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It was somewhat extraordinary, early one morning on what promised to
be another swelteringly hot day in New Orleans, to find 40 or so pharmacists
from around the world settling down to spend the day in a gloomy, chilly
and cavernous room deep in the Hyatt convention centre.
We were there to take part in a workshop organised and chaired by Theo
Raynor and Marja Airaksinen from the universities of Leeds and Helsinki.
This was possibly the first significant international
event on concordance for pharmacists, and Medicines Partnership was pleased to support it.
The rather inauspicious surroundings were to produce a number of surprises — some
positive, some less so — but all a challenge to assumptions about
the place of concordance in the world and the significant issues that
lie ahead of us.
The first surprise was the breadth of interest. Thirty participants from
every continent had registered for the symposium. Speakers were from
the UK, Finland and Australia. The diverse backgrounds of the participants
was an encouraging signal, although not an absolute assurance of the
true level of awareness and understanding. This would not be apparent
until we were further into the workshop itself.
The first sessions were designed to establish the principles of concordance
and to confirm participants’ levels of understanding of the concept
itself. As afficionados of concordance are only too aware, the language
of concordance can cause problems, with a significant proportion of people
who believe that concordance is now the politically correct word for
compliance, and who happily substitute one c-word for another without
seeming to recognise the difference between them.
Compliance (or adherence) refers to whether patients take medicines according
to the prescribed instructions. It measures patient behaviour.
Concordance is a shared decision making about medicines between a health
care professional and a patient, based on partnership, where the patient’s
expertise and beliefs are fully valued. It measures a process.
It was soon apparent that the terminology problem, which so often seems
to be a major stumbling block, was not going to be an issue at the workshop.
The difference between compliance and concordance was clearly understood,
irrespective of language barriers. There may not be a word for concordance
in Japanese, for example, but the participants from Tokyo University
of Pharmacy and Life Science, Niigata College of Pharmacy, Pharmavision
Company and Seven Pharmacy were fully conversant with the idea of partnership
between patients and health professionals. When we talked about applying
concordance in practice, they went on to make some interesting observations
about the importance of generational differences in Japan and how these
can be addressed.
At the opposite end of the spectrum, concordance clearly strikes a chord
in the developing countries. It may seem that concordance is a luxury
only affordable in the developed world, with its greater access to health
resources.
But, as the burden of disease worldwide shifts towards long-term chronic
illness, concordance becomes relevant everywhere. Diabetes in Asia and
AIDS in Africa are two examples where complex long-term medication regimens
are crucial to minimising the burden of disease on individuals and
society. Therefore it is essential that
patients understand and accept their treatment and are supported to follow
treatment
programmes. This is the essence of
concordance.
In working groups defined by geography, participants discussed the level
of knowledge of concordance in their countries and the potential for
concordant practice. Unsurprisingly, knowledge of concordance was judged
to be highly variable, with the lowest awareness in developing countries — Africa,
South America, the Middle East — and some wry comments from other
places, including: “They think they know, but they don’t
... mixing up compliance and concordance.” Sound familiar?
There was strong agreement about the need and potential for concordant
practice, but recognition that a range of different strategies would
be needed to suit local circumstances — “in Japanese way”,
summed up the views of one group.
Economics was seen as a key barrier in the US, while poor health systems
and lack of resources were identified as the major problems in Brazil
and Mexico, with the development of more drug information centres the
most realistic and positive first step.
The two-day workshop programme was interesting and varied. A range of
techniques was used to engage participants, including plenty of group
work, discussion, video and scripted vignettes. But underlying this stimulating
mix of material there was a sense that many pharmacists are steeped in
a paternalistic, instructional mode with patients and, despite all positive
intentions, they find a genuinely concordant model difficult to adopt
in practice.
It was a real concern to see that the International Pharmacy Students
Federation event on patient counselling appeared not to have taken on
board the principles of partnership with patients, but to reflect a purely “instructional” model.
Experience shows that once practitioners have internalised a particular
model of practice, habits are extremely hard to change. We cannot afford
to teach the professional leaders of the future that excellent patient
counselling consists of conveying complete and accurate information,
rather than understanding patients’ own beliefs and preferences
and using their professional knowledge to guide and advise, recognising
that patients are the ultimate decision makers.
Concordance is not a bolt-on, but a way of thinking and working with
patients that profoundly affects the way that patients and professionals
interact.
Pharmacists have a vital role to play in providing patients with clear
and accurate information about medicines to enable them to make fully
informed choices about their health. In order to help make best use of
the world’s scarce health care resources, pharmacists will need
to go further than information provision to engage patients on their
own terms.
This workshop demonstrated a recognition of this vital agenda, and an
enthusiasm to engage with it. It also highlighted some worrying gaps
in awareness that will need to be addressed for genuine progress to be
made.
The symposium programme and a selection of materials can be downloaded
from
the Medicines Partnership website |
The
Pharmaceutical Journal