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Putting concordance for taking medicines into practice
When the medicines that doctors prescribe fail to produce the benefit they expect, they often respond by varying the dose or selecting an alternative medicine. Thus doctors seem to behave as though non-compliance is a problem for other doctors. Although we know that about half of the medicines prescribed for patients with long term conditions are not taken as prescribed,1 the concerns of health professionals have focused almost exclusively on improving the quality of their own prescribing choices. Similarly, attention and resources devoted by pharmaceutical companies to discovering, developing, and promoting new drugs utterly dwarf their efforts to see that medicines are taken by patients. Yet non-compliance continues to represent a serious therapeutic deficit at the core of medical practice, with consequent massive personal, societal, and economic cost.
Patients do not comply with medication for several reasons.2 Non-compliance may be intentional or involuntary. It may relate to the quality of information given, the impact of the regimen on daily life, the physical or ental incapacity of patients, or their social isolation. Many interventions to overcome these impediments have been tried, but evidence of sustained success is scant.1
The difficulty for health professionals lies in acknowledging that it is the patients' agendas and not their own that determine whether patients take medicines. Patients have their own beliefs about their medicines and medicines in general. They have their own priorities and their own rational discourse in relation to health and care, risk and benefit.3 These may differ from and sometimes contradict those of the doctors. They are, however, no less cogent, coherent, or important.4
By drawing on these findings and insights a new relationship between
prescriber and patient was described.5 The term
concordance was introduced. While compliance describes the degree to
which the patient follows the prescribed regimen of medicines,
concordance describes an agreement between a patient and a healthcare
professional about whether, when, and how medicines are to be taken.
Concordance therefore refers to the creation of an agreement that
respects the beliefs and wishes of the patient, and not to compliance
the
following of instructions.
Doctors and patients may not always agree. The implication of concordance is that when this happens the patient's views take precedence. This poses challenging questions about choice and responsibility. If the only treatment to which the patient will agree falls substantially short of what modern medicine can achieve the doctor may be left with a burden of responsibility that is hard to manage emotionally, ethically, and legally.
Practitioners are constantly urged to be both patient centred and evidence based. Yet these two goods can conflict. The quest is for the best health outcome, but concordance implies that we must now redefine best outcome so as to reconcile what pharmacology can theoretically achieve with what the patient desires or can bear.
Non-compliance is a multifactorial problem and requires multifactorial responses. No single blueprint for concordance exists. Nor will concordance be achieved by acquiring new communication skills alone. Intentions must also change. Concordance cannot be delivered by the imposition of top down guidelines. Doctors and patients must learn how to "do concordance" not only on the basis of established evidence but also from their own reflective experiences and from new experimental studies.
Many questions need to be answered. Few of the usual sociodemographic and biomedical variables predict non-compliance. Can we identify some that do? What does a concordant process look like in practice? What difficulties does concordance raise for patients and how can they be overcome? How can the ethical issues for doctors be addressed? What needs to change in order to implement concordance?
A change in the culture of the doctor-patient encounter is needed now. Concordance presents new challenges for patients, doctors, nurses, pharmacists, pharmaceutical companies, policy makers, and others. Crucially, as we move forward, we must learn to create robust therapeutic alliances with mutual respect for both the doctor's professional opinion and the patient's personal decisions.
In 2002 the Department of Health endorsed and adopted the principles of concordance and created the Medicines Partnership Task Force (www.medicines-partnership.org) to carry this work forward. The task force comprises representatives from the medical, nursing, and pharmacy professional bodies, patients' groups, pharmaceutical industry, and academia. Its two year remit is to look for ways to implement concordance in the NHS so as to improve health outcomes and satisfaction with care.
The BMJ will publish a theme issue on "people taking medicines" on
11 October 2003. We, the guest editors, invite contributions from
researchers, patients, health professionals, policy makers, and other
stakeholders, to reach us by 15 April 2003. Submissions should be
made to www.submit.bmj.com, and the
editorial contact is Giselle Jones (gjones@bmj.com).
We hope to add to the store of evidence, experience, and
controversial debate, and to learn more about what concordance looks
and feels like in practice, how it is being taught to health
professionals and patients, how barriers to it can be overcome, and
to what extent we can produce evidence of clinical and other benefits
for patients, practitioners, and the NHS.
Marshall Marinker
Joanne Shaw
Medicines Partnership Task Force, Medicines Partnership, Royal Pharmaceutical
Society of Great Britain, London SE1 7JN
Footnotes
Competing interests: MM has acted on occasions as a consultant in health policy to MSD Ltd.
| 1. | Haynes RB, McKibbon A, Kanani R. Systematic review of randomised trials of interventions to assist patients to follow prescriptions for medications. Lancet 1996; 348: 383-386[CrossRef][ISI][Medline]. |
| 2. | Britten N. Concordance and compliance. In: Jones R, Britten N, Culpepper L, Gass DA, Grol R, Mant D, Silagy C, eds. Oxford textbook of primary medical care. Oxford: Oxford University Press (in press). |
| 3. | Britten N. Patients' ideas about medicines: a qualitative study in a general practice population. Br J Gen Pract 1994; 44: 465-468[ISI][Medline]. |
| 4. | Horne R. Representation of medication and treatment: advances in theory and measurement. In: Petrie K, Weinman J, eds. Perceptions of health and illness: current research and applications. London: Harwood Academic, 1997. |
| 5. | Marinker M, Blenkinsopp A, Bond C, Briten N, Feely M, George C, et al, eds. From compliance to concordance: achieving shared goals in medicine taking. London: Royal Pharmaceutical Society of Great Britain, 1997. |
© 2003 BMJ
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