Concordance Workshop - Preactivity (Lead Lecture).

Karen Ford - December 2011
Learning Objectives
• At the end of the session students will
have explored the concept of concordance
and increased their understanding of how
the concept can be applied to future
prescribing practice.
Karen Ford, De Montfort University
Karen Ford - December 2011
• Jargon or reality?
• Medicines Adherence
NICE 2009
Karen Ford - December 2011
• Compliance:
• ‘a willingness to follow or consent to the wishes
of another person’ Buckman 1997
What are your views on a compliant consultation?
• Refers to taking medicines in the right way and does not
regard patients rights Lahdenpera and Kynagas 2000
• Non-compliance suggests the patient has not done what
they were told by a doctor or nurse Gray et al 2002
Karen Ford - December 2011
• The process of prescribing and medicinetaking based on partnership
• Medicines Partnership
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• Definition use by NICE 2009:
• ‘The extent to which the patient’s action
matches the agreed recommendations’
• What are you views on this definition?
Karen Ford - December 2011
Cost of wasteful prescribing each
• The annual cost of loss to the NHS is £7–9bn, or
between 16 and 20 per cent of the total NHS budget
Bellingham 2001
• Returned medicines represent some of the cost- £230
million in 2000
Stoat 2000
Karen Ford - December 2011
Wasteful prescribing details:
• Adverse patient events (leading to
prolonged stays in hospital):
• £2bn sickness and absence
• Crime: £1–3bn
• Hospital acquired infection: £1bn
• Medication errors: £300–600m
Karen Ford - December 2011
Wasteful prescribing details:
• Clinical negligence: £400m (with potential
liabilities of between £2bn and £4bn)
• Malnutrition: £230m
• Occupational health and safety: £150m
• Avoidable management and legal costs: £100m
Bellingham (2002)
Karen Ford - December 2011
Cost of wasted medicines and
• Around £100 million per year in the UK
(NPC 2002).
• 617 million items dispensed in 2001.
• In England 2002 net NHS community cost of prescriptions = £6847
• In England 1999/2000 medicines accounted for £1.5 billion spent by
NHS hospitals
Granby 2005
Karen Ford - December 2011
Consequences of wasted
medicines and dressings
Reduced quality of life
Reduced life expectancy
An estimated 50% of medicines prescribed
for chronic conditions are not taken as
prescribed Stoat 2000
• Economic loss to society
Karen Ford - December 2011
• Suggests an equal partnership needs to
exist between professionals and patients
before patients will buy into the need to
comply with medication
• (RPSG & Merck Sharpe and Dohme 1997)
Karen Ford - December 2011
Patient/health care professional
partnership is not a new concept
• Griffiths report 1984
• Working for patients
• The patients charter
• New NHS Modern
and dependable 1998
Karen Ford - December 2011
Facts from Medicines Partnership
• At any one time 70% of the UK population
is taking medicines to treat or prevent ill
health or to enhance well-being NPC Plus
• Many long term illnesses are tackled by
means of prescribed drugs
Karen Ford - December 2011
Concept of the non-compliant
You or me?
The Expert Patient?
30% - 60% of patients
who fail to comply with
• 90% with some
medications -Humphries
• NICE 2009 ‘nonadherence should not
be considered the
patient’s problem.
Rather, it usually
results form a failure
to fully agree the
prescription with the
patient ‘
Karen Ford - December 2011
Risks associated with noncompliance
• Medication mismanagement accounts for
6% of unplanned admissions to hospital
Tierney & North 1995
• Non-concordance leads to
mismanagement of medical conditions,
readmission to hospital, development of
adverse effects and sometimes death
Henderson et al 1989, Cline et al 1999
Karen Ford - December 2011
Psychological theories behind nonconcordant behaviour
• The patients perception of the reason for being
prescribed the medication
• The rationale for treatment not accepted by the
patient therefore non- acceptance of prescribed
• Patients receiving conflicting advice
• Patients alter regime according to how they feel
• Poor coping strategies, anxiety, attitudes and
Karen Ford - December 2011
Socio-economic factors and
therapy related factors
• Complicated regimes -strong correlation
between polypharmacy and noncompliance Rudd 1993
• Side effects and long term treatment
• Cost Robertson 1992, Nystanga 1997,Cheesman 2006
• Socio-economic-unstable living conditions,
unemployment, lack of adequate social
networks Cheesman 2006
Karen Ford - December 2011
Dancing not Wrestling
Rollnick (2000)
Karen Ford - December 2011
Healthcare and condition related
• Health care system factors- lack of follow
up; poor capacity in the system to provide
patient education and patient-provider
relationship De Geest 2005
• Condition related- difficulty accepting
diagnosis and patient & prescriber having
poor knowledge
Karen Ford - December 2011
Non-compliance and the elderly
• Over 65s constitute 20% of the population
• 45% of medications prescribed are for this
age group
• Over 75s 3 out of 4 people are taking
prescribed medication
• 36% of older people take 4 or more
different medications on a regular basis
Karen Ford - December 2011
Causes of medication mismanagement
in the elderly
• Social vulnerability
• Physical vulnerability
• POLYPHARMACY ( 5 or more
medications taken concurrently)
• Dementia, confusion, impaired memory
• Impaired vision, and dexterity related
Karen Ford - December 2011
Barriers to optimal use of medicine
• What can you think of?
Karen Ford - December 2011
Patients have
to participate
as partners
as partners
are supported
in taking
Adapted from:
Bond C (2004) Concordance a partnership in medicines-taking. Pharmaceutical Press, pp 149 (Figure 8.1)
Karen Ford - December 2011
Karen Ford August 2010
Patients have enough knowledge
to participate as partners
• Information provided is:
-tailored, clear & accurate
-on treatment options
-on the risks v benefits
-accessible where patient feels confident to ask
questions and discuss issues
-sufficiently detailed
• Education empowers patients to manage their
own health
• Health professional needs to be skilled to
engage and regard
as important
Karen Ford
- December
Prescribing consultation involves
patients as partners
• Patients invited to talk about medicinetaking
• Professionals explain proposed treatment
• Agreement reached jointly
• Understanding and ability to follow
treatment checked
Karen Ford - December 2011
Patients are supported in taking
• All opportunities used to discuss
• Information effectively shared between
• Medications reviewed regularly with
• Practical difficulties addressed
Karen Ford - December 2011
Findings from a study
by Royal Pharmceutical Society &
Merck & Dohme (1997)
• Most influential factor is the belief patients
have about their treatment
• These beliefs are often at variance with
the best evidence from medical science
and consequently received scant- if any
attention from the prescriber
• To ignore the beliefs of the patient is to fail
to prescribe effectively
Karen Ford - December 2011
How might we achieve
• Patient choice
• Negotiation
• Patient involvement in decision making
• Achieving a therapeutic alliance
• An ‘open’ relationship
• Key principles outlined by NICE 2009
Karen Ford - December 2011
Key Principles NICE 2009
• Adapt your consultation style to the individual’s
• Tailored communication and how information
can be made more accessible
• Offer for patient to be involved in decision
making process about their medicines
• Remember increased involvement may result in
refusal to take drugs or stop taking drugs –
record keeping
Karen Ford - December 2011
Key Principles cont..
• Accept patient has the right to not take
medicines – even if you do not agree
• Be aware of patient beliefs and how they
perceive the need or not for a drug
• Provide additional patient information
relating to condition
• Recognise non-adherence is common,
most will not adhere at some time
Karen Ford - December 2011
Key principles cont…
• Adherence can be improved but no specific
intervention is recommended for all patients i.e.
tailor your intervention
• Review patient knowledge, understanding and
concerns about medicines.
• Review patient understanding of their condition
and need to take medicines at agreed intervals
with patient
• Offer repeat information and reviews- especially
for long-term conditions
Karen Ford - December 2011
Medication reviews
3 types:
Prescription review
Concordance & Compliance review
Clinical medication review
• Clyne et al 2008 NPC
Karen Ford - December 2011
Prescription Review
• Addresses technical issues such as anomalies, changed items, cost
effectiveness with script. May not need patient present.
• May include all or some of medicines prescribed but does not include OTC
or complementary drugs, mapped to professional activities e.g.
or basic medication reconciliation in hospitals
Concordance & Compliance review
• Addresses issues relating to patient’s medication taking behaviour. Usually
requires patient to be present and must involve patient or carer if changes
are to be made
• Includes all prescription drugs, OTC & complementary meds. Review
medicines use. Map to QOF, MUR, DRUM, Single assessment process etc.
Clinical Medication Review
• Addresses issues relating to patients medication taking behaviour but in
relation to their clinical condition. Patient/carer must be present.
• Includes all types of medication – a review of medicines and condition
• Links to QOF, enhanced service in community pharmacy
Karen Ford - December 2011
Case study- concordance
• Take care not to confuse compliance and
• What is the difference?
Karen Ford - December 2011
References and Further reading
• Banning M. (2004) Enhancing older people’s
concordance with taking their medication British Journal
of Nursing Vo. 13, No.11.
• Bellingham C. (2001) The Pharmaceutical Journal Vol
267 No 7175 pp741-742
24 November 2001
• Cheesman S. (2006) Promoting Concordance: the
implications for prescribers. Nurse Prescribing Vol.4
No.5 pp205-208
• Clyne W Blenkinsopp & Seal R (2008) A Guide to
Medication Review NPC Available on line @
Karen Ford - December 2011
Further reading cont….
• Granby T (2005) Evidence based prescribing Accessed 9/10/06
• Gray R., Wykes T., & Gournay K. (2002) from compliance to
concordance: a review of the literature on interventions to enhance
compliance with anti-psychotic medication Journal of Psychiatric
and Mental Health Nursing 9 pp277-284
• NICE 2009 Medicines Adherence January 2009 No. 76
• National Prescribing Centre Plus 2006 Available @
ramme/ (Accessed 20.12.11)
• Shuttleworth A. (2004) improving drug concordance in patients with
chronic conditions Nursing Times vol.100 November.
Karen Ford - December 2011
Further reading……
• Rollnick S Mason P Butler C (2000) Health
behaviour change a guide for practitioners
London: Churchill Livingstone
• Stoate H (2000) Concordance and wasted
medicines. House of Commons All Party
Pharmacy Group. London: House of Commons
• Taylor B. (2002) nurse-patient partnership:
rhetoric or reality Journal of Community Nursing
vol.16, issue 3 march.
• Weiss M & Britten N. (2003) what is
concordance? The Pharmaceutical Journal
Karen Ford - December 2011
This work was produced as part of the TIGER project and funded by JISC and
the HEA in 2011. For further information see:
This work by TIGER Project is licensed under a Creative Commons AttributionNonCommercial-ShareAlike 3.0 Unported License. Based on a work at
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Any logos or trademarks in the resource are exclusive property of their owners
and their appearance is not an endorsement by the TIGER project.
Karen Ford - December 2011
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