The nurse will see you now
pharmafile | September 20, 2004 | Feature | |Â Â Â
It used to be so simple. Doctors were the people and the only people who decided what medicines to prescribe, so pharma companies knew exactly who they had to target with their marketing messages, and which professionals their salesforces needed to build relationships with.
This position has slowly changed. The advent of PCTs brought formularies and restricted choice of treatments for GPs. District nurses were given access to a limited list of medicines they could prescribe without referral to a doctor and pharmacists are being tasked with the management of chronic illnesses.
Now comes perhaps the biggest change of all, and one for which the industry is ill-prepared. By the end of 2005, the government aims to have more than 10,000 nurses taking responsibility for the management of a wide range of minor ailments and chronic conditions and crucially they will have access to a much wider formulary.
A recent marketing module of the Pharmaceutical Marketing Society emphasised that the implications will be far-reaching for the pharma industry, yet few companies have even started to plan how to widen the scope of their sales and marketing effort to reach this new audience.
Growing role for nurses
Whether they like it or not, doctors' control of the choice of treatment is being further diluted and devolved to other front line HCPs.
About time too, says Barbara Stuttle, chair of the Association for Nurse Prescribing (ANP), who sees the new system as recognition of the advances which nurses have made over the past decade.
"Prescribing is just a tool to enable the appropriate care to be given to the appropriate person," she explains. "Legally, nurses have not been prescribing, but they have increasingly been making the clinical decision, which they have had to have signed by a doctor. The new protocols recognise the role that nurses are now playing in making prescribing decisions."
It was as long ago as 1986 that nurses were first given the freedom to start making treatment choices independently of a doctor. District nurses were given the powers (albeit with a very limited formulary) to decide appropriate treatment, an initiative which was followed up by extended nurse prescribing.
This was designed to cover minor ailments and injuries and palliative care, giving access to 180 POMs, as well as all the P and GSL medicines. But the system was very prescriptive, effectively giving nurses a narrow set of choices to make when selecting treatment for a particular condition. Which is why supplementary prescribing represents such a change, driven in part by a growing depth in nurses' skillbase, and in a larger part by the ever-changing nature of the NHS, which is seeing the role of nurses become more central to patient care.
It's a change which is requiring nurses and their employers to invest time and money in training and mentoring. Supplementary prescribers will need to complete 25 days' training, followed by 12 days' mentoring from their doctor although in reality that mentoring period is likely to be much longer. This will raise the expectation that nurses' roles will be enhanced, and developments in an ever-changing NHS seem to confirm that this is indeed happening.
"The development of diagnostic and treatment centres in the NHS, as well as initiatives such as NHS Direct both of which are nurse-led means that nurses are becoming the gatekeepers of healthcare," says Stuttle.
"The patients' voice is growing in importance within the NHS, and the nurses' enhanced role will play a big part in influencing the patients, who view nurses as being able to give them more time than doctors, and therefore building a close relationship. The pharmaceutical industry cannot afford to ignore such developments."
Nurses as customers
That view is backed up by Janssen-Cilag's supplementary prescribing manager Tina Billett, one of only a handful of industry people whose role is dedicated to building professional relationships with the new breed of prescriber. A former PCT director of nursing, she believes the industry simply doesn't accept what a big influence nurses already have in prescribing.
"The industry has not been interested in nurses," she contends. "And yet there are already nearly 28,000 district nurses and health visitors with limited prescribing powers, and they have been joined by 2,500 supplementary prescribers. The government wants to see this figure increase to 10,000 by the end of 2005. Within five years, there will be more nurse prescribers than doctor prescribers in the UK.
"Nurses have shifted from being influencers in prescribing to being customers and they are wary of big pharmaceutical companies. The challenge for the industry will be to break down these barriers, and that will require a better understanding of nurses' needs, and a refocusing of how the industry interacts with them."
The relationship between nurses and pharma companies is not close; nurses are perceived as contributing nothing to reps' targets and many only speak to a nurse if the doctor is not available. And yet this underestimates the huge influence that nurses already have on prescribing decisions.
"The industry doesn't accept how big an influence nurses are," says Janssen-Cilag's Billett. "And yet I have heard a consultant say, when pressed why he was not using a particular product: 'because my nurse says we have to use something else.'"
Billett claims that many pharma companies don't even know that nurses are already prescribing their products, and the doctor-focused professional relationship building means that most don't understand the various different levels of nurse prescribing.
If this is true – and the lack of dedicated supplementary prescribing teams within the industry seems to suggest it could well be – then a fundamental change in focus and structure will be needed to reflect this huge new group of customers.
A growing role for nurses in the NHS fits within all sorts of political agendas, so the trend is unlikely to be reversed. Sooner or later the industry is going to have to catch up, and that will be easier while there is still a relatively small number of qualified nurse prescribers rather than after the floodgates have opened.
The big opportunity
The good news is that for those prepared to rethink their approach, the door is wide open to take competitive advantage. Despite the wariness amongst nurses of what they see as 'big pharma' their new responsibility will require them to assimilate vast quantities of new information, and no one is better placed to help than the industry.
"Nurses' training budgets are always the first to be cut in the NHS," says Billett. "And yet information will be crucial to the system working. If pharma companies can change the language they talk, ensuring that their marketing materials and their professional relationships meet the needs of the new prescribers, they can become a very useful resource for nurses.
"Nurses still need the same level of information, but they talk a different language. They need their confidence in a product boosted, through real information. Nurses want education, not post-its and pens!"
In fact, education is only one part of the solution, according to Billett, who lists six things that pharma companies should be doing right now:
- A named link person for supplementary prescribing in each company: internal training of sales and marketing teams is crucial, and a champion will help achieve this
- Support and education for newly-qualified nurse prescribers
- Audit trails to look at experiences and prescribing patterns within the NHS; audit being an area where the industry has lots to teach the NHS
- Clinical management plans and Patient Group Directions: these will necessitate pharma companies working with each other
- Setting up and sponsorship of nurse-led clinics
- Masterclasses
Although most of these are relatively straightforward initiatives, they require a change in corporate mindset, removing the blinkered, doctor-focused approach which has dominated for years.
As Stuttle puts it: "Nurse and industry need to keep moving forward in the same direction. There needs to be a realisation that we are on the same side – we are both there for patients."
Supplementary prescribing is now a high priority Department of Health target for the NHS. Unless it becomes an equally high priority for the pharma industry, it will find itself alienated from a significant proportion of the prescribing community, missing opportunities to engage with a new customer group which, although initially wary, is looking to the pharma companies to help them effect a great change in the NHS.
How the industry handles the challenge over the next 12 months will have a lasting resonance on prescribing behaviour. It's time to pull our heads out of the sand.
