1. Concordance Karen Ford - December 2011
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Karen Ford - December 2011

2. 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

3. Concordance Jargon or reality? Medicines Adherence NICE 2009
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Karen Ford - December 2011

4. Definitions 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

5. Concordance
The process of prescribing and medicine-taking based on partnership
Medicines Partnership
Karen Ford - December 2011

6. Adherence Definition use by NICE 2009:
‘The extent to which the patient’s action matches the agreed recommendations’
What are you views on this definition?
This was initiated by the question ‘Why don’t some patient’s use their medicines as prescribed?’
Karen Ford - December 2011

7. Cost of wasteful prescribing each year
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
Adherence more like compliance than the partnership approach
Adherence more stick to where as concordance suggest harmony or agreement
Karen Ford - December 2011

8. 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

9. 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

10. Cost of wasted medicines and dressings
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 million
In England 1999/2000 medicines accounted for £1.5 billion spent by NHS hospitals
Granby 2005
Karen Ford - December 2011

11. Consequences of wasted medicines and dressings
Ill-health
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

12. Concordance
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

13. Patient/health care professional partnership is not a new concept
Griffiths report 1984
Working for patients 1989
The patients charter 1991
New NHS Modern and dependable 1998
Find alternative image
Karen Ford - December 2011

14. 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 2006
Many long term illnesses are tackled by means of prescribed drugs
Karen Ford - December 2011

15. Concept of the non-compliant patient
Deviant?
You or me?
The Expert Patient?
30% - 60% of patients who fail to comply with medication
90% with some medications -Humphries 2002
NICE 2009 ‘non-adherence 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

16. Risks associated with non-compliance
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

17. Psychological theories behind non-concordant 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 medication
Patients receiving conflicting advice
Patients alter regime according to how they feel
Poor coping strategies, anxiety, attitudes and beliefs
?reference
Karen Ford - December 2011

18. Socio-economic factors and therapy related factors
Complicated regimes -strong correlation between polypharmacy and non-compliance 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

19. Dancing not Wrestling Rollnick (2000)
Yes No
Karen Ford - December 2011

20. Healthcare and condition related factors
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
8.3 As children grow and develop, they should be encouraged to participate in decisions about their medicines and to take responsibility for taking their medicines. Older children with a long-term illness should, where possible, assume complete responsibility under the supervision of their parent/carer. Children develop at different rates and hence their ability to take responsibility for their own medicines varies. This should be borne in mind when making a decision about transferring responsibility to the child or young person for their own medicines. There is no set age when this transition should be made. Health professionals should assess, with each individual child, parents and/or carers when they can and want to be responsible for their own medicines. See Standards 3 and 4
Clinicians are able to demonstrate that they have sought and acted on patients' and their parents or carers views and that patients' agreement was sought for the medicine regime they have jointly agreed, especially for children or young people with long term or complex medication needs.
Young people, children and their parents or carers are involved in the design and delivery of professional development programmes on concordance. FROM: NSF for children and young people 2007 Standard 10
Karen Ford - December 2011

21. 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

22. 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 problems
Karen Ford - December 2011

23. Barriers to optimal use of medicine
What can you think of?
Karen Ford - December 2011

24. CONCORDANCE Prescribing consultations involve patients as partners
Patients have
enough
knowledge
to participate
as partners
Prescribing
consultations
involve
patients
as partners
Partners
are supported
in taking
medicines
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

25. 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 this as important
Karen Ford - December 2011

26. Prescribing consultation involves patients as partners
Patients invited to talk about medicine-taking
Professionals explain proposed treatment fully
Agreement reached jointly
Understanding and ability to follow treatment checked
Karen Ford - December 2011

27. Patients are supported in taking medicines
All opportunities used to discuss medicines
Information effectively shared between professionals
Medications reviewed regularly with patients
Practical difficulties addressed
Karen Ford - December 2011

28. 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

29. How might we achieve concordance?
Patient choice
Negotiation
Patient involvement in decision making process
Achieving a therapeutic alliance
An ‘open’ relationship
Key principles outlined by NICE 2009
Karen Ford - December 2011

30. Key Principles NICE 2009
Adapt your consultation style to the individual’s needs
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

31. 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

32. 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

33. Medication reviews 3 types: Prescription review
Concordance & Compliance review
Clinical medication review
Clyne et al 2008 NPC
Karen Ford - December 2011

34. Concordance & Compliance review
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. QOF 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

35. Case study- concordance element
Take care not to confuse compliance and concordance
What is the difference?
Karen Ford - December 2011

36. 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 pp November 2001
Cheesman S. (2006) Promoting Concordance: the implications for prescribers. Nurse Prescribing Vol.4 No.5 pp
Clyne W Blenkinsopp & Seal R (2008) A Guide to Medication Review NPC Available on
Karen Ford - December 2011

37. 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 pp
NICE 2009 Medicines Adherence January 2009 No. 76
National Prescribing Centre Plus (Accessed )
Shuttleworth A. (2004) improving drug concordance in patients with chronic conditions Nursing Times vol.100 November.
Karen Ford - December 2011

38. 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 vol.271
Karen Ford - December 2011

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Karen Ford - December 2011