Concordance — is it a synonym for compliance or a paradigm shift?
Professor Christine
Bond is
professor of primary care and head of teaching in the department
of general practice and primary care at the University of Aberdeen
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Christine Bond says that the concept of concordance is not fully understood by health care professionals and that it has yet to be accepted as a paradigm shift in health care provision
Non-compliance with the taking of prescribed, and often dispensed,
medicines leads to waste of a valuable resource and ineffective treatment.
Undisclosed
non-compliance can also confound future management of a patient’s
condition. In 1995, a working party was convened to explore the reasons
behind non-compliance with medicine taking. I was privileged to be a
member of that working party, charismatically and efficiently chaired
by Professor Marshall Marinker. Together we all made the journey from
a medically dominated, paternalistic view of non-compliance to one which
realised the patency of the patient’s perspective — and thus
concordance was born.
Achievements
What has been achieved since the publication of the working party’s
report “From compliance to concordance: achieving shared goals
in medicine taking”?1 There has certainly been an increased awareness
of the patient’s perspective by health care professionals and lip
service, at least, is now paid to this in the consultation. The exact
extent of health care professionals’ real understanding and application
of the principles of concordance to their interactions with patients
remains unquantified, as do the effects on patient outcomes. Isolated
research reports do indicate, however, that this sort of approach should
bear fruit.2,3 However for the most part, I cynically observe that my
colleagues happily substitute the word “concordance” for “compliance”,
believing this to be politically correct while not appreciating the difference.
There has also been an increased interest in the psychological and sociological
theories that can be applied to medicines taking (eg, the health behavioural
model, illness representation, attribution theory and the theory of planned
behaviour). Much of this theoretical work dates from 20 years ago or
more. It is sad that it has taken so long to link with colleagues in
other related and relevant disciplines to enhance our own professional-patient
behaviour and understanding.
The biggest achievement is Government funding for the Medicines Partnership
initiative, which has the remit to put medicines concordance — or
do we mean partnership? — into practice. This initiative has been
instrumental in successfully raising the profile of the importance of
informed decision-making through a range of approaches.
Concordance has evolved at the same time as other similar initiatives
that increasingly recognise the roles and rights of the patient or client
in a professional interaction. Medicine is no different in this from
other professions, such as education, and we are seeing a sociological
and cultural paradigm shift across our whole community. Within the health
care environment, other related mantras include patient autonomy, holistic
care, patient centredness, shared decision-making, patient partnerships
and patient empowerment. These are taken forward in such policies as
NHS modernisation, and the expert patient and patient information initiatives.
A topical example of the latter is “Ask About Medicines Week”.
This campaign is designed to increase patients’ access to information
about their medicines, in the belief that information will improve compliance — or
do we mean concordance?
Paradigm or synonym?
In its original conception, concordance represented a paradigm shift
in the way patients are treated by health care professionals. Compliance
with treatment is in many ways the key outcome of the old paternalistic
paradigm yet, as already implied, the word “concordance” is
still substituted too readily for “compliance”. We have seen
compliance, adherence and concurrence with treatment and now we have
concordance. But leaving aside conceptual understanding, there is a semantic
problem if we say patients are concordant with their treatment, when
we mean compliant. Although a patient is more likely to comply with a
treatment decision with which they were involved and fully agree, ie,
are in concordance with, and which takes into account all their beliefs
and expectations, it is by no means inevitable that they will.
It is timely therefore to rethink the concept of concordance, and consider
its implications and future.
Concordance ad absurdum?
Concordance is the name given to the “agreement between the patient
and the health care professional, reached after negotiation, that respects
the beliefs and wishes of the patient in determining whether, when and
how their medicine is taken ... and the primacy of the patient’s
decision [is recognised].” The perceived benefits of this open
and equal negotiated process are that patients will be empowered to share
all their concerns and expectations about their symptoms and their management,
including fears of side effects. They will receive a treatment which
acknowledges these and, ultimately at follow-up consultations, they will
also be able to report any decision not to take their medicines and to
discuss the reasons for this.
Inevitably the concept of concordance may lead to agreed decisions which
are not what the health care professional would want or advise on his
or her own. This is because the goal of the health care professional
is to treat symptoms or cure disease, and for the patient these are but
components of a spectrum of other life circumstances. So people continue
to smoke despite obvious respiratory problems, and others do not take
antihypertensive or lipid lowering treatments because they do not see
any immediate benefit to compensate for potentially suffering the side
effects of treatment. This is nicely encapsulated in the theory of planned
behaviour, one aspect of which predicts behaviour as a balance of the
likely outcome (“if I take these tablets I will improve my health”)
and the value placed on that outcome (“being healthy is important”).
As health care professionals, we assume being healthy is important for
patients but this may not be the case, and certainly not at the expense
of other factors, such as the pleasure derived from smoking.
Having accepted this, it is inevitable that there will be times when
an agreed decision may give the health care professional concerns, because
they know the patient is not doing the best for their health, whether
short term or long term. The medico-legal implications of this have been
much debated but, to the best of my knowledge, never tested. There is
an intuitive feeling that at the end of the day decisions have to be
the patient’s. However it is a role for health care professionals
to ensure that in coming to that decision the patient is fully aware
of the relative risks and benefits of this decision. An assessment of
this understanding is the responsibility of the professional. Documentation
of these discussions, and perhaps even signed agreements, may be something
for the near future in an increasingly complaint-ridden and litigation-bound
health care system. It is also something that clinical governance frameworks
should incorporate.
But although a decision not to take a medicine — the “best
treatment” — may, despite professional misgivings, be ultimately
condoned and supported, there may also be a patient who insists on being
prescribed a treatment for which there is no or little evidence of benefit,
or is contraindicated. Can we as professionals agree to the use of scarce
resources in this way? Should the needs of the population or patient
take priority? Should there be primacy for the patient’s views
under these circumstances?
Taken to even further extremes, what about the well-publicised issue
of body
dysmorphia,4 where patients desire limb amputation because the limb does
not feel part of them. In extreme cases some patients have effected their
own versions of amputation. Concordance still has to come to terms with
these situations and perhaps be rearticulated to remain credible as a
health care paradigm.
Implications for professionals
Professionals are now expected to practise “in a concordant way”,
yet the true benefit of concordance is still unclear. To date there are
no units of concordance so it cannot be quantified or causally associated
with any measurable outcome. Thus research evidence of improved patient
outcomes, even improved patient compliance, associated with concordance
are still awaited. Evidence of cost-effectiveness is even further in
the future. However, in the interim some of the associated mantras referred
to earlier have led to improvements in adherence and
satisfaction.2,3 Therefore it is right that we should, under whatever
umbrella, encourage professionals to talk to patients as equals, in a
non-judgemental way, eliciting their concerns and ensuring they are making
informed decisions. For prescribers, which for pharmacists includes those
making over-the-counter recommendations and prescribing on the NHS, all
of the above apply in order to maximise the benefit of the client contact.
For those dispensing
the prescriptions of others, there is an equally important role to discuss
progress with treatment, to motivate and inform. Eliciting ongoing concerns
is key, and the increasingly integrated role for pharmacists within the
NHS will support this role and maximise our contribution to effective
health care.
It must be recognised that this sort of interaction will come more naturally
to some patients and to some professionals than others.
Although professionals can be trained to practise in this way, not all
patients will want this approach, and another key role for the professional
is to assess the level of partnership the patient wants with respect
to decision making.
The future
Concordance as a paradigm shift has not yet arrived. But it has been
instrumental in focusing interest on the prescribing decision, recognising
the different patient perspectives and ultimately in generating resource
to support this important patient-centred agenda. As with pebbles smoothed
by the sea, its shape will continue to change as it moulds itself to
fit within the bigger ocean of health care.º
References
1. Marinker M. From compliance to concordance: achieving shared
goals in medicine taking. London: Royal Pharmaceutical Society;
1998.
2. Horne R, Hankins M, Jenkins R. The Satisfaction with Information
about Medicines Scale (SIMS): a new measurement tool for audit
and research. Quality in health Care 2001;10:135–40.
3. Little P, Everitt H, Williamson I et al. Observational study
of patient centredness and positive approach on outcomes of general
practice consultations. BMJ 2001;323;908–11.
4. Complete
obsession. Horizon. BBC Television 1999. |
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