Assumptions kill

It is some years since I last received so much as a branded pen. I have even had to resort to buying the things. Still I am retraining myself, though: it remains a challenge to keep hold of the same worthless ballpoint all through my working day. Big pharma is changing. Their once bountiful supplies of freebies have dried up.

Now those who peddled the freebies, the reps, are being culled too. They, like black rhino, find their territories gradually increasing to a point where one may never meet another of the same breed in a lifetime of wandering the landscape. Extinction beckons.

Why is this? Does nobody consider me worthy of a sales pitch any more?

No? Of course not! With the rise of the formulary committee, of NICE, of prescriber management, I have become a pen-pusher, a trifle, a twig on the tree, a cog in the machine. It is others who need to be pursued and persuaded nowadays. I only need to be managed to ensure I understand what those others want of me. The drugs market is changing and big pharma with it. They are concentrating on chasing this diminishing band of decision makers in our ever more centralised system of health care.

But these decision makers cannot be persuaded on the basis of a free pen, nor even a tastefully branded clock or paperweight. Mostly. They want to be able to sanctify their decisions by the gods of science and economics. They feed off research papers and a good price.

Herds of sales representatives are no longer needed but don’t be fooled. As big pharma reconfigures, what still remains key is how they sell in this new world. The World Health Organization notes companies currently spend about one-third of all sales revenue on marketing and that this is roughly twice what they spend on research and development.1

Adept at redefining health care itself, they are as interested in finding ways to sell what they make as to make medicines for which there is a need: even in the UK, promotional spending by drug companies is 50 times greater than spending on public information on health.1 Their research is skewed towards these ends.2 As commercial companies, profit overrides the purity of any quest for improved human health.

For most of us, there is no surprise here. Nor do we expect there is a perfect alternative waiting in the wings. But there is the potential that there is a better way. The prevailing assumptions may just be wrong.

What are these assumptions?

Well, for a start there is the idea that big is best. The ten biggest drug companies in the world account for over one-third of the market.1 Is this healthy?

A second is that centralised formulary decision making is better. To challenge this is not automatically to demand a return to the principle of ‘the clinician always knows best’. Formularies are good, but not flawless. The current system pushes the use of medicines whose provenance may have been manipulated. Roche has made billions of dollars from persuading governments and medicine agencies of the benefits of Tamiflu^®, yet its refusal to publish its full research evidence on the drug could be taken as a case in point.3

A third is the belief in market forces. These work well when it comes to cheap ballpoints. But I know for sure that I and the black rhino doubt its universal virtue.

• © British Journal of General Practice 2013