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Enabling patients to get more out of their medicines

Joanne Shaw
MA ACCA
Director
Task Force on Medicines Partnership
London
E:jshaw@medicines-partnership.org

"I've got quite bad asthma but I always used to try to keep my inhaler use to a minimum. You don't want to be dependent on it. But then a nurse explained to me that I shouldn't feel bad about keeping my symptoms under control. It has made me feel much better about taking it and my health has really improved." This comment from an asthmatic woman in her 30s illustrates the key role that nurses can play in helping patients get the maximum benefit from their medicines.
Using medicines to best effect is a vital issue for patients, health professionals and the NHS because:

  • On average, 70% of the population are taking ­prescription or over-the-counter medicine at any one time.
  • Every day 444,000 people receive a prescription from their GP.
  • The NHS drugs bill currently exceeds £6b and makes up over 10% of the total cost of the NHS.
  • As many as one in five patients fail to take the first step of collecting their prescription from the pharmacy.
  • Many patients on short-term treatment depart from recommended doses within a day or two of starting the course.
  • An estimated 50% of medicines for long-term conditions are not taken as prescribed.

Research has shown that many of the reasons why patients do not take their medicines are the result of conscious choices rather than practical difficulties or forgetfulness. People's own beliefs about medicines are the single most important factor influencing whether and how they take them. But patients' views of medicines and their ability to follow treatment plans are rarely discussed by health professionals.
For the last 2 years the Task Force on Medicines Partnership (TFMP) - a multisector initiative backed by the Department of Health, patient groups and doctors', nurses' and pharmacists' organisations - has been tackling the enormous cost to patients, the NHS and society that stems from patients not taking their medicines as prescribed, by implementing a concept known as concordance. Concordance refers to prescribing and medicine taking based on informed agreement between a patient and a health professional about the treatment to be followed. The TFMP has shown that three things are needed to put concordance into practice - and nurses have a key role to play in all three.

Equipping patients to be partners
Many people find that the patient information leaflet (PIL) that comes with their medicine does not answer all their questions - for example, PILs rarely say what the medicine does or how it works. Some people find the leaflets difficult to read and the long list of side-effects frightening. "PILs are too narrow, too negative and too late to be useful for most patients," says Professor Theo Raynor, an expert in the field of ­medicines information from the University of Leeds.
The TFMP is working with NHS Direct Online, the medicines regulator, professional bodies including the RCN, patient groups and the drugs industry to develop new, user-friendly medicines guides for individual drugs, linked to information about the disease itself and the main treatment options. This new, structured source of medicines information is currently being piloted in epilepsy and colds and flu and is available through NHS Direct (see Resources). Medicines guides can be tailored to fit the circumstances of the individual patient. For example, by entering their sex and the exact name and dose of the medicine they have been prescribed, patients will be able to read and print off a medicine guide that shows them what their medicine looks like and covers information that is relevant to them, such as advice about pregnancy or breastfeeding. In the future, nurses and other health professionals will be able to use medicines guides with patients to answer their questions and help them ­understand their medicines better and use them safely.

Involving patients as partners in treatment decisions
Many patients say that they would like more involvement in treatment decisions. This is true for patients of all ages and backgrounds. Last year's national CHI (Commission for Health Improvement) survey of ­primary care trusts (PCTs) showed that nearly half of the patients who filled in questionnaires wanted to be more involved in treatment decisions. More recent research by the TFMP highlighted that nearly half of people who had been prescribed a new medicine in the past 12 months said they did not know enough about other possible choices, such as a different medicine or an alternative type of treatment. October last year saw a groundbreaking new initiative: the first-ever "Ask About Medicines Week", intended to encourage patients to find out about their medicines and to become more actively involved in decisions about their own care. The campaign was supported by 400 partners all over the country, from national bodies big and small to local organisations providing care to patients at the frontline, including 150 PCTs.
Nurses are in an increasingly important position when it comes to prescribing and medicines management. By 2004 there will be 30,000 nurse prescribers, and beyond that, specialist nurses play a key part in the care of more and more patients with chronic conditions. Nurses are often in the position of recommending a medication to a doctor even where they do not sign the prescription themselves. But for many nurses, while counselling patients on how to follow treatments is very familiar, working with them as partners in treatment decisions is a new challenge.
The TFMP has a programme to train and develop a group of "concordance facilitators", including nurses, to implement concordance within their own professional practice and to pass on the skills to others. The concordance facilitators have been experimenting with different ways to teach concordance and have built a library of teaching and learning materials that can be accessed through the TFMP website (see Resources).

Supporting patients in medicine taking
The third essential requirement for concordance is for patients to be supported in taking their medicines once a regimen has been agreed. This is core territory for many specialist nurses in a number of different therapy areas, who already play a central role in explaining medication, and demonstrating how particular preparations are applied or how devices are used.
Many specialist and primary care nurses can be contacted by telephone if patients have problems with their medicines. But we are increasingly seeing nurses taking on a new role by proactively telephoning patients who are on medicines to check how they are getting on. The TFMP has been working with a number of projects of this kind to understand how effective they are and how they can contribute to concordance. So far, most have been funded by the pharmaceutical industry as part of support packages around particular medicines, such as Roche's antiobesity drug orlistat (Xenical). The results from some of these programmes in terms of increased compliance and patient satisfaction look very promising. Industry has learned through practical experience that programmes that seek to encourage medicine taking in a paternalistic way generally fail. In other words, reminding you to take your medicine because it does you good, however politely and supportively, has little effect. However, being proactive and available to answer questions, discuss problems and reassure, particularly in the first few weeks after the prescription, seems, for some conditions and treatments, to be a highly effective strategy. We hope that, if such approaches can be shown to satisfy patients, improve outcomes and have a positive cost-benefit, they may become more widely available as an integral part of the NHS.
Another area where nurses can support patients is through medication review. One of the milestones in the National Service Framework for older people is that everyone over 75 should have their medicines reviewed annually, or twice a year if they take four or more medicines. Medication review is a key opportunity for concordance as the patient and the health professional have a chance to discuss medicines in a way that enables the patient's own experiences with their medicines and their personal views and priorities to be fully explored.
Although medication review for older people has received most attention so far, it is equally relevant for anyone who is on long-term prescription medicines. The TFMP has produced a guide to medication review, together with the national collaborative Medicines Management Services programme, aimed at helping health professionals, including nurses, to deliver reviews that meet the needs of patients. It has summarised the principles of medication review as:

  1. All patients should have a chance to raise ­questions and highlight problems about their ­medicines.
  2. Medication review seeks to improve or optimise impact of treatment for an individual patient.
  3. The review is undertaken in a systematic way by a competent person.
  4. Any changes resulting from the review are agreed with the patient.
  5. The review is documented in the patient's notes.
  6. The impact of any change is monitored.

In addition to the guide itself, there is a suite of practical tools and real case studies that can be downloaded from the internet
(www.medicines-partnership.org/ medication-review).
The research that informed the guide included focus groups of older people, patients and carers. People were asked about their experiences of having medicines reviewed and what they would most like to get out of a review if they were offered one. They were also asked whom they felt was best placed to conduct reviews. We were interested to see that patients were very open-minded about who should carry out reviews. They recognised that no single person would necessarily have all the answers - for example, many of the people we spoke to were being treated for more than one medical condition and had been prescribed medicines by different specialists. There was a general feeling that GPs in particular are so overloaded that they are unlikely to be able to undertake a thorough review of medicines. "I don't suppose they'd find the time" was one of the many responses. Some people saw practice nurses as an ideal alternative.

Conclusion
The TFMP sees the implementation of concordance as a long-term enterprise requiring the involvement and commitment of all health professionals. There is increasing recognition that practice and specialist nurses are in the frontline of putting concordance into practice and have a vital role to play in helping patients get the most out of their medicines.

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Resources
Task Force on Medicines Partnership
W:www.medicines- partnership.org
NHS Direct
W:www.nhsdirect.nhs.uk