Consumerism, Information and Drug Prescribing Governance

Abstract

Background
In the UK, the availability of most pharmaceutical drugs is at the discretion of healthcare professionals. Recent innovations in information access, the rise of consumerist attitudes to health care, and the global market have challenged this hegemony. Concurrently, the UK government had addressed the governance of drug prescription through guidance to health professionals, issued via the National Institute for Clinical Excellence and parallel bodies, and based on assessments of effectiveness and cost-effectiveness.

Aim
To explore the dynamics of public access to pharmaceutical drugs and the consequences for the governance of drug prescribing in the UK.

Objectives and Data Collection
1. To study the impact of information and communication technologies on purchasing and use of prescription pharmaceuticals (review of prescription drug availability via the worldwide web, interviews with public and pharmaceutical companies)
2. To study the influence of health consumer and support groups such as the MS Society on the overall governance of drug prescribing in the UK (interviews and case study)

3. To examine the impact of a specific example of NICE guidance on patterns of drug prescription and private purchasing (survey of health authorities on prescription of specific drugs, review of literature on NICE guidance, interviews with authors of NICE guidance)

4. To access the issues around direct marketing of pharmaceuticals to the UK public (literature review on direct drug marketing to consumers, interviews with pharmaceutical marketing directors on direct marketing)

Analysis
Conclusions will be woven from these threads of data using standard qualitative data analysis methodologies. Draft findings will be discussed by a panel of stakeholders from public, voluntary groups, NHS and health professionals. The final report will be circulate to participants, and will form the basis for an online conference on drug prescribing governance.

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Summary

Background

For the past 50 years, pharmaceutical medication has fallen into two broad categories: those requiring a doctor's prescription and those available over the counter of pharmacies. Drugs available without prescription are generally for minor or self-limiting conditions, although, some can only be retailed in the presence of a qualified pharmacist. The selection of drugs for retail without prescription has largely been determined by evidence on safety, tempered by economic and political factors, such as restraining prescribing costs or encouraging self-medication for short term illnesses. Currently therefore, the availability of most drugs is at the discretion of healthcare professionals. While many patients have deferred to this paternalistic approach, recent innovations and high profile cases including the availability of drugs, such as sildenafil (Viagra), on the Internet, have challenged this hegemony. These factors may be summarised as follows:

§ Patient awareness of drug availability
§ Globalisation and free trade
§ Direct advertising of drugs to the public
§ Blurring the boundaries between medical, lifestyle and recreational drugs
§ Increasing influence of health consumer groups

While these pressures for a consumerist approach to drug prescribing grow, the UK government is moving in a contrary direction, with the establishment of the National Institute for Clinical Excellence (NICE) and parallel bodies deciding which treatments to fund, both on the basis of clinical and cost effectiveness criteria. These contrary pressures raise importance issues concerning the governance of drug prescription in a consumerist society, including equity between rich and poor, information-rich and information-poor; population health (for example, loss of herd immunity); and the management of adverse drug effects and interactions.

Research Design

Aim of study: To explore the dynamics driving the use of pharmaceutical drugs and the consequences for the governance of drug prescribing in the UK.
Research Questions:

· What are the dynamics of consumption of drugs traditionally requiring prescription in the UK?
· What impact does this dynamic have on the UK governance of drug prescription?

· Methodology of Interpretation:
· We will employ a multi-stranded approach to explore the 'jigsaw' of data from a multiplicity of angles, with a variety of quantitative and qualitative approaches, including:

· A review of the availability of prescription drugs to UK nationals using information and communication technologies, and regulation of marketing, based on analysis of web sites, discussion groups and e-mailing lists
· Interviews with a sample of people who have used ITCs to gain information or to purchase pharmaceuticals
· Interviews with other stake holders such as pharmaceutical firms; medical and pharmaceutical advisers; authors of NICE guidance; and consumer and support groups
· Case study of MS Society and its lobbying for the use of beta interferon in remitting-relapsing multiple sclerosis.*
· Review of literature relating to NICE guidance release and direct marketing of drugs to consumers in USA and elsewhere

* At the time of writing, beta interferon is probably the best case study to explore, but an alternative would be anti-TNF for rheumatoid arthritis and the Arthritis Research Council.

Outputs:
Draft and final reports addressing the research questions, widely disseminated among the various respondents to the strands of the study for preliminary comments.

A project Website, to promote the study and invite the public and other stakeholders to participate in a discussion forum, and provide another medium for publishing the final report. Other dissemination will follow the traditional routes of peer-revised papers in appropriate journals and conference papers.

Policy and Academic Implications

Because of the integrative nature of the analysis, a draft will be sent to a panel of stakeholders drawn from the samples of public, NHS regulatory bodies, support groups and commercial and industrial interests used in the study. Feedback on the 'credibility' of the analysis will be used in developing the final report.

The New NHS is promised to be more "patient centred" including greater user involvement in decisions about each individual's treatment. NICE recognises this by having user groups for wider consultation. The results of this project will help inform the debate about the governance of drug prescribing, and the issues around relaxing or preserving European rules restricting direct pharmaceutical advertising to the public. It will also enhance our knowledge of how the general public applies healthcare knowledge from the Internet.

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Contacts

Dr Nicholas Fox

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Outputs

Pharmakon Publications
Fox, NJ (2006: in press) 'Health Identities: From Expert Patient to Resisting Consumer', Health.

Fox NJ, Ward, KJ and O'Rourke AJ (2006: in press) 'A Sociology of Technology Governance for the Information Age: the Case of Pharmaceutical Consumption', Sociology.

Fox NJ, Ward, KJ and O'Rourke AJ (2005) 'The Birth of the E-Clinic. Continuity or Transformation in the Governance of Pharmaceutical Consumption?' Social Science & Medicine 61 (7) 1474-54.

Fox, NJ and Ward KJ (2005) 'Global consumption and the challenge to pharmaceutical governance in the United Kingdom', British Medical Journal, 331: 40-42.

Fox NJ, Ward, KJ and O'Rourke AJ (2005: in press) 'Pro-anorexia, Pharmaceuticals and the Internet: Resisting the Medicalisation of Body Shape', Sociology of Health and Illness.

Fox NJ, Ward, KJ and O'Rourke AJ (2005) 'Expert Patients', Pharmaceuticals and the Medical Model of Disease: The Case of Weight Loss Drugs and the Internet', Social Science and Medicine, 16 (6): 1299-1309.

Ward, KJ, Davis, M and Flowers, P (2006: in press) Patient 'expertises' and innovative health technologies in Innovative Health Technologies: Meaning, Context and Change, (Ed) Webster, A, London: Palgrave

Ward KJ, Fox N.J and O'Rourke, A.J (2006: in press) 'I love you to the bones': constructing an anti-medical Model of Anorexia, in Sociological Research Online - 2nd Special BSA Conference Issue: 'Politics Responsibility and Risk' Editors: Elizabeth Ettorre and Alison Anderson

Conference Presentations
Fox NJ (2005) 'Governing Pharmaceutical Technologies in the Age of the Internet'. (Innovative Health Technologies at the Health Technologies Assessment International (HTAi), Rome).

Fox NJ (2005) 'Technology Governance in the Information Age. The Case of Pharmaceuticals and the Internet'. (Critical Management Studies, Cambridge).

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