The Pharmaceutical Journal
Vol 268 No 7202 p836
15 June 2002

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How concordance challenge us to rethink our attitudes

By Jane Robson

Concordance is a term that is frequently used as a politically correct alternative to compliance. The Medicines Partnership programme (see www.concordance.org) is attempting to demonstrate the benefits of putting concordant principles into practice. However, as a profession, we will not be able to make any contribution to the development of concordance until the difference between compliance and concordance is clearly understood.

Compliance in medicine taking can be defined as the patient taking a dose at exactly the correct time and in exactly the correct way. Non-compliance has been defined as any non-trivial deviation from the prescribed medication regimen. It can be intentional or unintentional, and includes dosage errors, interruption of treatment, failure to take drugs at specific times, taking them at incorrect intervals, and the addition of other drugs.

Because the concept of compliance is viewed as paternalistic and deemed to be politically incorrect, concordance was introduced to describe a new way of making decisions regarding appropriate treatment. Concordance is a state of agreement between prescriber and patient. The patient is empowered and given the opportunity to share his or her health beliefs, opinions and values. Those beliefs are considered to be of equal value to those of the prescriber and both parties attempt to appreciate the position of the other. A compromise plan is arrived at which reflects both sets of beliefs and which the patient agrees to follow. A failure in concordance occurs when either the doctor or patient does not come into the encounter with honesty and openness. Concordance can improve compliance but it does not solve all compliance problems. Concordance should, however, reduce wastage of drugs, because the patient will not be given a prescription if he or she voices the decision not to take it.

Compliance and concordance are related but describe completely different things. Compliance describes outcomes. These outcomes may be related to clinical outcomes but not necessarily. The concept of sufficient compliance, when the absolute level of compliance achieved by the patient is compared with the extent of compliance required to ensure therapeutic success, may make this connection and be more helpful in providing pharmaceutical care. Concordance is not concerned with outcomes; it describes a process and a collaboration, which may or may not lead to improved outcomes.

Compliance may be achieved when concordance is not achieved; the interaction between these two concepts is illustrated below in a number of scenarios:

• A situation where the doctor and patient achieve concordance and the patient follows the resultant agreement is equivalent to the patient exhibiting full compliance
• A situation where the doctor ignores concordance and imposes his wishes on the patient, but they are followed exactly by that patient, is also an example of compliance
• An encounter in which concordance is achieved but the patient subsequently changes his mind and does not follow the agreed plan is an example of intentional non-compliance
• If the patient chooses to follow an agreement achieved either through concordant or non-concordant means, but fails to do so by accident, he is unintentionally non-compliant
• An encounter in which the patient through lack of honesty or openness agrees to a therapeutic plan that he does not intend to follow is an example of both non-concordance and non-compliance

It is important to remember that the term "non-concordant patient" is almost meaningless. If it denotes anything, it means a patient who has refused to take part in the decision-making process regarding treatment options, or possibly a patient who is not capable of benefiting from concordance because of confusion or unconsciousness. We cannot make a patient "more concordant", but we can improve the possibility of concordance being achieved, which would mean involving the prescriber as well as the patient.

Until pharmacists become prescribers, we cannot take full responsibility for concordance, since the major thrust of the concept is achieved within the consultation during which the decision to prescribe is made. However, pharmacists in traditional roles can help.

• Concordance is not possible without informed patients. As pharmacists we have the expertise needed to train prescribers to ensure they have the basic knowledge required to inform their patients.
• Pharmacists are usually the first port of call for patients after a new prescription is made. It is essential for all of us to take this opportunity to ensure that the patient understands why the particular medicines have been prescribed and that they are satisfied with the decision. This includes an awareness of adverse effects and the potential benefits of treatment. Counselling on handing over medicines should not merely include advice about the when and how of compliance, but should also actively seek feedback to identify the patient who has not been offered concordance. It is important to realise that some patients may not want to be involved in concordance and would rather be told what to take.
• Concordance must continue throughout the course of the disease and medicines review is essential to ensure that the patient is still satisfied with treatment and that they do not require any alterations. This includes an understanding of the attainment of outcomes. The role of the pharmacist in medication review has been clearly identified within the National Service Framework for Older people, but should be a routine part of the dispensing process. This is yet another argument for pharmacist management of the repeat prescribing process.
• Concordance is as important with the selection of over-the-counter medicines. Patients who want advice should be given as much information as they want to ensure safe and effective self-treatment.
• For concordance to be meaningful, all health professionals caring for a particular patient must understand why certain treatment decisions have been made. Pharmacists are in an excellent position to share details of the medication history and reasons for changes with other professionals across the primary/secondary care divide.

Concordance challenges us to rethink our attitude to medicines management. Are we ready to accept this challenge or will we miss the opportunity? I sincerely hope we will rise to the challenge, which we are most qualified to answer.