Marjorie C. Weiss

Introduction

‘Mrs Jones is being a non-concordant patient [sigh] again’. Or is she? Concordance offers a way forward when we, as pharmacists, notice that patients are not taking their medicines as prescribed. Yet concordance can fundamentally challenge our assumptions about the role of patients in a professional–patient interaction. It states that patients have a legitimate and valuable perspective on taking their medicines and that healthcare professionals should encourage patients, should they wish it, to become involved in decisions about their treatment. For these reasons, concordance is about a consultation process and not individual patient behaviour. Mrs Jones cannot be non-concordant on her own: it takes at least two, professional and patient, to have a non-concordant (or successfully concordant) encounter. The consultation could have been non-concordant but Mrs Jones, on her own, cannot have been. Mrs Jones can be non-compliant or non-adherent with her medicine but these have a distinctly different meaning from concordance.

What is concordance?

Concordance occurs when ‘the patient and the healthcare professional participate as partners to reach an agreement on when, how and why to use medicines, drawing on the expertise of the healthcare professional, as well as the experiences, beliefs and wishes of the patient’ (Marinker et al. 1997). It arose from the recognition that throughout the decades of research investigating interventions to help patients follow prescriptions for medications, there was still a high level of non-adherence. In a review by Haynes et al. (2001), interventions that used a combination of approaches in helping patients take their medicines, such as providing more convenient care, giving patients more information, providing reminders or offering medicine counselling, did not lead to large improvements in adherence rates. From this synthesis of research findings, there was a call to investigate more innovative approaches to assist patients with taking their medicines. Concordance is one such innovative approach.

This is not to say that terms like adherence and compliance can no longer be used. When referring to the extent to which patients take medicines as prescribed by their doctor or other healthcare professional, the words ‘adherence’ and ‘compliance’ are appropriate terms to be used. As a concept distinct from compliance or adherence, concordance may affect adherence although it is mainly concerned with improving the quality of health care through a shared understanding between professional and patient on treatment choices. Yet there are difficulties with words like adherence and compliance, which have overtones of the patient being disobedient or ‘naughty’ in not following the doctor’s instructions. Conceptually, terms like ‘compliance’ and ‘adherence’ reinforce a paternalistic doctor-knows-best model of health care and implicitly devalue the views and experience of patients as users of medicines. Concordance seeks to redress this balance by acknowledging that patients and customers have a key role in the decision-making of whether or not to take their medicine.

The term adherence has been usefully split into those who are intentionally non-adherent and those who are unintentionally non-adherent. Unintentionally non-adherent patients are those who do not take their medicine because of a number of reasons, e.g. because they are unable to read the label due to poor eyesight, or forgot to take a tablet because a medicine regimen is complex and difficult to remember. Appropriate solutions to unintentional non-adherence are big print labels, improved medicines information, simplified medicine regimens or adherence aids, such as a Dosette box. Intentional non-adherence is where concordance can play a role; previous research has suggested that patients make reasoned decisions about whether or not to take their medicines. Patients may alter their medicine-taking behaviour for a number of reasons, e.g.:

Concordance has been called a partnership in medicine taking and has three important ingredients: (1) includes an explicit agreement between two people; (2) is based upon respect for each other’s beliefs; and (3) gives the patient’s view priority although they may choose to have the professional make all the decisions about treatment. This third ingredient recognizes that once the patient leaves the encounter with the healthcare professional, they will ultimately have the casting vote to decide whether or not to take that medicine.

The concordance model

Concordance shares many characteristics with other models and themes currently prevalent in health care, most importantly those of shared decision-making and patient-centredness. There is a greater chance of a successfully concordant encounter when each participant knows what the other is thinking. For this reason, concordance shares many characteristics with shared decision-making, where both the doctor and patient share information with each other, when both take steps to participate in the decision-making process by expressing treatment preferences and they jointly agree on the treatment to implement. Shared decision-making may be considered part of the wider concept of patient-centredness. Patient-centredness has three themes: eliciting the patient’s perspectives and understanding them within a psychosocial context; reaching a shared understanding of the patient’s problem and treatment; and involving patients, to the extent they wish to be involved, in choices about their care. It is not a coincidence that the concept of concordance arose during the same time period that patient-centred care became dominant in healthcare policy. Concordance can be seen as part of the wider patient-centred political context but one which specifically focuses on medicine- taking behaviour. NICE has similarly produced guidance on medicines adherence which draws upon many of the themes relevant to concordance.

Concordance shares many features with the formative communication teaching guides, the Calgary–Cambridge guides as discussed in Chapter 17. Although designed as a formative aid in teaching medical students communication skills, the Calgary–Cambridge guides have a consultation structure which is readily adaptable to the pharmacy setting. These guides assume a chronology to the consultation with distinct sections on initiating the consultation, gathering information, providing structure to the consultation, building a relationship, explanation and planning and closing the consultation. The Calgary–Cambridge guide has been adapted to reflect two common pharmacy consultation situations of (1) handing out a new prescription and (2) issuing a repeat prescription, as shown in Box 18.1. Sample phrases or ‘catchphrases’ useful in conducting a concordant consultation in pharmacy are shown in Box 18.2.

The Medicines Partnership at NICE has developed a competency framework for shared decision-making with patients, describing the skills and behaviours professionals need to reach a shared agreement about treatment. In this document, shared decision-making and concordance are used synonymously, highlighting the common approach underpinning these concepts. These eight competencies are shown in Box 18.3.

The evidence for concordance

Already presented has been the Haynes Cochrane review regarding the use of interventions to help patients take their medicines; that current methods of improving adherence are complex and not very effective. Much of the information available about concordance relates to the doctor–patient consultation. As shown in Box 18.1, the concordant approach can be readily adapted to the pharmacy situation after a prescribing decision has been made. Examples are handing out new or repeat prescriptions, in repeat dispensing or in conducting a medicines use review. Yet pharmacists also have a role before treatment decisions about medicines are made: when giving over-the-counter advice or as pharmacist independent prescribers. The next sections will look at this evidence, drawing upon pharmacy literature where possible, as well as evidence from medicine. Medical literature may appear to be relevant only in the latter situation, i.e. before prescribing decisions are made. However, the evidence has resonance for the range of pharmacy consultations, both before and after treatment decisions have been made. These are grouped under four headings: eliciting the patient’s view; developing rapport with the patient; providing information; and the therapeutic alliance.