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How are you getting on with your medicine?

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

Prescribed medicine is the primary therapeutic intervention across the NHS. Nearly 600 million prescription items were dispensed in primary care in 2001 at a cost of over £6 billion to the NHS.(1) In future, if supplementary prescribing progresses as expected, an increasing number of these will be prescribed by trained and experienced primary care nurses.
The fact that a big chunk of NHS resources goes on buying medicines does not in itself indicate a problem. After all, medication is often a far better alternative than more invasive modes of treatment, and modern medicines have made a huge contribution to better health and longer, more active lives. But it is common knowledge that many people do not take their medicine as they are advised to, and there is plenty of research evidence to back this up.
As many as one in five people fail to take the first step of collecting their prescription from the chemist. And from one-third to a half of patients prescribed long-term medication don't collect their repeat prescriptions.(2,3) This figure is 45% for people on drugs to combat hypertension. And we know that even when prescription items are collected, many patients on short courses depart from recommended doses within a day or two of starting treatment. A key Canadian report concluded that for long-term illness, compliance tends to converge to approximately 50%, whatever the illness, whatever the treatment and regardless of the treatment setting.(4)
One effect of this is the financial burden on the NHS. Millions of pounds worth of prescription medicines are returned to pharmacies for disposal each year, and a great deal more are disposed of in private by patients themselves. But the main effect is in terms of avoidable ill-health. The real cost is seen in hospitals in the form of strokes, heart attacks and the long-term complications of illnesses such as diabetes. 
In the past, many attempts have been made to improve compliance, but few have been successful. In 1995 the Royal Pharmaceutical Society of Great Britain (RPSGB), together with Merck, Sharp & Dohme, launched an enquiry into the causes and consequences of noncompliance. They found that noncompliance is not just the result of incompetence on the part of patients. In many cases people do not follow treatment because they have made a definite choice not to. This choice is based on factors that are important to them and involves weighing up benefits against side-effects and risks (see Figures 1 and 2). Some of these factors would not be recognised as "rational" by medical science. They may be based on misconceptions about the nature of their illness and the way that medicines work, or the patient may be anxious about potential side-effects or the possibility of becoming dependent.

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The RPSGB enquiry led to a new understanding that patients are much more likely to follow the agreed treatment if it takes their own beliefs and values into account and involves them as active partners in treatment decisions. This meant that for the first time there was formal recognition of something caring professionals instinctively understand - that patients are not just the passive recipients of prescribing decisions: they have their own views about medicines, how they work, and how they are best used. Moreover, medicine-taking needs to fit into their daily lives. The result of this work was a highly influential publication(5) and a new word - concordance - that describes an informed agreement between a health professional and a patient about the course of treatment to be followed, rather than an instruction to "follow doctor's orders".

The Task Force on Medicines Partnership
The Task Force on Medicines Partnership (TFMP) is a new initiative, announced by Lord Hunt in 2001, to take forward the work on concordance and find ways of putting the concept of concordance into practice in the NHS. The TFMP involves representatives of nurses, doctors, pharmacists, patients, the pharmaceutical industry and the NHS. As Director, I am responsible for taking forward the TFMP work programme, with the support of the Centre for Medicines Partnership, based at the Royal Pharmaceutical Society in London.

The TFMP partnership work programme has five principal strands:

  • Communicating with patients and the public about ­medicine-taking and helping them to develop an ­understanding and awareness of their medicines.
  • Showing how to put concordance into practice by exploring model practices and setting up pilot schemes within the NHS.
  • Working with pharmacists, doctors and nurses to reflect concordance in their work so that they can support patients with taking their medicines.
  • Guiding the research agenda on concordance, especially how to measure and audit it.
  • Working with the Department of Health and other NHS organisations to ensure that patient partnership and concordance are embedded in key policy initiatives.

Over the next two years, nurses working in primary care are likely to see the impact of Medicines Partnership in several ways. First, some local practices will become involved in projects that apply and test medicines partnership approaches in a live setting. Second, they may encounter opportunities for education, professional development and training in the skills needed to develop partnerships with patients around medicines. Later this year, we will be recruiting Medicines Concordance Leaders to act as "product champions" and tutors in a dissemination programme that will commence at the end of 2003. And third, they may find that patients are more ready to talk about medicines issues as a result of communication and information from  Medicines Partnership. You can find more information about what Medicines Partnership is doing in these areas on our website (see Resources).

In the meantime, nurses working in primary care are already well placed to apply the principles of concordance in their ­practice by:

  • Asking patients about their experiences with their ­medicines.
  • Exploring their beliefs and concerns about their drugs.
  • Helping them to understand their illness and the ­importance of their medicine.
  • Explaining how the medicine works and therefore how it needs to be taken.
  • Highlighting problems with medication to other professionals involved in their care.

Conclusion
Noncompliance is often thought of as a practical issue. As long as the patient remembers what they need to take and can open the containers, the problem is largely solved. But we know that many people, rather than attempting (and sometimes failing) to follow instructions, are making conscious choices about what medicines they take, when and how much. Even when those choices have very damaging consequences for their health. The answer to this goes far beyond supplying dosette boxes. It means health professionals recognising in their daily practice that questions of medicine- taking are as important as decisions about what is actually prescribed. Nurses working in primary care are already well placed to support their patients by listening to them and talking to them about their medicines and by highlighting problems with medication to other professionals involved in their care. In future, as more nurses become prescribers themselves, many will be at the forefront of concordance, by involving patients as partners in prescribing decisions.

References

  1. Department of Health and National Statistics. Prescription cost analysis: England 2001. Available from URL: http://www.doh.gov.uk/stats/pca2001.htm
  2. Schering Laboratories. The forgetful patient: the high cost of improper patient compliance. Schering Report IX. Kenilworth, New Jersey: Schering Laboratories; 1987.
  3. Hammell RJ. Increased compliance means better health for patients, higher profits for you. Am Druggist 1981;184:98.
  4. Sackett DL, Snow JC. The magnitude of compliance and non-compliance. In: Haynes RB, Taylor WD, Sackett DL, editors. Compliance in health care. Baltimore and London: Johns Hopkins University Press; 1979. p. 11-22.
  5. Marinker M, et al. From compliance to concordance: achieving shared goals in medicine taking. London: The Royal Pharmaceutical Society; 1997. Available from URL: http://www.medicines-partnership.org.
  6. Stimson GV. Obeying doctor's orders: a view from the other side. Soc Sci Med 1974;8:97-104.
  7. Verbeek-Heida PM. Patients' views on doctors' prescriptions: management of illness episodes involving antibiotic prescriptions in daily life. Amsterdam: Department of Sociology, University of Amsterdam; 1992.
  8. Donovan JL, Blake DR. Patient ­­­­non-compliance: deviance or reasoned decision-making? Soc Sci Med 1992;34:507-13.
  9. Gabe J, Thorogood N. Prescribed drug use and the management of ­everyday life: the experiences of black and working class women. Sociol Rev 1986;34:737-72.
  10. Power R. People choosing their health care: an initial analysis of some Mass Observation Data from the Spring 1984 Directive on Health Services and Sickness. Paper presented to Annual Conference of the British Sociological Association, Manchester, 1991.
  11. Gabe J, Lipshitz-Phillips S. Evil necessity? The meaning of ­benzodiazepine use for women patients from one general practice. Sociol Health Illness 1982;4:737-72.
  12. Conrad P. The meaning of ­medications: another look at compliance. Soc Sci Med 1985; 20:29-37.
  13. Fallsberg M. Reflections on medicines and medication: a qualitative analysis among people on long term drug regimens. Studies in Education, Dissertation 31. Linkoping, Sweden: Linkoping University; 1991.

Resources
Task Force on Medicines Partnership
W:www.concordance.org
Medicines Partnership
Royal Pharmaceutical Society of Great Britain (RPSGB)
1 Lambeth High Street
London SE1 7JN
T:020 7572 2474
F:020 7572 2508
E:info@medicines-partnership.org