These pills come with sweeteners

Long before the row broke out over whether the NHS should pay for Relenza, the flu treatment, the medical profession was asking if pharmaceutical companies' marketing skills lure doctors into prescribing drugs whose benefits do not justify their cost.

Long before the row broke out over whether the NHS should pay for Relenza, the flu treatment, the medical profession was asking if pharmaceutical companies' marketing skills lure doctors into prescribing drugs whose benefits do not justify their cost.

The debate dominates the letters page of the latest edition of the British Medical Journal after Dr David Griffith, a consultant physician, pilloried pharmaceutical company sales representatives for wasting doctors' time and encouraging irrational prescribing in an article published in the BMJ in July.

Doctors, with their power to order that patients take particular drugs, paid for by the NHS and prescription charges, are the key to the fortunes of the pharmaceutical multinationals. Central to marketing drugs are one-on-one meetings between sales reps and either hospital doctors or general practitioners, depending on the type of treatment. Typically, sales reps have to make an appointment in the same way as a patient, and will receive only about five minutes of a doctor's time. Drug companies are also permitted to advertise their products to a "learned audience" in professional journals, but they are forbidden to advertise particular products to the general public. Just how much the big companies spend on marketing is kept well under wraps, hidden in their annual reports as part of their budgets spent on anything from administration to the cost of selling goods.

The usual defence of the sales reps is that they are the best means of keeping doctors abreast of the latest innovations in the drug industry and developments in existing treatments. Rubbish, said Dr Griffith. There is, he said, a plethora of non-promotional sources of information, and the more reliant doctors are on commercial sources of information, the less rational they are as prescribers. Worst of all, sales reps push new drugs, for which there are no published comparisons with existing treatments or economic valuations, thus slowing the take-up of proven worthwhile treatments.

The BMJ has since published claims of companies bribing doctors to see reps with free pens, stethoscopes and alarm clocks. Some doctors have also enjoyed "meals, weekends and other trips that can make life so much more pleasant" as one doctor put it.

Naturally, the sales reps see it differently. They are usually science graduates, who specialise in only a couple of medical fields, and so inevitably have a greater knowledge in their fields than jacks-of-all-trades GPs. Richard Tiner, medical director of the Association of the British Pharmaceutical Industry, says: "Doctors should turn the representatives' visit into a positive occasion, ask questions, demand information and make use of them."

Doctors also have access to continuing education programmes at their local hospitals which provide them with some objective context for reps' claims, although some would argue that they should already be capable of evaluating their claims.

There is even support for the freebies. "Without drug representatives' pens most NHS doctors couldn't write any notes, without their mugs we couldn't drink our coffee, and without their drugs we couldn't cure our patients," said one doctor in response to Dr Griffith.

Meanwhile, the pharmaceutical companies are pouring ever more money into Direct-to-Consumer advertising (DTC) in the United States, where they can advertise their products. Total DTC spending was $1.53bn (£956m) in the year to March, an annual increase of 16 per cent, out of overall promotional spending on consumers and physicians of $6.14bn. This is a tricky strategy. The recent supreme court ruling in New Jersey said this could increase the liability of drug manufacturers in medical litigation by eliminating the "learned intermediary" defence typically used in such cases. The proportionate increase in the number of consumers going to their doctor to request a drug is disappointing. Permission for DTC in Britain seems some way off, so doctors can look forward to many more pens and alarm clocks in the years ahead.