Super-rep: working with the new NHS
pharmafile | June 20, 2007 | Feature | Sales and Marketing |Â Â NHS, sales, strategyÂ
Every year could be called a watershed year for the NHS – it seems that constant change and reinvention is the norm. People in the pharma industry are probably sick of being told that the current year represents the biggest change in our national health system – even though its usually true.
Sometimes, however, fundamental changes take a few years to really have an impact, and that is one reason why the industry is not always quick to react to change – it's easier to wait and see. Unfortunately, this can often lead to the changes being forgotten among next year's big upheavals, which is fine until a sudden realisation dawns that things have advanced significantly, and the industry is not geared up to cope.
I'd like to suggest that this is what has happened with the big change made in 2004. Can you remember that far back? What earth-shattering event happened three years ago that we have omitted to deal with? Simple answer: supplementary prescribing.
The 'morphing' sales rep
First, the previously very limited prescribing powers of nurses were gradually widened to the point that suitably qualified nurses can now prescribe virtually any medicine. At the same time, pharmacists were given prescribing powers to help them play a bigger role in the management of long-term chronic illnesses – in many cases ending the need for patients to see a doctor in the first instance.
The recent encouragement for community pharmacists to contribute more to the provision of healthcare will only compound this process. And the consequences for pharma are widespread; in the future (in fact, in the present), working with these new prescribers is not an option. The question is, are we, as an industry, geared up to cope with this?
It used to be very simple. A rep would see a doctor, who made the prescribing decision, with a straightforward detail. If they were convinced, they would start prescribing that product, and if you covered the majority of doctors, sales would inevitably follow. For the rep, it was job done.
But in the new NHS, it's no longer really appropriate for reps to simply sell, even if they can identify all the prescribers and attempt to see them all – something which in itself is a vain hope. That means that sales reps must change their role, morphing from product promotion to true account management. The difference lies in having a real understanding of the varying needs of all groups of customers and building genuine partnerships to help meet those needs.
Much has been written about the death of the salesforce and whether it is still relevant as a model in this new diverse, health economics-focused environment. The answer is yes – but its role has to change dramatically.
"The empowerment of both practice nurses and pharmacists to prescribe a wide range of medications, together with the ongoing support by the government to deliver a new healthcare model, will need pharma companies to respond differently going forward," says Nigel Mansford, managing director of Pharmexx UK, an organisation which provides sales and educational support services to the industry.
Pharmacists and practice nurses who are undoubtedly competent in prescribing will need the education and support of the pharma companies to build confidence with the patient and with the new way of working."
Note the emphasis here on supporting the new prescribers. Mansford doesn't mention selling at all. Throw away the old paradigms, with their emphasis on short-term sales targets, and look to build a beneficial partnership: that seems to be the message. And it's one you'll hear from people within the NHS, too.
A new phase of prescribing
But it's not just the number of new prescribers which is presenting new challenges for the pharma salesforce: the whole area of self-medication is about to enter a new phase, according to Mansford. "As more products are being supported for re-classification from POM to P, we will undoubtedly see more of a shared care model emerging, with patient care establishing a base with pharmacist, doctor and practice nurse.
"Simple conditions once considered the domain of the doctor will be established at another level within the health service. Self-medication is an important industry and we must continue to support the existing brands and drive more patients to self-medicate."
Given that up until this point, the principle role of the salesforce has been promotional, where does it now fit in, and how can pharma achieve a situation where it works more closely with the new prescribers?
The first hurdle is to identify and understand who the new prescribers are, according to Jon Hodgson, managing director of Inventive Solutions. "We need to identify who these new prescribers are, and what, if any, communication and contact we have already established with them – they may already be target customers. Pharma will need to consider what level of prescribing these new prescribers are likely to be responsible for in the therapy areas where they operate and how this compares to existing, more established prescribers – does the potential prescribing merit target status and subsequent investment in promotion?"
The problem of customer accessibility
An equally important assessment to make is how accessible these new prescribers are, and if target status is justified, based on both prescribing potential and influence on prescribing. The decision will then have to be made as to what is the most appropriate means of promotion.
"This may involve the traditional salesforce if face-to-face communication is considered the best route, but equally, it may be the case that peer-to-peer communication is considered more effective," maintains Hodgson. "Equally, other forms of promotion such as e-promotion or direct mail might be the preferred route of engagement.
"Pharma needs to be aware of the potential for these important customer groups to grow; for example, nurse-led clinics and pharmacist medicines use reviews. With the advent of practice-based commissioning, PBC clusters will actively be looking for ways to offer patient services through more cost-effective routes.
"Services that have been provided by GPs may, in future, be more cost-effectively delivered by these new prescribing groups. Patients could potentially be triaged to determine whether they really need to see the GP or could be seen by the nurse or pharmacist. This could speed patient access to care."
All of which means the way primary care is delivered in many settings will change, and pharma needs to be able to adapt to these changes, and potentially help shape that future.
…but don't pension off the salesforce yet
Hodgson's colleague Wendy Gee, head of nursing at Inventive Solutions, maintains that there is a role for the salesforce in this new structure – albeit working in partnership with others in the industry and within the NHS itself.
"As an independent service provider, we have worked with numerous pharmaceutical PCT initiatives within formulary rationalisation, a service which is delivered by an independent nurse advisor supporting appropriate prescribing and cost savings to the NHS.
"Our services are set up with input from pharmaceutical reps, GPs or community pharmacists, along with our nurse advisers who are required to facilitate the process and ensure that patient notes are reviewed in line with local clinical protocols."
Gee sees a central responsibility for the salesforce when it comes to pharmacists, too. "It is evident that community pharmacists are given tight timeframes to deliver formulary rationalisation within their locality and therefore welcome pharmaceutical support with the introduction of independent service providers to enable a more efficient, effective and timely delivery of this process. Therefore, the salesforce is paramount in targeting specific community prescribers in line with their product to facilitate an offering of an independent service function."
If there is an important role for the salesforce to play, then what adjustments need to be made to accommodate these new customers? As we have already seen, transforming reps from salespeople to true account managers is central to success, not just with the new prescribers, but right across the changed NHS.
Time to say farewell to the seven-minute detail
Much of this requires a much better insight into the needs of the diverse customer groups, and this, in turn, requires a new approach, one based on listening to their needs rather than the traditional model of trying to sell them what is on the detail. One of the key things to understand is that the different prescribing groups will respond better to different styles of engagement, so the salesforce will have to widen its activity beyond the old-style seven-minute detail. And the tone will also need to change, probably taking a more educational and scientific character than a promotional one.
Given the sheer numbers of prescribers, and the bewildering diversity of who they are, the use of key opinion leaders and other clinical advocates will also probably come into the equation.
Mike Stowe, senior operations and business development manager at Pharmexx International comments:"For traditional pharma companies which currently call on GPs, more time will be required to be spent with the new prescribers. The use of up-to-date, efficient educational modules, which are delivered using the latest technology, will enable pharma companies to build on the success of working with all members of the healthcare team delivering patient care that is shared.
"The use of data in establishing essential links between professionals must also be considered and we should facilitate that delivery, whether that be through patient advice and information, or checklists for more serious conditions, that allow for the correct detection and medication from pharmacist to GP's surgery."
When it comes to engaging with the nurse prescribers, the appearance of specialist nurse adviser teams in recent years is perhaps a sign of yet another transformation of the 'salesforce'. Wendy Gee is, understandably, a strong advocate.
"Independent nurse adviser teams are given better access to prescribers and hold a clear professional relationship within their given code of conduct. The role of the nurse adviser supports appropriate prescribing and cost-savings to the NHS, and works within a tightly regulated process, which is welcomed by community prescribers.
"Successful delivery of clinical care within both audit and clinics over the past years means that the nurse advisor is now widely respected within primary care. Our on-demand chronic disease team has worked closely with pharmaceutical companiesand community pharmacists to assist in the delivery of formulary rationalisation, and due to their wealth of experience and expertise, both in disease management and commercial acumen, they have successfully delivered various services."
In Gee's experience, problems around using nurse adviser teams tend only to present themselves when services have not been fully briefed to the GP or prescriber, or where resistance is shown due to a lack of knowledge regarding confidence in using independent nurses – so using existing service providers with a credible track record is vital.
Long live the salesforce
But are such teams part of the salesforce? Certainly not in the traditional sense, in that they are not selling as such, but they are part of the customer-facing pharma team, they are managing relationships with key contacts, and building genuine partnerships to drive forward patient care in the NHS. And it's difficult to write a better definition of what the salesforce should be in the future.
Only die-hard traditionalists will mourn the passing of the old-fashioned rep – which is something very different from saying that the salesforce is dead. It just has to transform itself to adapt to the new market, and right at the centre of that is a huge bunch of prescribers who simply weren't on the sales radar before 2004 and, in some cases, haven't even been since then in a meaningful way.
Mike Stowe agrees that we should be viewing this particular change positively. "Pharmacists and practice nurses are well qualified to be able to prescribe and advise on conditions and patient medication, and we should all welcome this change of 'job function' which allows for greater use of the skills that are already in place. More importantly, it allows for a more efficient approach to patient care going forward. It's up to us within the industry to support each group with the best possible information and advice that allows this process to be successful."
Or put simply – the huge changes which were ushered in with the introduction of supplementary prescribing in 2004 are all part of the move to put patient care at the centre of our healthcare system.
Engaging with these new prescribers will require a similar approach from the industry. That means a significant rethink and remodelling of its salesforce role – but then you already knew that would be needed this year, didn't you?
Andy Newman is a freelance medical journalist. E-mail: andy@newmanassociates.co.uk
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