Editorials the case of teenage pregnancies. Nevertheless, taken together, these statistics suggest that it may be useful to ask why we are so consistently an outlier within Europe. Instead, each aspect of adolescent behaviour has elicited a specific response. A drugs “tsar” has been appointed, with responsibility for coordinating action on illicit drugs across government departments. The government’s health policy for England, Our Healthier Nation, emphasises the need to reduce rates of teenage smoking.14 Policy on teenage drinking is less well defined but is rising up the agenda under pressure from senior police officers. Each is addressed in the recently published Independent Inquiry into Inequalities in Health, but again the proposed strategies tend to address individual topics.15 Things may, however, be changing. The first report from the government’s social exclusion unit paints a graphic picture of what is wrong with Britain today, illustrating clearly the complex interaction between poverty, low educational achievement, and health.16 The unit’s consultation document on teenage pregnancy explicitly recognises the need to learn from the experience of our more successful European neighbours2 in a way that would have been unthinkable a few years ago. The social exclusion unit offers a real hope that these interconnected issues can be addressed, especially if it can be strengthened by public health expertise, which it currently lacks. It appears to have a genuine commitment to consulting widely and, hopefully, its use of the internet to elicit views will enable those in the rest of Europe to share their experiences with us. This is an initiative that health professionals, wherever they live, should welcome and engage with.
Martin McKee Professor of European Public Health European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London WC1E 7HT (
[email protected])
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Nicoll A, Catchpole M, Cliffe S, Hughes G, Simms I, Thomas D. Sexual health of teenagers in England and Wales: analysis of national data. BMJ 1999;318:1321-2. http://www.cabinet-office.gov.uk/seu/1998/teenpar.htm Bozon M, Kontula O. Sexual initiation and gender in Europe: A cross-cultural analysis of trends in the twentieth century. In: Hubert M, Bajos N, Sandfort T, eds. Sexual behaviour and HIV/AIDS in Europe. London: UCL Press, 1998:37-67. European Drugs Monitoring Centre. Annual report on the state of the drugs problem in the European Union. Lisbon: EMCDDA, 1998. WHO. The health of youth. A report of the 1993/1994 survey results of Health Behaviour in School-Aged Children: A WHO Cross National Study. Copenhagen: WHO, 1996. GeronimusAT, Korenman S. The socioeconomic consequences of teen childbearing reconsidered. Q J Econ 1992;107:1187-214. Schweinhart LJ, Barnes HV, Wiekart DP. Significant benefits: The High/Scope Perry pre-school study through age 27. Michigan: High/Scope Press, 1993. Commission on Public Policy and British Business. Promoting prosperity: a business agenda for Britain. London: Vintage, 1997. Department for Education and Employment. The skills audit: a report from an Interdepartmental Group. London: HMSO, 1996. Harker P, Harker L. Health promotion for children and young people: the importance of addressing underlying social issues. In: Moore HL, ed. Promoting the health of children and young people. Setting a research agenda. London: HEA, 1998. Flint AJ, Novotny TE. Poverty status and cigarette smoking prevalence and cessation in the United States, 1983-1993: the independent risk of being poor. Tobacco Control 1997;6:14-8. Helm T. EU nations urged to copy Britain’s flexible economy. Daily Telegraph. 1998 Feb 13:6. Clark AE. Measures of job satisfaction: what makes a good job? Evidence from OECD countries. Paris: OECD, 1998. Secretary of State for Health. Our healthier nation: a contract for health. London: Stationery Office, 1998. Independent Inquiry into Inequalities in Health Report. London: Stationery Office, 1998. (Acheson report.) Social Exclusion Unit. Bringing Britain together: a national strategy for neighbourhood renewal. London: SEU, 1998.
Direct to consumer advertising of prescription drugs An idea whose time should not come
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irect to consumer (DTC) advertising of prescription drugs is expanding dramatically in the United States, and there is some sentiment in favour of allowing this practice to come to the United Kingdom.1 Such advertising is a powerful tool, designed to create a demand, in order to maximise profits. Extending the scope of already ubiquitous promotions about “post-nasal drip,” “unsightly rashes,” or “cures” for baldness has little to do with educating patients or relieving suffering. It will, however, inevitably drain healthcare dollars, dramatically increase unnecessary prescribing, and strain patientdoctor relationships. Typical direct to consumer advertising for prescription drugs in the US consists of glossy promotional materials suggesting that the advertised product represents a major medical advance, accompanied (because of Federal Drug Administration regulations, and over the objections of the pharmaceutical industry) by tiny print “information” presented in medical jargon which virtually no consumers can understand.1 2 These advertisements—whose “rules for doing DTC right” include “always focus on benefits, not problems”3—are intended not to educate patients, nor to empower them 15 MAY 1999
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to be more intelligently involved in their own care, but merely to increase physician prescribing, regardless of need. This is hardly surprising since, even when marketing to doctors, pharmaceutical companies provide far less education than jargon and promotion,4 and many claims prove to be inaccurate or misleading.5 6 Advertisements to consumers are hardly likely to be more reliable. The industry likes to cite undertreatment of important problems such as hypertension as an argument in favour of advertising, exhorting the public to “Ask your doctor about. . . .”7 But do not expect to see consumers regaled with promotions about inexpensive diuretics or ß blockers, any more than about measles, mumps, and rubella vaccination or regular cervical smears. The issue is not whether deficiciencies in doctors’ and patients’ awareness exist, but whether promotions designed to increase demand, and profits, that focus primarily on “me-too” products in competitive categories3 4 can really be expected to benefit the public health. Doctors have a fiduciary responsibility to act in the best interest of their patients, and secondary goals, including increased income or professional stature, 1301
Editorials must be held subordinate to that primary commitment. For-profit companies, on the other hand, have a primary goal of maximising profits; indeed the responsibility of company executives is first and foremost to owners and shareholders. Though improving the public health may be seen as a desirable byproduct of company activities, concerns about health care cannot take precedence over profits: when the two goals conflict profit must win.2 8 Similarly, for proprietary companies no healthcare spending, no matter how expensive or inefficacious, is “inappropriate” if it increases profits. It is essentially irrelevant whether a drug unreasonably increases consumer expectations, forces doctors to spend substantial time disabusing patients of misinformation, diminishes the doctor-patient relationship because a doctor refuses to prescribe an advertised drug, or results in poor practice if the doctor capitulates and prescribes an inappropriate agent. Promotions of new and expensive drugs are successful if they increase sales, regardless of these other effects, and even if sales of rival products designed to treat the same diseases are not lessened.9 Ultimately, of course, consumers pay for these promotions, whether it be the fortune spent on promotions to doctors (estimated to be about as much in the United States as is spent for all medical school and residency training combined10) or the potentially even greater spending on direct to consumer advertising. Direct to consumer advertising of prescription drugs has been described as a “wonder drug” for the drug industry itself, because of its ability to affect patient demands—and in turn doctors’ behaviour.11 If they believe that patients want and expect drugs then doctors will prescribe them even when they know they are not indicated,12 even when patients don’t specifically ask for them, and even when an individual patient never expected the drug but the doctor thinks he or she did.13 All that is required for direct to consumer advertising to increase product sales dramatically is that some patients ask and that doctors begin to believe that many patients will be dissatisfied without it. We do not believe that drug companies should be blamed for valuing self interest above the needs of the
public. In our society that is how companies are programmed to behave. Nor should doctors expect anyone else to be our ethical watchdogs. It is our responsibility to serve as advocates for our patients and for the public health. Whenever the search for greater profits is allowed to siphon off valuable and scarce resources that would be better used to improve the health of our entire community, we believe it is our obligation to speak out in opposition. We hope readers of the BMJ will join us in opposing the introduction of direct to consumer advertising of prescription medicines to the United Kingdom. Jerome R Hoffman Professor of medicine Michael Wilkes Associate professor of medicine, Division of Internal Medicine UCLA Emergency Medicine Center, Los Angeles, CA 90024 (
[email protected])
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Pushing ethical pharmaceuticals direct to the public. Lancet 1998;351:921. Kaplar RT. It’s time to remove the brief summary from DTC print ads. Medical Marketing & Media 1998; No 5:45-8. Weinblatt L. DTC advertisers—you’re wasting your money. Medical Marketing & Media 1997; No 11:47-51. Stryer D, Bero LA. Characteristics of materials distributed by drug companies: an evaluation of appropriateness. J Gen Intern Med 1996;11:57583. Wilkes MS, Dobkin BH, Shapiro MF. Pharmaceutical advertisements in leading medical journals: experts’ assessments. Ann Intern Med 1992;116:912-9. Ziegler MG, Lew P, Singer BC. The accuracy of drug information from pharmaceutical sales representatives. JAMA 1995;273:1296-8. Holmer AF. Direct to consumer prescription drug advertising builds bridges between patients and physicians. JAMA 1999;281:380-2. Rennie D. Thyroid storm. JAMA 1997;277:1238-43. Wolfe S. Why do American drug companies spend more than $12 billion a year pushing drugs? Is it education or promotion? Characteristics of materials distributed by drug companies: four points of view. J Gen Intern Med 1996;11:637-9. Orlowski JP, Wateska L. The effects of pharmaceutical firm enticements on physician prescribing patterns: there’s no such thing as a free lunch. Chest 1992;102:270-3. Jenkins HW. Is advertising the new wonder drug? Wall Street Journal 1998 Mar 25:A23. Himmel W, Lippert-Urbanke E, Kochen MM. Are patients more satisfied when they receive a prescription? The effect of patient expectations in general practice. Scand J Prim Health Care 1997;15:118-22. Britten N, Okoumunne O. The influence of patients’ hopes of receiving a prescription on doctors’ perceptions and the decision to prescribe: a questionnaire survey. BMJ 1997;315:1506-10.
Does the new NHS need personal medical services pilots? They offer a testbed for primary care trusts
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t the time of its publication in late 1996 the Choice and Opportunity white paper was seen as heralding revolutionary changes in British general practice.1 The ‘‘listening exercise’’ by the then health minister, Stephen Dorrell, had identified once more the inflexibility of existing contractual arrangements as a major barrier to remedying poor quality primary care, particularly in inner cities. The Primary Care Act, squeezed through in the final weeks of the last government, allowed health authorities scope for the first time to commission primary care from any local provider within the NHS family, better tailored to meet local needs. Proposals were invited to pilot these new 1302
arrangements, though the possibility of experimenting with unified budgets for general medical services and hospital and community services was suspended. Altogether 567 bids of various shapes and sizes were received initially. After a protracted selection process 94 quietly went live in April last year. More white papers and much else have happened since the launch of this policy initiative. So do the personal medical services pilots still have something to offer the new NHS? Health authorities, community trusts, the NHS Executive, and general practices are exploring uncharted territory. Several factors have added to the challenge. As in the early days of fundholding, all parties BMJ VOLUME 318
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