Marketing Module: Nurses - The Future Influencers and Prescribers

A packed meeting room at Innovex's Bracknell headquarters of over 70 PM Society members and guests heard two distinguished and knowledgeable speakers describe how nurses will play an increasingly important role in prescribing decisions - and discuss the implications for the way pharmaceutical companies market their products.

(l-r) Barbara Stuttle; Mike Gale (PM Society Chairman), Tina Billett

Bringing the audience up to date with developments to the new legislation, identifying the scope and authority that it will give nurses within the prescribing environment, and predicting the impact that all this will have on prescribing patterns, the module examined what the industry should be doing now to build relationships with this new prescribing audience, and the most effective way to collaborate with nurses to maximise sales.

Barbara Stuttle started by describing prescribing as "just a tool to enable the appropriate care to be given by the appropriate person to the patient." She said that nurses in effect have been prescribing for some time, albeit that the final legal responsibility has rested with the doctor, who has needed to sign the prescription. But in many cases, nurses have been making the clinical decision.

However, this is not legally prescribing, although some limited legal powers have been assigned to nurses since 1986. First District nurses and Health Visitors were given control over a limited formulary, and then extended nurse prescribing, designed to cover minor ailments, injuries, health promotion and palliative care, gave nurses a greater range of treatments to prescribe - although by no means the whole national formulary. Given that 30% of all initial contacts with the NHS are for minor ailments and injuries, Barbara contended that the effect of this move should not be underestimated.

However, extended nurse prescribing is very prescriptive, with set treatments outlined for individual conditions, and giving access to a limited range of medicines: 180 POMs, plus all P and GSL products. Barbara told the meeting that this limited formulary had not kept up with the skills which nurses now have.

The new legislation, introducing supplementary nurse prescribing, moves the whole issue to a very different level. Supplementary nurse prescribers will have access to the whole national formulary for chronic conditions - much like pharmacists, as discussed in the last PM Society module - bringing into line the fact that nurses have de facto been maintaining chronic conditions for some years.

Barbara was passionate that this should be seen as a positive move: "Nurses want to help patients," she explained. "This move is not about what nurses can do instead of doctors - it's about recognising the role that they play in patient care, and giving them the tools to do the job." She also pointed out that nurses play a leading role in formulating Patient Group Directions (PGDs) - not prescribing as such, but exerting a great influence over condition group formularies.

So how will nurses become sufficiently competent to make prescribing decisions? Barbara was at pains to point out the difference between perception and reality, especially amongst the pharmaceutical industry, about the level of knowledge and skills that nurses have.

"There is a perception that it takes seven years to train as a doctor and five years to train as a pharmacist, but that you can become a nurse in five minutes!" she joked. Of course, the reality is very different, with nurses already spending a huge amount of time training.

"Many nurses are already qualified in skills terms to be prescribers," she said. "What supplementary prescribing does is give that competence a legal framework so that it can be applied without constantly bothering the doctor for a signature."



However, working towards becoming a supplementary nurse prescriber will require more training - and mentoring from doctors. As well as 25 full days' training - a significant investment both for the nurse and their practice - is followed by 12 days' mentoring from a doctor, although Barbara said that in practice many doctors were giving far more than this.

She also had some wise words for the industry about ongoing information. "All prescribers need the same information as 'medical prescribers'," she said. "They have the same legal responsibility. So you must treat them all as practical clinicians, and not differentiate between doctors and nurses in this respect."

In a "fascinating, fast-moving" NHS, the patient journey will increasingly flow around treatments, Barbara told the meeting. Much of the changes that are happening are putting nurses on the front line of this treatment, from the nurse-led NHS Direct - which she said will be "the biggest gateway into the NHS" - to diagnostic and treatment centres, with lots of different people supplying, administering and prescribing medicines.

"Nurses," stated Barbara, "will be the gatekeepers of healthcare. The industry should view this as a positive thing, because we are both on the same side, we are both there for patients!"

With the patients' voice increasingly being listened to, those groups of healthcare professionals who have the closest relationships with them - and Barbara contended that nurses lead the way here - will have an ever-increasing role and influence. So the industry must sit up and take notice of nurses right now.

This view was echoed by Tina Billett, who opened her presentation with the assertion that "the industry doesn't accept how big an influence nurses are" when it comes to prescribing. She recalled from her own experience how many consultants, when asked why they don't prescribe a particular medicine, say "because my nurse says we have to use something else!"

But the big change, according to Tina, is that nurses are shifting from being influencers to being customers. She said that within five years, there will be more nurse prescribers than doctor prescribers in the UK - a huge change. And the relationship between the industry and nurses is not as good as it should be, with the industry having traditionally shown little interest in nurses, and nurses in turn very wary of big pharmaceutical companies.

There are already 2,500 supplementary prescribers, and the Government want to see that figure rise to over 10,000 by the end of 2005. And Tina stated that the news from the universities is that the numbers enrolling for training make that target look likely to be achieved.

Tina asked some pertinent questions about how pharma companies are organised and briefed. "Some big companies don't even know that nurses are prescribing their products right now," she said. "You need to know which of your products fall into which category of prescribing. The lack of awareness of this issue in many pharma companies is alarming."

She called on the industry to redefine its structures and its sales targets to take into account the new type of prescribers. "For many companies, a rep seeing a nurse is seen as a waste of time - nurses are not seen as helping a rep meet their targets. The industry either has to re-educate its existing sales force, or create a whole new one aimed at nurses.

"One of the reasons that so many nurses view the industry with suspicion is that their horizons are different. Nurses are interested in long-term solutions; the pharma industry is always judged on its latest three-month figures. Getting over that will require a structural change.

"Supplementary nurse prescribing fits within the political agenda of the NHS at both a national and a local level. It will help meet all sorts of targets, from reduction in doctors' hours through to waiting time initiatives."

Tina outlined a number of questions which the industry should be asking itself in order to assess the impact of the new system on their customer base:
Tina echoed Barbara's view about the increasing role of nurses in the NHS. "We are seeing more nurse-led clinics, walk-in centres and consultant nurses. This means that nurses are the ones who are actually interfacing with the patients, so they are the people that the pharma companies need to be courting."

Building these professional relationships are crucial. No longer can the industry be so doctor-focussed. It must offer support and education to nurses, and it has much to offer here. Education is probably the most important aspect where the industry can endear itself to nurse prescribers, although as Tina pointed out, "nurse prescribers still need the same level of information, but they talk a different language to doctors."

Nurses training budgets are always the first to be cut in the NHS, so this is a gap that the industry can step in to fill, effectively opening the door to building relationships.

"A half day with 30 nurses will do so much good - and how long would it take a rep to see 30 doctors? Such an approach will help to build confidence in the industry amongst nurses. They want education - not post-its and pens!"

Tina finished by suggesting six partnership initiatives which pharma marketeers could undertake to start building better and closer relationships with nurse prescribers:

Questions
Unsurprisingly after two such challenging presentations, there were plenty of questions from the floor. Discussion ranged from the impact of controlled drugs legislation in the wake of the Shipman Report, to whether there really are enough nurses who are prepared to put themselves through the training to achieve the new status (more than enough, according to both speakers).

On this last point, Barbara Stuttle said that currently nurses are irritated and frustrated about not being able to "practise to their competency," adding, "prescribing is giving nurses the tool - otherwise it's like being told to dig a hole, but you can't use a spade!"

Conclusion
Nurse prescribing is here and is set to grow in importance, with both the numbers and degree of influence over prescribing decisions also growing. Supplementary Prescribing is now a high priority Department of Health Target for the NHS, so the pharmaceutical industry has to make it a high priority, changing its structures, the way it views nurses, and the way it communicates with all prescribers.

The PM Society would like to thank Innovex for their support in hosting this event and to the two speakers who gave such interesting and thought-provoking presentations.

Please go to the Events section of the website for further information about future PM Society events, including our House of Commons Speaker lunch on Monday 18th October. Details regarding our half day conference which will be held on Tuesday 30th November will be announced shortly. Please make a note of this date in your diaries.

Held on: 30/06/2004