You can lead a horse to water

1
You can lead a horse to water

• James Andrews

2
Patient Involvement Why Bother?

• Empowers patients to take some control of their
  health
• It improves the service you provide
• It helps support policy initiatives
• Patients who use NHS services think they should
  be involved
• Its their right to be involved

3
Barriers to Involving Patients

• They dont want to be involved
• Its the wrong time for them
• Its done in the wrong way for them
• Opportunity and time pressures for you

4
Definitions in Medicines Taking

• Compliance the extent to which a patient follows
  the instruction of the doctor.Measures patient
  behaviour
• Adherence the extent to which the patients
  behaviour matches recommendations agreed with the
  prescriberRequires patient involvement

5
If this is the answer, what is the question?
6
Consequences of non-adherence

• NHS
• Wasted resources staff time, money,
  investigations
• Increased admission or re-admission to hospital
• Poor service performance
• Failure to hit targets e.g. QoF

• Patient
• Feeling ill
• Poor outcomes
• Increased morbidity
• Increased mortality
• Hospital admission
• But also...
• Feeling in control
• Experiencing no side-effects

• Wider economy
• Avoidable days off work, carers
• Increased welfare payment
• Reduced life expectancy
• Increased pressure on social care

7
If this is the answer, what is the question?

• 70
• 10 600 000 000
• 7 600 000 000
• 12.7
• 30 to 50

8
One consequence of the traditional model
Source Fairview Pharmacy, London, 2004 -
medicines picked up from an elderly ladys home
9
Non-adherence Unintentional Intentional

• Cant take
• Unintentional
• Wont take
• Intentional

10
Wont take

• Reasons for Wont take include
• Side-effects
• Impact on life /lifestyle
• Unaware of benefits
• Cant fit them into routine
• Embarrassment
• Dont believe theyre ill
• Dont want to be dependent
• Beliefs about medicines

11
Another Definition in Medicines Taking

• Concordance shared decision making process about
  medicines taking, between healthcare professional
  and a patientMeasures the consultation process

12
NICE and Medicines Concordance
13
Key Concordant Consultation Skills

• Asking open questions
• Listening reflectively
• Summarising
• Asking key questions
• Eliciting self-efficacy for medicine-taking
• Eliciting outcome expectancies for medicine-taking

14
Concordant Consultations

• Why?
• To elicit from patients
• Problem recognition
• Concern about health problem
• Decision about medicine taking
• Self-efficacy for medicine taking
• How?
• Be non-confrontational
• Be collaborative
• Achieve a therapeutic alliance

15
Shared decision making
16
Examples
Barriers to optimal use of medicine
Inappropriate prescribing Mistakes in dispensing
or administration
Professional
Forgetfulness Inability to open containers
Practical
Information
Instructions not understood Poor understanding of
condition/treatment
Unpleasant side effects Inconvenience No
perceived benefit
Lifestyle choices
Beliefs about medicine
Unnatural Addictive Poisonous Diminishing efficacy
17
Reasons why people choose not to take medicines
Quotes from non-complying patients
youve upped it to fifty mgs or whatever I
took it for six daysthen I thought well Im a
bit tired so the next day I halved it. Thats
experience. (hypertension patient)
Basically I dont want to be dependent on these
tabletsIve been taking tablets well basically
for thirteen years Ive been taking these tablets
(epilepsy patient)
Im doing fine as I am, thanks. Ive had no dire
effects I think the treatment of hypertension
is fashionable just nowits easy for doctorstake
a pill and come back (hypertension patient)
Source Dowell J, Jones A, Snadden D., Exploring
medication use to seek concordance with
non-adherent patients a qualitative study.
British Journal of General Practice. 2002
18
Concerns about dependence and long term effects
Beliefs about necessity of prescribed medication
Source Horne R Weinman J (1999) Patients
beliefs about prescribed medicines their role
in adherence to treatment in chronic illness.
Journal of Psychosomatic Research 47(6) 555-567