Since 1999, an increase in the number of representatives has coincided with a reduction in GP visits. Ian Kennedy explains this apparent contradiction and how appointment-booking technology is encouraging practices to open their doors to representatives again.

SINCE THE MID 1990s it has been possible to model the relationship between the number of pharmaceutical representatives and the market share or revenues achievable from, not just a product, but a portfolio of products, promoted by a field force. These models also helped companies to understand the effect of co-marketing and co-promotion. Although based on historic data samples, often insignificant statistically, these models are still used.

By 1999 a number of observers, including the ‘Jigsaw’ people ‘ISIS’ (now known as Synovate), were commenting on the phenomena of decreasing access to doctors in an environment where sales teams were getting bigger and there were more teams, supplemented by contract sales forces. Their paper, first published in February 2003, showed how access had diminished. Monthly detailing numbers fell by 25% between the end of 1999 and the end of 2002, and GP visits fell by the same proportion. In the same period, the number of reps increased by an amazing 40% from 5,000 to 7,000! Today in the UK there are 12,000, of which 10,000 call on primary care. You might ask what the relationship is between these two variables. Were the reps hired to compensate for the falling details? Or were the falling details caused by the increase in reps? I’m fairly confident it is the latter.

The ‘Arms Race’

Competitiveness between pharmaceutical company’s sales and marketing departments intensified across the 1990’s and right into the new millennium. With sales forces constantly growing, the phenomenon was dubbed ‘The Arms Race’. The USA pharma field force strategies were blamed for unduly influencing UK field force sizes. The battle for the doctor’s attention by a multiplicity of reps in the USA was replicated here. And the same thing happened; too many reps calling on healthcare professionals resulted in ‘closing doors.’

Wall Street watchers feared the ever-increasing competitiveness where no one company would be brave enough to ‘right-size’ its sales force. Even the industry’s top CEO’s started to comment. On February 10th 2005, GSK’s JP Garnier commented, “if sanity can be restored and the Arms race starts to slow down, it will be good for the industry. We do not need these large sales forces to do the job. We need them because the competition is trying to increase their noise levels.” The following day, Pfizer announced a major re-structuring of its sales efforts, a restructuring which eventually led to the redundancy of 20% of its US and European sales forces in late 2006 and early 2007. This was followed by comments and action from Bristol-Myers-Squibb and MSD, and then AstraZeneca’s Tom McKillop was quoted as saying, “there is perhaps a saturation of sales and marketing effect”. Wyeth CEO Bob Essner then joined in by stating, “I think we have to be very careful about thinking about the number of people in the field and making sure Wyeth builds relationships with our customers through our representatives.” So the signaling between companies took place in 2005, but it is now that we are beginning to see major reductions in field forces, with other big companies starting to follow in Pfizer’s footsteps.

Diminishing Access

In the meantime, our very own UK NHS is changing. Everyone in a primary care practice has been, and still is, affected by the ‘new’ GP contract, now in its third year. It has more than doubled the administration load in the practice, it has necessitated new and improved workflow processes in practices, and, of course, it has apparently made GPs considerably richer! Nevertheless, more patients are being seen, and seen more quickly. Practice managers and PCT staff have had to focus on this and, in many cases; processes that do not focus on the patient are being eradicated. Unfortunately for the field forces, it is often the ‘medical’ reps (pharmaceutical and non-pharmaceutical) that are omitted from today’s primary care processes.

All too often, primary care staff have commented on the fact that there are too many reps queuing up for appointments, occupying space in the waiting room or causing congestion on the ‘phone system.

GPs have objected to the multiplicity of reps promoting the same product to them. When a practice manager takes action against this it is perhaps not surprising that the first solution they think of is to close the practice to medical representatives. Unfortunately this is what has been happening, and it is a continuing trend. The ISIS study predictions (see graph) show that the main core of doctors will continue to reduce or ‘limit’ the reps they see. Those that choose not to see reps at all increases substantially. The findings of the ISIS study in 2005

A Technology Solution

The closing practice phenomenon is most marked in certain geographies. At the time of the new contract in April 2004 most practices in greater London would not see reps. In areas such as the North East, East Anglia, and Scotland, the number of closing practices was marked and the trend continues.

‘On-line’ appointment-booking technology provides one solution to this increasing problem. The mediary^® online practice diary allows rep appointments to be collected online, and has been welcomed by primary care practices struggling with increased administration, the need for improved workflow processes and patient access issues. The service provides a solution for those practices that were critical of the number of reps and their interventions in the primary care process. No more queuing, or ‘phoning, or driving for miles by the reps, as they collect their appointments online, and when a rep comes to the surgery they have exclusivity for their ‘networking.’

Instead of practices just closing the doors to reps, the whole process is taken out of the patient management workflow. Due to criticism that the service might have been against the ABPI Code, it has been rigorously designed to ensure compliance and no fee is charged at the point of use for the service. The mediary board of management even went so far as to provide total transparency to an advisory group consisting of a former Minister of Health, former Head of the DOH and three industry CEOs.

The Future

Since the introduction of mediary’s electronic diary, we have recorded practices that have closed to reps, and those that have either re-opened or stayed open because of this online service. Little more than 66% of practices make appointments for reps to see customers. The remaining 33% either do not see reps or they see them speculatively without appointment. mediary market research indicates that around thirty of these appointment practices per territory will adopt the online appointment making system over the next two years.

Online appointment-making offers the benefit of improved relationships with customers who are happy to see the pharmaceutical and medical industry’s reps at the time they decide to put aside for them, not when such interventions are an inconvenience. It is a win-win situation.