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Concordance
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Letters to the Editor
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Concordance
Training in communication skills needed
From Mrs S. Steel, MRPharmS, and Miss A.-M. McCooey, MRPharmS
The activity of medication review has risen to prominence with the inclusion
of specific targets in the National Service Framework for Older People.
Medication reviews need to be evidence-based and patient-centred. Any
change in treatment that is required should be achieved through the process
of concordance, reaching an agreement with the patient that reflects
their beliefs and wishes.
During a recent pharmacist-led medication review clinic in a general
practitioner’s surgery we encountered some difficulty in putting
concordance into practice.
An anxious, 75-year-old woman with asthma and heart failure presented
at the clinic for a medication review. She took diazepam regularly for
anxiety and expressed some confusion about her asthma treatment.
After reviewing her prescribing records it appeared to us that she had
been under-ordering furosemide. To achieve concordance I (Anne-Marie
McCooey) thought that an explanation about heart failure and its treatment
was necessary and, recognising that she was extremely anxious, I attempted
to introduce the topic gently. I asked her whether she had heard the
term “heart failure” before going on to say that it was a
silly term as it sounded rather drastic and that all it meant was that
the heart perhaps was not working as efficiently as it once did. The
furosemide, therefore, worked as a water tablet, reducing the fluid carried
around the body and so reducing the pressure on the heart. It was, however,
important that she take it regularly. The patient seemed to be happy
with this explanation and the discussion returned to her confusion over
her asthma therapy.
The following day the patient telephoned the surgery to tell me that
she had been to see her GP that morning and told the GP that I had said
that she had heart failure and that she was so worried about it, she
had not slept the previous night. In discussing my experience with the
GP, I was relieved to be reassured that I had not done anything untoward
and that this woman’s anxiety is difficult to avoid.
Reflecting on this experience with colleagues, we identified specific
learning needs about communicating with patients. However, finding development
activities to improve skills in this area is proving difficult.
The National Prescribing Centre has identified clear competencies for
nurse prescribers and for potential pharmacist prescribers that includes
communication with patients, and training programmes are being designed
to support achievement and maintenance of competency for new prescribers.
In stark contrast, many more health care professionals are likely to
be involved in undertaking medication review and, although many of the
competencies required are the same as those for prescribing, few training
programmes exist.
Up to now, much education and training for pharmacists working in primary
care has been focused on managing the rapid growth in prescribing spending
rather than focusing on the clinical needs of individual patients and
helping them get the most out of their medicines. If the NHS is serious
about achieving medication review targets and putting concordance for
taking medicines into practice, then a dramatic shift in the focus of
continuing professional development activity is required for all health
care professionals who communicate with patients about medicines.
Sharon Steel
Anne-Marie McCooey
Pharmaceutical Resource Network
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