Jo Tsoneva - Professional Development Manager
Medicines Partnership is a two-year initiative, supported by the Department of Health, aimed at putting the principles of concordance into practice
Most health professionals would be shocked if they knew that up to half of all patients decide not to accept the therapeutic intervention most frequently used in the NHS - but that is exactly the situation with regard to taking medicines. Around 70% of the UK population are on a prescribed or over-the-counter medicine at any one time (Office of National Statistics, 1997), yet as many as 30-45% prescribed treatment for long-term conditions do not get their repeat prescriptions dispensed (Schering, 1997).
While this may not be surprising for asymptomatic conditions such as hypertension, it is also common among patients with serious illness and can have serious consequences. The potential benefits of treatment, as defined by evidence-based medicine, cannot be fully realised - NHS resources are used inefficiently; and the personal cost is an increased risk of ill health, long-term complications and disability. For example, one study found that 18% of renal transplant patients did not take their medicines as prescribed; in this group, the incidence of organ rejection was 91% compared with 18% in those who took their medicines as prescribed (Rovelli et al, 1989).
One reason for this mismatch between the expectations of health professionals and the behaviour of patients is a failure to recognise that the views and expectations of patients are major determinants of medicines-taking. It is now clear that patients’ beliefs and goals should be at the centre of decision-making about medicines, so the process of selecting and providing care must involve partnership and negotiation between the patient and health professionals.
Historically, the concept of concordance has been associated predominantly with medicine-taking but it is now more widely applied to the process of shared decision-making in health care. The concept is about patients making informed decisions about all aspects of their care with the support of health professionals. It has been incorporated into NHS policy in accordance with government commitment to developing patient-centred services (DoH, 2000) and has increased the emphasis on partnership in education and training for health professionals (Kennedy, 2001).
Concordance is not simply a politically correct name for compliance (unlike adherence). The two terms reflect fundamentally different approaches to care (Box 1). Compliance remains a useful term when applied in its strict scientific definition, but it has acquired a pejorative connotation of ‘doctor knows best’ because it is concerned only with the extent to which patients do as they are told or advised. It is important to note that, whereas compliance describes patients’ behaviour, concordance denotes a process. It is therefore appropriate to refer to non-compliant patients, but not to non-concordant patients - it is the relationship between the patient and the health professional that is non-concordant, not the patient.
Challenges to putting concordance into practice
Box 2 provides a guide to putting concordance into practice for the health-care professional.
It is a mistake to assume that concordance will simply evolve from good intentions. Health professionals can benefit greatly from training to help them explore the concept and practise working with it, and building concordance into professional relationships requires investment and commitment.
Perhaps the biggest challenge faced by any health professional seeking to develop concordant practice is to be able to set their own views to one side. For years, health professionals have employed a paternalistic approach to care by using their knowledge and experience to direct patients to the best course of action. Though rational and well-intended, we now recognise that this model of care is unsuccessful for many patients (though some, particularly older people, may still prefer not to be involved in making decisions). It can be difficult for health professionals to agree to a course of action that a patient has chosen when it is contrary to a view founded in scientific evidence or years of experience.
Underlying this dilemma is the concern that patients are making decisions that are genuinely well informed. Health professionals must, therefore, provide information that is appropriate and that fits with their patients’ health beliefs, but they must also provide it in a way that is understandable to each individual.
It can be difficult to decide how much information to give (for example, which side-effects to mention), where to obtain specialised information, and where the boundary of responsibility lies between the health professional and the patient. Communication skills are therefore a very important part of training. There is often an awareness that one’s actions may have to be justified if there is an adverse event with legal consequences, so careful documentation is essential. At present, there are no national standards to refer to and these issues must be tackled locally.
Nurses also face practical barriers to developing concordant working relationships. The requirements of policies and protocols may not match the patient’s agenda, and the time needed to talk about a patient’s concerns can be eroded by routine tasks such as screening or data collection. The demands of the new General Medical Services Contract are only one example of how an increased workload can compete for scarce time. These are potentially substantial obstacles to change and nurses need support to help overcome them.
The need for a multidisciplinary approach
While it is possible to practise concordance alone, it is much easier - and less confusing for patients - if colleagues share the same ethos. Patients will receive mixed messages if the health professionals they see deal with them in different ways. The potential for confusion is perhaps greatest between secondary and primary care but can also occur within a single practice when patients see different GPs.
Patients’ beliefs and behaviour affect all aspects of their care, so a multidisciplinary approach to promoting concordance is essential. One study of HIV health-care teams found that nurses and doctors had complementary skills and ways of working: doctors tended to educate patients about their treatment and risks, while nurses adopted a range of techniques to promote adherence (Gerbert et al, 2000). Nurses are often seen by patients as more approachable than other members of the care team, and this offers a strong foundation on which to build a concordant relationship.
For example, one study has shown that support from a cardiac nurse for people with congestive heart failure significantly reduced readmissions and length of hospital stay, and improved adherence; the study concluded that the nurse had a more candid relationship with patients and was better placed than the physician to intervene (Stewart et al, 1999).
This relationship is a valuable foundation on which to develop concordance not only for established activities such as specialist clinics but also for newer initiatives such as medication reviews. Nurses are therefore in a good position to act as champions for concordance.
How Medicines Partnership can help
Medicines Partnership offers tools and resources to help health professionals develop a concordant approach to practice. It is particularly keen to encourage multidisciplinary training - ideally, including patients’ representatives - and it provides information and contact details for courses and workshops designed for health professionals at all levels. The techniques used include open learning, teaching, facilitating workshops and providing support materials so that workshops can be run locally. A support package for running a concordance workshop is available from the University of Bristol and is suitable for NHS trust board members and staff in primary and secondary care. The focus is very much on providing practical advice - for example, one resource lists useful phrases that encourage a partnership approach (Box 3). Nurses can also contact the professional development manager at Medicines Partnership to discuss specific queries about learning and resources.
In 2002-03, Medicines Partnership organised a series of workshops to train concordance facilitators recruited from nursing, pharmacy and medicine. There are now 25 nurse facilitators nationally who can offer advice and varying degrees of support to colleagues wanting to develop concordance in their workplace.
A toolkit designed to help with the evaluation of concordance projects can be downloaded from Medicines Partnership website (www.medicines-partnership.org). By outlining the pros and cons of the different variables to measure, and the best ways to measure them, the toolkit will help everyone to build the evidence base about what works in concordance and what does not.
Other resources on the website include an extensive database of evaluated published studies of concordance, examples of incorporating concordance into health policy, a slide set about concordance, a toolkit and supporting literature for medication review.
The website also includes information about Ask About Medicines Week (which also has its own site at www.askaboutmedicines.org). This annual initiative is organised in coalition with Developing Patient Partnerships and Promoting Excellence in Consumer Medicines Information (PECMI). It aims to enable people to make better use of medicines by increasing understanding about medicines; creating opportunities to ask questions and raise concerns; encouraging health professionals to help people ask questions; helping people to get involved in decisions about medicine taking; and improving access to further sources of advice and information.
Concordance is not only a new way of working for health professionals but also a new way of thinking about their relationships with their patients. This may place extra demands on time and resources in competition with other important innovations but will pay dividends in the longer term. Medicines Partnership provides resources to support the development of concordance and encourages multidisciplinary training with the involvement of patients.
The assistance of Wendy Fairhurst, Nurse Lecturer, University of Manchester, and Maureen Webber, Practice Nurse, Norwich, is gratefully acknowledged.
Centre for Postgraduate Pharmacy Education, University of Manchester. (2003)Concordance Open Learning Pack. Available from www.cppe.man.ac.uk
Department of Health. (2000)The NHS Plan: A plan for investment, a plan for reform. London: The Stationery Office. Available at: www.nhs.uk/nationalplan/nhsplan.htm
Gerbert, B., Bronstone, A., Clanon, K. et al. (2000)Combination antiretroviral therapy: health-care providers confront emerging dilemmas. AIDS Care 12: 4, 409-421.
Kennedy, I. (2001)Learning from Bristol: The report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995. London: The Stationery Office. Available at: www.bristol-inquiry.org.uk/final_report/ index.htm
Medicines Partnership. (2003)Available at www.medicines-partnership.org/professional-development
Office of National Statistics. (1997)General Household Survey. London: ONS.
Rovelli, M., Palmeri, D., Vossler, E. et al. (1989).Noncompliance in organ transplant recipients. Transplant Proceedings 21: 1 (Part 1), 833-834.
Schering. (1987)Schering Report IX. The Forgetful Patient: The high cost of improper patient compliance.
Stewart, S., Marley, J.E., Horowitz, J. (1999)Effects of a multidisciplinary, home-based intervention on unplanned readmissions and survival among patients with chronic congestive heart failure: a randomised controlled study. Lancet 354: 9184, 1077-1083.