The healthcare system has undergone radical changes under the last two governments and the pharma industry has been forced to shift its sales priorities to take care of the bottom line. The creation of Strategic Health Authorities (SHAs) and Primary Care Organisations (PCOs), means the traditional sales target - the doctor - has relinquished some of their decision making power over prescribing and must work to set guidelines and protocols concerning both patient care and costs. The impact of these changes for pharma means an extra tier in the sales process with more people to sell to than ever before.

Christine Fearnley, field sales manager at Shire Pharmaceuticals says there has been a large priority shift into primary care and their sales teams have had to be dynamic in responding to changes in the company's business needs. As the NHS evolves and the company portfolio changes she says "structural and functional changes have been made along with additional support for staff training and development." Clearly pharma recognises and is responding to the rapid nature of the changes taking place in its marketplace.

"The fact that the NHS is undergoing enormous change means that the market has become more sophisticated and complicated in terms of selling pharma products," says  In2Focus chairman Steve Kerridge. "To be successful, pharma companies and sales organisations need to fully understand these (NHS) changes and the affect they are having on the key customer - the doctor."

"The most important change in the NHS environment is the shift in who makes the decisions when it comes to both purchasing and prescribing. The creation of PCOs means that formularies are being developed and access to key decision makers is becoming increasingly restricted."

Mr Kerridge says the groups involved in both purchasing and influencing purchasing now encompass a combination of health professionals and managers in different therapeutic areas. "Technically, GPs still have the choice to prescribe what they want, however the peer pressure and the collective decision making process within the PCOs make it difficult for individuals to rebel.

NHS decision makers change

"Reaching decision makers within the PCO is difficult. As elected representatives of the GP group, the individuals responsible for the prescribing formulary are known and heavily targeted - putting pressure on their time and receptiveness to sales approaches is challenging," he adds.

Along with the traditional sales and nurse teams, In2Focus offers: IT products and services, research, consulting and training programmes. This reflects an increasing trend among contract sales organisations (CSOs) and those offering customer relationship management (CRM) services  - a definite sign of the times.

"In the past," Mr Kerridge explains, "sales organisations like ours were only used to plug vacant medical sales territories, or to give an extra boost to launch a new product. Now pharma companies see us as an essential element of their strategy to implement successful marketing programmes."

Regulations and mergers

Mr Kerridge also points to other changes in the sales environment, saying regulatory bodies such as the National Institute for Clinical Excellence (NICE) have also affected new product launches. "Uncertainties surrounding NICE recommendations and the consequent affect on prescribing have led to a need for enhanced resourcing flexibility when products finally get the green light."

Graham Hawthorn, co-founder of Integrated Healthcare Solutions (IHS), sees NICE recommendations and National Service Frameworks (NSFs) as a business opportunity for salesforces. "Any company that can get its product recommended by NICE needs to capitalise on that commercially, communicating that to PCTs. The more credibility you can get behind your product, the more likely it is going to be used and approved," he argues. "Doctors are not only under pressure to provide value for money from the health authorities and their peers, but also from new government organisations."

He adds that GPs will now be influenced by their targets for the new GMS points and that decision makers have to ensure that their chosen prescribing options fit in with local Health Improvement Programmes and NSFs in key therapeutic areas.Mr Hawthorn believes that patent expiry issues also mean companies need to accelerate sales uptake later in the product lifecycle to maximise impact and that changes to the NHS do not occur in a vacuum.

"While the NHS is changing at a rapid pace, so too is the pharmaceutical industry. As more companies find themselves involved in mergers there is a greater need for flexibility in terms of sales and marketing, both with regard to sudden downsizing and upsizing in order to manage new portfolios.The combination of these changes demand a repositioning of sales organisations and a greater flexibility in the resources they provide. Pharma companies find consulting services an increasingly popular part of their portfolio in an effort to more carefully target its audience and adapt to NHS modernisation.

In2Focus offers market intelligence and Mr Kerridge says that pharma companies make contact at all stages of the product lifecycle. "We help plan their pipeline strategy and new product development programmes, evaluate factors that contribute to brand awareness and usage and protect brands as they near the end of their product life."

Mr Hawthorn also considers consulting to be an important part of the sales process and says CSO/CRM companies are building on the uncertainty the industry feels about tackling the changing NHS. "They know it's changing but don'tknow how to attack. Contract sales companies can offer solutions with advice about that changing environment," he says.

Peer-to-peer approach

IHS also uses peer-to-peer approaches, with doctors being deployed in traditional sales roles in specialist areas, like oncology, to target specialists that were proving difficult to access. Mr Hawthorn describes the peer-to-peer dynamic as a "very powerful" way to access and sell to key consultants and opinion leaders, and says it has a "credibility that you can'treplicate". He also believes doctors working in a sales environment are in a better position to challenge colleagues and peers, perhaps uncovering the truth as to why a drug is not being prescribed, providing a useful information link for the pharma company.

More than just a sales call

One way to optimise rep visits is to think in terms of more than just a sales call. Ms Fearnley says: "The number of reps and customers has not changed much across the UK, therefore they have to add more value to their calls. Clinicians are under a great deal of pressure so there has to be added value over and above a call, that can help the customer meet their objectives as well as the patient."

Shire has specialist units for primary care and hospital sales, and relies on permanent headcount ranging from fresh graduates to experienced reps. Instead of importing its salesforce in on a temporary basis, Shire's secret to success is to develop sales careers within the company, vigorously recruiting reps looking for career progression. This practice of retaining talented individuals is its weapon of choice, when it comes to battling for a slice of customer attention.

However, turnover is not synonymous with contract sales; In2Focus also believes in retaining and training their staff. Mr Kerridge explains: "It's vital that the turnover of sales reps is kept to a minimum, securing continuity over crucial launch and development phases. A high level of investment in developing the capabilities of sales teams is needed, both in terms of training and assessment."

All this has to be achieved  at the same time as gaining access to the changing customer base but the benefit of experienced contract teams is clear - increased levels of customer knowledge, continuity and quality of sales outcomes.

When should a pharma company typically begin to consider salesforce issues? Salesforce allocation is usually structured around the priority of products in a company portfolio, but many companies still leave it very late to bring the CSO on board.

Mr Kerridge says: "We are typically approached around the time of launch but forward-thinking companies are getting us involved earlier in the planning phase to make sure that the most effective teams are deployed.This early entry strategy is an increasing industry trend, with Mr Hawthorn explaining that the changing environment means "actively targeting companies that have launches coming up in the next 12 to 18 months An existing product which needs a push, a "kick-start" could be the reason pharma calls in contract staff.

"It could be a rival product about to launch or that the product itself is under generic threat within the next 12 to 18 months or particularly for small-to-medium-sized companies it could well be that they are required to out-think, rather than ou-muscle some of the big pharma companies.

New approaches for new targets

This area is certainly where he sees IHS' new PCT-access teams benefiting clients. He explains that the company's sales solutions are geared towards the changing NHS and its interaction with industry. The PCT-access team initiative, unique to the UK, comprises doctors that "speak to their NHS peers and colleagues on behalf of industry".

The rationale behind the teams, is that  access to the key people within the NHS is certainly more challenging, so there are bigger decisions being made by smaller groups of people and the pharma industry has to ensure they target and access them. "The aim of the team is quite simply to open the doors to those decision makers," says Mr Hawthorn.

One way in which In2Focus is satisfying the need for new sales approaches is with co-funded teams, something which the company believes it pioneered. Mr Kerridge says: "The model is based on two companies sharing a single salesforce, promoting only two brands and each co-funding partner receiving 50% of all in-call activity, meetings, etc.

He argues this enables a higher quality sales interaction and pull-through of product sales. This compares well to the traditional 'Jack of all trades' syndicated model where teams can have up to six different companies vying for their time, leaving the teams with a corresponding number of different products.

Changing relationship with GPs

Given the changing environment, and the parameters within which they now operate, are NHS doctors still worth pharma attention? Mr Hawthorn says: "The GPs are a target, but for years protected their right to prescribe. What seems to be happening is that PCTs - and there about 300 in the UK ­ are becoming more influential in terms of telling the GPs what they can prescribe. There'll be an approved list or an approved formula and for companies that don't have their product approved at PCT level there will be less relevance, and in some cases, no point in having reps selling to doctors, because the doctors will have their hands tied. Companies need to ensure they've actually got their product endorsed by a PCT and then deploy reps at the ground level to go in and encourage GPs to prescribe more of it.

"In the past pharma companies had a business-to-consumer relationship and sold to GPs who then prescribed the product. With the advent of PCTs, it's almost like a business-to-business-to-consumer relationship, with the PCT being the middle business. It has changed the dynamic of the sales process; it's now a longer, more complicated process.

Mr Kerridge says the best way industry reps can optimise drugs sales is by targeting an ever-increasing range of decision makers. "While the GP remains a key target, sales representatives also need to reach the PCO, pharmacist, members of the PCO prescribing committee, the health authority on big issues, and the supplementary prescribers."