Pharma pours millions into the NHS for non-research work—but we don’t know what the money is being spent on
BMJ 2024; 387 doi: https://doi.org/10.1136/bmj.q2264 (Published 23 October 2024) Cite this as: BMJ 2024;387:q2264
- Hristio Boytchev, investigations reporter1,
- Piotr Ozieranski, reader2,
- Mostafa Elsharkawy, freelance data scientist3
- hboytchev{at}bmj.com
An analysis by The BMJ has found that pharmaceutical companies pay tens of millions of pounds to the NHS each year without the public being told what the payments are for. The findings have led to calls for a shake-up of current transparency rules so that patients can see why payments are being made to the NHS.
Pharmaceutical companies paid £156m to NHS trusts in England between 2015 and 2022, according to new analysis of the Disclosure UK database. The Association of the British Pharmaceutical Industry (ABPI) database requires participating companies to disclose cash payments and other benefits in kind to healthcare professionals and organisations. Even though the scheme has been lauded as one of the best among its industry run peers in Europe,1The BMJ has uncovered widespread confusion about the intended purpose of the payments. For example, if any of these payments are for “educational” purposes that could be linked to the promotion of pharmaceutical products.
“There is a big difference between publishing some numbers and creating effective transparency,” says Margaret McCartney, a general practitioner and transparency campaigner. She questions if it is “in the patient and public interest that such massive transfers of value are occurring between the pharmaceutical industry and the NHS.”
“When companies dole out over £156m, they aren’t doing it out of the goodness of their hearts, they are doing it because they expect some kind of return on their investment. The unanswered question, so far, is what they want,” comments Joel Lexchin, professor emeritus at the school of health policy and management at York University, Toronto, Canada.
“Transparency is key to improving trust between patients and clinicians,” says Julia Cumberlege, a member of the House of Lords and chair of the Independent Medicines and Medical Devices Safety Review published in 2020. The review focused on problematic drugs and medical devices—such as pelvic mesh that has harmed women—and called for more transparency and regulation of industry payments to doctors and the NHS.2
“We all have a right to know about payments made by the pharmaceutical and medical devices industries,” says Cumberlege.
Lack of detail
Disclosure UK is not meant to name the recipients of payments related to companies’ research and development, such as company sponsored clinical trials.3 And companies are not required to detail the exact nature of the remaining payments, including any possible association with promoted products. Instead, Disclosure UK lists broad categories such as donations and grants, events, services, joint working projects, or consultancy.
The BMJ approached trusts for more detail but few were able to explain the purpose behind these payments. Most payments went to large teaching hospitals, and many told The BMJ they didn’t recognise or couldn’t verify the figures. Guy’s and St Thomas’ NHS Foundation Trust in London, for example, did not “recognise these figures as accurate.” Some trusts said they found mistakes in the data, but would not provide more detail. Instead, they asked The BMJ to submit freedom of information requests for a detailed payment breakdown.
The only payment type where contextual information may be available in Disclosure UK is for joint working, where the NHS and pharmaceutical companies pool resources on joint projects. These payments comprise only 14% of the overall value of payments to trusts between 2015 and 2022 and, even then, information can be hard to access. Details of these joint projects should be provided on the websites of the pharmaceutical companies—but when The BMJ tried to inspect the nature of the biggest 10 such payments, only in five cases did it find links on company websites that led directly to specific projects, such as informatics for personalised healthcare4 and asthma treatments.5
Millions for the trusts
The BMJ tracked all disclosed non-research payments to NHS trusts in England from 2015 to 2022 reported in Disclosure UK. The analysis involved developing an algorithm that corrected numerous mistakes and inaccuracies that drug companies made in identifying NHS trusts as payment recipients and considered payments reported under the names of both the trusts as well as their sub-units, such as hospitals and clinics. The analysis was complicated by missing unique identifiers for payment recipients, which are not mandated by ABPI. Because of these shortcomings, as well as the failure of many trusts to provide exact figures, the numbers can only serve as estimates.
In total there were 58 302 payments worth £156 882 790 made to 217 trusts. These payments make up a fifth of the value of all payments to healthcare organisations listed in Disclosure UK, such as general practices, commissioning bodies, professional societies, royal colleges,6 and medical schools.
The top 10 recipients accumulated £49 820 043, representing 32% of the total value of payments. They were Guy’s and St Thomas’, University College London Hospitals, Manchester University, Imperial College Healthcare, University Hospitals Birmingham, University Hospitals of Leicester, Oxford University Hospitals, King’s College Hospital, Barts Health, and Royal Free London NHS foundation trusts.
The top 10 largest payments were worth £6 237 936. Most of the payments were relatively small, with 94% of payments below £10 000.
Of the 220 trusts operating in England between 2015 and 2022 only three received no payments, including two ambulance trusts.
Calls for a stricter system
International experts slammed the quality of Disclosure UK data and the lack of transparency of the NHS trusts. In the US, research and non-research payments to teaching hospitals and several types of healthcare professions, such as physicians and nurses, are disclosed by law, even if they are of low value.7
Lexchin says, “We need to realise that when trusts are telling people to file freedom of information requests for information that should be public, voluntary disclosure is not the solution to transparency. Legislation like the Sunshine Act in the US that mandates disclosure by drug and device companies of transfers of value greater than $10 to teaching hospitals is what is required.”
Quinn Grundy, assistant professor in nursing at the University of Toronto, adds, “For true transparency to exist, data on pharmaceutical company payments to publicly funded hospitals need to be not just available but easily accessible, accurate, complete, and provide enough detail that members of the public can understand why the company made the payment and what the hospital does with the money.”
James Larkin, postdoctoral researcher at the Royal College of Surgeons in Ireland, who has used industry transparency databases for his research, is not surprised by the lack of quality data in Disclosure UK. He said such data generally allow for big picture statements, but are not precise enough for detailed analysis. That runs counter to one of the pillars of the transparency system, which is to safeguard against undue influence or corruption. Without detail, it’s difficult to identify potentially suspicious payments. “If a journalist or a lawmaker wants to go through the data with the intention of finding individual cases of bribery, it would be difficult,” Larkin says.
“This is an example of why it is so important to have legislated transparency reporting,” says Barbara Mintzes, professor of evidence based pharmaceutical policy at the University of Sydney. “You should not be required to file a freedom of information request to obtain information on how much money a hospital has received from a pharmaceutical company,” she says. “Hospitals are public institutions that operate within the NHS—this information should be publicly available and easy to access. The public has a right to know if a hospital receives industry funding, as well as what that funding is for.”
“Disclosure UK is widely regarded as a European leader in transparency,” said Amit Aggarwal, ABPI executive director of medical affairs and strategic partnerships. Since its launch, the database has evolved, he said. “However, we recognise there is always room for improvement, and we welcome constructive recommendations,” he added. “Disclosure UK is only one, albeit crucial, element to ensure appropriate prescribing.”
The Department of Health and Social Care has been working with healthcare providers on updated guidance regarding doctors’ potential conflicts of interest and has sought views on proposed mandatory payment reporting following recommendations of the Cumberlege review, a spokesperson said.
NHS trusts responses
The BMJ offered the 10 trusts that, according to its analysis, had received the most payments the opportunity to comment on the data.
Guy’s and St Thomas’ NHS Foundation Trust
“We do not recognise these figures as accurate for the trust. Guy’s and St Thomas’ is one of the largest, most research active trusts in the country and works with pharmaceutical companies to develop better treatments that improve the quality of care for our patients.”
Imperial College Healthcare NHS Trust
“Imperial College Healthcare is one of the most research active NHS trusts in the UK and so we would expect to have one of the highest research incomes from across all sources.
“What is included as ‘non-research’ funding in Disclosure UK data can, in fact, still be related to research in our hospitals. For example, as well as receiving payments from industry for delivering commercially sponsored clinical trials, the trust also receives funding from industry for some trials that are sponsored by the trust.
“The trust also supports the pharmaceutical industry in the development, evaluation, and assessment of drug safety, which also attracts funding that tends to fall outside the definitions of research funding used for Disclosure UK.
“Some of the payments reported in Disclosure UK as being made to Imperial College Healthcare NHS Trust were actually made to Imperial College London.”
University College London Hospitals (UCLH) NHS Foundation Trust
The trust first asked The BMJ to submit a freedom of information request. It then did an analysis of the Disclosure UK website for the currently available years 2020-2022 and said that most of the payments concerned University College London and not the trust, “with less than £80 000 over three years relating to UCLH.”
Oxford University Hospitals (OUH) NHS Foundation Trust
“OUH is the one of the largest hospital trusts in England, and therefore it is also one of the largest recipients of industry funding.”
Manchester University NHS Foundation Trust (MFT)
“MFT is one of the largest research and innovation trusts in the country, and as such we would expect to be among the highest level of recipients of such payments which support our research and innovation work programmes. All our activity takes place within the framework of NHS England, ABPI, and all other applicable guidance.” The trust asked for a freedom of information request for details.
Barts Health NHS Trust
“We are one of the largest trusts in the country and occasional non-research income from pharmaceutical companies, used for staff education and development, accounts for 0.023% of our £2.4bn annual turnover. By comparison, on average we attract £10m each year through our commercial research portfolio, which accounts for 0.4% of our annual income.”
University Hospitals Birmingham, University Hospitals of Leicester, King’s College Hospital, and Royal Free London NHS trusts did not answer.
Footnotes
This feature has been funded by the BMJ Investigations Unit. For details see bmj.com/investigations
Commissioned, peer reviewed.
Competing interests: PO’s former doctoral student was supported by a grant from Sigma Pharmaceuticals, a UK pharmacy wholesaler (not a pharmaceutical company). The authors have declared no other conflicts of interest.