Broad but shallow markets in primary care: why reach beats intensity
There’s a type of primary care market that looks big on paper and then behaves small in real life. Big, because almost every practice is involved. Small, because the average prescriber only sees a handful of meaningful decision points each month. When you are operating in that kind of environment, broad awareness matters, but the limited market size means the cost of provision becomes the strategic constraint. The obvious trap is to confuse volume with opportunity.
A million dispensed items does not mean a million moments of choice.
Most of the real choice happens at initiation and at switch.
Everything else is a continuation rarely reviewed by an HCP.
A case study: contraception in England
Contraception is a classic broad but shallow market. One which we’ve worked with extensively.
On dispensing volume alone it is substantial. In England, NHS prescribing data show around 5.92 million user-dependent contraceptive prescriptions and 1.10 million long acting reversible contraception prescriptions dispensed in the community in 2023.
But dispensed items are heavily inflated by repeat prescribing. The market dynamic becomes clearer when you switch the lens from items to starts and switches.
A UK routine data study defined new users of combined oral contraceptives as women aged 18 to 49 with no combined oral contraceptive use in the previous two years and reported an incidence rate of 48.5 new users per 1,000 woman-years in the UK in the later study period.
That is the key insight.
It implies that initiation opportunities are measured in hundreds of thousands per year nationally, not in millions. Then you add switching and early discontinuation.
Evidence from the THIN primary care database reports that within one year of starting a combined oral contraceptive:
9.8% of new users switched to an alternative combined oral contraceptive
9.0% changed to a different prescription contraceptive method
Among those who did not switch method, 34.8% did not continue beyond three months
So you do not just have initiation. You have a second wave of decision points from early review, intolerance, and switching.
Now put this into prescriber reality.
England has roughly 39,770 fully qualified GPs by headcount.
Even with generous assumptions, the average prescriber is looking at low double digit meaningful decision points per year for oral contraception.
In other words, for the average GP this is not weekly repetition. It is occasional.
The implication: behaviour change needs engineered repetition
If a prescriber only encounters a decision point occasionally, you cannot rely on natural clinical repetition to do the work for you.
You need to create repetition through education and reinforcement. And you need to do it at a sustainable cost per interaction, because the market does not throw off enough decision points to justify an expensive model. This is why, in broad but shallow markets, the programme design often matters more than the marketing.
Are you reaching most practices, or repeatedly speaking to the same few?
Are you building recall and confidence for when the rare moment arrives?
Can you afford enough touches per prescriber to make the message stick?
The evidence base here is sobering but useful.
What can we learn from health systems initiatives to move prescribing behaviour?
This is a problem health systems struggle with also. A 2025 JAMA Network Open systematic review found that in studies with the lowest risk of bias, focussed on targeted educational detailing to healthcare professionals around two-thirds reported a significant improvement in at least one prescribing outcome, with a median absolute improvement of 4 percentage points in the targeted prescribing behaviour. This supports the idea that educational outreach can shift prescribing, but typically by modest amounts that become more meaningful when applied at scale, which is exactly why scale and repetition matter..
Cochrane work on educational outreach visits has also found they can influence professional practice, with effects varying by context and target behaviour.
And overviews of outreach in practice point to a familiar theme: multifaceted approaches that combine outreach with other levers, such as audit and feedback, reminders, and practical tools, tend to perform better than single channel activity.
So the question is not whether promotions and education works.
The question is whether your delivery model can create enough high quality touches, across enough of the system, without the cost base collapsing.
This pattern is not unique to contraception. Contraception is just an unusually clear case study because the repeat prescribing element is so obvious. But the broad but shallow pattern shows up again and again in primary care.
If you look at how our healthcare systems implement policy you find our healthcare system struggle in the same way to influence behaviour. Here are two examples;
Pain management
Pain patch prescribing as a reference signal.
A pain patch example that illustrates the dynamic very cleanly is lidocaine plasters.
A policy analysis comparing England and Ireland found that the English approach of issuing guidance was associated with only a 5.8% immediate decrease in dispensing, whereas the Irish approach using a reimbursement restriction was associated with a 97.3% immediate decrease.
Two lessons jump out.
Passive measures often deliver small, slow change in broad but shallow categories
When the system cares about cost, structural levers can move faster than information alone
Promotion and creating awareness is essentially a passive measure, therefore its interesting to note that the systems themselves have the same issues in shifting behaviour as the life sciences industry it is also indicative of the benefit a sub-national access approach can have when policy is introduced with the correct levers.
It is a reminder that where clinical decision points are infrequent, behaviour change rarely happens just because something was published, a guideline was updated, or a few calls were made.
Anxiety and Insomnia
Benzodiazepines as a reference signal.
Benzodiazepines are another example where the number of meaningful decision points is smaller than the background noise of repeats.
In UK primary care data focused on anxiety-related prescribing, the incidence of benzodiazepine prescriptions was reported at 4.6 per 1,000 person-years at risk in 2018. The same analysis also noted that a large proportion of prescriptions were issued for durations longer than guideline recommendations.
This is broad because almost every practice sees anxiety and sleep issues. It is shallow because genuine new starts and major treatment decisions are not daily events for most prescribers.
So the awareness challenge is identical.
You must build safe habits and confidence in clinicians who will only occasionally need to apply the knowledge.
A practical way to think about investment
If you are planning an activity in a broad but shallow market, I find three questions cut through the noise.
1) What is the true decision point volume
Do not start with items. Start with initiations and switches.
If you do not have a direct consultation dataset, proxy it through prescribing and routine evidence, and be explicit about assumptions. The direction of travel matters more than false precision.
2) What reach is required
If almost every practice is relevant, then you do not win by going deep on a narrow slice of prescribers.
You win by being widely present and consistently remembered.
That means measuring:
Coverage across practices and local systems
Frequency of contact over time
Message recall and confidence, not just activity counts
3) What cost per touch can the market sustain
When decision points are limited, the only scalable answer is cost disciplined delivery.
That usually means an intentional channel mix.
Person to person contact tends to be the strongest driver of behaviour change, but it is also the most expensive unit. Digital and group formats can stretch reach, but often need to be integrated with human interaction to perform.The right mix depends on the market and the behaviour you are trying to shift, but the economic logic is consistent.
In broad but shallow markets, cost per reached prescriber is not a finance metric. It is the strategy.
Closing thought
If you take one thing from the contraception case study, let it be this:
In primary care, many markets are system wide but the decision points are scarce.
That is exactly when awareness matters most, because you cannot rely on frequent clinical repetition.
And it is exactly when cost matters most, because the market cannot pay for an inefficient engagement model.
Build for reach. Build for repetition. Build for a cost base you can live with.
There are many primary care markets, some may surprise you, that fit the definition of broad but shallow and capacity restraints are increasing these issues, whats your experience with these markets?