Editorials

Not to be taken as directed

Putting concordance for taking medicines into practice

When the medicines that doctors prescribe fail to produce the benefit they expect, they often respond by varying the dose or selecting an alternative medicine. Thus doctors seem to behave as though non-compliance is a problem for other doctors. Although we know that about half of the medicines prescribed for patients with long term conditions are not taken as prescribed,¹ the concerns of health professionals have focused almost exclusively on improving the quality of their own prescribing choices. Similarly, attention and resources devoted by pharmaceutical companies to discovering, developing, and promoting new drugs utterly dwarf their efforts to see that medicines are taken by patients. Yet non-compliance continues to represent a serious therapeutic deficit at the core of medical practice, with consequent massive personal, societal, and economic cost.

Patients do not comply with medication for several reasons.² Non-compliance may be intentional or involuntary. It may relate to the quality of information given, the impact of the regimen on daily life, the physical or ental incapacity of patients, or their social isolation. Many interventions to overcome these impediments have been tried, but evidence of sustained success is scant.¹

The difficulty for health professionals lies in acknowledging that it is the patients' agendas and not their own that determine whether patients take medicines. Patients have their own beliefs about their medicines and medicines in general. They have their own priorities and their own rational discourse in relation to health and care, risk and benefit.³ These may differ from and sometimes contradict those of the doctors. They are, however, no less cogent, coherent, or important.⁴

By drawing on these findings and insights a new relationship between prescriber and patient was described.⁵ The term concordance was introduced. While compliance describes the degree to which the patient follows the prescribed regimen of medicines, concordance describes an agreement between a patient and a healthcare professional about whether, when, and how medicines are to be taken. Concordance therefore refers to the creation of an agreement that respects the beliefs and wishes of the patient, and not to compliancethe following of instructions.

Doctors and patients may not always agree. The implication of concordance is that when this happens the patient's views take precedence. This poses challenging questions about choice and responsibility. If the only treatment to which the patient will agree falls substantially short of what modern medicine can achieve the doctor may be left with a burden of responsibility that is hard to manage emotionally, ethically, and legally.

Practitioners are constantly urged to be both patient centred and evidence based. Yet these two goods can conflict. The quest is for the best health outcome, but concordance implies that we must now redefine best outcome so as to reconcile what pharmacology can theoretically achieve with what the patient desires or can bear.

Non-compliance is a multifactorial problem and requires multifactorial responses. No single blueprint for concordance exists. Nor will concordance be achieved by acquiring new communication skills alone. Intentions must also change. Concordance cannot be delivered by the imposition of top down guidelines. Doctors and patients must learn how to "do concordance" not only on the basis of established evidence but also from their own reflective experiences and from new experimental studies.

Many questions need to be answered. Few of the usual sociodemographic and biomedical variables predict non-compliance. Can we identify some that do? What does a concordant process look like in practice? What difficulties does concordance raise for patients and how can they be overcome? How can the ethical issues for doctors be addressed? What needs to change in order to implement concordance?

A change in the culture of the doctor-patient encounter is needed now. Concordance presents new challenges for patients, doctors, nurses, pharmacists, pharmaceutical companies, policy makers, and others. Crucially, as we move forward, we must learn to create robust therapeutic alliances with mutual respect for both the doctor's professional opinion and the patient's personal decisions.

In 2002 the Department of Health endorsed and adopted the principles of concordance and created the Medicines Partnership Task Force (www.medicines-partnership.org) to carry this work forward. The task force comprises representatives from the medical, nursing, and pharmacy professional bodies, patients' groups, pharmaceutical industry, and academia. Its two year remit is to look for ways to implement concordance in the NHS so as to improve health outcomes and satisfaction with care.

The BMJ will publish a theme issue on "people taking medicines" on 11 October 2003. We, the guest editors, invite contributions from researchers, patients, health professionals, policy makers, and other stakeholders, to reach us by 15 April 2003. Submissions should be made to www.submit.bmj.com, and the editorial contact is Giselle Jones (gjones{at}bmj.com). We hope to add to the store of evidence, experience, and controversial debate, and to learn more about what concordance looks and feels like in practice, how it is being taught to health professionals and patients, how barriers to it can be overcome, and to what extent we can produce evidence of clinical and other benefits for patients, practitioners, and the NHS.

Marshall Marinker, co-chair. 
Joanne Shaw, director. 

Medicines Partnership Task Force, Medicines Partnership, Royal Pharmaceutical Society of Great Britain, London SE1 7JN

Footnotes

Competing interests: MM has acted on occasions as a consultant in health policy to MSD Ltd.