THESE DAYS, pharmaceutical companies must aim not just for efficiency but for effective marketing. Effectiveness can be defined as the achievement of a response in which the drug is adopted and prescribed. This realignment from efficiency to effectiveness parallels the NHS’s increasing focus on outcomes. Decision-making structures are changing Why is the old approach so urgently in need of an overhaul? One of the major reasons is that the structures of, and environment for, decision-making, are changing radically in the “new” NHS. For example, in general practice, doctors are by no means the only decision-makers; nurses and dispensary managers have their say as well. An estimated 28,000 district nurses and health visitors now have limited prescribing powers. In addition, there are 2,500 ’supplementary prescribers’ - a number that is expected to quadruple by the end of 2005. Hospital and community clinicians are accounting for a high proportion of prescriptions - incontinence nurses make most decisions about continence and stoma appliances, which are a significant element of spending. New roles, often associated with decision-making power, are emerging all the time. Pharmacists are increasingly positioned to influence the scripts that get written. The proposed new pharmacy contract would increase pharmacists’ role in ensuring that patients are compliant. For a drug like Lipitor, compliance can be far lower than expected. If pharmacists can increase compliance, the amount of prescriptions will increase. Pharmacists could also influence prescribing behaviour by identifying additional patients who might benefit from a treatment. Decisions Are Being Made At Different Levels Along with the proliferation of decision-makers, another complicating factor is that prescribing decisions are now being made at different levels of the NHS structure. Through the increasing use of formularies, drug choices are tending to be made collectively within a practice, rather than by individuals. Under the new GMS contracts introduced in April 2004, PCO (Primary Care Organisation) contracts are with a practice as a whole, rather than an individual practitioner - another reason to expect prescribing choices to be made at practice level. The public too are a source of pressure on prescribing. Through talking to friends, or from their own reading, television watching and internet research, patients are increasingly impelled to ask GPs for specific medicines. Adverse media reports may create patient resistance to a particular drug, just as reports of successful drug trials will create demands for it before it is on the market. OTC availability of drugs such as statins could cause problems down the line: patients may decide to buy these over the counter for the time being, then, on reaching 60, ask their GP for a prescription. This could pose a dilemma if the patient’s risk does not fall within the guidelines for prescribing, particularly as patients prescribed statins require monitoring, which costs money. Patient power is also manifested in the form of patient groups. The UK now has over 200 national patient groups and over 2000 patient support groups. The influence of these groups can be judged from the fact that the largest national group, the British Heart Foundation, has a budget of over £100 million. These groups engage in lobbying, for example in the context of NICE assessments. Some groups also fund specialist nurses, often in conjunction with industry. In both of these ways, as well as through their dialogue with individual patients, the groups may influence the choice of prescription drugs. All this adds up to a complex and demanding environment for healthcare decision-makers. What does it mean for pharmaceutical companies? The restructuring of healthcare decision-making implies that SOV-based approaches, however effective in conventional terms, may not reach those with the ability to respond as intended, that is by writing scripts. Even if the approaches do reach the right ears, decisions may be constrained by various external pressures. How the Industry Can Respond To become effective, as opposed to merely efficient, it is vital for the pharmaceutical companies’ marketing departments to know their new targets. In view of the rise of the practice formulary, and the new contracts between PCOs and practices, much promotion is going to have to occur at account, rather than at individual, level. Sales people need to fully appreciate the pressures and constraints their targets are working under. For instance, with GPs being encouraged to spend longer seeing each patient, there will be less time to see pharmaceutical company representatives. It is essential that the reps are ready to make the most of any time they get with decision-makers, by providing exactly the information that is needed, with an appropriate amount of detail. Parroting the detail sheets is not enough. GPs can get that information and more from published trial results or Internet sites such as doctors.net.uk. An example could be as to whether a practice has been involved in clinical trials, so the GP may have known about the drug before the rep did. There are a variety of strategies that some forward thinking Pharma companies have been exploring to ensure they put the right information in front of the right people. The ability to map networks of KOLs (Key Opinion Leaders) requires significant research, but repays the effort by enabling more effective targeting and segmentation. In the case of smaller companies, it is prudent to review vacant territory strategies, evaluating the difference between covered and vacant territories and then using lateral thinking to find alternative ways to cover important vacant territory (mailings, symposia and face-to-face calls with selected KOLs all being options). Consideration of influence networks and vacant territory strategies have led some companies to go for a complete restructuring of the sales force, or even its dismissal in favour of other techniques. Collaborative approaches, where the pharmaceutical company funds education or nurses, have proved a successful way to reach decision-makers, but may be beyond the reach of smaller companies. Technology can also help companies evolve and execute their new marketing strategy. Reformulating targeting and segmentation is made much easier if you can map networks of influence, backed by up-to-date databases that offer the ability to create profile and identify links between individuals. NHS decision-making processes can be hair-raisingly complex. To achieve marketing effectiveness in this new environment, it is essential for pharmaceutical companies to be able to identify the real decision-makers and approach them in the right way. There is a silver lining. Decisions will be longer term because of frameworks provided by formularies and so on. There will be fewer decision-makers overall, so provided you have the right information it is possible to target marketing approaches more accurately than ever before.