The Pharmaceutical Journal
Vol 268 No 7202 p837-838
15 June 2002

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Letters to the Editor

Concordance

A valuable contribution to make to debate

From Dr K. Pollock and others

In a recent article Rob Shulman raises a number of important issues regarding the limits of concordance.¹ In addition to identifying some unusual and quite extreme cases in which the model can be applied within intensive care, he calls for the concept of concordance to be subjected to critical scrutiny, and identifies a number of limitations to its relevance. We believe this call for a critique of concordance is timely and offers the opportunity for debate to move forward.

Although it is interesting and valid to explore the boundaries of concordance, the fact that the model may not be applicable in all clinical scenarios does not detract from its utility in most. Nevertheless, we do not agree that the examples which Shulman presents as incompatible with concordance actually lie outside the model.

One of the critical features of concordance is its orientation within a different epistemological setting to the traditional positivistic model still underpinning much medical practice, and the ideologically driven concept of "compliance".² Concordance redefines the nature of the relationship between patients and professionals. It recognises the competence of patients to make judgements about preferred health care outcomes which are grounded in their personal goals and values, and which may be at variance with the "expertise" or "rationality" of professional judgement.

Concordance focuses on the consultation as a transaction, involving a two-way exchange of information and ideas and consequent generation of shared understandings between patient and practitioner. The goal of a concordant consultation would be to reach a negotiated agreement about the treatment and management of illness. Patients and professional would feel able to express and explain their preferences and achieve an understanding of the other's point of view. Wherever practicable treatment decisions should prioritise the informed choices of the patient. Where the patient chooses to delegate decision making authority to the professional (or others, eg, carers), this is still a "concordant" option: there is every difference between the transfer and the appropriation of authority. Patients may wish to adopt different levels of participation at different stages of their illness. In addition, and quite crucially, there is nothing in the concordant model that specifies that patient (or carer) preferences can ride roughshod over the equitable distribution of resources, that professionals are obliged to abdicate all responsibility for practising good medicine, or that any individual (as patient or otherwise) is entitled to jeopardise the health and wellbeing of others in his society.³ The patient's definition and shaping of his own wellbeing, however, is another matter.

Concordance does not merely shift the boot to the other foot, so that it is the patient, rather than the professional, who becomes the dominant player. An important goal in implementing concordance is to move away from this kind of simplistic opposition. The crux of a concordant consultation is that it achieves a shared awareness and mutual respect for participants' points of view. Where agreement cannot be reached, at least there will be an understanding of why not. Most patients are reasonable and protective of their own best interests. Many decisions about treatment are made independently and without discussion with health professionals. In achieving a more patient-centred consultation, the goal is normally to increase lay participation and assertiveness, rather than to curtail it. Far from being unreasonably profligate in their demands on resources, there is increasing evidence that informed patients opt for more conservative (and often cheaper) treatment options than would be recommended by their doctors.^4–6

The important thing is that patients should be provided with access to as much information about their illness and available treatment options as well as the opportunity to discuss these with their health care professionals, because they need to achieve their preferred level of involvement in decisions about their own health care. The point is that in practice this still does not usually happen. The issue is about how to make it the norm rather than the exception. Concordance has a valuable contribution to make.

Kristian Pollock
Concordance Research Fellow

Alison Blenkinsopp
Professor of the Practice of Pharmacy

Janet Grime
Concordance Research Fellow
Department of Medicines Management,
Keele University

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