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Mapping strategies

Tools to help define and reach the increasing numbers of decision makers

An illustration of the world with a graphic overlayedDecisions to use a particular drug were once almost exclusively the preserve of the prescriber. Now, as we all recognise, the prescriber is becoming less and less important. The pharma industry has adjusted to this change with new strategies targeting a variety of clinical and non-clinical decision makers, but often we don't actually know who is really influencing decisions. The processes are complex, varying across therapy areas and from one geographical area to another, and they involve informal as well as formal influence networks. More and more, companies are turning to stakeholder mapping tools to help elucidate these processes. This approach requires detailed and systemic research to produce highly visual representations that condense this complex decision-making landscape into a structure from which a course of action can be devised. Understanding the complexities of these processes means that companies can reach the right people with the right messages.

Increasingly, of course, companies have NHS-liaison managers targeted at decision makers such as PCT commissioners and leads, prescribing advisors and those influencing formulary committees. This is all well and good when it is clear who the decision makers are, but we have moved from a relatively simple decision-making model that everyone understood, to one which is much more complex. Now it is usually a whole host of interacting stakeholders that affect decisions on whether to adopt, or continue to use, a particular drug. Moreover, such decisions are often made over some time, with an accumulation of influences leading to a groundswell of support for a particular course of action. A 'one size fits all' approach has thus become less effective and relevant to pharmaceutical companies.

Stakeholder analysis
Stakeholder mapping is an analytical method of modelling decision-making processes that allows decisions to be understood more easily. It also provides a framework for clarifying the next steps. Essentially, a stakeholder map identifies all the individuals or groups that may influence decision making, then assesses and sorts them according to their influence on the decision.

The first task is to define the situation, ie what is it that we are trying to understand? Normally the question would be: "What are the circumstances that lead to a physician prescribing drug X?"

The physician is likely to be guided by a policy or set of policies. Therefore, we want to know the following: What are the policies guiding this decision? What room is there for decision making within the policy framework? And, finally, what are the processes for deciding on policy?

As well as the formal policy, there could be any number of other, often informal, influences on doctors' decisions, such as their own training, influential journalists, their peers or articles that they have read in journals.

Fig 1: Typical stakeholder relationship map


How does it work?
The method of identifying stakeholders includes the formal processes that lead to policy making (peer-reviewed literature, NICE, PCT committees and so on), plus all the other informal influences such as the media or influential thought leaders working in the relevant therapy area.

Sometimes it is useful to group the stakeholders into tiers; the first tier is the direct influences, the next tier is the influences on the influencers, and so on down the line. Depending on how detailed the analysis needs to be, there could be many tiers of stakeholders.

Once the stakeholders have been identified, the next step is to profile them: How influential are they? How interested are they in the issue? How do they exert their influence? Are they advocates?

It is usual to draw two types of diagram when mapping – a stakeholder relationship map (fig 1) and an influence versus interest matrix (fig 2).

The relationship map is a broad overview of the situation showing the main influencers and how they interact. It gives an impression of the network of influence by identifying the main influences and showing the links between them. In most cases, the links are a flow of money, information or leadership/authority. The example in fig 1, which has been made anonymous, shows the network of influencers in the primary care setting for a specific therapy area giving NHS/governmental influences, sources of information, relevant societies, bodies and events.

Fig 2 shows the influence versus interest of the societies on the stakeholder map. It is important to understand these attributes to see whether a stakeholder needs to be addressed and, if so, how. For example, in many healthcare decision-making processes, the Department of Health could exert a great deal of influence. Whether it does or not depends on how engaged it is. Similarly, the diagram shows that stakeholder S06 is the most influential in the general area, but that it is not overly interested in this particular decision-making process. It may be possible to stimulate interest if appropriate. Stakeholder S26, on the other hand, is extremely interested in the decision and moderately influential. This amount of influence may be enough to have a high impact, or alternatively work may need to be done by the company to raise the stakeholder's influence, for instance by raising its profile.

Fig 2: Influence vs interest grid


Local stakeholder mapping
Stakeholder mapping can be undertaken for a sales region or territory. Mapping down to this level can involve a great deal of resources and, since the expertise needed to produce stakeholder maps will be in a consultancy or with an individual or group of individuals in head office, it is rarely feasible to centrally produce a series of maps covering the entire country. However, stakeholder mapping can be employed usefully in two ways: a map of a typical local area can provide a template to which local knowledge can be added or, alternatively, the company can produce maps for contrasting areas where, say, a drug has and has not been adopted. This would provide a model to understand the positive and negative influences on product usage.

Local templates: As an example, we plotted the local structure of infection control for a client. There were two parallel organisations, the Health Protection Agency's Health Protection Units and the PCT public health and infection control hierarchies. On paper, the structures and relative roles of these two were reasonably clear, however in practice they were anything but. We produced a map of a typical area indication where some of the variation might occur, but only local knowledge could clarify the exact structure.

When mapping down to a local level, it is possible to build in details of individuals and their influence and views. We were able to populate these maps with the names of the key roles and often the individuals in those roles. At this level, the client can verify how much the local situation fits the theoretical model, fill in any gaps in the names and find out the dynamics of the decision-making process, particularly the influence of individuals. People's ability to affect decisions is based not just on their power in terms of formal position, of course, but on their individual knowledge and credibility. It also rests on personality, in terms of level of interest, motivation and/or persuasiveness, as well as on their energy and interest. A hospital consultant who, in theory, should be highly influential, but who rarely turns up for formulary meetings, may be less influential than a GP with a high level of interest and drive who pushes through decisions. This is not the easiest of things to identify, but over time more information can be added, giving an increasingly clear picture of the situation.

A model of local influencers: In this example, a company wanted to understand the decision-making process behind the adoption of a certain cardiovascular drug and identify those organisations and individuals with the most influence at local level. Such local influencers can be identified using a combination of existing knowledge in the company – particularly in the field force – and public domain information. This is then validated and supplemented by local intelligence gathering.

The company can plot on a stakeholder network map the key players in the decision-making process, including bodies, committees and individuals. The main structure of this map is determined by the formal administrative structure of PCTs and other local bodies (such as the cardiac networks) and how they interact to form decisions. Research at a local level, with interviews to find out what really happens on the ground, brings more individual links into the mapping.

Thus, it is often possible to establish a model's success and lack of success in identifying potential points of intervention.

Stakeholder mapping is time-consuming and imprecise. As with any model, it is inevitably approximating a real situation. However, as a means of understanding who is influencing healthcare decision making and forming an effective and targeted approach to them, it is extremely valuable. It is not surprising that, in today's complex healthcare environment, companies are choosing this method to help build product success.

The Authors
Neil Kendle and Tom Kendle are from Kendle Healthcare
To comment on this article, email

26th August 2009


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