriber, yet they continually report back that professionals seem shocked or upset that they have done a bit of research.

Patient power and patient choice are the new buzzwords in the NHS. Work from groups like the Long Term Conditions Alliance suggest that expert and well informed patients actually make treatments more effective and ease the burden on professionals. Such work also suggests that informed patients can actually have a hand in improving quality. I may be in a minority, but I would not dream of taking any medicine without checking it out and looking at my options.  For a serious condition, I would be fiercer still. I would expect any decent product manufacturer to make that process easy for me, yet in the UK I suspect for many that this would be far from easy. DTC would allow me greater information and choice.

On the internet many products are being sold DTC, and I suspect sometimes unsafely. This market is not going away. Electronic purchasing is on the increase. In the expanding markets of China and India this has interesting commercial implications for the decades ahead. As a consumer, I would be happier to go to a web resource established by a reputable company.

I would be safe in the knowledge that I would get accurate and appropriate information and that a good company would ensure its resource was evidence-based and quality controlled. It's time to ditch paternalism and conservatism and treat patients as responsible adults. Why can't the industry enter into alliances with patient groups and pilot new models for prescribing in the UK? It is in the interests of patient groups to help people get the best information and outcomes, which is surely also in the best interests of reputable companies.

Would industry spend be more effective if it actually engaged and involved patients?

The Author
Ray Rowden is an independent health policy analyst and a director of Mental Health International Development.

2nd September 2008


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