Primary Care Pharmacy September 2000 Vol 1 No 4 p93-95

Viewpoint

Achieving concordance

FT: How did it all begin?
MM: My work with The Society began in 1995 when I was invited to chair a working party of experts inquiring into problems with medicine-taking. The Society, in partnership with Merck, Sharpe & Dohme, were interested in looking at the problem of non-compliance.

Why was the concordance group set up?
The working party produced, in 1997, a report, which was called "From compliance to concordance". During its production, a meeting was held that allowed members of patients' representative groups to comment on the report. This was one of the most important meetings that we held, as the patients' representatives were very critical of the preliminary discussion document that we had produced. It became evident that their criticisms were well founded. Although we had carefully examined the research on medicine taking, we had not truly appreciated or valued the patient's point of view. We understood that their view was different from that of health care professionals but we had not acknowledged that it was as valid. The main criticism that the patient groups had was that they not been consulted earlier and they were right. The impact of consulting them was a very important step. As a result, our final report was fundamentally changed from the original discussion document and, out of this, the notion of concordance arose.
Is there a difference between compliance, adherence and concordance?
I do not think there is a difference between adherence and compliance. I think adherence is just a more "politically correct" way of saying compliance. Concordance is a totally different concept.

So, what is concordance?
A definition of concordance that I used recently when writing to a Minister of Health is that it is a new approach to the prescribing and taking of medicines. It is an agreement reached after negotiation between a patient and a health care professional that respects the beliefs and wishes of the patient in determining whether, when and how medicines are to be taken. Although reciprocal, this is an alliance in which the health care professionals recognise the primacy of the patient's decisions about taking the recommended medications.
In other words, compliance is simply another way of saying that patients should follow doctor's orders. Concordance is about the patients being empowered to manage their own life and to be satisfied with a consultation.
This is a very difficult statement and it can be a headache for health care professionals, especially pharmacists and doctors. It means that if patients come to informed decisions that they do not want to take their medicines, or that they do not want to take them in the way that research and science suggests that they should, that decision has to be accepted without dismissing or rejecting the patient. In other words, the patient may reject the medicine but the pharmacist or doctor should not reject the patient because of this decision. On the contrary, the challenge is to stay with the patient, while remaining true to what we believe about medical science. That is difficult for health care professionals and it is an enormous change from anything that has happened before.
Another difficulty is that, although the word concordance is used widely now, it is occasionally used as a synonym for compliance. They are totally different words and meanings.

Does concordance lead to compliance?
My instictive reply is it must or should. However, the bit of me that says that is the bit of me that looks at the problem through the eyes of medicine and evidence.
Compliance and satisfaction may be at odds. We know that 50 per cent of the time, patients on long-term medicines do not take their drugs as prescribed. That is an incredible statement about waste, loss, morbidity, or even mortality, that might be prevented - let alone the economic cost to society. However, the patient must be free to choose, we must not be repressive or practice "coercive health". I would like to see concordance lead to more optimal medicine taking - an improved quality of medicine taking.

What are the major barriers to concordance from the health care professional's perspective?
The barriers from the view of the health professional include: uncertainty about (and absence of training in) the skills required to conduct a concordant negotiation; time to negotiate; how to reconcile the conflicts between continuing commitment to the best care of the patient, serious respect for the patient's beliefs and wishes, and the professional responsibility to remain faithful to the best evidence from clinical research.

And from the patient's point of view?
The main barriers to concordance for patients include: the unequal balance of power in the encounter between patient and health professional; the fear of not being taken seriously; the fear of rejection and anxieties about accepting the additional personal responsibility for the consequences of deciding to deviate from what bio-science suggests is the appropriate treatment.

Are patients given sufficient guidance or information about treatment options?
The health care professions, the pharmaceutical industry and the Royal Pharmaceutical Society, among others, are all keen to provide clearer information to patients. Patients have access to an enormous amount of information on the internet, which is good news, but not all of this information is of good quality - the good sites need to be "kite-marked".
The problem with the information produced by the pharmaceutical industry (and it is not their fault) is that most of the information provided to patients in leaflets and so on is, I think, written with the advice of lawyers. This is done to insure the company against litigation but it means that the poor patient gets all the bad news (ie, detailed descriptions of side effects and warnings). No-one seems to mention that the patient may feel a lot better or that the disease may be checked or cured, if they take the tablets. Patients have said that they want to hear the good news and not just the warnings. So, there needs to be a change in the culture.
Any treatment is a balance between risk and benefit. All medicines have their downsides and some of the most powerful medicines have the worst downsides. In the end, the only way to resolve the risk/benefit issue is to bring the patient into discussions about treatments, give them all the information and allow them to choose. For example do they wish to take a drug when:

• it might shorten their life but will improve the quality of that life? (I would make that choice any day, if I had a serious condition)
• it might lengthen life but with a diminished quality?

A patient may say: "Now that it has been explained to me, I have decided not to take the medicines and put up with the illness." This is a legitimate decision for a patient to make once they have been properly informed of the choices.

What part has the pharmaceutical industry played in the concordance group?
MSD have been wonderful in their support of the project and there are representatives from the industry on our advisory group. It is likely that, in the future, other companies will join in and will be very helpful. I guess that certain companies will want to support specific initiatives - research, conferences, education and publications - and they are important and positive partners in this. It is very much in their interest that we get it right.

What is the role of the pharmacist in concordance?
Well, I am not a pharmacist myself but my view is that they are of enormous importance.
There is a paradox within pharmacy - community pharmacists want to be two things and the public need them to be two things. On the one hand, they have to be white-coated professionals who understand about science and medicines. On the other, they have to be immediately accessible when the public want to drop in for advice and information and be informal. Both are enormously important roles. I see people every day visiting the local pharmacy to ask about their illnesses and getting helpful, intelligent advice in an informal, accessible way. This is enormously important. This is equally true of pharmacists working in health centres and primary care practices. It is vital that the partnership between pharmacists and doctors should become even closer. Good doctors have always valued this relationship.
Pharmacists working in partnership with doctors in practices are a very important development. I can envisage, because I am a radical, that, in the future, doctors will make a diagnosis and recommend a class of drug for the patient to take. The doctor will then refer the patient to the pharmacist, who will decide which drug from the class should be used and who will manage its use. As concordance is a process of negotiation, I can imagine the discussion relating to the diagnosis taking place between the doctor and patient. The detailed negotiations about treatment might well take place with a pharmacist.

What education and training do you think is needed?
I think we need to have a big education and training drive. There is an education pack on the concordance group website (www.concordance.org), which is one of the most interesting things on the site. Training should not be about passively learning new tricks, it must become research-driven in itself. It must explore what we mean by concordance, preferably during the process of doing it, so that we find out what does or does not work. Concordance is still a good idea in the making.
For this to succeed, we need a massive campaign for public involvement. This might include the use of television, radio, women's magazines - all the usual forms of communication with the public. A very influential way of raising the issue of concordance would be to incorporate it into soap operas, such as East Enders or The Archers, in much the same way as with AIDS and breast cancer. This is a great way of discussing the issues in a grown-up way.

What about improving drug wastage?
This should be resolved to a great extent by the successful use of concordance. Patients who do not wish to take a drug simply will not receive a prescription or will not have it filled. That may mean a loss of business to pharmacists but makes sound clinical sense. And pharmacists and doctors are never going to be short of work. Often, when treatment does not work, doctors try changing the dose or the type of tablet and it makes no difference. This is because they have not addressed the fundamental question of whether the patient believes in the diagnosis or takes the treatment. "Non-compliance" or "failure to comply" implies that the patient is at fault, when the fault lies in a failure to reach a true understanding.

How will the role of pharmacists change if they are allowed to prescribe more medicines than at present?
The role will change, obviously. I believe that, as far as is safely possible, the use of drugs should be shifted from secondary to primary care, from doctors to pharmacists and nurses, and from all health care professionals to over-the-counter status. I say this because I believe in patient empowerment and patient choice. Obviously, we have to consider patient safety, too, but there has to be a carefully negotiated line between being concerned for patients' safety on the one hand and being controlling and coercive on the other. It is a fine line and I tend to be on the liberal side of it. I tend to the view that our society is becoming too risk-averse.

What does the group hope to achieve in the future?
The concordance programme is funded until autumn, 2001. Discussions are taking place with the Government and other bodies as to how the initiative should be taken forward. I am hopeful that it will be taken forward, because everyone - the Government, the NHS, health professionals, the public and the pharmaceutical industry - has to deal with the problem. They are all attracted by the solutions that the group is proposing. So, watch this space.