bmj.com NEWS Ж Urgent action is UK news GPs and specialists lack understanding and respect for each other, report says, p 4 needed to improve World news GlaxoSmithKline is fined record $3bn in US, p 2 chronic pain care, Ж References on news stories are in the versions on bmj.com says report Dutch GPs agree to refer fewer patients and prescribe more generics Tony Sheldon UTRECHT The long running dispute between the Dutch ministry of health and Netherlands general prac- titioners is over in a deal seen as guaranteeing stability and growth for the profession, defining their position as the gatekeepers of care. But in return for annual budget growth and extra funding for modernisation and innovation, GPs must realise savings worth millions of euros from generic prescribing and refer fewer patients to more expensive hospital care. GOLDMAN/AP/PA DAVID Supporters of the Affordable Care Act celebrate the court’s decision on Capitol Hill The minister of health, Edith Schippers, and the GPs Association chair, Steven van Eijck, signed the “covenant” barely eight months after US Supreme Court upholds almost two thirds of the Netherlands general practitioners had demonstrated against cuts in funding which, they feared, threatened modern Obama’s health reform act Dutch primary care.1 Janice Hopkins Tanne and vowed to repeal it on his the individual mandate was not Schippers had intended to claw back €99m NEW YORK first day in office if he is elected supported by the commerce (£80m; $125m) from the GPs’ budget, which By a vote of five to four, the US president. clause in the US Constitution, they had overspent in 2011, arguing that the Supreme Court upheld the However, when Romney was because people who did not rate of increase in health spending was “unten- health reform act, known as the governor of Massachusetts, he buy insurance did not engage in able.” Affordable Care Act. endorsed that state’s health commerce. The government had But the new deal cancels any proposed claw Health reform immediately reform law, which included a relied on that clause to support back which would have seen the tariffs GPs can became a hot issue in this year’s mandate that all residents buy the individual mandate. charge for care cut from January. In addition she election campaign, which ends health insurance. Today about Instead, the court said the has promised to make every effort to ensure any with voting on 6 November. Many 95% of the state’s residents mandate could stand as it relied overspend in 2012 will not result in tariff reduc- US citizens object to the health are insured. Massachusetts’ on Congress’s power to tax, such tions. In particular increased costs related to reform act as an expansion of health reform served as a as the penalties levied on those cooperation between GPs’ out of hours services government and the government model for President Obama’s who do not buy health insurance. and hospital accident and emergency depart- telling them what to do. health reform bill. Now Romney Republicans said this showed ments would not be clawed back. President Barack Obama as presidential candidate is Obama was raising taxes, an Instead the budget for GP care will, in line made a television address saying denouncing a plan similar to the anathema in an election year. with other areas of healthcare, increase by that the decision showed that one he supported. The individual mandate is 2.5%. In addition an extra 0.5% will cover mod- “here in America, the wealthiest Republican leaders in the important for health reform ernisation and innovation to promote what the nation on earth, no illness or House of Representatives said because it spreads the cost of ministry of health says is GPs’ “central role” in accident should lead to any they would vote to repeal the healthcare among a larger pool providing a concentration of care locally. family’s financial ruin.” He said it health reform law on 11 July, as of insured people—the young The ministry recognises GPs’ “gatekeeper role.” “was a victory for people all over they have done before. There and healthy as well as older and The GP, in turn, is charged with “limiting as far this country whose lives are more is no chance the Democratic sicker individuals. as possible” referrals to specialist hospital care. secure because of this law.” majority in the Senate will The court ruled in favour of the The GPs Association and the ministry are urging Mitt Romney, the Republican approve such a repeal. expansion of Medicaid to cover closer cooperation between out of hours GP candidate for president, said, “If The Supreme Court’s ruling on as many as 17 million uninsured services and emergency departments to prevent we want to get rid of Obamacare 28 June sustained the individual people who were on low and patients’ “unnecessary” attendance at hospital. [health reform], we’re going mandate, the key requirement middle incomes but above the In return, GPs must make savings of €50m to have to replace President that US citizens buy health poverty level. a year savings by cutting back on prescribing Obama.” He called health insurance or pay a penalty. Cite this as: BMJ 2012;344:e4498 expensive patent medication. reform bad policy and bad law However, the court ruled that Ж EDITORIAL, p 12 Cite this as: BMJ 2012;344:e4510 BMJ | 7 JULY 2012 | VOLUME 345 1 NEWS GlaxoSmithKline is fined record Capturing $3bn in US for unlawful practices patients’ lives Bob Roehr WASHINGTON, DC boards, and supposedly independent continu- Annabel Ferriman BMJ GlaxoSmithKline has agreed to plead guilty and ing medical education (CME) programs,” and This portrait of an 85 year old Londoner, Jack Hardy, pay $3bn (£2bn; €2.4bn) in penalties for unlaw- lavish travel inducements to promote unauthor- is one of 25 photographs portraying the home lives ful promotion of prescription drugs, failure to ised uses of the drug. of patients at an inner city practice in east London. report safety data, and false price reporting. The company was fined for failing to report The exhibition, called “What counts rather It also signed a 123 page corporate integrity certain data on the safety of the antidiabetes than what can be counted,” was conceived by agreement with the US Department of Justice drug rosiglitazone to the FDA. That included two doctors at the practice, Kate Adams and Paul that regulates its activity for the next five years.1 information on cardiovascular risk obtained Kelland, who wanted to emphasise the importance The fine is the largest on record imposed on through post-marketing studies, including those a drug company in the United States and fol- ordered by European regulators. lows closely on the heels It also promoted off- Bill Corr, deputy secretary of the Department of another huge penalty, label use of the anti- of Health and Human Services, said in a state- $1.6bn, levied on Abbott asthma drug fluticasone, ment, “Today’s historic settlement is a major Laboratories in May for the anticonvulsant lamo- milestone in our efforts to stamp out healthcare its marketing of valproic trigine, and ondansetron, fraud.” acid.2 which is approved only The deputy attorney general, James Cole, GSK’s agreement cov- for postoperative nau- added, “At every level we are determined to stop ers several of the its sea. Kickbacks were paid practices that jeopardise patients’ health, harm leading drugs. It illegally to healthcare profession- taxpayers, and violate the public trust.” promoted the antidepres- als for prescribing these Andrew Witty, GSK’s chief executive officer, sant paroxetine for treat- and other drugs. This said in an extended statement released by the GSK’s chief executive Andrew Witty: “In the ing patients under the age US, we have taken action in all levels” defrauded federal health company: “Whilst these [violations] originate of 18, even though the insurance programmes in a different era for the company, they cannot Food and Drug Administration never approved such as Medicare and Medicaid. and will not be ignored. On behalf of GSK, I want the drug for that age group. The company also The company reported false drug prices that to express our regret and reiterate that we have created “misleading” journal articles claiming “resulted in GSK’s underpaying rebates owed learnt from the mistakes that were made.” efficacy of paroxetine in that population, when under the Medicaid Drug Rebate Program,” the He added, “In the US, we have taken action in fact “the study failed to demonstrate efficacy,” justice department’s statement said. at all levels in the company. We have funda- the justice department said in its statement, and Under the corporate integrity agreement GSK mentally changed our procedures for compli- it hid trials that had negative findings.3 may no longer pay its marketing employees ance, marketing, and selling. We have removed GSK illegally promoted bupropion for weight according to sales figures. Company executives employees who have engaged in misconduct. In loss, sexual dysfunction, substance addictions, may be held personally accountable and forced the last two years we have reformed the basis on and attention-deficit/hyperactivity disorder and to give back bonuses and long term incentives which we pay our sales representatives.” other off-label uses. It also used “sham advisory “if they . engage in significant misconduct.” Cite this as: BMJ 2012;345:e4568 Closure of surgery in Camden was a casualty of NHS changes Tom Foot LONDON closed surgery, adding: “We remain no competitive tender—as is normally A public inquiry into the closure of a concerned about the remaining two the case—and the new company was GP surgery in north London that was contracts held by The Practice at the not vetted by its NHS paymasters.