Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence

Healthcare professionals should adapt their consultation style to the needs of individual patients so that all patients have the opportunity to be involved in decisions about their medicines at the level they wish.

Consider any factors such as physical or learning disabilities, sight or hearing problems and difficulties with reading or speaking English, which may affect the patient's involvement in the consultation.

Establish the most effective way of communicating with each patient and, if necessary, consider ways of making information accessible and understandable (for example, using pictures, symbols, large print, different languages, an interpreter or a patient advocate).

Encourage patients to ask about their condition and treatment.

Ask patients open˗ended questions because these are more likely to uncover patients' concerns.

Be aware that the consultation skills needed for increasing patient involvement can be improved.

Offer all patients the opportunity to be involved in making decisions about prescribed medicines. Establish what level of involvement in decision-making the patient would like.

Discuss with the patient why they might benefit from the treatment. Clearly explain the disease or condition and how the medicine will influence this.

Explain the medical aims of the treatment to patients and openly discuss the pros and cons of proposed medicines. The discussion should be at the level preferred by the patient.

Clarify what the patient hopes the treatment will achieve.

Avoid making assumptions about patient preferences about treatment. Talk to the patient to find out their preferences, and note any non˗verbal cues that may indicate you need to explore the patient's perspective further.

Healthcare professionals have a duty to help patients to make decisions about their treatment based on an understanding of the likely benefits and risks rather than on misconceptions.

Accept that patients may have different views from healthcare professionals about the balance of risks, benefits and side effects of medicines.

Be aware that increasing patient involvement may mean that the patient decides not to take or to stop taking a medicine. If in the healthcare professional's view this could have an adverse effect, then the information provided to the patient on risks and benefits and the patient's decision should be recorded.

Accept that the patient has the right to decide not to take a medicine, even if you do not agree with the decision, as long as the patient has the capacity to make an informed decision and has been provided with the information needed to make such a decision.

Assess the patient's capacity to make each decision using the principles in the Mental Capacity Act 2005. To lack capacity patients must: (a) have an impairment of or disturbance or malfunction of brain and mind, and (b) demonstrate lack of capacity to:

• understand the information relevant to the decision

• retain information for long enough to use it in the decision

• use or weigh information as part of the process of making the decision

• communicate the decision (whether by talking, using sign language or any other means).
  
  More information is available in NICE's guideline on decision-making and mental capacity.

If the patient has specific concerns, record a summary of the discussion, because this may be helpful in future consultations.

Encourage and support patients, families and carers to keep an up˗to˗date list of all medicines the patient is taking. The list should include the names and dosages of prescription and non˗prescription medicines and herbal and nutritional supplements. If the patient has any allergic or adverse reactions to medicines, these should be noted.

Be aware that patients' concerns about medicines, and whether they believe they need them, affect how and whether they take their prescribed medicines.

Ask patients what they know, believe and understand about medicines before prescribing new treatments and when reviewing medicines.

Ask if the patient has any specific concerns about their medicines, whenever you prescribe, dispense or review medicines. These may include concerns about becoming dependent on medicines and concerns about adverse effects. Address these concerns.

Be aware that patients may wish to minimise how much medicine they take.

Be aware that patients may wish to discuss:

• what will happen if they do not take the medicine suggested by their healthcare professional

• non˗pharmacological alternatives to medicines

• how to reduce and stop medicines they may have been taking for a long time, particularly those known to be associated with withdrawal symptoms

• how to fit taking the medicine into their daily routine

• how to make a choice between medicines if they believe they are taking too many medicines.

Offer patients information about medicines before the medicines are prescribed.

Offer patients information that is relevant to their condition, possible treatments and personal circumstances, and that is easy to understand and free from jargon.

Check that patients have any information they wish about medicines when the medicines are dispensed.

Discuss information on medicines with the patient rather than just presenting it. The discussion should take into account what the patient understands and believes about the condition and treatment.

Do not assume that the patient information leaflets (PILs) that patients receive with their medicines will meet each patient's needs. Address concerns that patients may have after reading the standard PILs.

PILs contain information for patients on how medicines should be used. It is a legal requirement that this information is included on the label or within the packaging of a medicine.

Patients differ in the type and amount of information they need and want. Therefore, the provision of information should be individualised and is likely to include, but not be limited to:

• what the medicine is

• how the medicine is likely to affect their condition (that is, its benefits)

• likely or significant adverse effects and what to do if they think they are experiencing them

• how to use the medicine

• what to do if they miss a dose

• whether further courses of the medicine will be needed after the first prescription

• how to get further supplies of medicines.

Be careful not to make assumptions about a patient's ability to understand the information provided. Check with the patient that they have understood the information. Information for patients should be clear and logical and, if possible, tailored to the needs of the individual patient.

Suggest where patients might find reliable information and support after the consultation: for example, by providing written information or directing them to other resources (for example, the NHS website).

Provide inpatients with the same information as patients in other settings. Information should include:

• what the medicine is

• how the medicine is likely to affect their condition (that is, its benefits)

• likely or significant adverse effects and what to do if they think they are experiencing them

• how to use the medicine

• what to do if they miss a dose

• whether further courses of the medicine will be needed after the first prescription

• how to get further supply after discharge.

Recognise that non˗adherence is common and that most patients are non˗adherent sometimes. Routinely assess adherence in a non˗judgemental way whenever you prescribe, dispense and review medicines.

Consider assessing non-adherence by asking the patient if they have missed any doses of medicine recently. Make it easier for them to report non˗adherence by:

• asking the question in a way that does not apportion blame

• explaining why you are asking the question

• mentioning a specific time period such as 'in the past week'

• asking about medicine-taking behaviours such as reducing the dose, stopping and starting medicines.

Consider using records of prescription re˗ordering, pharmacy patient medication records and return of unused medicines to identify potential non˗adherence and patients needing additional support.

If a patient is not taking their medicines, discuss with them whether this is because of beliefs and concerns or problems about the medicines (intentional non˗adherence) or because of practical problems (unintentional non˗adherence).

Be aware that although adherence can be improved, no specific intervention can be recommended for all patients. Tailor any intervention to increase adherence to the specific difficulties with adherence the patient is experiencing.

Find out what form of support the patient would prefer to increase their adherence to medicines. Together, you and your patient should consider options for support.

Address any beliefs and concerns that patients have that result in reduced adherence.

Because evidence supporting interventions to increase adherence is inconclusive, only use interventions to overcome practical problems associated with non˗adherence if a specific need is identified. Target the intervention to the need. Interventions might include:

• suggesting that patients record their medicine˗taking

• encouraging patients to monitor their condition

• simplifying the dosing regimen

• using alternative packaging for the medicine

• using a multi˗compartment medicines system.

Side effects can be a problem for some patients. If this is the case you should:

• discuss how the patient would like to deal with side effects

• discuss the benefits, side effects and long˗term effects with the patient to allow them to make an informed choice

• consider adjusting the dosage

• consider switching to another medicine with a different risk of side effects

• consider what other strategies might be used (for example, timing of medicines).

Ask patients if prescriptions charges are a problem for them. If they are, consider possible options to reduce costs.