Published: 05/12/2002, Volume112 No. 5834 Page 15

'It is estimated that up to 40 per cent of antibiotic use in the NHS is inappropriate, but a nice source of profit to the industry' What are the causes of inappropriate and inefficient prescribing of pharmaceuticals and the cost explosion that is throwing the finances of primary care trusts into deficit?

The current estimate of the cost of bringing a new drug to the market is $800m. A new chemical entity discovered today will be tested in the laboratory and on animals before the company gets a clinical trials certificate and can test it on humans. By the time it is tested on humans and receives marketing approval, 10-12 years will have passed With compulsory evaluation of clinical and cost effectiveness in England by the National Institute for Clinical Excellence, companies now have to acquire not only a marketing licence but also the approval of NICE to ensure reimbursement for their drug in the NHS. So far NICE has been very generous to the companies, adding, it estimates,£600m to the cost of the NHS.

Such decisions may be distorted by poor clinical and economic evaluation, whose biased results create company profits but inadequate improvements in population health.Much industrial testing is of high quality, but when hundreds of millions of dollars are at stake, 'gaming' at the margin is inevitable. For example, there may be loading of the dice with excessive dosage of the old product so that its sideeffects are exaggerated and the new product is shown to be superior.

1There is considerable evidence of poor design and reporting of trials by clinicians and economists.

2The industry invests heavily in marketing, often using data from poorly peer-reviewed papers in journals to persuade doctors of the merits of their new medicaments. Perhaps 30 per cent of company expenditure is invested in marketing. It funds 'conference tourism' for doctors and increasingly nurses, some of which has been shown to lead to returning doctors adding useless and costly drugs to formulae.

3Many doctors appear to lose their critical facilities when confronted by a skilled drug representative, which means that drugs are used inappropriately and inefficiently.

It is estimated that up to 40 per cent of antibiotic use in the NHS is inappropriate, but a nice source of profit to the industry.

This is not an isolated example - much of the expanding use of statins, used to reduce cholesterol and cardio-vascular risk, may not be cost-effective.

4A study of western Scotland showed that appropriate and efficient treatments after heart attacks, such as beta-blockers, were not being prescribed for poorer, socially excluded groups.

One reason for this is that such drugs are out of patent and low in price. The industry makes little effort to market cheap generic drugs, focusing its efforts on new, expensive branded products protected by patents.

Unfortunately, many of these are of little novelty: a recent study of new cancer drugs launched in Europe in 19952000 included few novel products and often 're-packaged' known products at prices up to 350 times the original.

5The UK pharmaceutical industry is a major employer and exporter. But inefficient use of its products consumes scarce NHS resources. So how can the energy of the drug barons be used to produce more health?

One policy worthy of evaluation is investment in counter-detailing - for example, Kaiser Permanente in California invests heavily in countervailing industry marketing hype with its own marketing efforts targeted at improving physician knowledge and encouraging adherence to cost-effective practice guidelines.

This is an urgent role for PCTs:

monitoring, evaluating and performance-managing GPs' prescribing.How can it be financed? There should be a levy on all industry marketing - for every pound they spend, 50p has to be paid to government so that PCTs can counter-detail the mischief of the industry.

Hopefully the government will act soon to curtail waste and protect patients.

REFERENCES 1Geddes J, Freemantle N, Harrison P et al. Atypical antipsychotics in the treatment of schizophrenia:

systematic overview and meta regression analysis. Brit Med J 321,1371-6, 2000.

2Morgan S, Barer M, Evans R.

Health economists meet the forth tempter: drug dependency and scientific discourse Health Economics, 9, 659-667, 2000.

3Chren M, Landefield M. Physician behaviour and their interactions with drug companies, J of the American Med Association, 2 71,684-689, 1994.

4Marshall T, Rouse A. Resource implications and health benefits of primary prevention strategies for cardiovascular disease in people aged 30 to 74: mathematical modelling study. Brit Med J, 325, 197, 2000.

5Garattini S, Bertele V. Efficacy, safety and the cost of new cancer drugs. Brit Med J, 325, 269-71, 2002.

See news focus, pages 10-11; letters, page 23.

Alan Maynard is professor of health economics at York University.