Prescribing medication is the most common form of medical intervention in the UK for various conditions. Many people are on long term and multiple medication and obtaining the maximum benefit from their treatment is a major challenge for the NHS.

Common problems that relate to medicine taking are patients suffering from adverse drug reactions and patient compliance.

Between 5-17% of hospital admissions are due to adverse reactions to medicines and, even in hospital, 6-17% of older patients have an adverse drug reaction during their stay. This costs the NHS £0.5 billion each year in longer stays in hospital, to say nothing of the human cost to patients and their carers.

A contributory factor to adverse reactions is polypharmacy, where a patient is prescribed more than one drug. This both increases the risk of adverse drug reactions and of hospital readmission in older people. Whilst Department of Health guidance on the subject in Implementing medicines-related aspects of the NSF for Older People says prescribing of four or more drugs is not necessarily bad, and indeed may be necessary, it acknowledges that it is a risk factor for potential harm from medication and should be monitored.

It is thought that up to 50% of people may not take their medication as intended, whilst medicines taken by older people account for almost 50% of the NHS's drugs bill.

For patients, the main issues are their beliefs and values about their conditions and prescribed treatment, the fear of adverse drug reactions and poor understanding of the intended affects of their medication. Furthermore the lack of monitoring and follow-up of the affects of medicines by health professionals and over or under prescribing only serve to enhance the problem, making it less transparent.

This picture results in avoidable ill health, premature death, unnecessary hospital admissions and additional costs to the NHS. Against this background, medicines management is an important strategy to improve the effectiveness of prescribed medication and better health outcomes for patients, which is the ultimate aim.

What is medicines management?

Medicines management is a concept to help patients get the maximum therapeutic benefit from their medicines through targeted support by health professionals. The key element is the involvement of patients in the decisions about prescribing and there is a move away from compliance to concordance.

Concordance is a new approach to prescribing that puts patients' views at the centre, recognises the importance of involving them as partners in prescribing decisions, and supports them in medicine-taking.

Successful implementation of concordance is dependent on health professionals who understand the importance of partnership with patients in relation to medicines issues, and have the appropriate attitudes, knowledge and skills to ensure successful treatment. As older people receive around 50% of prescription items the emphasis of medicines management currently is on the over 65s and their carers.

What are the aims of medicines management?

Effective medicines management needs to take place in both the primary and secondary care settings. It is best achieved by:

• Helping people to get the most from their medicines to maintain or increase their quality and duration of life.
• Ensuring that people do not suffer from illness due to inappropriate or inadequate therapy.
• Ensuring that medication is optimised early in the treatment programme and that patients have access to the most appropriate treatment for them.

• Supporting patients in using medicines and empowering them to manage their own care and reducing waste of medicines.

• Involving not just patients but also, where appropriate, their carers.

• Reviews that take into account the use of over-the-counter medicines as it has been demonstrated that a significant proportion of older people use such medication to maintain health or prevent ill-health, treat minor aliments or use to supplement or replace prescription medicines.

A study published by the Medicines Partnership (A Question of Choice: Compliance in Medicine Taking) highlighted the key issue that patients choose not to take their medicines rather than forget. According to the study there is strong evidence that, despite the introduction of new medicines which have fewer side-effects and are more convenient to use, many people still do not take them as prescribed, even when not doing so can have life-threatening consequences. Some of the factors causing non-compliance:

• Complicated medication regimes are associated with low compliance rates.

• Above average rates of unwanted side-effects are linked to lower compliance rates.

• If there are conflicts of beliefs between patients who are prescribed medication and the professionals who prescribe for them, patients are less likely to take their treatment. Communication skills would be very important in this situation.

• Non-intentional non-compliance is higher among people affected by cognitive and /or physical impairments.

• Medicines are least likely to be taken as intended by the prescriber if the treatment is only seen as having a preventative as opposed to a curative or a short-term distress-relieving role.

What is happening in the NHS?

Recognising this situation, the Department of Health in England, set up a Medicines Management Action Team with the aim of promoting this process and to encourage clinicians and managers to redesign local services around the needs and conveniences of patients. Amongst other initiatives, the Action Team has supported a national pilot trial of structured medicines management service based in community pharmacies and a network of Primary Care Trusts who have developed innovative schemes in this area. The main theme is working in partnership with patients and encouraging them to take an active role in their own care.

As part of the National Service Framework for Older People, GPs should be reviewing the medication of the over-75s on an annual basis and those taking four or more medicines should have six-monthly reviews. In secondary care, all hospitals are required to have in place systems that enhance older people's use of medicine while in hospital and discharge, such as allowing patients to use the medication they bring on admission. And where appropriate, self administration schemes that encourage patients to take their medication as they would when at home which makes it easier to control.

And by 2004 every Primary Care Trust is to have schemes in place so that people can get more help from pharmacists in using their medicines.

However, this presents a challenge for a number of reasons. For example, communication between primary and secondary care needs to improve, particularly when using comprehensive medication records, providing information on compliance and administration issues on admission and clarity on medication use on discharge.

The clinical governance development plans for NHS organisations need to have specific arrangements agreed and in place to implement quality assurance and monitoring measures for the key activities of medicines management. There also needs to be greater transparency of local prescribing decisions and shared care guidelines to reduce possible post code prescribing as well as conflict of prescribing responsibilities between primary and secondary care. This would involve the hospital Drugs and Therapeutics Committees working closely with the relevant groups in primary care to establish evidence-based formularies that are linked to clinical guidelines, providing greater clarity.

A patient held record is required which should contain details of current medication allergies and administration problems to allow health professionals to provide the appropriate patients support. For older people whose needs can be assessed by health and social services through the single assessment process, the patient held record needs to be part of this process.

Finally, to provide a patient-centred service there needs to be an increase in the number and type of prescribers so that consistent and appropriate prescribing takes place. This is where the issue of supplementary prescribing by pharmacists or nurses comes in.

Although this activity can take place in a number of possible locations such as Walk-In Centres, nurse led clinics and community pharmacies, the proposals currently require the clinical management of patients to be operated by two named health professionals, which may restrict access and have a delaying effect on the continuity of care. This also does not take into account the fact that patients are increasingly being looked after by teams rather than individual health professionals.

However, training nurses and pharmacists for their extended prescribing roles does not include issues around concordance. Since successful implementation of concordance is dependent on a significant change of culture in the health service, the preparation of a new generation of supplementary prescribers offers a unique opportunity to incorporate concordance training at the start of their prescribing careers.

Medicines Partnership

The Medicines Partnership Programme aims to support the implementation of concordance practice within the NHS through five specific areas:

• Influencing the education and professional development of doctors, nurses and pharmacists to equip them with the attitudes, knowledge and skills to implement concordance in their professional practice.

• Communicating with and supporting patients and the public with medicine taking and facilitating a better understanding and awareness of the effects of their medicines.

• Working with policymakers and associated groups such as the Department of Health to ensure that patient partnership and concordance are embedded in the design and delivery of key policy initiatives.

• Using the existing research evidence base to support concordance, developing measures and audit processes to assess the results of concordance projects and commissioning new research.

• Demonstrating practical examples of concordance projects and their measurable benefits.

To implement the aims of the Medicines Partnership a Task Force was set up and funded by the Department of Health in January 2002 under the joint chairmanship of Dr Jim Smith (Chief Pharmaceutical Officer at the Department of Health) and Professor Marshall Marinker.

The Task Force has a multi-disciplinary membership comprising doctors, pharmacists, nurses, patients, NHS managers, academics and the pharmaceutical industry. Although the Medicines Partnership covers England only, there are observers involved from the other three countries in the UK.

In addition to the core staff who organise the day to day running of the programme, the Medicines Partnership has established a broad network of advisors who have an expertise in concordance. This network has formed an R&D advisory group and has provided input to policy documents and other initiatives. Health policy areas include medication review, supplementary prescribing, the diabetes and renal National Service Frameworks and the Epilepsy Action Plan. In addition, the Task Force is considering whether to submit a business case for the development of NICE guidelines on concordance.

During its time of operation the Medicines Partnership has developed a number of projects with the National Collaborative Medicines Management Services Programme based at the National Prescribing Centre in Liverpool which provide guidance to local organisations to improve the quality of their medication review processes. They include a guide to medication review, a set of tools which can be downloaded for health care professionals and patients to use, a library of case studies showing medication review in action, a directory of tools in use around the country and the report A Question of Choice: Compliance in Medicine Taking.

On a practical level, the Medicines Partnership is currently supporting 12 best practice projects across the country showing concordance in action. The projects are with a number of disciplines including doctors, pharmacists, nurses, dieticians and voluntary workers covering areas such as diabetes, multiple sclerosis, care of older people, Parkinson's disease, HIV, asthma, cardiovascular disease and obesity.

Opportunities for the pharmaceutical industry

Clearly the industry is involved at the Task Force level with representation on the group itself. Those companies that are not on the Task Force should develop working relationships with the representatives to ensure that their views are heard particularly when comments are required on various aspects of health policy.

On a local level there are a number of ways in which the industry can facilitate the development of medicines management in the NHS.

The proposal to have supplementary prescribing provides an opportunity to get to know, understand the needs as well as influence a whole new group of prescribers.

Other areas of involvement are to support the development of medicines management initiatives through training on medication reviews and concordance issues for nurses and pharmacists. There are also support audits of medication reviews and the development of evidence based formularies across primary and secondary care. And help exists for the provision of information to patients to improve concordance and support the recommendations of the Medicines Management Partnership in the National Service Frameworks.

By supporting health professionals and patients in more informed medicine taking, the pharmaceutical industry can ensure better access to appropriate medication, and help patients receive the benefit from their treatment and reduce wastage.

Ultimately this should lead to patients leading healthier lives and cost-savings for the NHS and better communication between pharmaceutical firms and governemnt health organisations.

For more information visit the Medicines Management Partnership website: www.medicines-partnership.org