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The end of salesmanship?

Published on 18/08/14 at 06:54am
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Although my specialism for the last 35 years has been clinical research, I actually started in the pharmaceutical industry as a salesman. The first thing I learned was that there is not a thing on this earth that anyone buys, that somebody doesn’t have to sell.

Now when I graduated as a biologist  we had recently been through the drug  scandals of the 1960s, including the  thalidomide disaster and – more relevant to this piece – the massive over-selling of benzodiazepines by Roche.

But my initial misgivings were soon put aside as I immersed myself in a world of technical discussion and quick results. Coming from a brief period in laboratory research, the latter in particular was a refreshing change.

Medical selling was fun, character-forming, and paid well. There was a great deal of entertainment of doctors, some of it quite lavish, but I justified that with the argument that I was only buying their time and attention, and they could make up their own minds about the drugs we were offering them.

That was, however, until I moved on to my next company, where I actually received high quality sales training. I was taught how to maximise product advantages, minimise problems and lead doctors to an inevitable decision.

At a big training event I attended, any concerns that we were being unfair to customers were dispelled by reinforcing our conviction that our product really was the right choice, and all we were doing was transmitting that to the prescriber.

I well remember a non-steroidal  anti-inflammatory, one of many and with nothing to distinguish it, being described by managers as ‘a salesman’s product’.  They knew it was nothing special, and it was down to us to get it prescribed. So where was our belief in product quality then?

A far from heavenly marriage

Fortunately for my cognitive dissonance,  I then moved into clinical research and product quality was something I had to investigate,  not promote. Initially working in peri-marketing studies, I was nevertheless exposed to conflict between R&D and marketing.

A cynic might say that drug development is fine until the data get into the hands of the spin doctors, for which there is some justification, but is drug development up until that point really free of bias? I don’t think so, and neither does Dr Ben Goldacre, whose ‘Bad Pharma’ I have reviewed in this series already.

In addition to such issues as publication bias and study design fiddling, Goldacre makes the point that the purpose of pharmaceutical selling is to distort evidence-based medicine (EBM),  a thesis which I would like to explore here.

To kick off, I wonder why anyone would be surprised by that proposition. A number of studies have been published which show that promotional gifts to doctors and other healthcare professionals do influence prescribing.

There are now very strict controls on the value of such gifts, but even a pen with a drug name on it has an effect. And why shouldn’t it? That’s its whole purpose. It’s a part of sales and marketing. Similarly, why should anyone be surprised that a visit from a drug rep might increase the likelihood of a doctor making a particular prescription decision? That’s what the rep is paid to do.

Don’t believe everything you hear

This next bit might seem an irrelevant digression, but please bear with me. The last decade or so has seen a very noticeable growth in scepticism, especially when it comes to healthcare.

Note that sceptics are not cynics: they simply ask questions about claims that are made. The internet has meant that there are few hiding places for people who have irrational agendas, enabling the mobilisation of armies of bloggers and tweeters to shoot down false claims.

Much of the flak has fallen on the alternative medicine camp so that, for example, the NHS Choices website at last states clearly that homeopathy does not work, despite government fence-sitting. Interestingly, the relentless attacks on the pharmaceutical industry by alternative medicine supporters achieved nothing, because those attacks were irrational.

It was left to the sceptics to have a real effect, by asking questions about what the industry was doing and claiming. We now have the AllTrials campaign, originated by sceptics and gathering substantial support from major companies.

To its discredit, the ABPI continues to reject AllTrials, and has even misrepresented some historical facts in the run-up to the publication of ‘Bad Pharma’. No alternative medicine organisation has signed up to AllTrials either, perhaps because they have nothing to shout about regarding their own R&D.

The soft sell

So the industry is coming under much increased scrutiny from people who know what questions to ask, and some of the answers can be uncomfortable. I recently heard that the US accounts for 50% of global spending on cancer treatment, but only has 5% of the world’s cancer cases.

The US healthcare system costs twice as much as the UK’s NHS per capita but outcomes are not much different overall. For this reason, the Holy Grail for most pharmaceutical marketers is the US market, which they see as the most profitable. I have direct experience of this, where a UK company’s investors pushed for penetration of the US market at the expense of Europe (and ignored the Far East where much of the clinical research had  been conducted).

The irony of the situation is that the American system is economically inefficient – but attractive to drug companies ‘because’ of this inefficiency. The reason has to be that strategy is determined by keeping shareholders happy, which has been the case since corporations (in the modern sense) emerged in the 1600s.

Today, healthcare is quite rightly focussing more on the patient. This has been a government mantra for years, under successive administrations, which to my mind is more political window-dressing than a rationally developed policy. The highly controversial Health and Social Care Act does not mention EBM anywhere, yet patient choice is its central theme.

Presumably it’s uninformed choice regarding treatments. It is left to others  to analyse the real implications of a  patient-centred approach. Simon Denegri and Mark Flannagan (Pharmafocus, May 2014) for example highlight the current lack of real patient involvement on the part of both pharma and the NHS while, to be fair, the new NHS chief executive has started his job  with fine words on the subject. All three confirm that the problem exists.

Patients beyond the pale

Denegri and Flannagan do point out the barriers to patient involvement, especially the ‘Chinese wall’ that has existed for decades between companies and patients. I would not want to see direct to patient advertising of prescription drugs, but we now have far better channels of communication than ever before, and great opportunities to collect experience of real medicine users.

In passing, I often reflect on the weakness  of randomised controlled trials (RCTs) to assess drug safety (they are powered for efficacy testing not safety), but we can capture far more adverse event information directly from patients, even if it lacks the sort of quality  we might expect from RCTs.

One of the most difficult to defend statistics is that the pharmaceutical industry globally spends twice as much on sales and marketing as it does on R&D. This rather undermines the oft-repeated claim that companies need profits to fund development of innovative  drugs. No, such profits are far more likely  to be fed into more promotion.

Plus, as we have seen, the cash goes to the most lucrative markets. Healthcare payers are getting wise to this, and can see how much effort goes into convincing prescribers that  a mediocre drug is superior, compared with the amount devoted to finding drugs that really are superior.

But it’s easy to see the business pressures that face companies. Ploughing profits into R&D is a very long-term and high-risk strategy, whereas throwing money at sales can give quick results, exactly as I found back in my medical rep days.

How can this be mitigated? There are those who advocate taking R&D away from the drug companies and centralising funding independently. History does not support this – how many innovative drugs emerged from the communist bloc?

The profit motive will always apply while drug companies are businesses, and the only option I can envisage (perhaps I lack imagination!) is to nuance the environment to encourage a shift towards patient needs.

One such initiative is the Early Access to Medicines Scheme launched by the MHRA  in April 2014. I’ll take the opportunity to dismiss the very ill-advised Medical Innovation Bill being pushed heavily by Lord Maurice Saatchi, which risks exploitation of patients by quacks and has been opposed by a wide range of medical organisations and charities.

We have to change, or we’ll be changed anyway. So will sales and marketing go  away? Of course they won’t, while drug companies exist as businesses. But we do have a grossly unbalanced system, where R&D is the poor relation to promotion, and drugs are developed to make the biggest profits irrespective of the needs of patients.

Like the banks, pharma firms need freedom to apply their resources effectively, but must be properly regulated. Regulation does not mean channelling research into formulaic processes; right now, it’s quite possible to comply 100% with clinical research legislation while still doing bad science,  as we found with TGN1412. 

As Denegri and Flannagan point out, this can’t go on, patients ultimately pay our bills, and we need all the friends we can get.

Les Rose is a freelance consultant in drug development and can be contacted at: les@pharmavision-consulting.co.uk

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