Dr Phil Hammond, broadcaster and GP returner in Bristol

Evidence-based medicine is stifling clinical freedom

Are clinical guidelines killing off the drug rep? There are still a few sellers on the road, ricocheting from one hostile GP surgery to another, but they have that desperate, haunted look of the hunted. Many companies have frozen primary care representative recruitment and a few have dispensed with a sales force altogether. So who is to blame?

Prime suspect has to be evidence-based medicine. All those worthy individuals spend hours locked away in darkened rooms trying to construct a meta-analysis out of apples, pears, plums, and perhaps even the odd cherry. Evidence-based medicine tries to give us the best answer for any clinical question you care to name, and if a particular drug is not among the answers, there is little point trying to sell it to today’s NHS. Evidence-based medicine provides us with clinical guidelines and practice formularies, which give us ‘computer says no’. My local formulary has distilled all its prescribing expertise into red, amber, and green codes. These days, you don’t need any medical training to prescribe, but it helps if you’re not colour blind.

The trouble with evidence-based medicine is that people are different and large multi-centre trials are not always the answer. As Dr Allen Roses, a former vice president at GlaxoSmithKline, admitted in 2003, ‘the vast majority of drugs—more than 90% of them—only work in 30–50% of patients.’ Sometimes you need clinical freedom to experiment off formulary because the best evidence doesn’t work. However, the NHS doesn’t do freedom anymore.

Dr Roses’ hope was that pharmacogenomics would race ahead and provide more individualised drug regimens, but it has proved to be a tough nut to crack. In the meantime, the randomised controlled trial is still king and anyone selling a ‘red drug’ is peeing in the wind. We GPs are in danger of becoming a brain dead tribe of tick-boxing idiots.

Labour has once again stuffed doctors’ mouths with gold, and public service values have been replaced with a big money chase. The reward for GPs is keeping prescribing costs down and giving everyone a homeopathic dose of simvastatin. Everyone wins except patients. I’d love to know if prescribing advisers swallow the drugs they advise. Would you?

The internet may also be contributing to killing off the rep. Why go to a meeting when you can download the salient points from a website? You cannot replace human interaction with bland software though. The human effect is what gives medicine its power and appeal, and the same applies to education. Therefore, it may be the Association of the British Pharmaceutical Industry that has sounded the biggest death knell to reps—the argument goes that holding a pork pie meeting in a Travelodge will attract the hard core doctors who really want to be there; the reality is that no-one is going to turn up. For better or worse, doctors are human: the idealistic ones never attend meetings; the rest like to be indulged.

So what of the future? There are plenty of monoclonal antibodies in the pipeline to keep secondary care reps alive, if only NICE agrees to these therapies. But does that mean doctors don’t need to know about the drugs NICE blocks? There are patients out there who have failed to respond to all the NICE-approved drugs for their condition, and who, at the very least, deserve to know about drugs that could help them but which are deemed too expensive for the NHS. My guess is that if drug companies can no longer get any joy from GPs, they will sell directly to patients. Herceptin, anyone?G

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