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Medicines adherence

Short Text

Involving patients in decisions about prescribed medicines and supporting adherence

Introduction

This pathway covers how healthcare professionals can involve adult patients in decisions about prescribed medicines and support adherence. The clinical guideline scope does not cover children and young people, however, the recommendations may be considered for a child or young person who is deemed competent to express a view on their prescription.
Between a third and a half of medicines that are prescribed for long-term conditions are not used as recommended. This represents a health loss for patients and an economic loss for society.
Non-adherence should not be considered the patient's problem. Rather, it usually results from a failure to fully agree the prescription with the patient in the first place and to support the patient once the medicine has been dispensed.
Non-adherence falls into two overlapping categories: intentional (the patient decides not to follow the treatment recommendations) and unintentional (the patient wants to follow the treatment recommendations but has practical problems).
To understand non-adherence we need to consider perceptual factors (beliefs and preferences) that influence motivation to start and continue treatment as well as practical factors.
This requires:
  • an open, no-blame approach that encourages patients to discuss any doubts or concerns about treatment
  • a patient-centred approach that encourages informed adherence
  • identification of perceptual and practical barriers to adherence at the time of prescribing and during regular review.
In this pathway 'medicines' is used as a general term to refer to prescribed medicines that are self-administered and includes tablets, syrups, ointments, creams, eyedrops and suppositories.

Source guidance

The NICE guidance that was used to create the pathway.
Medicines adherence. NICE clinical guideline 76 (2009)

Quality standards

Quality statements

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topic.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

17 December 2013 Minor maintenance update.
17 May 2013 Minor maintenance updates.

Supporting information

Glossary

Patients for whom medicines are being considered or have been prescribed

Patients for whom medicines are being considered or have been prescribed

Supporting adherence

Supporting adherence

Supporting adherence

Assessing adherence

Healthcare professionals are not always aware when patients don't use their medicines as prescribed. Assessing adherence is not about monitoring patients but rather finding out whether patients need more information and support. You should routinely assess adherence in a non-judgemental way whenever you prescribe, dispense and review medicines. You should consider:
  • asking patients if they have missed any doses recently; make it easier for them by:
    • asking in a way that does not apportion blame
    • explaining why you are asking
    • mentioning a specific time (such as in the past week)
    • asking about medicine-taking habits
  • using records of prescription re-ordering, pharmacy patient medication records and return of unused medicines to identify non-adherence and patients needing support.

Interventions to increase adherence

Patients may need support to help them use their medicines effectively. This may take the form of further information and discussion or changes to the type of medicine or regimen. Any intervention to support adherence should be discussed with the patient, considered on a case-by-case basis and should address the concerns and needs of individual patients.
If a patient is non-adherent discuss whether this is because of beliefs and concerns (intentional non-adherence) or practical problems (unintentional non-adherence).
Address any beliefs and concerns the patient has about their medicines.
Because evidence is inconclusive, only use interventions to overcome practical problems if there is a specific need. Interventions might include:
  • suggesting patients record their medicine-taking
  • encouraging patients to monitor their condition
  • simplifying the dosing regimen
  • using alternative packaging
  • using a multi-compartment medicines system.
If side effects are a problem:
  • discuss benefits, side effects and long-term effects and how the patient would like to deal with side effects
  • consider adjusting the dosage, switching to another medicine, and other strategies such as changing the timing of medicines.
Ask if prescriptions costs are a problem and consider options for reducing costs.

Source guidance

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Reviewing medicines

Reviewing medicines

Reviewing medicines

Patients may use medicines long term. The initial decision to prescribe medicines, the patient's experience of using the medicines and the patient's needs for adherence support may change over time and should be reviewed regularly.
Offer repeat information and review, especially when treating long-term conditions with multiple medicines.
Review at agreed intervals patients' knowledge, understanding and concerns about medicines and whether they think they still need the medicine.
Ask about adherence when reviewing medicines. Clarify possible causes of non-adherence and agree any action with the patient (including a date for follow-up).
Bear in mind that patients sometimes evaluate prescribed medicines in their own way (for example, by stopping and starting them and monitoring symptoms). Ask the patient if they have their own way of weighing up their medicine.

Source guidance

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Improving communication between healthcare professionals

Improving communication between healthcare professionals

Improving communication between healthcare professionals

Patients may be under the care of healthcare professionals from different disciplines and specialties at the same time. Responsibility for patients' care may be transferred between healthcare professionals and medicines reviews may be carried out by healthcare professionals other than the prescriber. Good communication between healthcare professionals is needed to ensure that fragmentation of care does not occur.
When reviewing medicines inform the prescriber of the review and its outcome.
Ensure there are robust processes for communicating with other healthcare professionals involved in the patient's care.
On transfer between services (for example, discharge from hospital) give all patients and subsequent healthcare or other providers a written report containing:
  • the patient's diagnosis
  • a list of all medicines the patient should be taking
  • clear identification of any new medicines that were started
  • clear identification of any medicines that were stopped with reasons
  • clear information on which medicines should be continued after transfer and for how long
  • any known adverse reactions and allergies
  • any potential difficulties with adherence and any actions taken (for example, provision of a multi-compartment medicines system).

Source guidance

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Patient and service user experience in adult NHS and mental health services

Patient and service user experience in adult NHS and mental health services

Patient and service user experience in adult NHS and mental health services

For more information, see:

Paths in this pathway

Pathway created: September 2012 Last updated: December 2013

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.

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