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Opinion leaders - opportunities for a win-win in healthcare

Published on 09/10/03 at 04:10pm

Innovation in prescribing behaviour can be driven in three main ways. Doctors may prescribe differently in response to pharma industry marketing, to top-down management initiatives (such as NICE guidance) and in response to peer group influence.

Direct marketing carries much suspicion. Clearly, there is a principle motive to promote sales of a particular product and this will be rightly seen as a reflection of the needs of the pharma company rather than the needs of patients or the NHS.

The NHS is plagued with management initiatives that often conflict with local realities. The aim of a consistent high-performing service may be laudable but given local pressures (and the absence of centrally funded recourses to meet them) corporate cynicism will be the standard response. In contrast, peer group leadership is a powerful, neutral and effective way to promote new ideas, new practices and inevitably new prescribing.

It was always ever thus. The clinical teaching of undergraduates and the consultants ward round were always the way new ideas were introduced, shared and implemented. In primary care there is a trickle-down process where problematic cases are effectively managed by local specialists in an effective way; and like the ripples from a rock dropped in a pool the effective clinical practice spreads outward into primary care.

Medical learning and the ability and willingness to change clinical behaviour are governed by the principles of adult learning theory. This is well described and mirrors in many ways the traditional clinical teaching model. The aim of learning is to effect a change in behaviour and one such change is in prescribing behaviour, with obvious implications for the uptake of products.

This theory is based on the pragmatic demands adults make when embracing new ideas and adopting new behaviour. They must perceive the need for change and be offered ideas that can be directly applied in their daily work routine with clear evidence of likely benefit.

Since, compared to marketing or top-down policy, peer group influence comes closest to fulfilling the criteria for effective adult learning it is most likely to produce effective change; hence the opinion leader. It is also endemic in doctors behaviour. In theory, prescribers might read a paper or even receive a sales detail that will influence their behaviour but in practice these stimuli to behaviour change are unreliable.

Opinion leaders can have a major impact on the use of products, not because they market them, but because they present a case for unmet need and challenge their colleagues to address the service provision that should be there. They do this within a learning environment that is familiar and comfortable to most doctors: a local acknowledged expert sharing their special knowledge, just like on a ward round. Recruiting opinion leaders is therefore a sensible option for companies with new and innovative products.

A good opinion leader will not be a slave of industry. Indeed, such thoughts, if apparent, would probably undermine them. Clinicians always carry conflicting priorities with respect to their work. First, and hopefully most, they are patient advocates, recognising the needs of their client group within healthcare and striving to ensure patient care is improved. At the same time they will probably carry broader managerial responsibility within the concept of service delivery, which will involve considering broader issues of meeting local health needs within a tight financial envelope. There is an inevitable dynamic tension here: duty to ones patients versus duty to the overall running of the local NHS.

A good opinion leader will be focused on the former  a passionate advocate for the patients they see and have responsibility for. They will exemplify the highest standards of conduct in following the ethical principles of their profession in always putting the interests of their patients before all else.

From the point of view of product sales there is obviously an issue of balance here in choosing opinion leaders who have good credibility and high integrity but who will still deliver an overall message of commercial benefit.

Most doctors have attended meetings where the speaker has kept ramming home the name of the sponsors product and come away wondering if they were on piece rates with so many pounds for each use of the product name. Such meetings are a disaster: the alleged opinion leader looks like a facile dupe and anyone in the audience with an ounce of intelligence will make a mental note to avoid product X. In contrast, meetings where the focus is on community-based morbidity, unmet need and poor quality of life among the patients will naturally engage caring professionals. The fact that behaviour change will increase sales of one or more products should be an afterthought, or perhaps not even voiced at all. This is, of course, far easier where there is only one obvious treatment to address the need or one obvious market leader, which will pick up the lions share of any increases in prescribing in the disease area.

Where there is a need for a more product-focused approach this will best be done in other and parallel ways, perhaps with simultaneous sponsored nurse support or other collateral benefits. An alternative might be collaborative working with all companies with an interest in a disease area jointly funding an opinion leader programme through an outside agency, knowing that each will gain a proportion of the increased sales that should result.

To support one product against alternatives within the meeting requires arguments both sound and credible that can support the sponsors product against the competition. This was possible with simvastatin, given its better outcome-based data compared to many other hypolipidaemics. It can be used within the context of public concern about adverse effects, as in nedocromil in asthma, versus inhaled steroids (not that it saved Fisons!) and perhaps more tangibly with tacrolimus in atopic eczema.

Currently, the use of glitazones for the treatment of diabetes is an exciting area for this approach, with evidence of a more physiologically sensitive mode of action but a price bracket and a poorer long-term evidence base that left NICE sceptical.

The use of opinion leaders should be based on the concept of a win-win situation where people with integrity support better care for their client group. And the sales figures should be seen as a bonus, albeit well deserved.

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