THINGS HAVE JUST GOT DARKER – and it has not gone unnoticed by me, my colleagues, patients and patient groups and, of course, you – the pharma industry. Why are the omens for the immediate future not looking so good?

The waiting game

“Cuts keep patients waiting for drugs” – The Daily Telegraph, 20th August 2005

It’s the national sales conference season, and much is in the air. While you have been gathered together looking at sales targets, market share, new papers and licences, it seems that I and my colleagues are obstructing the availability of the products you are selling. In fact, “tens of thousands of patients face potentially fatal delays in receiving the best drugs for their diseases because of Government cuts” is the stark reality that looms over us all, affecting you, me and the patient in different ways.

The reality of the situation is not new – costs, savings, budgets – but the manner in which these problems have presented themselves to the patients and the general public is sending out shock waves of significant magnitude. Recall your last sales call – did your customers seem happy, proud and satisfied with their jobs? Or did they appear somewhat caught up in this complex decision-making process, burdened by intangible responsibilities, toeing party lines and, in some areas, compromised by clinical decisions based on short-term cost savings? “Doctors can prescribe a drug when the MHRA has licensed it; but in practice it is rare to get NHS funding until NICE has made a recommendation.”

Thus we have the following pattern repeating itself around the country. A new drug is launched, a company promotes it, the customers receive messages, physicians try to prescribe, but the process is blocked, prevented or blacklisted. Dig beneath the surface on your next call, and you may find that the doctor really wants to prescribe, but some pain-in-the-******** adviser like me won’t let it happen . . . Then the patient hears about a ‘new wonder drug’ and goes to see the doctor . . .

Talking in the dark

“Patients left in the dark about life-saving drugs” – The Daily Telegraph, 22nd August 2005

It now appears that “doctors are concealing treatment options that are not available on the NHS”. But why would they do this, when it conflicts with their own ethics? And when your company has spent a fortune researching, developing and marketing a new treatment?

The answer is actually quite logical. There is an interesting principle in psychology known as ‘cognitive dissonance’. This is an effect of the human desire to appear ‘rational’ to oneself (and others). Just look at the following experiment, which actually took place.

A young man was hypnotised and told to go to the shops, as he usually would on a Saturday afternoon. However, he was also told to carry out three anomalous tasks: take an umbrella, despite the fact that it was hot and sunny; buy some wine, despite the fact he was a teetotaller; and walk by a very long and unusual route. On his arrival back, the following discussion happened:

What’s striking about this is the fact that had we not been party to the ‘instillation’ of certain actions into the subject’s mind, this conversation would seem perfectly normal. But what is more astounding is the fact that when you read about this particular experiment in its full context, it is quite obvious that the subject was not lying: he truly believed in his answers.

This is the nature of cognitive dissonance. The subconscious mind has already thought about the answers to the questions before they ‘emerge’ into the conscious brain. Thus the subject, with no knowledge of the hypnotist’s instructions, will truly believe in the answers he or she provides.

What does this have to do with prescribing?

More than you might expect. When the doctor faces the patient, the doctor’s thoughts may run rather like this:

• The patient has breast cancer.

• There is a new drug for breast cancer that seems to be the best on the market.

• I am unable to prescribe this new drug for breast cancer.

• I want to do the best for my patients.

How does the doctor resolve this? Well, they may prescribe the drug – and get told off. They may be able to continue prescribing and getting told off, or they may actually not be allowed to prescribe the drug at all. In the latter case, there will be an ongoing conflict in the doctor’s mind, between wanting to do the best for the patient and believing they are not prescribing the best treatment available . . . In order to stop the brain suffering uncomfortable ‘dissonance’, the doctor needs to believe that

• Maybe I don’t want to give my patients the best treatment (don’t like the sound of this because it makes me look like a bad doctor!) . . .
  

  OR

• Maybe this new drug isn’t the best treatment available after all (mmm – plausible, maybe we need more evidence, maybe the drug has side-effects – either way, I am not a bad doctor for not using it).

Remember that many of these thought processes are unconscious. In the experiment I described earlier, the subject truly believed the reasons for what he had done – the alternative would have been that his behaviour was irrational. We can’t cope internally with a sense of unreason, so we ‘rationalise’.

Please think about this on your next call to a GP, prescribing lead or consultant. It’s important.

Looking for a guide

“Breast cancer sufferers fight for new drug” – The Daily Telegraph, 22nd August 2005

So why are we here? I find myself asking this question with increasing frequency. Am I here to treat patients? To save the Trust from financial disaster? To keep my head above water? I have many reservations about what the future holds, now that planning is turning into evolution. There are bodies, agencies and organisations telling me what drugs to approve and not approve, and there are different ones telling you how to promote, market and run educational meetings.

So have our jobs become simpler with all these people helping us? How can we reach our goals through this forest of policy enforcers? And if you and I are doing our jobs so wonderfully with guidance coming out of our ears, why is it that a group of women in the UK suffering from breast cancer are having to invoke the Human Rights Act to seek a Court Judgement in order to receive their chemotherapy – with the sad prospect that many of them will pass away before the Courts make a decision?

Welcome to the real world.

 OMAR ALI is the Formulary Development Pharmacist for Surrey and Sussex Healthcare NHS Trust and is a PCT Formulary Adviser to 2 PCTs. He is a lecturer on the MSc on Pharmacy Practice at Portsmouth University and is also an adviser to three Drugs and Therapeutics Committees in the South of England. Omar is a National Speaker in the UK (cardiovascular, diabetes, mental health) and is an Executive Board Member for the National Obesity Forum. He can be reached directly on alipha@aol.com