The NHS Five Year Forward View outlined how the NHS should change. It described three improvement opportunities: a health gap, a quality gap, and a financial sustainability gap. It also proposed a series of measures to bring about the “triple integration” of primary and specialist hospital care, of physical and mental health services, and of health and social care.

For 2017/2018 the National Service Improvement Priorities for the NHS are:• Improving A&E performance.• Strengthening access to high quality GP services and primary

care.• Improvements in cancer services and mental health.

How effectively the NHS implements the proposed changes is as always very much open to question, however the landscape continues to change.

What Isn’t Changing in the NHS?Irrespective of government policy and current priorities, certain factors are predicted to be ‘constants’ for the foreseeable future. Three key constants which are of most relevance to the pharmaceutical industry are:• Budgets within the NHS will be limited,

perceived as “never enough” and therefore the cost of treatment including cost of medicines will constantly be challenged.

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• “Capacity” to treat patients to the standards required by the NHS and patients will in many areas be scarce and again perceived as “never enough”.

• The NHS will continue to flex its “buying power” and demand increased value for those suppliers it chooses to do business with.

Competitive Positioning for PharmaGiven the above competitive landscape, pharmaceutical companies are carefully analysing how they should compete when positioning their products in the marketplace.

Michael Porters view of competitive strategy is that, to succeed, a company needs to make strategic decisions based on a value-cost trade off, and either compete through differentiation or alternatively via low costs. Therefore, in environments where pharmaceutical companies are promoting “me too” products in competitive areas (often defined as “red oceans”) the winners will

be those companies that either provide true differentiation in a way attractive to buyers, or alternatively supply their products at a price which is attractive to those buyers. Companies that provide no perceived differentiation or cost advantage will perform sub optimally.

W. Chan Kim and Renee Mauborgne developed this thinking further in their books “Blue Ocean Strategy” and “Blue Ocean Shift” by describing companies that develop new strategies by breaking the value-cost trade off, which opened a new market space where both differentiation and low cost were possible. An example of this in the pharmaceutical industry market would be the introduction of a new first in class medicine, backed up by excellent data, a competitive price and with no real competition.

In Apodi’s recent experience the clear majority of brand teams we engage with are swimming in “red oceans” and seeking ways to be successful in highly competitive sectors, where their customers perception is that product differentiation is limited. Much of this papers content is aimed at commercial teams facing this type of situation.

Current Promotional StrategiesOver the last four years, some pharmaceutical companies have become increasingly sophisticated and effective in how they aim to promote products in the marketplace, particularly those companies launching specialist medicines. Some of these best practices will be noted later in this paper, however, sub optimal promotional strategies are still common and may include, but are not limited to, the

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The Changing NHS

How effectively the NHS implements the proposed changes is as always very much open to question, however the landscape continues to change

The paper serves as an update to a previous paper published by Apodi in 2014 and considers the challenges faced by pharmaceutical companies in addressing the changing competitive landscape within the National Health Service (NHS) in the UK. The principles outlined in the paper are applicable to several healthcare economies, as are the challenges they address.

following types of situations and activities:• A focus on “noise” only to create the maximum use of

product. This is normally in the form of large traditional sales forces focused on a reach and frequency model. Several companies have attempted to increase the value of this promotional resource through key account management (KAM) structures. However, in many cases this structure has not changed the nature of engagement with the NHS. Much of the work undertaken by KAMs remains as the traditional product focused sell, rather than with a focus on true value.

• Several new products being launched are “me too” products with minimal differences from existing therapies and no proven data in improving patient outcomes over and above existing standards of care. Even when companies launching such products feel they have a unique selling point, their key customers (i.e. HCPs in the NHS) view is that there is very little difference between all the therapies currently available and therefore choices should be made on acquisition costs alone. In such situations companies are experiencing significant problems in getting market traction due to a lack of real (i.e. perceived) differentiation or enough of a cost advantage. The general view is that most new launches in the UK over the last few years have failed to meet the expectations of pharmaceutical company shareholders.

• Some companies focus very narrowly on the drug that they sell, rather than the role the product plays in the overall cycle of care. As a result, companies are very selective about the benefits they promote and often ignore the impact a product may have on the overall care pathway. In such situations, companies appear often to be surprised when the NHS adoption of their therapy doesn’t meet their expectations.

In addition to some of the challenges outlined above, it is also worth noting that traditional promotional strategies are now not working as effectively as they have in the past. General practitioners (GPs) often don’t want to engage with sales representatives and clinical commissioning group (CCG) decision makers are closing the doors on KAMs. Several reasons for this shift in access behavior have been put forward, including the current time pressures NHS staff are under. However, a fundamental principle of accessibility will always be the perceived value that any engagement with pharma personnel brings. Current evidence would suggest this seems to have diminished from the perspective of the pharma industries most important customers (i.e. the prescribers, or prescribing influencers).

Traditional promotional strategies can however be a natural reaction to the competitive landscape that companies face in the marketplace. Particularly given that ineffective measurement systems within the NHS mean that those companies focused on the provision of value across a whole care pathway often don’t get rewarded for the value that is created in that pathway. Furthermore, the compliance and regulatory environment in which promotional activities can be delivered make it difficult for

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companies to:• Engage effectively with the NHS.• Help drive improved patient outcomes and at the same time

drive product uplift.

As a result, it is often easier and less risky for companies to revert to type when making investment decisions about the promotional strategy to be deployed.

The challenges faced by commercial teams are not all “doom and gloom” however, as with any highly demanding and difficult market, there are opportunities to stand out from the crowd.

The Opportunity for PharmaIn 2006, Michael Porter (in partnership with Elizabeth Teisberg) used his considerable expertise on competitive strategy to address challenges of the healthcare system in the U.S.A with the publishing of the book “Redefining Health Care”. This envisioned a health care system focused on improving

value where all products must deliver better results or lower costs for the same results with ‘me too’ products either being improved, repriced or phased out. The book also identified new opportunities for suppliers such as pharmaceutical companies.

Forward thinking brand teams are developing these and other opportunities to promote products in a way which is perceived as offering real differentiation. Examples of such strategies include:• Delivering unique value to patients over the full cycle of care

– focusing on care not just product through the support of patients and the heath care provider.

• Demonstrating value based on studies of long term results and costs of alternative therapies.

• Ensuring products are used by the right patients.• Ensuring products are embedded in the right care delivery

processes.• Building promotional campaigns based on value, information

and customer support.• Offering support services that add value rather than reinforce

cost shifting.

Pharmaceutical companies that start to engage with the NHS by delivering real value to the NHS will be rewarded with:• Improved knowledge of the care pathway.• A better reputation.• The ability to deliver more differentiated services.• The opportunity to develop better value products.

Developing A True Value Based Promotional ModelIn our original White Paper, we noted that several pharma companies were beginning to adapt to this new environment and that these companies would develop an “early mover” advantage by improving their sales structures, marketing campaigns and their ability to collaborate more effectively

It is important to note that these Companies are not totally abandoning the more traditional models of promoting products

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with their customers. We predicted that this change in the competitive landscape would be accelerated but in 2014 noted change was still slow.

In 2018, this change has accelerated with some pharmaceutical companies embracing value-based models particularly as more specialist medicines are introduced. Typical characteristics of this activity are as follows:• The deployment of key account manager teams or patients

access manager teams who are totally focused on delivering value to the NHS and patients.

• The introduction of “customised, flexible” solutions to local health care economies that take advantage of any one or more of the opportunities noted in the previous section.

It is important to note that these companies are not totally abandoning the more traditional models of promoting products. They understand that the key to successful brand promotion is to identify the most appropriate solution based on the

Case Study 1 – Integrated Promotional and Partnership Model

Situation: An established, company with a dedicated team of 30 territory managers. Detailing effort, for their premium dermatology product, was to a traditional cohort of primary and secondary care HCPs in a competitive busy marketplace with the following characteristics:• Diminishing access in

Primary Care.• Lower priced competitor

products driven by CCG endorsement and formularies.

• Declining sales.• Restrictive target customer

lists drive by Rx value.• High patient satisfaction

with the product vs. a GP perception that the product was too expensive to prescribe.

• Strong health economics data demonstrating increased patient compliance and cost effective long-term prescribing with limited team skills and capability to deliver impactful messaging.

Apodi Solution: Via collaborative joint-working with the client company it was decided to re-focus, re-frame and re-train the entire team of territory managers into key account managers and specialised development managers with a focus on adding value and creating a sustainable platform for product growth• Newly created 22 key

account managers and 8 development managers.

• Re-focused, re-targeted and re-trained the team to deliver value-added detailing and concise, localised health economics data to key HCPs and CCGs to demonstrate the true value of the product versus the unit cost.

• True key account management with the KAMs assuming full responsibility for their healthcare economy via individual account planning and the removal of restrictive target call lists.

• Additional traditional, flexible detailing via an experienced syndicated team to ensure consistent, high quality product messaging was delivered to drive the delivery of product benefits versus competitor products.

Outcomes: A highly skilled and energised team who take full accountability for their specific geographies by managing those customers who can directly impact their business via formulary and prescribing decisions. Allowing:• A successful mix of

traditional detailing and specialised value-added account management.

• Maintenance of an experienced, highly successful salesforce with the ability to switch efforts in line with new product pipelines and strategies.

• Increased formulary adoption and advocacy of value vs. unit cost.

• Increased market intelligence leading to valuable insight into market dynamics and formulary threats allowing proactive interventions with key stakeholders.

• Retention and maintenance of key formularies including Bart’s and Alder Hey.

To supplement these approaches Apodi has also introduced its innovative Sourcing: Speed: Duration Model to assist companies in identifying the most appropriate value based programmes specific to the individual circumstances that the companies face and the requirements of patients and

the NHS. These programmes address one or more of the following challenges:

Sourcing: Sourcing development programmes are about finding suitable cohorts of patients to enter a pathway.

Speed: Service development programmes which can address capacity blocks and drive patients through pathways as quickly and efficiently as possible and deliver improved access to medicines.

Duration: Duration programmes are about supporting patients on their treatment to improve concordance and adherence and thus improve time on therapy.

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competitive environment the specific brand faces. In some circumstances this will mean the more intelligent deployment of traditional methods of promotion, albeit implemented through more highly educated representatives, or via intelligent customer interactions delivered by highly accountable and empowered key account managers (not just rebranded representatives) who can deliver value in every call.

Apodi still recommends a promotional model that mixes the traditional (but modified) practices of the past with the value-added model of the future. We call it the Integrated Partnership and Promotional Model. The competitive landscape has still not changed sufficiently at this point in time to justify a more dramatic shift. However, the Integrated Partnership and Promotional Model provides the flexibility to encourage pharmaceutical companies to adapt in parallel with the changing environment within the NHS (see figure 1).

The case study below demonstrates how an evolving promotional strategy can maintain access and achieve sustain-able value-added interactions for the company and the HCP.

Summary examples of recent Sourcing: Speed: Duration Model programmes designed and deployed by Apodi for our clients are illustrated in the case studies below:

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Case Study 2 – Sourcing and Speed: Addressing the Challenge of Improving Patients’ Access to Newer Therapies

Situation: A slower than anticipated adoption by primary care of a new class of medicine in cardiovascular medicine largely driven by:• Relatively low confidence

in primary care around initiation despite positive NICE guidance.

• Poor GP understanding of the cohorts of patients who would benefit most.

• No mechanisms in place for bringing suitable patients in for review and assessment on a regular basis.

• Consultant led prescribing was slow to permeate out to GPs.

Apodi Solution: A programme of “Integrated Care Clinics” was delivered over a three-year period, which:• Brought secondary care

into the community in an integrated manner.

• Identified many patients who were eligible for newer agents in line with guidance.

• Delivered a convenient “one-stop-shop” to patients.

• Left a legacy of improved understanding in primary care.

Outcomes:Nationally the programme delivered:• A consistent increase in

review and treatment in line with guidance.

• A 30% increase in appropriate prescribing in line with NICE guidance.

• An average of 4.3 recommendations for new product class were made per clinic.

• Surveys demonstrated a high level of patient experience and satisfaction with Net Promoter Scores of > 76%.

Figure 1. The Apodi Integrated Partnership and Promotional Model

Commercial Account ManagerSecures and manages win:win agreements with CCGs which incorporate value solutions in the care pathway.

Apodi Healthcare Value SolutionsManaged Care Programmes helping CCGs and HCPs identify, educate, triage, treat and manage patients.

Promotional / Educational ResourcePull through favourable guidelines from the CCG in Primary Care to capitalise on specific opportunities for Company Brands – not ‘detailing’ the brands.

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Case Study 3 – Speed: Addressing the Challenge of Patient Activation

Situation: A lower than expected uptake in prescribing of a specialist consultant-initiated medicine, mainly caused by:• Lack of capacity and

specialist nurse time in secondary care to implement initiation and carefully titrate the therapy with the supporting information necessary, to ensure patients were stabilised before being handed over to primary care.

• Long waiting times for access to the therapy due to already oversubscribed outpatient clinics.

• Reticence of primary care to receive a patient into their care unless they were stable and low risk.

Apodi Solution: Apodi designed and deployed programme of specialist nurse led, therapy specific, “Initiation and Titration Clinics” which were delivered in participating trusts as a package deal to overcome these capacity challenges.

Outcomes:To date over 4,000 patients have attended clinics and have been stabilised onto their medication before being passed onto primary care.

Patient feedback scores have been excellent with Net Promoter score of 94%.

Current trusts are extending contracts and have rated the service as highly valuable.

The programme is expanding across more trusts.

Most patients are successfully stabilised onto therapy with very low discontinuation rates driving an attractive client ROI which warrants continued investment.

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Driving Value into The NHS NowThe first step in developing a value-based promotional model is to decide on the appropriate value-based solutions the pharmaceutical company wishes to deploy for its customers. Once these are identified the company can then set about transitioning its sales force structure and how it markets its products and services.

Fundamental to the process of transition, is an understanding of the competitive landscape. The move towards a value-based environment is taking time within the NHS. Therefore, it is important that companies pace their rate of change in parallel with the rate of change within the NHS. A mix of traditional and more value-based promotional strategies are likely to be most effective at the current time.

a) Improving the Value of “Noise”Many commentators suggest that the noise model is dead and that companies need to look elsewhere to drive sales performance.

This is misleading because creating noise is hugely important in any sales environment. The key is the content and whether it is effective. The traditional representative is finding access increasingly difficult as GPs face growing patient demands and administrative burdens. GPs often see interactions with representatives as providing little, if any, value and are simply not willing to spare the time to listen to a detail. In instances where GPs do perceive value is being delivered, they are more likely to open their doors and engage in a manner which presents an opportunity to influence prescribing behaviour.

Put simply, pharmaceutical companies should be looking at a sales structure model that encompasses the following characteristics:

NOISE+VALUE= EFFECTIVENESS

Some observers believe that the pharmaceutical sales representative is one of the world’s most under utilised resources. For most companies, their representatives are still the people who interact with customers far more than anybody else. These customers appear now to be even more important in the buying process and therefore common sense would seem to indicate that representatives’ role is more important than ever, not less so. Yet the only way that this can be the case is if the role of the representative changes from delivering a detail to delivering value, otherwise customers will continue to refuse access and react negatively to any interaction.

The footprint of a successful and valued HCP interaction should include as a minimum:• Intelligent conversations with customers about the care

pathway with, of course, the role of product within that pathway.

• Consulting to, and with, the customer about therapies and disease areas.

• Advocating improved patient outcomes and assisting GPs in delivering them.

• Providing additional value based on the individual preference and needs of the customer.

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As highlighted earlier, one of the key constants in the NHS going forwards will be enormous time pressure, and therefore any new role for representatives must also be supplemented with new ways of accessing customers, for example through multichannel processes which deliver engagement and value in an acceptable manner and at a time and place driven by customer preferences.

b) Why Customized Value WinsA key role of the engine room is to provide value to customers that is value over and above that provided by competitors and so enabling the company to grow market share. Historically, much promotional activity to GPs has been based on a key fact, that all the customers are the same. This is obviously not the case. However, marketing departments wishing to provide customised value to customers are often unable to do so for several reasons:• Representatives and others are not skilled in nor indeed

tasked with identifying individual value requirements of customers.

• Technological solutions have so far been found to be ineffective or companies have failed when attempting to execute them.

Pharmaceutical companies need to visualise their solutions in the broadest sense and ensure that the total value offering includes:• The core product (i.e. the medicine). Clearly this is a hugely

important part of the overall value proposition including efficacy, evidence, safety, treatment characteristics, place in pathway, cost effectiveness etc.

• Enhanced value solutions – these can include additional services, such as promotional and marketing communications based on clinical and cost evidence (real world data) to help providers make better choices and improve healthcare delivery. Patient and clinical help lines, product support, access to key opinion leaders, staff training, services that improve the patient experience and so on.

To provide this value in a customised way, the company needs to find out from the customer what value means to them, collate the information effectively and deliver that value. Companies are starting to pilot closed loop marketing solutions aimed at doing

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Case Study 4 – Speed and Duration: The Challenge of “Patient Monitoring”

Situation: The slow uptake of a very effective specialist medicine in an oncology setting due to:• The high level of patient

monitoring required over the first few weeks of therapy.

• A lack of cancer specialist nurse (CNS) time and capacity to deal with additional monitoring requirements for the product and to offer ongoing patient support.

• Patient preference not to have to keep coming back to the trust for additional monitoring to be carried out.

Apodi Solution: A pilot programme has been deployed involving placing “Apodi Specialist Flex-Nurses” into key trusts to act an immediate point of contact for the patient once the decision to prescribe the therapy has been made and patient consent obtained.

The Apodi specialist nurses deliver patient initiation and monitoring activities which can take place from within a clinic in the trust, or a locality clinic, or a homecare setting dependent on trust preferences and protocols.

The Apodi team delivers ongoing patient support (homecare and telephone based) once the monitoring period is over to maximise patient concordance, adherence and time on therapy.

Outcomes:Nine oncology units have enrolled into the pilot programme and have an Apodi specialist nurse working with them who is dedicated to support patients prescribed the client’s medicine.

Over a hundred patients have enrolled in the first few months and are receiving a high level of support and monitoring delivered by their named nurse.

Patient feedback is extremely positive with:• 100% of patients felt they

were treated with dignity and respect.

• 100% of patients feel listened to and any concerns have been answered.

• 85% of patients feel they understand their treatment much better than before.

• Overall Net Promoter Score of 90.

Trusts are looking to expand the programme to match the increased demand on capacity. The client has deemed the pilot to be a success and wishes to roll the programme out nationally.

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just this. These are of course helpful, but the key is educated people trained and armed to identify and deliver value to every healthcare economy.

Conclusions:In the changing landscape of the NHS today what are the key challenges and solutions?

The challenges in our view centre around the ability to engage with customers in meaningful ways which allow the customer to recognise the added value from the interactions they are having as well as the value being brought to their investment decisions around which therapies to recommend. Failure to do this will reduce customer access and open opportunities for the competition.

All customer interactions should be delivered by empowered, informed and appropriate staff at the right time and with the right speed of delivery and all solutions deployed must be based upon delivering value initiatives which create success for patients, success for the NHS and deliver a reasonable return on investment for the pharma company.

This is not ever easy to achieve, but at Apodi we feel in the last four years we have helped multiple pharmaceutical companies move nearer to solving this dilemma.

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Case Study 5 – The Multi-Channel Approach

Situation:Apodi had designed and developed a patient support programme on behalf of a pharma client as a value-added service which would provide bespoke tailored education and support to patients to improve concordance and adherence.

The original strategy was for the client KAM team to position this service within key secondary care units such that they participate and enroll patients. However due to the pressure of several strategic imperatives such as new product launch and new indications, the KAM team found it challenging to position the service effectively and were not able to get units to participate.

Apodi Solution:Apodi deployed a multi-channel partnership manager (MCPM) with a specific responsibility to support the KAM team by following up leads on HCPs who had expressed an initial interest in the service to drive through unit participation in the service.

Once a KAM delivered an initial discussion with an HCP and they had expressed an interest in the service and were willing to be contacted with further details, the MCPM would take over full responsibility for providing all the information required. They would follow up with all the key stakeholders until the trust service level agreement had been signed and the service had gone live in that trust.

The MCPM role was particularly cost effective as it was home-based with all contact with HCPs delivered remotely using phone, email and co-browsing technology.

Outcomes:The MCPM role was deployed for 3 months and in that time 26 priority trusts agreed to take part in the service and signed a trust service level agreement.

The client considered the MCPM role to be a highly cost-effective solution to value added service positioning within key NHS accounts.

Driving Access Solutions: Identifying and implementing the most effective solutions to drive access to our clients’ medicinesAbout Apodi:• Working in close

collaboration with our pharmaceutical clients, we identify and implement the most effective solutions to drive access to our clients’ medicine(s).

• We support our clients around the launch of their products and all subsequent periods in the product lifecycle.

• The solutions are always people-based involving the deployment of promotional resource and/or healthcare professionals often supported by innovative technology.

• Our services are primarily aimed at promoting to and educating healthcare professionals on specific medicines and/or delivering patient programmes that help:

• Identify appropriate patients.• Provide additional capacity

to assist the NHS in treating patients.

• Encourage patient adherence to medicines.

• Our solutions make a real difference by improving the lives of patients, supporting the NHS and driving a commercial return for our clients.

• We always implement the most effective solutions brilliantly.

If you want to know more about how Apodi can add value to your commercial strategies, please contact the business development team on 01628 500894.