A crucial question for pharma in this new era is: Who is the customer? In the past, the pharmaceutical industry has centred its promotional activities around the individual doctor armed with a prescription pad. However, the situation is changing, says Sobanja.

"In the UK specifically but also across Europe, prescription decision-making powers are becoming much more diffuse. Now, pharmaceutical companies have to influence people at three different levels," he says.

"The first is the national level. If a company wants its product included in national guidelines or the disease area raised to the status of a priority area, they will need a powerful machine in place to influence government and national healthcare bodies."

The second level is working with local influencers and prescribers. "Even though this is home territory for pharma, companies are going to have to develop their offering."  However, it is the third level that is potentially the most novel and exciting – working with patients, says Sobanja.

"Traditionally, the patient has been a passive recipient of healthcare, relying on the advice of the doctor. However, the patient is on the march. Empowered by the expansion of the internet, patients want information and involvement in their own healthcare and pharmaceutical companies need to be involved at this level. This is a tough proposition when companies are banned from promoting directly to patients. They need to refocus their attention away from their specific medicines and towards greater involvement in disease areas, to become part of the conduit of information to patients. The patient is not yet king but he is more demanding, more thirsty for knowledge and more willing to participate in his own healthcare and you can see this happening across Europe. "

According to Sobanja, the best opportunity for companies to interact with patients is to expand their existing activities with patient organisations.

"Patient organisations across Europe are becoming more important. For example, in the UK, Diabetes UK was heavily involved in the development of the National Service Framework on Diabetes that outlines best practice in managing the condition. In addition, the cancer charities were instrumental in changing the guidance from NICE by activating the appeals procedure."

Not only are they powerful organisations at national level, but they have direct contact with patients. "Many patient organisations give out information about medicines to their members, even guidance on what brand names to ask for. When you consider that half of patients who ask for a brand name drug are given it, patient organisations are not cuddly groups pharma can work with in the background, they are prescribing influencers," says Mike.

A big challenge for pharmaceutical companies in this changing healthcare environment is to review their own methods. Companies need to ask some hard questions – are we doing the right thing or should we use new, more innovative approaches? "Companies are looking at the productivity of their sales force and working on ways to get more return from their investment," says Richard Purchase, director of service development at contract sales organisation Innovex UK. "Even though rep numbers are high, access to the customer is down, so companies are starting to question whether they should focus their efforts on certain customers – for example, high prescribers or those doctors that are more receptive to their messages for whatever reason."