Have you ever received a payment from a pharmaceutical company? While you may think the practice is a world away from the day-to-day life of a community pharmacist, figures show that the amount the pharmaceutical industry spends paying pharmacists and other healthcare professionals is vast – and is growing.

In 2015, the UK pharma industry made £340.3 million in payments to pharmacists, doctors and nurses, according to figures from the Association of the British Pharmaceutical Industry (ABPI).

Up until now, these figures have been collected as aggregate payments – a cumulative figure reported by the ABPI’s members, covering all of the payments they made to healthcare professionals every year. This

figure was just £41m in 2014.

But from 30 June 2016, companies have begun to report payments by including the name of each individual healthcare professional, starting with payments made during 2015. These details are being compiled

in a searchable public database managed by the ABPI.

No smoke without fire?

Previously, unless either the company or the healthcare professional went out of their way to declare the information, it was difficult to know how much a pharma company had paid an individual healthcare professional.

While both parties would insist that the payments are completely legitimate – for example for participation in research, speaker’s fees or travel costs to attend conferences – the perceived lack of openness left healthcare professionals open to accusations that the payments were made by companies looking to curry their favour, and indirectly influence their advice and decisions.

While healthcare professionals would instinctively recoil from any suggestion that a payment would influence them, it seems this is not a totally baseless suggestion.

In July 2015, an undercover investigation by the Daily Telegraph alleged that NHS staff and prescribing advisors offered to work as consultants for a pharma company. The reporters posed as representatives of a fictitious drug company who were seeking to influence decision-makers to switch patients to the medicines they manufactured.

For £15,000, one formulary development pharmacist at Surrey and Sussex NHS Trust – who resigned after the article was published – offered to organise meetings for the fictitious drug company in Dubai, where members of formulary boards would be paid £1,000 a day to attend and learn more about its products, the newspaper claimed.

Threat of sanctions

The investigation triggered a number of actions that culminated in the announcement of the ABPI payments database. In August 2015 – just a month after the Daily Telegraph investigation – health secretary Jeremy Hunt announced that individuals will be prosecuted if they are found to have accepted inappropriate gifts, payments or hospitality from companies.

Clinical commissioning groups (CCGs) and NHS trusts must now keep their own mandatory registers of payments made by drug companies to health service staff. Anyone found to breach the rules faces the sack, and prosecution under the Bribery Act, which can result in unlimited fines and up to 10 years in jail.

This has been dubbed the Sunshine Rule, after similar legislation that has been in force in the US since 2013. The comparison is an interesting one, as evidence from the US suggests that payments to doctors is linked to changes in prescribing decisions.

In a study published online in June in the US journal JAMA Internal Medicine, doctors who accepted even a single pharma industry-sponsored meal were more likely to prescribe certain branded drugs. For every $1,000 in total payments doctors received, the branded statin prescribing rate increased by 0.1%.

The study authors looked at an open payment database with the details of 280,000 doctors who received a total of 63,500 payments in 2013. Interestingly, 95% of the payments were for meals that had an average value of less than $20. So if these seemingly small payments can have an effect on healthcare professionals, then it’s only right to scrutinise all payments made by drug companies.

“Cult of collaboration”

This is what Dr Margaret McCartney, a GP in Glasgow and a media commentator, is campaigning for. Along with Dr Ben Goldacre, a campaigner for transparency in healthcare, and other doctors and academics, she runs the website whopaysthisdoctor.org – a voluntary website where doctors can declare their pharma interests and “sources of income or benefits from other organisations relevant to medical practice”.

Speaking at an event organised by the Guardian Healthcare Network, Dr McCartney said she has concerns about what she calls “the cult of collaboration” – the increase in partnerships between pharmacists and other healthcare professionals, and the pharma industry. She says these relationships lack “proper interrogation”.

“I’m morally distressed by collaborative working,” she says. “This practice has not been interrogated and this is not a situation that I have complete faith and trust in.”

In the US study, the vast majority of payments were small and arguably token gestures, but Dr McCartney argues that “small things can make a big difference”. This is why she is in favour of healthcare professionals in the ABPI database being transparent about every payment – down to “every pen and Post-it note”.

“I think healthcare professionals should declare everything,” she says. “We should not need drug companies to tell us what to do – doctors, pharmacists and healthcare professionals don’t need to be incentivised to do well.”

Outgoing Royal Pharmaceutical Society (RPS) president Ash Soni agrees, as he says this level of transparency “makes things simpler”, adding: “As a body, [the RPS] has been clear that we expect people to declare everything.”

It’s only right that pharmacists declare their interests, to quell any questions of improper conduct, he says. “We have experts at the top of the profession and they need to be proud of it. But they have to declare [their] conflicts of interest [with drug companies], so people can say whether it’s useful insight or if we should not be involved.”

Mr Soni’s message to pharmacists is clear: “You have a responsibility to [declare] and it’s up to other people to decide if it’s a conflict of interest.”

Defending pharma

Unsurprisingly, the pharma trade body defends its members. Virginia Acha, ABPI executive director of research, medical and innovation, says there’s nothing necessarily untoward about healthcare professionals being paid by the industry.

Jobbing pharmacists may need to be reimbursed for their time spent doing research, CPD and other educational activities that are necessary to keep up with a rapidly changing field, she points out.

She also emphasises that it’s unrealistic to expect healthcare professionals to be able to find out about drugs, treatments, or the latest clinical trials, without attending conferences or professional meetings. She suggests that as the industry is in a position to be able to offer financial help to do so, it should be able to.

“I would be pleased to see that my GP had all the latest information. It would reinforce to me that the care I am given is fully up to date and the best in the world. Patients need the NHS, but they also need the pharma industry. Neither one can do their best for patients on their own.”

Guilty by association?

Mr Soni worries that the ABPI database means that pharmacists will be “tarred with the wrong brush” if they accept payments from drug companies. But he still feels full declaration and honesty is the best policy, he says.

“Transparency gives pharmacists a chance to show that what you’re doing is right. I have been involved in trials and advisory boards for the pharma industry, because I believe it enables better [drug] utilisation and [patient] care. But we have to be clear that people are not allowed to get away with things. We need to know that the right things are being done and for the right reasons.”

But it seems that not all healthcare professionals share Mr Soni’s view. An ABPI survey in May of more than 500 healthcare professionals – including 127 pharmacists – found around a quarter (26%) said they believed disclosure of payments was unnecessary, and around a third (34%) said they either had not or were unlikely to give their consent to disclose payments. So far, 30% of healthcare professionals have withheld their consent for payment information to be disclosed on a named basis on the public database.

Unlike the NHS registers required under Jeremy Hunt’s UK Sunshine Rule, it is possible to opt out of the ABPI database, by contacting each pharma company and requesting that the details they hold are withheld or removed.

Legitimate interactions

The database will include fees for participation in research and development and clinical trials – one of the most common ways that pharmacists work with the pharma industry.

For example, in May the British drug company GSK published the results of what the firm dubbed the “groundbreaking” Salford Lung Study. This study looked at real-world evidence of how patients with chronic obstructive pulmonary disease (COPD) use the drug Revlar, in a normal clinical setting. Some 130 high street pharmacists in Salford, Trafford and South Manchester took part in the study – collecting data on the value of the drug in everyday life and in typical patients.

GSK is also one of the ABPI’s biggest members, and as the manufacturer of Revlar, sponsored the Salford Lung Study.

The community pharmacy researchers on the trial team would have had to decide if they agreed to have any payments made public; GSK’s UK general manager Nikki Yates says the company had already started getting disclosure statements from healthcare professionals who take part in their studies, and have had “very few that have withdrawn their consent”.

“People who have said that they will not disclose are not ‘baddies’,” Ms Yates argues, but they “don’t understand how this is going to play out”. She adds: “We have to support healthcare professionals that agree to disclosure by applauding and commending those that say ‘yes’.”

Changing NHS environment

The Salford Lung Study is an example of the kind of collaboration between pharmacists, doctors and the pharma industry that Mr Soni feels will become more common as the NHS seeks to justify its medicines expenditure.

“I’ve seen recently that CCGs are working with industry to demonstrate outcomes from drug utilisation. From the pharmacist’s perspective this means engaging with pharma companies about real-world data so that we can give the best advice about the value of the medicines we’re using. Pharmacists are the experts in medicines so that [knowledge] is valuable.”

Mr Soni wants to encourage more pharmacists to work with the industry – and fears that the ABPI database could dissuade pharmacists from taking part in future research and collaborations.

“There’s a changing environment, and pharmacy’s relationship with companies is in the context of an increased clinical role for pharmacists in the NHS. There’s an expectation that [pharmacists] work with industry so that patients can access treatments. So we have to find ways to deal with these problems,” he says.

The ABPI database now enables us to put a number – to the nearest pound – on the price the pharmaceutical industry pays for a pharmacist’s knowledge, as well as that of other healthcare professionals.

But it will be much longer – and require much more debate – before the public truly understands the value of this knowledge. The database will start the conversation and allow the public to ask questions. It will be down to each pharmacist to be prepared to justify their payments and prove the value of their knowledge – to the pharma industry as well as patients.