THURSDAY 16 DECEMBER 2004

MS MARGOT JAMES, MR MIKE PALING, MR RICHARD HORTON, MS JENNY HOPE AND MS LOIS ROGERS

  Q560  Mrs Calton: I was actually in the middle of asking two people a specific question, helpful as the exchanges have just been. Can I come now to Ms Hope and remind you of what the question was. Do you ever feel that you are being used by drugs companies as a promotional conduit or as a vehicle? If this happened what would you do?

  Ms Hope: I do not feel that I am being used but I feel I am a target for promotional and marketing activity. I think there is a difference. If there is a story there, if there is some news merit, if I think the news values holds up on something I am being offered which is obviously promotional for the company involved then that takes precedence. If there is a benefit—either direct or indirect—to the drug company involved then so be it but I do not feel used and I can weigh up everything that comes in front of me with those news values in mind: should the public know about it? Is it of interest? Would it be wrong if I kept it a secret?

  Q561  Mrs Calton: When you are writing drugs stories how often do you rely on opinion leaders—I think Ms Rogers has already addressed this to some extent—or patients suggested to you by a drugs company? Does it ever work that way round? What procedures would you follow to check whether such a story is reliable?

  Ms Rogers: That does not happen.

  Q562  Mrs Calton: From what you were saying you actually have some very direct relationships with researchers.

  Ms Rogers: I have a very good network of people and I know exactly what funding they have had from who because, as I said earlier, everybody has and these are people I know well and whose views I would respect.

  Ms Hope: I would concur with Lois that I too have what I hope is a good network of contacts to call upon but the PR industry sets great store by opinion leaders which slightly mystifies me. I just see it as doctors they can call upon to back up what has been said about a drug. It may well be because they are an investigator or because they have many years' experience in the area. That is fine, but you know where they are coming from. If you feel the need—and I usually do, I do not rely on single-source stories—to talk to somebody else then I talk to somebody in my bank of contacts about where this information comes in the whole stream of information about a drug, where the drug might have its place in the future. I fear that the influence of these opinion leaders is really rather something that has been got up, to be honest with you, by the PR industry.

  Ms Rogers: Can I just add to that, even the expression "opinion leader" to me is a deterrent because if I happen to be talking to someone from a drug company and they say, "Have you spoken to so and so about this?" that would immediately tell me that that person in the pocket of that drug company. That would be exactly how I would interpret it so I would be disinclined to talk to them.

  Q563  Mrs Calton: Can I ask each of you something which is probably a little unfair but nevertheless I shall ask it: have either of you written up a story and subsequently thought to yourselves, "I really should not have done that because had I had the time or whatever to look into it more fully I would not necessarily have covered this story"? Have you ever regretted putting a story in because it has caused an adverse set of reactions in the public arena?

  Ms Rogers: No, but I can say that I would regret seeing things in the media generally that I think are misleading about the value of particular drugs and products.

  Ms Hope: My biggest regret is the Pill story and I had no choice about running that. That was a story out there that had to be run and had to be followed it up. We assiduously followed it up; we assiduously contacted and talked to people and criticised the original decision and the basis on which it was made but all the caveats were lost in the general furore surrounding it. It had dreadful consequences that you could see unfolding from day one.

  Q564  Dr Taylor: I am very interested in your comments about opinion leaders and your active disregard of them and I really want to go to Ms James because a quote from your website is: "The effective development of opinion leaders in all your stakeholder groups is essential for your commercial success." How do you set about identifying these opinion leaders and how do you use them? We have heard that two important newspapers—if they get any hint that these were opinion leaders that were selected by you—would shy off.

  Ms James: I think the evidence was actually slightly different. I think I am right in saying that Jenny checked with other doctors; she did not disregard opinion leaders supplied by companies. If there is a question in your mind then you will go to another doctor as well and I would expect any good journalist to do that. The way we go about identifying opinion leaders, it depends on the condition and how big a pool of expert doctors exist. Obviously if it is heart disease there are a lot of people; if it is a very small, narrow niche in cancer there are not many. There are a lot of variances, but in principle we start off with a conversation with a client and the client already has some doctors that they are working with clearly. A lot of those doctors will be triallists so some of the opinion leaders self-select by participating in trials and leading clinical trials; they will be natural opinion leaders for us to work with. Beyond that we will look at all sorts of databases to identify which doctors have an interest in which fields and we will start targeting a few doctors who have published research in a similar area and are known to have an interest. We might establish some relationships with them. It is a long term process really, over many years.

  Q565  Dr Taylor: Can I broaden it out and go back to ghost-writing? I was absolutely horrified to hear Dr Horton say that some—even leading—articles can be ghost-written. In years of practice somebody like me has always regarded BMJ leaders and Lancet leaders as the gold standard. Are you implying that there are some journals that do accept ghost-written leading articles and how do you check to see if something is ghost-written? Or am I wrong in assuming that something that is ghost-written is somehow second-class?

  Dr Horton: To start with The Lancet we ask people who write for us whether they have written the article themselves or whether someone else has collaborated. If they have had somebody ghost-write it and they deny that then they will be telling us an active lie if that is the case. I think we have fairly robust—as robust as we possibly could have—procedures for picking that up. However, people do lie and I can give you an example. We received a review earlier this year on a particular subject which had been commissioned. This review was about a particular treatment for a particular neurological disease. As with most things these days it is submitted on a disc as a Word document. The clever thing about Word documents is that you can go into the properties part of a Word document and see various messages that have been written by the person who has been the author. The author of this paper said, "I've written this paper; there was a link with Novatis" and he had had some assistance with the writing of it, but it was his paper and there had been absolutely no substantive input from the company. When we went into the properties field of his Word document it said: "Marketing approval required please" and a little tick box next to it. We were able to go back to the author and say, "Come on, we've caught you out here". The paper was rejected, he went away and we have not heard from him since. I think there are examples of out-and-out lies that come from supposedly independent scientists who are presumably on a substantial retainer fee to get their articles seeded in journals. This is the constant conflict we have in trying to weed these out. It gets worse as you get down the food chain of journals because there the very viability of those journals depends entirely upon the re-print revenue that they get from the editorials, the research articles, reviews and so on. It is critical that if those journals are to survive they are financially successful and then the relationship they have with the sponsoring organisation as an industry becomes much more powerful and influential. There have been examples, for example David Healy's work where he has shown very clearly in his British Journal of Psychiatry paper—which he gave a summary of in an oral session here—how information is commissioned by industry through third party medical communications companies and then gets seeded in the literature and that information has a systematic bias in favour of a particular drug or issue. That is the thing we are constantly trying to fight against.

  Q566  Dr Taylor: Do you think doctors recognise that there is what you call a food chain of these journals and they are sufficiently aware—and I am not asking you to name them but I am sure I know quite a lot of them—of the quality of the ones at the bottom end?

  Dr Horton: They are certainly aware of the food chain of journals, but it is the way the articles then get used. If you get what is essentially a promotional piece of work written up and it looks beautiful in print and it is all fantastically typeset and that gets given to a doctor, whether it is in The Lancet or the journal of whatever it might be down the food chain then it looks credible. It has the imprint of the journal and the publisher attached to it. There is an authenticity given to what are often completely spurious views not owned by the author him- or herself.

  Q567  Chairman: As a non-medic, how aware would the average doctor be of the quality within this food chain of what he or she was reading?

  Dr Horton: I would believe—maybe I am naïve—that most doctors would be aware of the fact that the BMJ and The Lancet are somewhere hopefully near the top and then you would have leading speciality journals in the middle and then there is a whole bunch of third and fourth rate promotional journal that sit somewhere at the bottom. I would hope they would understand that, particularly those in the general practice community. They will not necessarily have the academic background and critical appraisal strengths to be able to discern which are strong and which are weaker articles.

  Q568  Chairman: So key prescribers could be fed a load of rubbish by these at the lower end.

  Dr Horton: They are, daily. That is what drug representatives are there to do, to feed them rubbish; that is their job.

  Q569  Dr Taylor: Going on from that, Ms James in your submission you give us some of the rules you follow to preserve the integrity of articles written by your editorial staff on behalf of doctors, one of them is that some doctors do not have the time or the writing skills necessary for publishing their own work and value this service. I do not want to argue about the writing skills because we are all notoriously bad at writing, but I do argue with the other bit because surely if you have done a piece of work that is worth publishing you will find the time to write that up. Is this not rather stimulating the production of articles that the people doing the research were not that bothered about?

  Ms James: I do not think so. It is extraordinary how busy doctors are. They are not just doing research, a lot of them are seeing patients, a lot of them are justifying what they do to budget holders and all of that; they are very, very busy. I know you are a doctor so I shall be careful what I say, but doctors are not necessarily trained in things like time management and organisational skills. I think what we find is that very often if we leave it to them they know they have to do it but months pass. That really is our experience.

  Q570  Dr Taylor: I would not argue with that. We certainly never had time to do the yellow cards.

  Ms James: That is very important, too.

  Q571  Dr Taylor: But if you have done a bit of work you are desperate to get it out.

  Ms James: I accept your point but I think the service really came about partly because of people's desperation to get this work published. It is not just the doctors who are keen it is the companies as well.

  Q572  Dr Taylor: Mr Paling and Ms James, how do you actually build up relationships with journalists?

  Mr Paling: We do not build relationships with journalists; we do not have contact with journalists. The only time we have material that is appearing in a newspaper or a magazine is paid-for advertising space so that is through a very different channel. My company does not even plan and buy that either but we are really filling the space; that is all, and that is paid for and it is branded.

  Q573  Chairman: Would it not help you sometimes to have contact with journalists?

  Mr Paling: I cannot honestly say that I have had contact with a journalist in my life apart from a friend who was a sports writer with The Mirror.

  Ms James: I think in days gone by the word "relationship" might have been more applicable because there was more time to get to know people, take people out for lunch and so on. These days I think the relationship is much more business-like. If we think we have a story we will assess the likely press who are going to be interested and our staff might speak to ten journalists four times a year. It is not that huge a part of our business. We have a media office staffed by two ex-journalists who take the lead whenever we have a media programme to undertake and I think they probably have daily contact with journalists. They used to be journalists; they know them. It is quite a hard question to answer really.

  Q574  Dr Taylor: Going on to promotional campaigns—by which we mean really advertising campaigns—do you target patients? Do you target nurses? Do you target doctors? Where do you target your campaign?

  Ms James: I am sure Mike will want to come in here because I know that is his area of expertise and we do advertising as well. Advertising is 80% aimed at doctors, increasingly aimed at nurses and to a very limited extent aimed at consumers. There has probably been about five to ten disease areas where the company has decided that it wants to use advertising to reach patients and consumers.

  Q575  Dr Taylor: What about over the counter drugs?

  Ms James: That is predominantly aimed at consumers, yes.

  Mr Paling: We work across a number of audiences, as you say. When it is over the counter medicines we are largely aiming at the end user or sometimes at the pharmacist who has a role in advising a customer or a patient. In terms of prescription work we do, the vast majority—90% of it—would be aimed directly at the doctor who maybe in a specialist sector or more likely to be a general practitioner. The only time we would do anything which was not branded would be when it was a disease awareness campaign. We have been involved in one of those which I mentioned in my submission.

  Q576  Dr Taylor: The contract to run this campaign comes from the maker of the drug presumably.

  Mr Paling: We would agree with the company concerned depending on the nature of the product who we would be aiming our advertising at, yes, and they would have a budget although we do not actually buy space as I said so we would not be controlling that budget.

  Q577  Dr Taylor: Would you have any control over the content of the advertisement, for example?

  Mr Paling: We would develop the content of the advertisement in agreement with the client. We would jointly develop a brief. Our role is really to put that into a communication form and have that medically and legally approved through the normal system, which I am sure you will get onto.

  Q578  John Austin: I have a question for our two journalists. You talked about the way you are fed information to try to produce stories, but to what extent have you been obstructed by pharmaceutical companies in trying to gather information about stories you want to write? Can you give us some examples of where you have been obstructed in trying to obtain the truth?

  Ms Rogers: I will give you a recent example. I did something a few weeks ago about testosterone patches because I thought it was a very interesting example of the way something had been promoted. They are produced by Proctor and Gamble; they are initially trying to get licence approval for their use in post-menopausal women who have had their ovaries removed but they have managed to seed across the whole of the media a huge number of articles about how testosterone patches will be the answer to Viagra for women. There has been quite a lot of data that has emerged suggesting that testosterone does not actually work very well and, not only that, it has never been tested properly as a drug but it might have extremely unpleasant side effects in the formation of male characteristics et cetera. The food and drug administration in America turned down about two or three weeks ago the licence application for this product. I tried to ring Proctor and Gamble and they were very, very difficult. I put in any number of calls to Proctor and Gamble but I kept being put through to answering machines with messages left from last September. Eventually I rang their offices in America and got a call back at about eight o'clock on a Friday night, a day after I had attempted to get a response to the question: what was their reaction to the suggestion that testosterone patches were potentially harmful? The reason they take so long to come back to you is because they hope that if they do not you might lose interest in pursuing the idea and not write it.

  Q579  John Austin: In one sense that is them obstructing you by not giving you information.

  Ms Rogers: That is the normal way they would do it.