Bad Medicine: Nofreelunch

I am a nobody. A bang average medical student who found a home working in the inner city of Glasgow. I also felt like a square peg in a round hole but I tried hard to fit in with my chosen profession. Twenty years ago drug reps were omnipresent in general practice, providing lunch and restaurant nights out, paying for Christmas parties, and offering international trips and endless freebies. I accepted the status quo because it was all I knew, for the hospitals had been just the same. Doctors were entitled.

And when I became the local prescribing lead this largess escalated with offers of a lot more hospitality and highly paid ‘teaching’ opportunities. In the late nineties during the statin wars, a rep cupped my ear and simply said ‘money’, wanting me to promote Lipobay. I heard stories of far, far worse excess too. Money slewed everywhere. Doctors bragged that they were too intelligent to be influenced by the largess, but the prescribing numbers told a very different story. I stopped seeing reps because it just seemed the right thing to do. I then stumbled across nofreelunch. org, started speaking out, and wrote some complaints to the ABPI. Never did I imagine anyone would listen or take notice. But it was a message that many wanted to hear and things began to change. Freebies were limited, rules were tightened, and fewer drug reps were employed. It was certainly different from the past. I hoped it had all gone away.

But business is business and money is money. The industry retreated and regrouped. The industry certainly is less visible but no less active now. I hear the rising chatter of the hospitality culture again. This is not in primary care in the main, for our prescribing is limited greatly through the use of formularies and inspections. Money is focused in the hospital sector, which authors much of the guidance. It was supposed to be different, with a code for disclosure through the APBI, but new transparency is opaque as the code is voluntary.¹

The industry is still spending big, with £50 million a year paid directly as cash to NHS doctors or as benefits in kind. Cash enveloped as ‘consultancy’ or ‘adviser’ fees amounts to around £30 million a year, equating to £1500 for each adviser contact. The rest is spent on supporting ‘education’ through the payment of conference fees and providing accommodation and travel — the average course fee is £450 and the average travel and accommodation gifts come to £500. In total there are 50 000 recorded payments to doctors, but there is no record of the huge number of unpaid contacts with the industry.² Let’s also remember the old practice of ‘astroturfing’, where companies use charities and patients’ advocacy groups for product placement; the industry spends over £10 million a year on this.³

The policing of it is all voluntary, with no mandatory disclosures, so it is highly likely that the self-reporting does not reflect the real situation. And doctors are predictably hidden behind data protection legislation, so as little as 55% of payments can actually be attributed to individual doctors.

What to do? If doctors think their advice is so important to advance medical research, why not give it for free? Or give this cash directly back to the NHS? If consultants want to attend conferences then they should pay for them themselves. The conference circuit is just hospitality masquerading as education, and has little more value than a simple webinar. It takes two to tango, so why is there no mandatory obligation about disclosure from the GMC?

This is no way for public servants to behave and after two decades the situation still stinks. It’s time for nobody doctors to speak out; post your stories of excess because there is no such thing as a free lunch.

• © British Journal of General Practice 2019