Have you taken all your tablets this week?

The prescription of medicines is central to medical care and drug costs amount to around 10% of NHS expenditure. Between 2006 and 2007, the NHS in England spent £10.6 billion on drugs, around three quarters of which was in primary care. Studies of different disease states have found that 30–50% of patients do not take their prescription medicines. The estimated drug cost of unused or unwanted medicines in the NHS is around £100 million annually.¹ There is also a real clinical cost to patients not taking medicines as prescribed, with a potential for increased morbidity and mortality. A Cochrane review concluded that improving medicine taking may have a far greater impact on clinical outcomes than an improvement in the treatment itself.² So what can doctors do about this issue?

There is a large body of sociological and psychological literature that has examined how patients take medicines. This literature indicates that patients use their own ‘evidence base’ to decide how and when to take them. Patients stop and start medicines to see their effect, adjust doses according to their understanding of how medicines work and make their own judgements on the balance of benefits and side effects.³ One of the most striking aspects of the research is that patients generally do not report to doctors how they take their medicines. While most doctors will recognise this behaviour, it is not part of usual practice to ask specifically about it. More open recognition and discussion of patient medicine-taking habits might reduce health and economic costs.

Nomenclature around this issue has been a little confusing. The term ‘compliance’ is often used to describe whether or not a medicine has been taken. This implies that the patient should respond obediently to instructions from the doctor. Most of us no longer practice medicine in such a paternalistic way and a better term is ‘adherence’. This describes the extent to which the medicine-taking behaviour matches agreed recommendations from the doctor and presumes a shared decision to prescribe between patient and doctor. Concordance is a broad term which covers the process of incorporating patient beliefs and preferences in the decision making and in some definitions also includes wider supportive care for the patient.

Non-adherence can be intentional (ie the patient has decided not to take medicines because of their beliefs and concerns) or unintentional (ie practical problems such as packaging and dose frequency). Recent guidance from the National Institute for Health and Clinical Excellence suggests that doctors consider the processes of deciding to prescribe and the actual taking of a medicine as separate areas for intervention.⁴ Doctors have an opportunity to influence adherence during the consultation, while working with other professionals in the team, and at a managerial level through service planning.

Shared decision making during the consultation is the starting point for adherence and requires good communication. As an analogy, let us think about watching a game of snooker on the television, the professional players make it look easy, but when you pick up a cue yourself you realise how difficult it is. To the patient a consultation can appear to be easy, but it looks this way because of the expertise of professionals involved. A consultation is an incredibly complex process and we can all continually improve our skills.

The consultation is the core business of medical practice and doctors are specifically trained and examined to perfect the process.⁵ All consultations are time limited and in secondary care can take place in less than satisfactory environments, on a ward or in open spaces in outpatients. While the focus of the consultation is often disease orientated, patients have a need for information and involvement about their treatment whatever the setting and in this context it is important that the subtleties of shared decisions are not missed.

There are broadly two aspects of the consultation to consider, the style and the content. If a prescribing decision is approached in a shared way then the style of the consultation will reflect that openness, focusing on the patient's wishes and concerns. This seems very obvious but we should always master the basics.

An important content of the consultation is the information given. A feature of medicine today is the wealth of information available to patients. We need to remember that this has to be presented in different ways for different patients. Knowledge is best acquired if it is delivered in a way that reflects that individual patient, each having different pre-existing beliefs, understanding and concerns. Giving the same information in the same way to each patient is unlikely to be effective. It should be remembered that medicine taking is a behaviour that is unique to each individual. Establishing the influences on individual patient's adherence will allow targeting of any interventions required.

As adherence is a behaviour based upon beliefs, information and experience, it follows that it will change over time. It is therefore essential for the optimal management of long-term conditions that patients are followed up and their treatment altered according to their changing health and beliefs. The threatened reduction in hospital follow-up appointments could adversely affect adherence, and hence clinical outcomes, particularly in complex patients. Doctors should be free to decide on follow up according to individual patient needs, not solely upon a disease or cost basis. In their managerial roles they need to persuade non-clinical colleagues of the benefit of patient follow up.

Whether we work in primary or secondary care, we all work in teams. Each member of the team needs to be aware of adherence issues and be able to document concerns or insights in the record for all to see. Close working between pharmacists and doctors is a real strength of hospital practice which can be lacking in primary care. Pharmacy colleagues are able to provide reassurance that prescribing is appropriate and can supply patients and their families with practical suggestions to make medicine taking easier. Community pharmacists perform medication reviews which could specifically focus on adherence problems.

Non-adherence is wasteful of resources and leads to suboptimal treatment. Through consultation skills, team working and managerial roles, doctors can and should do something about it. So the next patient you see, be sure to ask them, ‘Have you taken all your tablets this week?’. You may be surprised by the answer.

• © 2009 Royal College of Physicians