Thursday, May 10, 2012

Pigs and Lizards...


31st May 2003, the BMJ  published a cover story called “Food, flattery and Friendship” which was accompanied by a a thought provoking, one may even say, controversial cover  showing the pharmaceutical industry folks as lizards slinking around a table, while the doctors were depicted as pigs, gorging on the spread on the table..well..like pigs. It unleashed a torrent of emotions amongst the medical fraternity, some stoutly defending their close affinity to the industry, while others nodded their heads in disapproval condemning their colleagues for selling their souls. Amongst the second group, there were 2 types, first the Edwin Gales, who were the quintessential traditionalists, the ones no one could challenge, not only because of their clinical expertise, but also because they firmly practiced what they preached and genuinely stayed away from the pharmaceutical industry. The second type were the more interesting ones, ones who could be labeled as being hypocritical and perhaps joined the queue of criticism because they weren't part of the gravy train, rather than having a logical reason. Sort of "I love you" if you take me to a fancy restaurant, "I hate you" if you don't...ahh...the fickleness of human beings!

The dichotomy of the situation continues to be fascinating and a recent informal meeting with a GP who had taken up the cudgels of being the Clinical Commissioning group in North London was quite informative to say the least. There was clear belief that education in primary care had to be improved, about appropriate use of drugs, appropriate use of strips and that would deliver the "holy grail"  of improving ling term outcomes, reducing drug costs etc etc...no argument that could be faulted and in fact he was one of many GPs who I have recently met who are passionate about making those necessary changes. At the same time, he was keen on not involving pharmaceutical industry as he didn’t want to "taint" the programme, didn't want them to "hard sell" their products. I had to ask..."So how do you commission this? Use finances from the NHS budget?"...to which he replied affirmatively. But then slowly, as the Jack Daniel made it's way into the system, realisation struck that this money would have to come via disinvesting from somewhere else, and surely there was too much wastage in the hospital on the hill. And that in a nutshell was the problem...to invest in the future; we are facing the stark reality of disinvesting in the present.  "Let's strip down the diabetes centre" to invest more in primary care is the mantra but that needs to be tempered with the provision of having those centers to take  care of the complications e.g. dialysis, retinopathy etc. You need the present to take care of the "sins" of the past, so who has time or money for the future?? When financial bottom lines end-March rule the roost and there are "evidence" of poor care in the  present being thrust in their face, where exactly is the energy of the former PCT or CCG leads to deal with the avalanche of the future?

Maybe this is where the relationship between healthcare professionals and pharmaceutical industry need to change. Recently, I spent some time with a scientist who works for a reputed company and I sat and listened to her teams journey in trying to discover a new type of Insulin. I heard about the struggles, the endless nights of toil, the boardroom negotiations, the failed experiments and the unbridled joy amongst the team when they felt that perhaps the right chain mutation may have been found........wasn't this someone who shared the same passion as me to improve things, someone who was fighting the same battle, just in a different format? The cynics will, rightly, argue that it's simply because there is a need of the relevant company to increase their profit margins and yes indeed, the industry is a profit driven business, not a charity. However, to simply label companies such as Novo Nor disk or Eli Lilly as money grabbing heartless souls is also turning a blind eye to the contribution done over the years to diabetes care. As with most things in life, nothing is black and white and if one is silly enough to believe that because Company X paid for the registration of an educational event, one is going to start prescribing their product and ignore all clinical and safety data, then that’s just treating educated adults as mindless drones. If someone does do that, then, my healthcare colleague, you have forgotten the basic tenet of the Hippocratic oath ego "Do no harm".  For want of a better word, if that's what you do, then you are disingenuous and deserve all the criticism the system can offer you.
So perhaps we need to think as to how we can engage pharmaceutical companies to help us to improve patient care. How about thinking of asking companies to scrap all the bits and bobs or scatter gun approach to education in certain areas or regions? Why not invest that money and time into doing structured education led by a group of individuals from primary and secondary care to deliver it? How about creating something like a Diabetes Practice Passport (thank you to my good colleague Mike Cummings for coming up with that one!) whereby you device minimal standards each surgery should have before they are "qualified" to provide diabetes care to the population. To give it more teeth, how about Commissioners mentioning to GP surgeries that they risk losing their Diabetes QoF points to another surgery of they don' t have the "passport"? So many things we can do to improve diabetes care and such big roles pharmaceutical industry can have to improve that...think of the logistical structure, support, experience they can bring into it.

What about the other side of the coin? Well, if we have to adapt and learn, so does the industry. Let me take this opportunity to talk to you...directly - if you are reading this blog. Its time for YOU to act as support structures of professionals, showing a genuine interest in improving things rather than talking about your drug for the umpteenth time.  I get it, it's the best thing ever invented since Adam strode this earth, but can you please back off and let me make my judgment on that please? Time for you all to also think outside the box, think of skills you have and we don't. More and more, healthcare professionals are being asked to become "business minded", " data analysts"...well, do try and help us with that a bit, if you can? You can help facilitate warring organisations, petulant colleagues to get around a table...so do give it a try. Think of social media, think of what Innovation you can bring to the NHS, think of Joint Working Initiatives, try and see what you can do to make my life easier and no, it doesn't always or just involve money. Supporting good research, research grants, education portfolios...the possibilities are huge...trust me, even in a hard nosed business climate of the NHS, good relations and "being there" is far more likely to help your product rather than stuffing it down our throats with ultra aggressive marketing. And then again, if your drug is truly and genuinely good and scientific evidence backs that, fear not, it will come to the fore!

The good news is that the signs are there...companies such as Sanofi, MSD, BI etc are light years away from what I remembered them as a trainee...and good on them too. Some were already there, some are trying to get there and that can only be a good thing for the benefit of a struggling NHS.  There is indeed no such thing as a free lunch but I always have one and only 1 challenge for those who criticize pharmaceutical industry or even fellow professionals for their "association". A bit like Tom Cruise in Jerry Maguire I say..." Show me the money". In a tax based system which s creaking at the edges, struggling to provide universal high quality care in the present...where is the money, motivation or drive to invest in the future...which is exactly what education and research is. We are struggling with the present, what hope does the future have??  Anyone who has tried to go through a research application process via "normal" channels will understand what I mean....trying to get the Ring to Mordor seems like a walk in the park in comparison!
So possibly time for all of us to grow up, mature and treat each other for what we are. We are not folks who will blindly write your drugs neither are you organisations who just represent a dollar or pound sign. Let's be honest, without any pharmaceutical support, organisations such as the Young Diabetologists Forum, that forum of educational support for trainees in diabetes, would, simply...cease to exist. As would a specialist organisation such as ABCD or PCDS.

Maybe someday we will be able to re draw that BMJ front cover...maybe no longer lizards and pigs but maybe, just maybe as 2 different breeds of the same species…both trying to improve patient care.  Those who read this blog know my geeky comic book side, so why not a reference to that? It's the time of comic book movies…Avengers is out there doing great business. Watch the movie, read the comics...you will find disparate heroes with their foibles, big egos with their own agendas. However when the time came to fight a bigger cause, they all came together and saved the day.

Question is whether the industry will answer the call of "Assemble"....if you do, that will make a far better BMJ cover, I assure you. 

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