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Working successfully with pharmaceutical companies

As an increasing number of nurses qualify as nurse prescribers it is important that their professional judgment is not influenced by commercial considerations. Heather Simmonds explains how to work with the pharmaceutical industry

Heather Simmonds
Director
Prescription Medicines Code of Practice Authority (PMCPA)

It is important that nurses are aware of what activities pharmaceutical companies are permitted to undertake so that they remain free from undue influence while at the same time learning to work with the pharmaceutical industry and others to ensure that they are up-to-date with the latest treatments and medicines for the benefit of patient care. As increasing numbers of nurses qualify as nurse prescribers, this becomes even more of a priority. So how can nurses ensure that relationships with the pharmaceutical industry remain both productive and ethical?

The rules of engagement
Two sets of rules govern these relationships: The Association of the British Pharmaceutical Industry's (ABPI) Code of Practice for the Pharmaceutical Industry and the Nursing and Midwifery Council's (NMC) Code of Professional Conduct: Standards for Conduct, Performance and Ethics to which all practising nurses are required to adhere. Some of the provisions of the ABPI Code are mirrored in Clause 7 of the NMC Code, which sets out the rules for nurses in relation to acceptance of gifts, favours and hospitality and the need to declare any conflicts of interest. These rules are designed to ensure that nurses do not allow their professional judgment to be influenced by commercial considerations - an issue that becomes ever more pertinent as nurses take on prescribing responsibilities.
The ABPI Code covers the promotion of medicines for prescribing to health professionals as well as the provision of information about prescription-only medicines to the public. The Code has many requirements about the content of promotional material, including the need for all claims to be accurate, balanced, fair, not misleading, whether made in writing or by representatives, and capable of substantiation. The Code places restrictions on the provision of samples, promotional aids, meetings and hospitality, and controls the conduct of representatives. The Code also covers the provision of information about prescription-only medicines to the public and relationships with patient organisations. The Code reflects and extends beyond UK law.
So how can nurses work with the pharmaceutical industry for the benefit of patients within the provisions of both the ABPI and NMC codes?

Representatives
Representatives will probably be the most common forms of contact that nurses have with the pharmaceutical industry. The Code applies to what representatives say as well as the materials they use. Representatives must maintain a high standard of ethical conduct and must be properly trained. Representatives have to pass an ABPI examination. They must not use any inducement or subterfuge to gain an interview and no fee should be offered or paid for the grant of an interview (Clauses 15 and 16).
It is important to have realistic expectations of meetings with representatives and to understand what they can and can't offer. For example, pharmaceutical companies can sponsor a wide range of meetings such as presentations at GP practices. Sponsorship must be disclosed in all papers relating to the meeting and any published proceedings. Payment for rental for rooms to be used for meetings cannot be made to you or any other prescriber, either directly or indirectly, under the ABPI Code (Clause 19.1).
If a company is sponsoring a meeting, it must be the scientific or educational content that attracts delegates to attend the meeting. Companies are not permitted to use lavish or deluxe venues, and venues renowned for their entertainment facilities should be avoided. Meetings wholly or mainly of a social or sporting nature are unacceptable.
Likewise, it is not reasonable to ask companies to provide hospitality unless it complies with the Code. Hospitality can only be provided in association with a scientific meeting, a promotional meeting, a scientific congress or other such meeting. Hospitality must always be strictly limited to the main purpose of the event and secondary to it, and cannot be offered to spouses or other such people unless they qualify as a delegate in their own right.
Representatives can be a very useful source of information on medicines. If you are seeing a representative from a company that has products in a disease area that you are interested in, they should be able to provide information on the disease itself as well as medicines for treatment. Some companies may also have patient materials that you may find useful to distribute to patients when talking about their illness. Meetings can be an excellent opportunity to improve knowledge.
Under the Code, companies can also sponsor delegates' attendance at educational meetings as long as the requirements of the Code are met. Companies can only provide economy air travel to delegates sponsored to attend meetings.

Gifts and medical and educational goods and services
No gift, benefit in kind or pecuniary advantage can be offered or given as an inducement to prescribe, supply, administer, recommend, buy or sell any medicine (Clause 18). Pharmaceutical companies are allowed to provide promotional aids that are inexpensive (no more than £6 plus VAT and of a similar perceived value to the recipient) and relevant to the recipient's profession or employment.
Companies can provide medical and educational goods and services that will enhance patient care or benefit the NHS and maintain patient care (Clause 18.4). While these can cost more than £6 plus VAT, they must not be provided in such a way as to be an inducement to prescribe, supply, administer, recommend, buy or sell any medicine. They must not bear a product name, but can bear a company name, and the involvement of the pharmaceutical company must always be made clear. Therapy review programmes, which aim to ensure that a patient receives optimal treatment following a clinical assessment, are permitted and can be a productive and mutually beneficial way to improve patient care by working with the pharmaceutical industry.
However, it is unacceptable for a company to assist with a switch programme where all patients on medicine A are simply switched to medicine B without any clinical assessment. Companies could promote a switch from one product to another, but must not assist in carrying it out.

How to make a complaint
The Prescription Medicines Code of Practice Authority (PMCPA) administers the Code at arm's length from the ABPI. Anyone can make a complaint to the PMCPA under the Code. Health professionals are encouraged to forward concerns about pharmaceutical companies to the Director of the Prescription Medicines Code of Practice Authority, 12 Whitehall, London SW1A 2DY. Alternatively complaints can be emailed to complaints@pmcpa.org.uk.
If complaints are found to be in breach of the Code a number of different sanctions can be applied. In each case where a breach is ruled the company must cease the practice in question and take all possible steps to avoid a similar breach in the future. A detailed case report is published at www.pmcpa.org.uk. Additional sanctions are imposed in serious cases and can include an audit of the company's procedures to ensure compliance with the Code, the recovery of promotional items and the requirement for publication of a corrective statement. Companies can also be publicly reprimanded, "named and shamed" through advertisements in the medical and pharmaceutical press. A rarely used sanction is suspension or expulsion from membership of the ABPI.
Further information on the Code and complaints procedure can be found at www.pmcpa.org.uk and advice on the Code can be obtained by calling 020 7747 8880. Full details of all completed and ongoing cases are available on the PMCPA website.

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Resources
Prescription Medicines Code of Practice Authority
W: www.pmcpa.org.uk

Nursing and Midwifery Council
W: www.nmc-uk.org