Master craft

Marketers must use their dexterity to establish drug recognition, consensus and remove the barriers to treatment by doctors

When first presented to a doctor, a new product is generally assessed against - and slotted into - current practice. The net result is that the product is compared to existing treatments and, as we all know, runs the risk of only being used when the doctor can see a need for it such as with a difficult to treat patient and/or where the treatment of choice has failed. This demands that we - as marketers - ensure effective, differentiated and meaningful positioning of our products from the outset.

But no matter how effective we are at positioning our product, there comes a time when we have soaked up all available capacity in the market and sales/market share growth begins to slow. It is at this point that we must consider market shaping/market development or market expansion, not when growth has stalled completely.

A number of factors should be considered when deciding what approach to take and when, not least where, the levers for growth lie, as well as our own market position.

Logic suggests market shaping/market development comes first. Why? Because this is about changing current management or treatment practice of an existing market, rather than encouraging more patients to see doctors, a slower and more expensive process, even when you have the ability to appeal directly to consumers.

Clearly if this is a relatively new or significantly under-developed market, then market expansion will come much sooner - perhaps even before launch - as was the case with Viagra. Generally though, market expansion comes later, when the product has established a strong position in the existing market. This helps to ensure that the benefit of more patients being treated is felt by your product and not by your competitors.

INCREASING TREATMENT NUMBERS
How you develop or shape the market will depend on the specific drivers in that market. If we use the patient flow (or patient pyramid) as our guide, there can be a number of reasons why patients are not currently being treated. Our challenge is to identify where this is occurring in that patient flow, what the barriers to current or more extensive treatment are and any associated inhibitors - easier said than done in some cases.

We then need to determine how best to change current thinking and practice by providing the 'solution'. This solution may or may not be a medicine.

Firstly, patients may not actually be receiving prescriptions. They may have been diagnosed as having the condition that we can provide a solution for, but they may not currently be receiving a prescription medicine. After all, the first tenet of medicine is 'do no harm' so doctors might delay treating a patient at all, or suggest using something other than a prescription medicine. This can often be the case in early stages of a condition, perhaps when it is asymptomatic and the doctor does not see an urgent need to treat.

Here we must demonstrate the medical consequences of not treating these patients and convince doctors of the need to treat early. This may be challenging, especially when there is no acute or apparently pressing need. Enlisting the help of acknowledged and respected experts to change thinking and provide the evidence is thus crucial. The expert does not necessarily have to be a traditional national or international key opinion leader (KOL). In many cases, for general practitioners, a local specialist to whom the doctor refers patients can be just as, if not more, powerful in helping doctors see the need to treat the non- or under-treated patients.

Clearly, if targets to which doctors agree they should be treating are lowered, this results in a larger potential patient population. Look at how treatment of dyslipidaemia has changed significantly since the introduction of statins. Lower targets than the current 5 mmol/l for total cholesterol - as in the Quality Outcomes Framework (QOF) - and 3 mmol/l for LDL-C are now being proposed (4 and 2 mmol/l to be exact) especially in high-risk cases such as those patients with established cardiovascular disease or diabetes. This is quite a challenge for doctors given the nature of the dose response for statins.

Another option is to develop the 'thinking' behind treatment. Once primary objectives have been achieved in the majority of the patient population, it is common to see goals being extended. For example, treating hypertension was initially about achieving a healthy blood pressure. However, now that available treatments have increased the chances of success, secondary goals are coming into play, for example protective effects to avoid damage to organs.

CHANGING BEHAVIOURS
It is important to remember that achieving behaviour change takes time. Firstly, there is a need for evidence to establish the benefit of the product, then to develop consensus on when and how best to treat patient populations. This will be vital for getting acceptance for it in everyday practice. We know that in the UK if it is not in QOF, it is not a priority within primary care.

Do not underestimate the challenge. Doctors will have already started to treat those patients with an obvious and pressing need. We need to demonstrate how to identify these other patients and why they should consider treatment ie, change motivation and prescribing behaviour.

Obviously there is a limit to how far we can push this, particularly in this age of cost-effectiveness, evidence and restricted budgets. Unless we can convince the key decision makers of the need to treat, we may be facing a thankless task and perhaps risk losing credibility, potentially limiting any future development.

BETTER DIAGNOSIS
Another area to consider is non-treated patient recognition or diagnosis. As we know, some patients are not actually diagnosed or are not diagnosed with the condition from which they actually suffer. There can be a number of reasons for this. In this day and age, unless there is a 'test' and a hard number that defines the disease or condition, a straightforward diagnosis can be a challenge. We take it for granted that diagnosis is the doctor's key role, however it is more of an art than a science in some cases. Different diseases can present in the same way or one can mask another, making the doctor's life difficult. Doctors do not deliberately miss the diagnosis. In some cases they may give the patient a different, more palatable label, particularly if the treatments are very similar.

Again we need to understand why this is happening. Is it a lack of knowledge? Is it down to diagnostic skill? Is there a lack of motivation to look for - or perhaps even treat - these patients? Do doctors just not recognise the issue? GPs are generalists after all and see many different conditions.

Unless we can unlock the reasons behind it, we may well throw a lot of time, effort and money at the problem, but to no avail. We need to bring the issue of lack of recognition or appropriate diagnosis to doctors' attention in a non-threatening, non-critical way. Telling a doctor the he has got it wrong in his major skill area will not produce positive results.

Once we understand the main reasons for under-diagnosis we can provide the solutions. Again, there will be a requirement for consensus on the need to diagnose in particular patient groups, based on the consequences of not treating optimally. Working on the whole undiagnosed population is just not going to be effective. Doctors will see this as a cynical attempt to build sales. We, therefore, must create that elusive win-win by uncovering a need, and getting doctors to recognise and act upon it.

Sometimes it may be that there is no simple way for prescribers to identify the relevant patients. In such senarios some companies have needed to develop a specific test to identify the appropriate patient for treatment with their medicines. A good example is Herceptin and HER2 positive breast cancer. Just having the test does not necessarily mean treatment will be optimal for all suitable patients, but it will make a big difference.

Also, having the diagnostic test or tool in place does not necessarily mean it will be used. After all, you can give away tools but - as with all things in life - those that are free often do not create any real feeling of value in the recipient. They may just sit on a shelf somewhere.

Doctors need to be encouraged to use the test or tool in their daily practices, and this is all about the correct motivation. Doctors must see the need and value to them, their practice and their patients before they do something different. Similar strategies to those for extending treatment are appropriate.

Sometimes what gets in the way of suitable patient identification or diagnosis is not the lack of will, but rather lack of resources - usually time. Hence, the classic - and now perceived by many UK general practitioners as the standard - solution is to provide a people resource to do the necessary screening, following the provision of asthma nurses by GlaxoWellcome many years ago.

However, all of these efforts to change doctor behaviour will be unsuccessful if there is not some form of positive feedback to show the doctor that they are doing the right thing, achieving positive results and making a difference.

BOOSTING PATIENT PRESENTATION
It is often tempting to think that encouraging more patients to present to the doctor is the secret to developing the market.

The problem is, if the doctor cannot readily diagnose or identify the appropriate patient, or is not willing to prescribe a suitable treatment, then much of that effort is wasted. It's all about timing.

The majority of marketers will know that timing is all important in an established market, particularly for the market leader. However, there are situations when a strong number two in the market or even a more focused player that is dominant in a particular segment can benefit from market expansion. It is all about linking the appropriate patients to your product in the doctor's mind (aka effective, differentiated and meaningful positioning). The more we can use patient pictures to help doctors to better make the link. After all, that is what they do, link patients to treatments.

The problem with market expansion is that it can be a slow and expensive process as we are trying to change patient behaviour in an environment where we cannot speak directly to them about the product.

Clearly, we can raise awareness of the disease and encourage interest in seeking a solution, but what we do not want to do is encourage large numbers of the 'worried well' to seek treatment. Doctors already have many of these and it will do us no favours if we are seen to add significantly to this group.

Once again it is about first establishing the recognition, consensus, appropriate action and positive feedback, and then removing any significant barriers (eg, resource and, or funding, as is the case with Alzheimer's) before encouraging new patients to seek treatment - not the other way round.

DEVELOP OR EXPAND THE MARKET?
Market development and market expansion are challenging, time and resource consuming strategies. They definitely have their place at the appropriate time in the life cycle of many products.

However, many marketing strategies seem to focus far too much on new patient and prescriber capture. Are we sure that we have exhausted the potential among existing patients, that is are we maximising compliance and adherence? Too often this way to increase sales is ignored.

So next time you start thinking about market development or market expansion, make sure you are also focusing on your existing patients.

The Author
Dr Paul Stuart-Kregor is a director at The MSI Consultancy and can be contacted at pstuartkregor@msi.co.uk