What if the way we understand the world is wrong?
What if it's not politicians and world events that shape our lives,
but business deals...?
It's natural for people to fight against change,
but change IS coming and we need to adapt to it.
Deals made in secret, high up in a boardroom
or over a drink in a car in the dead of night.
It is over, dude.
It is gone.
If you can't do it, artificial intelligence can.
Our every waking hour has been transformed by these deals,
reprogramming us to think and behave in a different way.
While we're competing with these large monolithic banks
that are very bureaucratic, we could run circles around them all day.
This is the story of these deals.
These ideas were ahead of their time.
Online payments can change the world.
Who made them?
Why?
And what do they mean for our future?
In this series, I'm going to look at three key aspects of our lives
and how they've been revolutionised by these deals.
How did work go from something we do to who we are?
It's not a person, it's a performer, right?
Oh, sorry. It's not a person? It IS a person.
I'm a person sitting in front of you.
Who wants to kill cash, and why?
Our vision is to have a cashless society.
Card payments are the best way to pay and the best way to be paid.
But in this film, I want to look at health.
GPs in the UK prescribe over a billion tablets every year.
This notion of the pursuit of happiness, it's not realistic!
It gets all of us to be on drugs!
Prescriptions for antidepressants have seen the biggest increase,
more than doubling in the last decade.
So, if I gave you some antidepressants now,
what would you do with them? They'd be in the Irish Sea, mate.
How did we become an overmedicated society?
We're trying to protect people from excess medicine.
You couldn't. Yeah, we failed.
It was a business plan, a strategy...
..to make living itself an illness
and patients of every one us.
MUSIC: Requiem in D Minor by Mozart
New York, 1976.
The American CEO of a large pharmaceutical company
does an interview with a business magazine.
In that interview he made a throwaway comment,
but he gave a fascinating insight into the business of big pharma.
His name was Henry Gadsden, and his candid comment
was that he wanted to sell pills to everyone
and make prescription drugs as normal and matter-of-fact
as having a stick of chewing gum.
It was this dream, this vision,
that would come to drive the marketing machinery
of one of the most profitable industries on Earth.
Four years on from Gadsden's interview,
a psychiatrist stood at a gathering
of the American Psychiatric Association.
He was here to present a new manual,
which would herald a major shift in the way mental illness
is defined and diagnosed.
The book was the third edition
of the American Psychiatric Association's
Diagnostic And Statistical Manual, or DSM.
Its aim was to classify every single mental health condition,
including newly identified disorders.
The man chosen to write it was a 41-year-old psychiatrist
called Robert Spitzer.
His new manual, DSM-III,
would change our understanding of mental illness
and would introduce 265 diagnostic categories
that would transform the theory and practice of mental health.
After a long, awkward silence,
the audience burst into applause.
APPLAUSE
The psychiatry establishment had given its seal of approval.
The DSM-III would be published.
This was the moment that would change psychiatry forever.
Some seven years earlier, the psychiatry profession
was facing an escalating crisis of legitimacy.
A famous study called The Thud Experiment
revealed people were being locked up in mental institutions
without any clear diagnoses.
Eight perfectly healthy students were sent into American hospitals.
They each claimed to be hearing voices,
saying "empty", "hollow" and "thud".
Despite having nothing wrong with them,
seven were admitted, and diagnosed with serious conditions,
including schizophrenia.
DSM-III, the manual which was supposed to save the credibility
of the profession, would be a revolution in psychiatry.
A paradigm shift in how the profession
would diagnose mental health.
Allen Frances was on the DSM-III task force.
The DSM is, in some ways, used well, a wonderful document.
It's not that there's one right way of defining a disorder,
but it's much better having one way than 20 different Towers of Babel.
And to have ability for clinicians to communicate with one another,
to communicate with patients, to educate one another about disorders,
to do research, it's very useful to have a common language.
DSM-III became a kind of cultural phenomenon.
It was a bestseller, wasn't it? It not just WAS a bestseller,
every single year since, it's sold hundreds of thousands of copies.
There's something comforting in having a label
because that reduces the sense of being uniquely damned -
"I'm not the only person in the world with this."
It gives a sense of, "We know what to do. We have procedures."
The power to label is therefore a power to help,
but it's also, possibly, a power to destroy.
At the time, in the States,
there were many factors driving the need for standardisation.
Mental health policy-making in government was on the increase,
and mounting pressure from health insurers meant psychiatrists
needed to demonstrate the effectiveness of their practice.
But the range of new conditions that DSM-III offered
and the checklist approach to diagnosing them
also allowed pharmaceutical companies to create niches
for the development of a whole host of new medications,
which were then relentlessly marketed.
What was it about the categorisation, Allen,
that allowed the drugs companies to take advantage?
The major one was having criteria sets.
Very valuable for improving reliable communication,
but dangerous in the hands of drug companies
because they could come up with checklists, which they did.
So, DSM-III was published in 1980.
1987, Prozac comes out.
Prozac had been around for about 15 years,
so a useless thing that suddenly becomes one of the biggest
blockbusters in the history of the pharmaceutical industry.
How did they do this?
They did this by extremely clever, aggressive marketing,
which made use of the DSM-III as a way of disease-mongering.
Peddle the illness to sell the pill.
If you can get the public to think that the aches and pains
of their life are easily soluble with a pill,
then you have a marketing phenomenon
that will generate tens of millions of dollars every year.
MUSIC: Squares by Beta Band
By the time the fourth version of the DSM was published in 1994,
more than half the panel members had one or more financial links
to the pharmaceutical companies.
Allen Frances was now chair of the task force.
How do you feel about that?
In all the work I did on three DSMs over many years,
did I ever have a drug company person call me
and say "do this" or "do that" or "pick this guy" or "that guy"? No.
I think the reason that I was appointed to IV
was a realisation that the system was expanding too fast
and a need to stabilise it.
But III's like that and IV's like that? Yeah.
So it didn't work. Well...
Now you're being a BBC reader. I will shoot that down.
Your worst question.
OK, we received 94 suggestions for new diagnoses.
We accepted only two.
We were trying to protect people from excess medicine.
It turned out just the opposite.
So even though you tried to do something about it,
you tried to rein in this over-diagnosis, you couldn't?
Yeah, we failed.
Despite the best intentions of the DSM,
it played a major role in widening the net around diagnosis.
That spelt big profits for drug companies
who could now market their products to as many people as possible.
In 1991, pharmaceutical giant Pfizer
had just had a new antidepressant called Lustral,
also known as Sertraline,
approved by the Food And Drugs Administration.
The CEO, Bill Steere, was quoted at the time
as saying that the company had three objectives.
The first was to get marketing and research closer together.
The second, to get marketing and research closer together.
And, yep, you've guessed it,
the third was to get marketing and research closer together.
What they came up with would go on to be used around the world.
# Hallelujah!
# Hallelujah... #
Pfizer had done its homework.
It knew that 75% of prescribing for depression was done in primary care,
so they provided the funding for DSM-III creator Robert Spitzer
to create a tool for doctors to diagnose depression more easily.
They scouted for general practitioners to help them.
The one they found was Kurt Kroenke.
So it was a little more than almost 25 years ago
and I was presenting at a primary care mental health meeting in 1991.
Bob Spitzer, he came to the meeting, actually
to scout out some GPs who he might involve in this project.
He came up, introduced himself.
From there we developed the first version,
which is called the PRIME-MD.
But what really became popular was the depression piece of it
and, erm, it's called the PHQ-9 because it has nine questions.
Right. It has those nine questions because those are what we call
the criteria or the symptoms for major depression.
We ended up coming up and scoring it
because initially people would have to go through an algorithm
to figure out how often the symptoms were present.
And I think that was the final thing, because it's a score.
Just like people are used to looking at their blood pressure
or their blood sugar, they like numbers and doctors like numbers,
so once we created the 0 to 27 score,
it seemed to become even more popular.
The patient health questionnaire, or PHQ-9,
rapidly became the national and international gold standard
measurement tool.
Patients are scored on a range of questions
about how they've been feeling over a two-week period.
Is PHQ-9 widely used in the NHS in Britain?
Erm, yes.
I was actually surprised because they published a paper
and the PHQ-9 was the most commonly used in general practice,
and I thought, "Wow, it must be a really good scam."
I talked to a colleague, a general practitioner in the UK,
who said, "But it's free."
VOICEOVER: Sertraline, the drug that Pfizer wanted to market
when it funded the research into PHQ-9
was the third-most widely prescribed antidepressant
on the NHS in 2015. James Davis,
a former NHS psychotherapist turned research academic,
is an outspoken critic of the depression scale.
It will determine whether or not you have depression.
OK. And if so, how depressed you are.
The higher you score on this test, the more likely it is
you're going to be prescribed an antidepressant. OK.
In fact, I would be advised to prescribe you antidepressants
should you score in the moderate to severe categories.
So even if it's moderate, you could still prescribe them to me?
Yes, absolutely, but that's not to say people
who are mildly depressed don't get antidepressants.
A lot of people with mild depression do receive antidepressants.
OK, wow. Let's give it a go. Yes, let's see how you do.
"Over the last two weeks, how often have I have been bothered
"by any of the following problems..."
Do I just click on one of these? Yes.
"Little interest or pleasure in doing things." Several days.
"Feeling down, depressed or hopeless."
Several days.
"Feeling tired or having little energy?"
Quite a lot.
"Thoughts that you're better off dead or hurting yourself."
No.
I've got a score already, look.
10 out of 27, which gives me moderate.
I'm moderately depressed, yeah?
I needed to score over 10 out of a total of 27
to be diagnosed as moderately depressed
and, according to clinical guidelines in the UK,
an antidepressant can now be prescribed.
So here you have a company setting the bar for what constitutes
having a form of depression for which a drug is needed very low,
while at the same time as manufacturing those drugs
and profiting from them.
Once you knew about the Pfizer connection,
how did you feel about it?
It didn't bother me because I knew this was not a product
that we're going to sell, it was just...
They would sell the drugs, through.
Yeah, but they made it free to...
I was just interested in better ways of diagnosing these conditions
in primary care because the treatment in many cases
doesn't need to be a drug, it could be therapy. It could be
talking to a psychologist, it could be self-management.
So you didn't feel that this was an opportunity for them to make money,
basically? Yeah. No, well...
They didn't drive the classification cos that was set in stone.
This was just an easy way to officially make the diagnosis
in general practice.
I would say on this, the PHQ-9 or any depression scale, is innocent.
I think it's the use of it and if it feels like it's pushing me
to use a particular type of treatment or overtreatment, erm...
that could be done with any scale.
It shouldn't be "12, starter pill, see you back."
There should be a brief conversation,
but where it saves time is, it used to be the doctor was supposed to ask
all of those questions during the visit.
Well, here it's done in advance, and so it gets you to the point
you'd say to the patient, "Looks like your scores are high,
"looks like these are some of the symptoms we see with depression,
"what do you think?" So it's a starting point.
Pfizer says PHQ-9 was never intended to replace
a consultation with a doctor.
MUSIC: All that Glitters by Death in Vegas
This Blackpool GP agrees.
I think there is the perception that some GPs do overprescribe
or reach for a prescription pad as a solution to people's problems.
However, I would say most GPs will take a clinical view
on what they feel is appropriate.
But this is a town where depression is so rife,
it's bordering on an epidemic.
High levels of unemployment,
chronic disease and social deprivation
have all contributed to £1.5 million worth
of antidepressants being prescribed here last year.
In Blackpool, we certainly have a high level of prescribing.
Much more than you would expect looking at the statistics
for other areas.
These are often people who came to Blackpool when they were younger,
had a good time here and now they're running back to Blackpool
when they run into problems.
They often have substance-misuse problems, depression.
We sort them out, they move, and then we get another family
or person to replace them with the same problems.
I think that's one of the reasons we don't see the same improvements
as other areas.
39-year-old Matt fits that demographic.
He's been living with long-term substance misuse
and was recently put back on antidepressants.
What medication did they put you on?
I've tried lots and lots of different ones.
I've tried Citalopram, Fluoxetine.
I'm on Sertraline at the moment.
They've put me on the highest dose.
What does it feel like to be on antidepressants?
What's it actually like? It's, erm...
Well, at the time when you're prescribed them,
because you're...in crisis,
you're kind of desperate for any help,
so you're kind of, like, "I'll do whatever you say."
When you're starting to feel better,
do you know whether it's you or the drugs?
No. No, I don't.
That's the...that's the...
I don't know where my addiction starts and stops.
I don't know where I start and stop
and I don't know where the pills start and stop.
There is clearly a genuine demand for drugs
for the clinically depressed, but that's not where the big money lies.
Research submitted to a parliamentary committee
on prescribed-drugs dependence estimated that around £70 million
is lost every year in England
to unnecessary long-term antidepressant use.
When you look at the actual costs being incurred by the NHS
for antidepressants, that comes in at about £44 million a year.
When you look at the Benzodiazepine drugs,
these are the sort of drugs taken for mild anxiety,
people on those unnecessarily,
that comes in at about £15 million a year
so if you dealt with just those two groups alone,
you'd be saving the NHS in England alone around £70 million a year.
The criticism isn't to do with drugs.
"We should have no drugs at all" - that's not the criticism.
The criticism is that people get put on the drugs,
they get parked on the drugs and they get left on the drugs.
But we know from places like Blackpool
that depression rates are known to be higher in deprived areas,
where people struggle with unemployment and poverty,
which makes the issue of who needs them and who doesn't a complex one.
Do you think, Marie, in a way that...
antidepressants just enable poverty, essentially?
That is a very complex question.
If you have decent home circumstances,
if you have financial stability,
if you don't have a drug problem or an alcohol problem,
if you're not a victim of domestic violence or abuse,
you're more likely to be able to engage and move on.
But if you cannot function, you can't earn,
if you can't earn, you can't improve your social situation,
so an antidepressant might help you to function a bit better
and to remove yourself from those circumstances.
What do you think would make a kind of long-term difference to you?
I would like to get off antidepressants in the long-term,
and meeting up with other people in the same situation
is the way forward for me.
But in Blackpool, it kind of...
There are services that are good and services that are not good
in my experience.
No disrespect to doctors, but I think it is a quick, sort of...
"Have the pills, you're on your own, sort the rest out," kind of thing.
"We can stop you getting dangerously low,
"but we can't actually sort out your problems."
It's become the norm to be taking medication, not the exception.
The meds are essential.
Some people think, get rid of the psychiatric meds.
They're absolutely essential for the 5%.
They're absolutely harmful when they're misapplied to the 25%.
Medication that's very useful for the few
becomes dangerous and harmful when it's applied to the many.
Do you think, Allen, therefore,
that what we are doing is diagnosing society as well as the individual?
We're sort of saying, "We are more stressed, we are more overworked,"
when the reality is, we AREN'T more overstressed or overworked
than previous generations, but we're simply identifying it
and then providing a problem
that we can then provide drugs to provide the solution?
Different eras will understand the distress of human life differently.
The conceit that there's a simple answer to complex problems
usually leads to more harm than good.
WOMAN: Depression hurts in so many way.
Sadness,
loss of interest,
anxiety.
You only have to look at the way antidepressants are marketed
in the States to see how far the stresses of modern life
have become things to medicate.
And I have to say it's nice
that there's a low risk of sexual side effects.
But there's one condition that entered the mainstream
and soon became one of the most misdiagnosed conditions
in American medicine.
ADHD, or Attention Deficit Hyperactivity Disorder.
It was the fourth version of the DSM
that gave us the current definition of ADHD.
Within a year of the manual being published,
500,000 children in the States were diagnosed with the condition.
One in seven children are being treated today.
Come on in, Hodges.
Come on in.
Dr Larry Diller is a paediatrician who favours talking therapy
over prescribing stimulant drugs.
Remember my name? What's my name? Do you know my name?
Erm, Diller.
Yeah, Dr Diller!
VOICEOVER: This family are looking at alternative methods of treatment
for their son, who has ADHD.
You're doing talking therapy with Dr Diller and trying other things.
How do you feel about the meds? Do you think they work?
What is your feeling?
Without a doubt, they create the best version of himself
that we can have right know.
Is there any downside to the meds, do you see, in him?
I think the sleeping is a factor.
There will be a time when he doesn't sleep all night.
But we usually give him Melatonin at night,
and it's a herb.
And he does just fine with it.
So, yeah.
So, how many of the kids that you see would you say
are genuinely ADHD?
I'd say one out of ten kids that I see.
One out of ten? One out of ten.
Wow.
The others have varying degrees.
So, there is a genuine condition of ADHD.
It does exist? Yes. That will get people very angry
if you say ADHD is a social construct only.
But, what you're saying is,
the other nine kids perhaps don't need drugs or whatever it is.
But drugs do work on the short-term.
I've never been against the drugs.
I have been against the drugs as a first and only treatment
for all kinds of children's problems.
We're going to play a game, guys. You know how I like to play a game.
Few would deny it exists, but the lack of a definitive medical test
means ADHD has been open to misinterpretation,
over-diagnosis and ruthless marketing on a massive scale.
How many kids in Paddy's class have been diagnosed, would you say,
with ADHD? I would say a third.
And that's not a hunch, that's me talking and networking
with other mothers, and them discussing their children
and whether they're on meds or whether they're not.
A third of them? And, of those third,
would you say for many of them, meds is the, kind of, first port of call,
the thing they will go to? Yeah, they do.
Many of the pharmaceutical companies marketing ADHD drugs
have at one time or another referred to the research
of one child psychiatrist prominent in this field.
Based here at the Massachusetts General Hospital,
his name is Joseph Biederman.
In 2002, he meets with major drugs manufacturer Johnson & Johnson.
He wants to create a new research institute for child psychiatry
at the hospital, but he needs the cash to do it.
They make a deal to subsidise the costs
to the tune of 500,000 a year.
This is from the executive summary.
It says, "The mission of the centre is to create a common ground
"for strategic collaboration between Johnson & Johnson and the paediatric
"psychopharmacology research programme at the hospital.
"An essential feature of the centre is its ability to conduct research
"satisfying three criteria."
And number three is stated clearly -
"It will move forward the commercial goals of Johnson & Johnson."
The hospital says the centre, which ran from 2002-2006,
was for scientific and educational purposes,
and not to promote Johnson & Johnson drugs.
But Biederman was hugely influential to drugs companies,
publishing papers on ADHD,
saying it was widespread and vastly underdiagnosed.
He also promoted childhood bipolar disorder,
saying that even two-year-olds could be manic-depressive.
An anti-psychotic drugs market for children was created
off the back of his research.
I began investigating the record of Dr Biederman,
pooling his research, looking at his funding sources,
talking to people about him and what his real reputation was,
and discovered that he was very much, erm...
at the vanguard of prescribing powerful, anti-psychotic
and anti-epileptic, anti-seizure drugs, to very young children.
He was very eager to prescribe more medications to young children
and he was heavily funded by the pharmaceutical industry,
many of whom were selling the very drugs
that he was preaching should be prescribed.
The drug companies put Biederman on a platform
that nobody else could get close to.
In terms of travelling throughout the country,
he and his colleagues were the main speakers everywhere.
I was at a meeting, if Biederman just breathed a drug in exhale,
probably 10,000 doctors would start prescribing it in America.
That's the degree of power he had at one point.
He is so adamant and so sure and has people falling in behind him
because he's so sure, that you can't actually tell what's really going on
inside of his head because he brooks no dissent.
He's so driven towards his goal.
In fact, that's what his boss said to me.
It's like,
can you imagine a drug company influencing Dr Joseph Biederman?
He's a hard man to influence if he doesn't agree with you.
But then, later on, it was revealed that, in fact,
he had all these briefing papers, presentations to drug companies,
where he was telling them in advance,
"This is where I think the research will go if you fund it."
A US senator said, "How can you be telling people
"what the research will show before you did it?"
Biederman and his associates, Thomas Spencer and Timothy Wilens,
reportedly accrued over 4 million in consultancy fees
from pharmaceutical companies.
They maintained that the money never influenced their work.
You know, I would say that we realised, our group realised,
that there were errors made in our reporting internally.
And that's all been corrected.
Moving forward, people like myself continue to do work
but at no personal gain.
That money does not come to me, there's no personal remuneration.
It goes to the institution.
But I'm very dedicated to the idea that academia needs to work
with industry to come up with better innovative medications
for the condition.
DR ALLEN FRANCES: It's very, very easy to give a diagnosis.
You can do that in two seconds.
Almost impossible to get rid of a diagnosis.
And once you apply a label of ADHD or autism to a five-year-old kid,
that may haunt them for the rest of their lives.
It's often applied in 20 minutes
by someone who's very inexperienced in the diagnosis,
who's unaware of the long-term risks.
I think, what I always say about this is,
psychiatric diagnoses should be written in pencil.
We should be able to erase them over time -
to sunset them when they're wrong.
To take into account the long-term view.
I always recommend underdiagnosing
and taking the time to find out how nature takes its course
because you can't really be accurate when you're diagnosis someone
based on a brief experience at one point in time of your life,
except if they have a very severe condition.
Severe conditions we can be pretty accurate on, even on first contact.
With ADHD, it's not just the labelling,
it's also the drugs themselves, isn't it?
You put somebody on drugs - Ritalin, Adderall, whatever,
age five, six, younger in some cases.
Three, two.
There are 10,000 two- to three-year-old toddlers
in the US on stimulant drugs.
And what do you think about that?
It sucks.
We don't know how these medicines work in kids.
It's a vast, public health experiment with no informed consent,
giving kids with very immature brains very powerful drugs,
with no information about their long-term impact.
We shouldn't be redefining childhood as a psychiatric disorder.
But the future for the drugs industry
isn't about putting people on pills because they're ill
or unable to cope in certain situations.
In the future imagined by the likes of Henry Gadsden,
we wouldn't be taking drugs to make us better,
but to keep us in our prime.
In recent years, ADHD stimulants like Adderall and Ritalin
have become the drug of choice of many British university students
wanting to keep alert while swotting for their exams.
These so-called brain drugs have found a following
in the world of today's cut-throat, corporate climbers.
Eric? Hey, Jack.
How's it going? Good, thank you.
Come on in. Wow!
There's some pills.
This man isn't ill.
He just believes that pills can optimise his mind and body.
So, what are you going to take? What do you do in the morning?
Do you just take a load of these? Well, yeah.
It's about signalling your body
and starting to get the right molecules flowing in there.
For me, personally, in the morning,
I'll take my main nootropic, the Nootroo.
So, these are nootropics?
Nootropics are substances that enhance learning and memory
while being safe and protective of the brain.
This is like a caffeine, a main nootropic,
a Noopept or Phenylpiracetam - the real brain-enhancing substances
that facilitate inter-hemispherical communication.
Inter-hemispherical communication - I love that.
This is Acytel-L-Carnitine, works for your mitochondria.
Riboflavin. Biphosphate.
This is another limiting factor for the mitochondria.
This is like breast milk without the vitamins.
More like the immune-boosting things that, like, go in there.
This one is Serrapeptase - an enzyme from the stomach of a silkworm.
There's not a tonne of research on it,
but all these things, no-one's incentivised to give them to you
so you've got to go out on your own a little bit
or, like, do research and learn...
..you know, what's what.
In case you missed any of that, Eric takes nootropics,
a mix of compounds, supplements and stimulants
that claim to improve cognitive function,
increase alertness and strengthen memory and recall.
And you're getting all of that, aren't you?
Yes, it's actually slow for me. I'm, like, bored.
Every conversation I do, every e-mail I do,
everything I blog or write or post is that much faster
and that much more efficient.
People have gone beyond just trying to tune out, zone out.
They want to tune in.
They want to, like, actually get into the stuff.
If you're doing stuff that impacts the world,
every minute you're more efficient...
If you're reading more efficiently, typing more efficiently...
Do you ever feel just like chilling out a bit? I meditate.
We'll see the meditate. We'll throw on this EG headset in a bit.
What are you putting on now?
This thing mo... detects your brainwaves.
The sound is going to change, based on how close
to a meditative state that I'm in. That's how I relax, but, you know...
WOMAN: As you exhale, let go of...
What was once a fringe movement with users sourcing their stimulants
on the web, nootropics has become a backable business proposition,
with one manufacturer receiving funding from a major tech player
in Silicon Valley.
Erm, are you happy?
I think so. Erm, I mean...
The session has been paused due to a drop in signal quality.
Follow the instructions on the screen to continue.
Let me just do the last 12 seconds, and then we can look at the chart.
As popular as these so-called smart drugs have become
amongst Silicon Valley millennials,
the reality is that these are drugs you don't need to take.
They're optional extras for the well,
and not a necessity for the sick or ill.
Back at the coal face of the UK's health service,
the cost of drugs that patients need are spiralling -
more than £15 billion in 2016, and growing.
Prescription drugs are the single biggest spend in the NHS
after staffing.
There are two different types.
Branded patented products, whose prices are set by the government,
and unbranded generic drugs, whose prices are set by the market.
When a drug goes from being branded to generic,
that means that, in theory, they should become cheaper.
But, in fact, the complete opposite can happen.
When it's branded, the price can be controlled through NHS rules.
But when it becomes generic, anyone can produce it.
Now, that's fine,
unless only a couple of companies CAN actually produce it.
Then they can charge what they like,
and the NHS has no choice but to accept it.
In November 2012, here in this room in London,
a deal was struck that took advantage of a business opportunity
the NHS had unwittingly presented.
Two executives from a company
specialising in niche generic medicines
were giving a presentation to investors.
In it, they talked about their drugs portfolio
and how the UK is an attractive market
because of its unrestricted pricing on unbranded medicines.
The opportunity presented to investors in that boardroom
exploited a loophole in the way prices are regulated -
one already allowing the costs of some drugs
to increase by thousands of percent.
Times journalist Billy Kenber broke the story.
So, there were two guys in particular that you honed in on.
Tell me about them.
Yes, a guy called John Beighton and a guy called Guy Clark,
who were both reasonably senior employees at a company called AMCo,
who gave a presentation to some investors
and talked about the fact that the NHS encourage generic pricing.
They talked about the fact they didn't have competitors
for these drugs, and gave projections for some of
them of the value of the market
and the value that they paid for them earlier on.
They were laying bare some of the key aspects of this pricing freeze.
There were actually making a presentation in a London hotel...
Openly describing it. Openly describing it to other investors?
To other investors. Yes, exactly.
AMCo was bought by Canadian pharma group Concordia International
in 2015.
In 2011, it put the price of a thyroid medication
up from 16p a tablet, to £9.22.
The company was able to do this openly and transparently.
While the cost of branded medicines is under tight control,
the market for generic off-patent drugs is less regulated,
as costs are normally kept down by competition between rivals.
Most of these drugs were being manufactured
by the same small group of companies.
They had specifically identified this loophole and were performing
the same trick, if you like, time and time again.
Were the bigger pharma companies involved in this as well?
That was one of the other interesting aspects.
The reaction of the industry after the first set of stories
was to say, "This is shocking,
"but this is a tiny corner of the industry.
"We don't approve of these guys. It doesn't reflect the mainstream
"big pharmaceutical companies, and we'd be happy to see it stopped."
VOICEOVER: But, the reality is, big pharma companies are also doing it.
Companies like Pfizer.
It sold the UK distribution rights of an epilepsy drug
to a company called Flynn Pharma,
who de-branded it and made it generic.
When the cost went up from £3 to £68,
GP Steve Pike went public and blew the whistle.
Can you tell me what happened when you first realised
that something was going on?
Well, in about September 2012,
Flynn Pharma wrote to all general practitioners across the country,
informing them that they'd taken over the marketing authorisation
for a drug called phenytoin, which was known at that time as Epanutin,
and was produced by Pfizer.
What happened was it was still being produced
in the same factory by Pfizer.
It was still being delivered to the UK by Pfizer.
So, in fact, Flynn Pharma's only role in this, we believe,
was actually to take the orders and to sort out the pricing.
And, of course, it's that pricing which was the main issue,
because in the letter that we received from Flynn Pharma,
there was no mention of the fact that the price
was going to be increased by 24 to 27 times.
I mean, that's extraordinary, isn't it?
Over the last four-and-a-half years, the NHS has spent
an extra £150 million on this drug.
When you found out that there was going to be this massive price hike,
what did you do? Well, essentially, the Department of Health
could not do much about this because the drug companies concerned
had not actually broken any rules with regard to pricing.
Steve Pike took Flynn Pharma and Pfizer
to the Competition and Markets Authority.
Pfizer were fined over £85 million
and Flynn Pharma received a penalty of over £5 million
for breaking competition law.
Both disagreed with the rulings, and are appealing the decisions.
There are other examples. A study by the European Cancer Congress
showed that 14 cancer drugs have increased by between 100% and 1,000%
in the last five years.
A life-saving hydrocortisone tablet
has gone up from 70p a pack, to £88.
The body that represents the generic drugs industry
says these price hikes are anomalies.
The normal way that the generic industry works
is there are multiple manufacturers of the same product,
and the price that is charged in the marketplace is set by competition.
So, pharmacists buy from them,
they obviously want to buy at the lowest possible price.
That actually produces the most efficient market in Europe.
If the price goes up,
that will attract new entrants into the market,
it creates competition, and the price goes down.
So there's a commodity cycle...
..a commodity market cycle around the pricing of medicines.
The second thing is, most of the companies don't look at their
profitability product by product, they look at it overall.
So, for a large company, a number of their products, 30% to 40%,
they'll be making no profit on, but they can continue to produce
those for patients because they're making higher profit on others.
We would never try to justify a price increase
that wasn't for a good reason.
But that is precisely what has happened.
Some of those that are being spoken about may be justified,
may not be justified. I don't know.
But we have to look at the benefit that generic competition
brings as a whole.
There are patients who have been taken off thyroid drugs
as a result of this price hike. Their health has suffered.
But what you're saying in your defence is,
overall, the NHS as a whole,
they've saved money because of generics become...drugs cheaper.
But these are specific people, who might be watching
this programme now, who no longer have treatment as a result directly
of these price hikes. If you look at that sort of therapy area,
where it's a very complex area,
there are a range of products available.
For a few patients, a specific product,
which because it's complex,
because there are few patients, will be expensive, is right.
For other patients with the same condition,
there are equally good alternatives
where there's more competition and lower prices.
So it's important that the right product is chosen
for the right patient and, as I say, for a lot of these products,
the choice is, do you keep those small number of patients
on the product that is best for them,
or do you decide investment in that product
to keep it on the market can't be afforded?
The terrible thing here is that we have patients who need
this specific drug, and it's this specific drug
where the price has been increased by between 2,000% and 12,000%.
At this specific time, there are no alternatives on the market.
I don't know the circumstances of that.
There may be a good reason for that. There may not be a good reason.
Warwick, you do know the circumstances,
but you can't talk about it.
I don't know the circumstances. You must do.
It's been widely reported.
I've learned not always to believe what I read in the newspapers.
You don't think those price increases happened?
The price increases happened.
There are investigations into some of them.
Those investigations, quite rightly, will show whether,
at the end of the day, they were appropriate increases or not.
Concordia International is the latest company to be investigated
by the Competitions And Markets Authority
for suspected unfair pricing.
They gave us this statement.
It went on to say that the NHS has never raised any concerns
about its transparent price rises,
but clearly the government is concerned enough about this issue.
Earlier this year, a new law was passed to close the loophole
that has allowed the more excessive price hikes to happen.
Most of my colleagues are very defensive about the health service.
We are all patients, our families are patients,
my elderly parents are patients and we worry about whether there will be
enough funding left to run the health service as it is.
This is probably the first time in my professional career
that we have to admit we cannot afford health care.
Finally, it's got to that tipping point where you're actually told
you really do have to balance your books next year.
The only way you can do that is to examine every aspect of health care
you're currently providing,
and which ones are you going to have to either withdraw or limit
in order to balance the books the following year?
The future funding of the NHS and how to make it run more efficiently
has become a critical issue.
But, despite treating a million patients every 36 hours,
the NHS relies on manual analysis of test results
and an outdated system of pagers and desktop computers.
There was one deal that promised to get patients
from test to treatment quicker, but it was to prove controversial.
In 2014, three men from London flew to California
to do a deal with the boss of Google.
Google were to describe this deal as the most significant
in their history.
The company they bought was called DeepMind.
Google reportedly paid in excess of 500 million for DeepMind -
a company barely three years old
but already a world leader in artificial intelligence.
A year later, DeepMind did another deal -
this time with the Royal Free Trust,
covering three of London's biggest hospitals.
DeepMind now had access to the confidential records
of 1.6 million people.
Why?
It wanted to put artificial intelligence
at the heart of the UK's health service to build computer algorithms
which could help doctors detect the early signs of chronic disease.
They declined to talk to me, but a spokesperson
did have an issue with us talking to this outspoken critic.
It's fascinating because before this deal became public,
a memorandum came out and it showed what they thought they were getting.
So, on the NHS side, it said they would have reputational gain
from being associated with a company at the forefront of new development,
to paraphrase.
On the DeepMind side, it was much more sober.
It was, we're getting a clinical test bed, oversight,
and the core aspect of it, access to data for machine learning research.
The NHS had approached DeepMind to develop an app
that could help medical staff quickly detect early warning signs
of acute kidney failure by triggering mobile phone alerts
when a patient's vital signs or blood results
are flagged as abnormal.
The medical records of over a million patients
were handed over to help them build it.
There was an outcry about patient confidentiality.
None of the patients involved were told that their data was being used,
and most had never even had an acute kidney injury.
But what also raised eyebrows
was that the NHS was giving away this data for free.
And DeepMind weren't charging for their services.
So, what was the REAL motivation?
The problem here is that we do have a very powerful entity
behind DeepMind, and its long-term ambitions are clear.
And the fact that DeepMind has now said there's not a trust
in the country they haven't spoken to is somewhat concerning.
The fact we don't have any safeguards
except for their word is problematic.
The NHS argued that patient data was anonymised and encrypted
so that this was no different from any other third-party agreement
processing data.
But in July, the Information Commissioner disagreed
and said that the DeepMind trial had failed to comply
with data protection law
and that innovation does not need to have for its price
the erosion of fundamental human rights.
It's not about whether you like or don't like Google or DeepMind,
it's, are the rules being applied in the same way to everybody?
And are we looking at what their history is and what their plans are
and how we ensure that public interest is met at all stages?
DeepMind has said it wants to be
one of the most transparent companies working in NHS IT,
but behind the promise of these technologies
lies the crux of the dilemma in the age we live.
Silicon Valley tech giants like Google, Facebook and others
feed on the fact we suspend our privacy rights
in return for new technology built with our data.
It raises questions over whether it might quickly become
a de facto monopoly over NHS health analytics.
If you go under their framing and say,
"We're just a health IT provider,
"there are other health IT providers."
Well, yes, but people don't care about a company
you've never heard of in the same way they care about Google,
which knows more about our lives than any other company.
So I do think it's unprecedented that a subsidiary of Google
would be getting into a centralised public health service.
DeepMind's algorithm is the medical Holy Grail -
not treating a patient when they're ill
but treating them before they get to that point.
For some, this is already a reality,
but only if you can afford it.
MUSIC: L'amour Est Un Oiseau Rebelle by Bizet
This is Viavi, an exclusive London clinic
where they provide bespoke health care packages
by collecting every bit of data available from your body.
If I start with a test you can do at home, in order of least enjoyment.
OK.
First, we have the stool kit.
We've got cardboard trays to capture the stool on.
Here we have a saliva test.
Really interesting to capture the change in hormones
over the course of a day.
They use DNA mapping to create a detailed health assessment.
Sabine Donnai is the company's chief executive.
People get so much data that eventually it's very difficult
to filter out what's relevant for me.
Because you might go onto the web and half the articles might say
vitamin D is good for you,
and half of them might say don't take too much Vitamin D.
So, what's right for you? I might say, "I'm going to run a marathon,
"I'm going to be super-fit,"
but that's not really what I should be doing.
And what you get is the strategic thinking behind it
because it's not just about the data.
It is about identifying the one or two things that are going to
make the biggest difference in the continuum of my health.
So the DNA mapping and the ability to identify these weakest links,
this is a whole new world, isn't it? Yeah, yeah, it's brilliant.
Viavi's own website describes its clients
as leaders in business and of nations.
People in control of their worlds.
And to get this kind of bespoke MOT,
this ultimate MOT on your body,
erm, how much does it cost?
The MOT itself costs £9,000.
What we do offer, and what most of our clients do take on,
is what we call the after-care.
How much is it going to cost me a year, roughly? £13,000.
£13,000. It's a lot of money. Yeah.
So, they've got all my data - what have they found out about me?
So, when we look at your generic risks that we get out of your DNA,
you definitely have quite a few predisposing factors.
Those are called snips, OK? Yes.
And snips are mistakes that you will have inherited
from either your mum or father.
The important one that we looked at, your genetic background is
you're quite at high-risk of Alzheimer's.
It's an increased risk of Alzheimer's at an older age.
At an older age? So, you're looking at about a 23% increased risk.
Now, this is a risk factor, Jack, so I really want to stress that.
I don't want you to sit here and say, "I'm going to get Alzheimer's,"
because that is not the case. Right.
So we can focus on reducing that inflammation in your system.
And that's why the right type of exercise to control your
blood sugar, the control of your body fats,
the control of any inflammatory factors
is going to be very important.
And it sounds like a massive mission, but it really is not.
Right. So there's something you can do about it?
It's not a given that you will get Alzheimer's...
Definitely not. No, no, right, right.
It's, in any case, it's old age,
so over 80, you're looking at an increased risk.
Remember, I mean, science is changing on a daily basis.
The likelihood that in a year's time we're going to know so much more
on what to do to avoid it is the most likely scenario.
Already we know way more than last year
on what we can do and how to influence it.
What is extraordinary, apart from the personal stuff,
is that you've been able to find this out
because of the ability to drill into the DNA
in a way that most people can't, actually, just from having...
You know, so that extraordinary.
Yeah. The whole point is to try to stay away from medication
as much as possible because medication controls things.
Ideally, what you're trying to do is change the chemical reaction
from early on, so there's no need to control. Right. Absolutely.
I sort of think... There's a kind of an initial shock
that you're being told anything about yourself
which is, you think, "Oh, my God!"
There's a kind of alarmist thing which is about...
..you're going to get Alzheimer's, possibly.
You're 25% more likely to get Alzheimer's when you're 80,
but when you actually break that down, you think, well,
I'll be quite glad to be here when I'm 80.
And, you know...
There's an initial shock to what you're being told
because you're being told something.
And then that kind of wears away and then you start to just analyse
what you have been told and you start to think...
I don't really know why I'm being told this.
It's a strange... It's a really weird thing.
Erm, so I don't know how...
I don't know how useful it is, actually.
I think it is only useful if it is about being told about something
that you are definitely or very, very, very likely to get,
that you can do something about.
With artificial intelligence on the wards
and DNA mapping on Harley Street,
health care in the future, whether you're inside or outside the NHS,
will be all about risk.
A clear, diagnosable illness has become a fuzzily defined list
of potential illnesses you might get in the future.
I have a good friend who advises elderly patients of two things.
One, don't fall. Two, don't go to doctors.
The problem of over-diagnosis and overtreatment is very, very endemic.
A very serious problem.
The NHS is being torn apart and privatised and underfunded
in just the way the public system in the United States was destroyed.
The very rich will be getting way too much treatment
that will be harmful to them, and everyone else will have trouble
affording treatment in a way that will be harmful for the neglected.
What does mild obesity mean?
People now talk about prediabetes - what does that mean?
We both are at risk of over-diagnosing
thousands and thousands more people.
Some people push very low levels of cholesterol and say,
let's start the common, classic drug called statins.
And there's a big debate. Guidelines have come out -
is primary prevention with statins beneficial?
So it's likely we are probably using too many statins
in thousands of patients.
And I think, with all medical and psychological disorders,
we have to be careful where we draw the line
of labelling somebody versus just educating people.
We are all ultimately at risk of getting something,
but do we dare take the risk of not following the prognosis?
Next time, the deals that will one day kill off cash.
Online payments can change the world.
The idea that you can actually sign up online
and be able to start moving money like that was a big game-changer.
How they will make you spend more...
The more transactions which are moved from cash to card
is a benefit for banks.
..and how they will turn YOU into the new currency.
Data is the new oil
and payment data is probably the best quality oil in the business.
To explore further how digital technologies
are transforming societies, go to the BBC web page on screen
and follow the links to the Open University.