The challenge is that we currently have no measure of non-adherence, only wastage
Around the table (left to right): Laura Southall, Margaret MacRury, Ashley Cohen, Paul O’Hanlon, Steve Bremer, Clare Worrall-Hill, Dr Bill Beeby
The true cost of medicines non-adherence is an important topic for debate, especially in the context of a cash-strapped NHS. “Around £800 million is going to waste every year and no-one is getting hold of the problem. Is this the opportunity for pharmacy to come of age?” asked Paul O’Hanlon.
This set the scene for a lively debate about the key factors fuelling non-adherence and the potential solutions to the problem, including how pharmacists and GPs could work together more effectively.
Medicines optimisation is fundamental to adherence, but John D’Arcy stressed this had to be viewed in the wider context of Pharmaceutical Price Regulation Scheme [PPRS] clawbacks and the large use of generics. “It’s all about optimisation but it’s linked to cost containment and the naughty word of rationing.”
Mr O’Hanlon agreed that switching of branded generics was a barrier to compliance and the panel gave examples of how patients viewed this. Clare Worrall-Hill said that among people with Parkinson’s disease there was often mistrust if the patient received a different brand, while Dr Beeby often had patients asking for the “real one”.
Ashley Cohen explained that the problem was caused by pharmacists having to wear two hats, clinical and commercial, and having to buy as cheaply as they could. “Which generic brand is used will depend on what’s ‘flavour of the month’ with the CCG,” he explained. “The way the contract is constructed builds distrust, but our job is to reinforce that they are not different.”
One way around wide variations in generics was for purchasing to be carried out over a wider locality, suggested Dr Beeby, so people didn’t see changes every month and between pharmacies in their area.
To really understand adherence and perceptions of generics, Laura Southall said it was necessary to get down to the patient level and find out whether non-adherence was intentional or non-intentional so it could be dealt with effectively. “Intentional is as much as 70 per cent and pharmacy is not doing much to tackle it. Sending a reminder text message to these patients will do nothing but annoy them.”
Paul O’Hanlon and John D’Arcy discuss pharmacists’ role
Her suggestion was to have the patient and pharmacist sitting together for a one-to-one motivational conversation. This intervention also had to be separate to an MUR; everyone agreed that MURs were about ‘usage’, not adherence, and would be a blunt instrument if used in this context. “MUR is a once a year activity, but monthly conversations work better for adherence,” said Margaret MacRury. “We should be asking people whether they are taking their medicines and why they are not coming back sooner, and then managing medication usage after that.”
Dr Beeby also questioned the value of MURs. “I don’t want to see the 99 ‘I’m OKs’. But I’m not seeing enough of the ones that need to be flagged up.” Instead, he wanted a better way of screening those with compliance problems and then, as suggested, having a longer, adherence-specific conversation with them.
Everyone agreed that using visual aids, such as graphs on how a medicine could improve their health, would help incentivise compliance, especially in a silent disease like hypertension where taking the medicine could make people feel worse. Meeting a patient’s personal goal was another good way of communicating the health benefits of compliance. Ms MacRury gave the example of one patient who just wanted to be able to sing in the choir again and walk up stairs without stopping.
There was a general recognition during the debate that data was lacking and this prevented pharmacists and doctors from dealing effectively with the problem. “The challenge is that we currently have no measure of non-adherence, only of wastage,” pointed out Mr O’Hanlon.
Mr Cohen said the amount of waste he saw in his practice was staggering, and he thought Mr O’Hanlon’s estimates may be conservative. He gave an example of one patient who had accumulated about £1,000 of unused inhalers. “Patients are embarrassed to tell their GP they’re not taking their medicines.”
Dr Beeby agreed with this. “There is no blood test for wilful non-compliance and no-one admits to it.”
Mr D’Arcy said that he was disappointed by the general attitude of some patients who thought, “I’ll keep ordering it to make it look like I’m taking it”. He gave the example that if someone was collecting blood pressure tablets and they were non-compliant, blood pressure would stay high and the dose would be increased, creating even more wastage. “What’s the checking mechanism here?”
The panel volunteered some solutions. Dr Beeby admitted that GPs’ Quality and Outcomes Framework (QOF) was misused and that there needed to be better measures of non-compliance. Ms Southall suggested analysing PMR data to identify non-compliant patients, while Ms MacRury wanted an audit trail for ‘prn’ medication so pharmacists could feedback to GPs.
Re-ordering unwanted medicines clearly caused waste and the panel thought 28-day prescribing may help identify non-adherence and minimise wastage.
Ms MacRury felt strongly that repeatable prescriptions were the single biggest factor that could help pharmacy better manage adherence, as they allowed pharmacists to have regular conversations with patients about whether they were taking their medicines or not. “If we own the monthly prescription, we can do more but the challenge is changing regulations and working practice to take away the supply function from the pharmacist.”
Dr Bill Beeby and Ashley Cohen consider patient issues
However, Dr Beeby said it wasn’t always convenient to go the pharmacy every 28 days, for example, if someone were picking medicines up for their housebound parent. It also fuelled the transaction costs. “One size does not fit all. By shortening the supply length you get perverse effects so we need a range of solutions.”
Mr Cohen disagreed. “It’s not a huge ask to get people to come to the pharmacy. We do weekly deliveries too and people like the contact.” He thought seven-day prescriptions using compliance aids was particularly effective in his pharmacy, because it helped identify non-adherence which he then flagged up to the GP.
Mr O’Hanlon agreed that compliance aids could be used to monitor adherence if they were returned back to the pharmacist for disposal. That enabled the pharmacist to see immediately what the patient had taken and when.
One suggestion to improve adherence was for the NHS to do more to raise awareness of generic medicines and educate patients on the value of medicines. “The NHS has a social responsibility. We’re all shareholders of the NHS and even young children need to be educated about the NHS,” said Mr D’Arcy. Other sources of patient education also need to be reviewed, for example patient information leaflets (PILs).
Dr Beeby felt that side effect warnings in PILs were not proportionate and scared people off. Mr D’Arcy agreed that they were essentially ‘manufacturer protection certificates’. He wanted patient support groups to play their part in explaining some of the issues of non-adherence.
Ms Worrall-Hill said Parkinson’s UK has a support line where patients can share experiences with the newly diagnosed, but she wanted to see more support given at the point of diagnosis and signposting to patient groups. “We recognise the need for professional input from pharmacists and are looking to work more closely with frontline healthcare professionals.” She cited a recent successful project in Wales that involved training pharmacists on Parkinson’s disease.
The idea of displaying the cost of medicines on packs got the thumbs down because it was an “evidence-free policy dictated down by the Health Secretary” that would be costly and impractical to implement at the ground level. Ms Southall said it would work for very expensive drugs such as some of those for rheumatoid arthritis, which had a 50 per cent non-adherence rate, as it would help patients appreciate their medicines more.
The pharmacist’s role had to start with a simple conversation, concluded Mr D’Arcy. “There is high trust in pharmacy and it’s important to reinforce the message. Another important thing about pharmacy is that because it’s a shop, there is an element of informality, so if you ask the right questions you’re much more likely to get the right answers.” But he added: “At some point you have to start rationing.”
A survey of over 2,000 people carried out on behalf of Omnicell for its report – ‘The true cost of medication non-adherence’ – found that: