Joumat cf Marketing Management, 1997, 13, 315-325

Steven Lawther^ Gerard B. Hastings^ and R. ^ ^Centre for Sodal Marketing, University of Strathclyde, 173 Cathedral Street, Glasgow, G40RQ and ^NHS Executive — Northern and Yorkshire Region, Benjield Road, Newcastle upon Tyne, NE64PY, UK

De-marketing: Putting Kotler and Levy's Ideas into Practice The concept of de-marketing was initially proposed by Kotler and Levy in 1971. Sime then only limited consideration has heen given to this theory or how to apply it in practice. This paper examines existing definitions of de-marketing and considers a recent attempt to use a de-marketing strategy on a service {general anaesthesia in general dental practice). The study sought to use both primary and secondary research to identify the nature of the problem and to develop a de-marketing strategy, u>hiist ensuring that none of the parties involved mould be inconvenienced or disadvantaged. It presents the experience with dentists in the case of de-marketing general anaesthesia and, in the light of this experience, seeks tc better understand the nature of selective de-marketing. The findings suggest that de-marketing can provide original insights and allow a different approach when attempting lo change service provision, ln particular the adoption of a consumer orientation and the use of marketing took (such as the marketing mix, segmentation, targeting and positioning) can add a new level of sophistication to service planning.

Introduction In 1971 PhiUp Kotler and Sidney Levy first put forward the idea of de-marketing — tiie notion that marketing could be used to damp>en and control demand as weU as generate and satisfy it. Since then there have been few published attempts to further understand this notion or assess whedier their ideas work in practice. This papwr redresses this balance using the case of a dental health service that was a suitable candidate for de-marketing to develop a greater understanding of the nature of selective de-marketing.

Roder and Levy' Ideas Marketing is typically perceived as a mechanism for furthering or increasing, and then satisfying, demand. However, at any point in time demand levels may be below, equal to or in excess of those desired by an organisation. In the latter case a tool for reducing or controlling demand is required. This process is known as demarketing and was defined by Kotler and Levy (1971) as: "that aspwct of marketing that deals with discouraging customers in general or a certain class of customer in particular on either a temp»rary or permanent basis." 0267-257X/97/040315 + 11 $12.00/0

©1997 The Dryden Press

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Traditional marketing tools are used, but in reverse: for example, the marketing mix variables are adjusted to "cool" demand. Advertising and sales promotion activity is suspended, price may be increased or distribution channels can be changed to make the produd less accessible. This wiU result in demand being curbed and the produd being effectively de-marketed. Kotler and Levy identified differing types of de-marketing, dependent on the nature of the demand that it is necessary to reduce. These are: (1) General de-marketing; (2) Selective de-marketing; and (3) Ostensible de-marketing.

General de-marketing

This occurs when demand for a produd or service is deemed to be too high. Demarketing is undertaken effectively to shrink total demand to an acceptable level. Demand may exceed the potential supply for a variety of reasons: (1) Thene may be a temporary shortage of products, with the company unable to meet the resultant demand. This presents the problem of adjusting supply to meet the unsatisfied demand by, for example, increasing production capabilities through plant expansion. However, long term solutions like this wiU not resolve temporary shortages, therefore companies must seek to contain demand to reduce the risk of further aggravating product shortage. (2) Chronic over-popularity may exist for a product or service. This is of particular relevance for manufacturers of exclusive products where scarcity contributes to their quality image and widespread popularity will undermine this. Alternatively, producers may simply not wish to cope with high levels of demand for practical reasons. (3) The decision may have been taken to eliminate a product for which a level of demand stiU exists. The chaUenge for the company is to eliminate the demand, or encourage customers to accept substitutes, without lcsing their goodwiU.

Selective De-marketing

Selective de-marketing is concemed with a company seeking to reduce demand within certain segments of the market amongst specific types of consumer. For example, a motorway service area may seek to discoiirage footbaU fans or a pub may want to de-market itself to underage drinkers. As Kotler emphasized, the classification of customers into "desirable" and "undesirable" may raise ethical questions and can be interpreted, in some instances, as discrimination.

Ostensible De-marketing

Ostensible marketing involves the manufacturer appearing to discourage demand, with the actual intention of increasing it. This reUes on the prindple that customers

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wiU be attracted as the product becomes harder to obtain. For example, a concert promoter wiU promote a concert as "nearly sold out — limited number of tickets left", with the hidden intention of encouraging potential attenders to rush out and purchase tickets. De-marketing, Kotler and Levy argue, presents unique problems. There is a danger of over-reducing demand or harming long-term customer relations, particularly with selective de-marketing. Bad customer relations as a result of demarketing one product wiU counterad the effect of marketing other products — there is a difficult balance to be stmck between marketing and de-marketing products or services. Kotier and Levy also acknowledge that their pap>er is purely theoretical and that there is a need for careful research to substantiate and clarify their ideas. This injunction apparently feU on deaf ears. An extensive literature search revealed only one significant article about de-marketing (Mark 1994) and none that have attempted to put the theory into practice. This paper wiU start to fill this gap by examining an attempt to actuaUy use selective de-marketing on a real service. The experience of de-marketing in action and the contribution made by de-marketing to the strategic planning process wiU be examined to clarify Kotler and Levy's original ideas.

The Problem Service The service in question was general anaesthesia in general dental practice — what is commonly referred to as "going to the dentist to get gas". Concem has been expressed about the use of general anaesthesia in general dental practice for many years. (The Spence Report 1981; Editorial 1987). Though serious incidents are rare, it is acknowledged to be more dangerous than the alternatives, and fatalities occasionally do occur. This led a working party on general anaesthesia, sedation and resuscitation in dentistry, headed by Poswillo (1990), to call for reductions in its use except where there is clinical justification. This has contributed to an increasing reluctance among younger anaesthetists to administer anaesthetics in general dental practice. Nonetheless, general anaesthesia continues to be used on a discretionary basis; the rates of use vary between districts in a way that cannot be explained by epidemiological differences (Dental Data Update 1990). It has also been reported that non-clinical factors account for one third to one half of general anaesthetic administrations (Woolgrove and Cumberbatdi 1984). There is a need, therefore, to reduce — but not eliminate — the use for general anaesthesia. In particular, certain categories of people who are currently using the service need to be discouraged from doing so. Changing service provision is complex. In the UK, general dental practitioners are independent contractors, and run their practices as small businesses. They are not employees of the health service and cannot be told what to do, although some limited control is possible through their NHS contracts. Any programme of change, therefore, has to be largely voluntary and mutuaUy acceptable. Consequently, when the Northern and Yorkshire Region of the NHS Executive dedded to tackle the problem of general ana^thesia, marketing (and, by extension, de-marketing), with

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its emphasis on mutually beneficial exchange, seemed to offer an obvious way forward. Furthermore, given the need to reduce the use of the service by certain types of consumer, this seemed an ideed opportunify to apply Kotler and Levy's idea of selecdve de-marketing. However, because there was so litde experience of de-markedng to draw on, the Health Authorify approached it caudously, anxious to determine its value. Specifically, they wanted to find out if it coulcl offer original insights, new soludons and a workable way forward. It was therefore dedded to produce a detailed demarketing plan and see if this could meet these criteria.

Problem Definition Research The first step in developing a de-markedng plan was to condud research that would clarify the problem. SpedficaUy there was a need to n:\ap the occurrence of general anaesthesia in the Region, to determine how the dedsion to use genereil anaesthesia is made, and by whom, and to find out how to infiuence key decision-makers. In addidon, it was important to ensure that none of the pardes involved (padents, dentists and other professionals) would be distressed, inconvenienced or disadvantaged by any de-markedng strategy. The research adopted a ciistomer orientadon, examining the decision to use general anaesthesia from the point of view of both professionals and padents, assessing their respecdve needs and the extent to which these are currently being met and how they could be met in the future. The research with padents focused on parents, because, as PoswiUo (1990) highlighted, around 70% of general anaesthedcs are administered to children.

Method Primary and secondary research were conduded. The secondary research involved an analysis of recent service usage data ("sales data") for general anaesthesia and the related epidemiological stadsdcs. The primary research comprised a combinadon of focus group discussions and indepth interviews. These methods are commonly used in market research, and increasingly in medical and dental research (Biinkhom et al. 1983; Leather and Roberts 1995) and are eminently suitable for idendfjong and explaining complex atdtudes and emodons. They overcome some of the disadvantages of quandtadve methods, especiaUy non-sampUng enor such as the superficiaUfy of response and, given the concem of the research witii the complexifies of the general anaesthedc choice process, these methods were felt to be most appropriate here. Eight focus groups were conduded with (parents of) padents (Table 1), and five with dentists (Table 2). Twenfy depth interviews were conducted with dendsts and twenfy-six with other dental health professionals, induding hospital consultants, anaesthetists, health authorify advisors and academics.

De-marheting:

Tablet.

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The composiHon of the parent focus groups

Croup

Age cf children (years)

Use of general anaesthetics

Social economic group

1 2 3 4 5 6 7 8

3-9 3-9 1CM5 10-15 3-^ 10-15 3-9 10-15

High High High High Moderate Moderate Low Low

ABCl C2DE ABCl C2DE C2DE ABCl ABCl C2DE

Findings The secondary research confirmed that there was indeed a problem with the distribution of general anaesthesia. As in the rest of the country, the level of provision varied significantly within the Region without suffident cbnical explanation. In particular, "hot spots" of over-provision emerged. The most important findings to emerge from the primary research concern how the dedsion to use general anaesthesia is made; tiie (very limited) influence of patients on this dedsion; the structure of provision and the prospects for change. The Dedsion

In spite of the fact that patient demand has been dted as a reason for dentists continuing to supply a high level of general anaesthesia (Posv^rillo 1990), it is very apparent that the dentist predominates in the decision whether or not to use it, with the patient being relatively disempowered. Dentists acknowledge this influence and use their professional judgement to prescribe the treatment they believe to be appropriate. ITus judgement about general anaesthesia varies between dentists, with three different types of general anaestftesia user emerging: — Committed Users. These dentists have extensive experience of using general anaesthesia, have grown used to it and developed positive attitudes towards it Spedfically they are inclined to feel that the benetits outweigh the drawbacks. "Hiey actively choose general anaesthesia as an alternative to other procedures. Furthermore, committed users are typically older dentists who are senior within their practice. As a result their influence is great. Table 2. Composition t^ dentist focus groups Group 1 2 3 4 5

Age of dentist (years) 20-39 40-60 40-60 20-39 20-60

Incidence of general anaesthetics High Moderate High Low High

Providing general anaesthetics Mixed Mixed Mixed Mixed

•

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— Non-committed Users. These dentists are also current providers of a general anaesthetic service, however they are not actively in favour of its use. The service is provided either to compete more effectively with other dental practices in the area or because they are junior assodates of dentists who are committed users. —Non-users. Non-users tend to hold negative attitudes to general anaesthesia, having ceased to provide an anaesthetic service post-Poswillo or having recently qualified and, therefore, received training discouraging the use of general anaesthesia in general practice. Most non-users are located in areas with low and moderate levels of provision. Despite holding negative attitudes, they are defensive of cUnical freedom for other dentists to opierate as they see fit.

TTte Influence of the Patient

The patient's influence on provision is very much secondary, simply serving to reinforce the status quo. For example, although those parents who use the service often find the experience of taking their child to a general anaesthesia session fairly traumatic, they are generaUy unaware of alternative procedures, or that general anaesthesia has potentially very serious risks attached to it. Furthermore, they typically defer to their dentist's judgement. In ttiis way a cyclical pattem develops. Dentists provide general anaesthesia, patiente experience it and view it as the norm, patients come to expect it and dentists continue to provide the service. This "self-perpetuating general anaesthesia culture" resulte in high levels of general anaesthesia being sustained.

The Structure of Provision

The structure of general anaesthesia provision varied across the Region. In some areas provision has been centralized in one location (for example, a comnnunity dental clinic or hospital) and has completely ceased in general dental practice, in others the bulk of provision has centralized, but continues to be supported by a number of practices who spedalize to some degree in general anaesthesia. In a third set of areas, no centralization has taken place. General anaesthesia continues to be widely available in general dental practice, and is supp>orted by a peripatetic anaesthetist. Tlie first two structures have had similar effects, greatly reducing the use of general anaesthesia. This happ>ens because the structures require those dentists who wish to continue using general anaesthesia to refer patients away from their own practice, and just Uke any other smaU business o-wner, they are reludant to turn away customers in this fashion, and, effectively, to send them to their business rivals. A natural disincentive to refer to other dentists for treatment exists, with dentists more Ukely to attempt to treat a patient under local anaesthetic in their o-ivn practice. The final strudure of provision creates no disincentive to refer amongst dentists and sustains general anaesthesia use at high levels. There is also a more dired finandal incentive for these dentists to continue providing general anaesthesia — they wiU

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all have made a considerable capital investment in the high-tech equipment now required to provide this service. CruciaUy, the adoption of these different structures has depended first and foremost on the preference of dentists in that area.

The Potential for Change

Dentists who are currently providing general anaesthesia resist the suggestion that there is any need for a reduction in this provision. This view is supported by their positive attitudes towards general anaesthesia, a beUef that they are providing the right level of service and a strong resentment of interference in their clinical judgement or professional independence. There is also a wider reluctance amongst the dental profession to accept the need for any redudion in levels of general anaesthesia, with dentists defensive of clinical freedom and, accepting of different treatment philosophies, and strongly resistant to interference from outside bodies. Despite this, other organizations such as the Health Authorities, the local Postgraduate Dental Institute, Community Dental Clinics and anaesthetists do have an impact, albeit a limited one, on dentists and their dedsion-making. Organizations which are weU perceived by dentists can a d as "pressure groups" on the dentistry profession. An example of this was the PoswiUo report itself, which resulted from pressure from anaesthetists relating to general anaesthesia practice.

Developing the De-marketing Plan The research has been used to develop a de-marketing plan. The key elements of this are positioning, segmentation, targeting and the marketing mix.

Positioning

"Positioning" means developing an appropriate image for the de-marketing project in the minds of the target segments (Kotler 1988). Dentists are crudal here in that they have a great deal of power over the decision to use general anaesthesia, and wiU resent any attempt by an outsider to reduce this power. The image must therefore be one of professional co-operation, oi local ownership and oi mutual interest. This can be achieved by radicaUy altering the focus of the plan. Instead of emphasizing the issue of safety, which would raise professional hackles and caU into question individual's clinical judgement, it could address the problem of fiiture provision. HighUghting the increasing reluctance of anaesthetists to provide general anaesthesia in general practice enables the initiative to be presented as a necessary response to extemai pressures, rather than as interference in dentists' clirucal freedom.

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Segmentation

Segmentation aUowed the RHA to identify areas of problenn inddence and severity (Andreasen 1995). The researdi highlighted that a selective de-marketing strategy needed to be adopted in areas of high inddence and amongst dentists who are stiU heavily involved in general anaesthesia. The segmentation of dentists by their commitment to genera! anaesthesia has made it possible to identify those who are potentiaUy more receptive to the concept of reducing levels, as weU as the "hard core" of dentists who remain resistant to change. However, it is also clear that the overaU tone and message needs to be consistent for aU dentists and other professionals, emphasizing the fact that the plan has broadbased support amongst ttieir peers. Patients wiU have a more limited role in any change programme. The obvious strategy of simply warning them of these dangers of general anaesthesia seems inappropriate, given the lack of control over the service. Such an approach is likely to cause considerable alarm and risk antagonizing and alienating the dentists. It is dear that those in high inddence areas who are used to having general anaesthesia avaUable wiU need help in adjusting to any reduction. It is also apparent that dentists wUl have a key role to play in re-education of the public towards alternative procedures, again emphcisizing the need to retain their co-operation and "ownership" of the plan.

Targeting

The method of communication could also be detennined from the research. The antagonistic attitudes of dentists towards bureaucracy imderpins the whole strategy. Any intervention that was perceived as bureaucratic or coming from individuals lacicing knowledge at the sharp end of dentistry — so caUed "wet fingered dentistry" — wiU fail. The need is for dentists to have ownership of an initiative for it to have credibility. The emphasis also needs to be placed on local problems being solved at a local level.

Marketing Mix

AU four elements of the marketing nrux were considered in the development of the plan: —Product. Two alterrwtive produd offerings emerged from the research. The first is the need to reduce the use of general anaesthesia to improve patient safety. The second is to reduce it as a managerial response to tiie inevitable reduction that wiU happen as a result of the tendency for younger anaesthetists to refuse to provide ihe necessary back-up service. It is now dear that the former wUl be rejeded by aU dentists — users and non-users of general anaesthesia — as an unacceptable interference in clinical judgement The second produd offering, however, has much more potential as it can be

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presented as a joint response by dendsts and regional offidals to an extemal threat to padent welfare. - Promotion. Communicadon will be a key element of the mix. The message must Bt with the product, and crucially be seen to originate from respected peers. Therefore, a communicadon strategy with three stages was developed. First, a debate about the issues of general anaesthesia among dental professionals would be stimulated by publishing papers in the appropriate joumals (e.g. Hastings et al. 1994). Second, working parties would be established in areas of high provision to raise issues at a local level. These would comprise well respected individuals, including anaesthedsts and working dendsts. Consumer needs and the current research will be fed into these working parties. Third, in the longer term, local dentists will be encouraged and helped to educate their padents about the changes. - Price. The plan will have to tackle two financial implications of change. First, any acdon will need to be co-ordinated across any given area, to ensure that individual dendsts did not lose competitive advantage by acting alone. Second, compensation will need to be provided for previous capital investment in general anaesthetic equipment. In addition, the "psychological" price of change will need to be acknowledged. Noh\'ithstanding de-marketing dentists will need to compromise, and accept some changes to the ser\'ices they provide, by extension limiting their clinical freedom. The resulting sensitivides will need to be handled with care. -Place. Key areas of high provision have been idendfied by the research. However, care will be needed to ensure that they do not feel unfairly singled out for attention, or that their professional judgement is being selecdvely criticized. There will also be issues of place for any replacement centralized service. In particular, there wiJl need to be located — and seen to be located — conveniently for patients.

Conclusion This paper has examined Kotler and Levy's idea of selective de-marketing and how it works in pracdce. Specifically it has looked at its potendal for contributing to the strategic planning process and the extent to which it could provide original insights, new soludons and a viforkable way forward. Our experiences with general anaesthesia suggest a selective de-marketing approach does hold considerable benefits for organizadons wishing to reduce demand for a product or service. In particular, a consumer orientation is a powerful initial stance to adopt. Marketing tools, such as the marketing mix, segmentation, targedng and positioning, all help to convert this stance into a workable plan. They have allowed the Health Authority to understand the consumer, reducing demand with reference to their needs and wants and to target efforts and resources in proportion to problem incidence and likely pay-off. Furthermore, in the case of general anaesthesia, this plan has provided original insights into the problem and significantly changed the Health Authorities approach to it. Previously, the Health Authority would have adopted one of two approaches to

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the general anaesthesia problem. First, they could have appealed to practitioners' logic by providing them with information about the dangers of this procedure. This is a fairly uncertain route to take, as it assumes a purely rational and clinical decision making process, which is not apparent with genera! anaesthesia. Alternatively, they could have used force, by applying contractual controls or financial penalties. This would probably cause resentment, and may even result in dentists leaving the NHS altogether. By contrast, de-marketing added a new level of sophistication to service plarming, enabling the Health Authority to present it as a shared challenge, that, with the correct approach, could be turned into a mutually beneficial opportunity. Although the characteristics of dentists may not constitute a sample or case that can be generalized to all selective de-marketing situations, the experience in the general anaesthesia case does allow us to better understand the practical process of selective de-marketing. It is not satisfactory to view de-marketing as simply the opposite of conventional marketing. Marketing tools need to be used sensitively to address the particular requirements of reducing demand emd to avoid dentrimental effects on consumers in the long term. In conclusion, this paper suggests that selective de-marketing does have the potential to provide new solutions for organizations wishing to reduce demand and is a workable way forward.

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Woolgrove, J. emd Cumberbatch, G. (1984), "The Use of General Anaesthesia in General Etental Practice", Joumal of Dentistry, 12, pp.243-246.