Prescribing is a complex adaptive sys-tem and so measuring the outcome of

treatment with prescribed medicines is difficult. There are a variety of factors thatinfluence an ideal treatment outcome,many of which will not be in the control ofthe prescriber and most of which evolveindependently over time.

It is clear that patients will not benefitfrom treatments if they do not take themat all, but questions still remain:• Do we know whether patients receive anadequate explanation to ensure that theyhave a realistic expectation of what theirmedicine can do for them? • Are there any known factors that willaffect a patient’s ability to comply withtheir treatment that should be consideredand addressed by the prescriber with thepatient every time they prescribe? • Should there be time set aside in everyprescribing consultation specifically for thepurpose of identifying and exposing barri-ers to adherence so that, for example, apatient’s attitudes to their treatment canbe explored and any misconceptionsaddressed?

The degree of difficulty that this adher-ence challenge presents means that com-missioners are more likely to focus onmore readily accessible improvementmeasures in a commissioned service,such as inputs, processes and outputs.

But this is not enough on its own, and com-missioners now need to refocus on adher-ence services as a means of achievingimproved outcomes and minimising avoid-able costs associated with overusage, orindeed underusage if this leads to a moreexpensive intervention. Is the ‘do-nothing’option sustainable?

In the era of value-based healthcarethe pharmaceutical industry has renewedinterest in adherence because the intrinsicvalue of medicines will not be fully realisedunless patients are well motivated and fac-tors that adversely affect adherence areidentified.

The tension between the nationalfocus on improving treatment outcomesand the local focus on structures andprocesses adds an additional dimensionto the study of adherence as a proxy ofmore significant outcomes. Can medicinesadherence be adopted as a universal ‘key

Figure 1. OneHeart, an example of a nonpromotional adherence support service provided byAstraZeneca as part of a Joint Working framework

OneHeart: a personalised acute coronary syndromes (ACS) patient support pro-gramme – supporting medicines optimisation and improved patient self-manage-ment in the NHS.

Almost half of ACS patients discontinue their treatment within 12 months afterbeing discharged from hospital. Those that do, double their chance of dying or hav-ing a nonfatal MI. In addition, there is only a 44% uptake of cardiac rehabilitation inthe UK.

OneHeart is a personalised ACS patient support programme that looks at tacklingpatient beliefs towards their disease through health psychology techniques.

Effective implementation of the OneHeart programme could deliver outcomes suchas reduced hospital admissions, improved uptake of cardiac rehabilitation, improvedadherence to medication, improved patient satisfaction and improved patient qualityof life.

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Achieving better outcomesthrough adherence servicesAndrew Riley BPharm, GPhC

Our series on adherence withprescribed medications considers how it can beimproved and the cost ofwasted medicines reduced.Here, the author discusseshow better outcomes can beachieved through adherencesupport services.

outcomes improvement driver’ and agreedlevels of adherence set for different treat-ments and conditions?

A new adherence serviceSetting targets for adherence to medicinesas the basis for a new adherence serviceis dependent on whether a reliable meas-ure of performance can be agreed and

whether a baseline can be establishedfrom which targets for improvement canbe set.

One of the most significant variablesfor adherence is the motivation level ofpatients and this is partly determined bythe value that prescribers bestow on thetreatment they are prescribing. While set-ting targets for improvement in adher-

ence can focus on those factors that mostaffect it, the motivation of prescribersthemselves can be adversely affected ifthey are set adherence targets that areunattainable.

In the context of a new adherenceservice should we consider three levelsof adherence: minimal, achievable andexcellent?

Anything less than minimal acceptableadherence should act as a prompt for theprescriber to consider discontinuing treat-ment in favour of an alternative treatment,as below minimum acceptable levelspatients are more likely to incur all the dis-benefits of treatment without any of thebenefits.

Minimal acceptable adherence shouldprompt the prescriber to improve othermodifiable factors. For example, patient/carer motivation levels can be improved byproviding accessible educational supportthat emphasises the benefits that drugtreatment can bring, eg anticoagulantscan reduce stroke in AF patients. Patientscan also be provided with cues andprompts using digital (eg care planningapps) and telephony (eg pretimedreminder texts) solutions.

Achievable adherence focuses on theneeds of well-motivated patients andmaintaining their improved adherence,measured using a treatment diary.Consolidating the changes that haveresulted in the measured improvementwill be easier if this corresponds with anoticeable improvement in control ofsymptoms – maintaining a behaviour thatdrives improved adherence will be harderfor disease-modifying treatments whosebenefits are less visible.

In this case adherence support willneed a concerted effort from both theprescriber and patient/carer workingtogether to demonstrate a sustainedresponse in measurable disease param-eters, eg controlling high blood pressure,blood cholesterol or glucose associatedwith improved adherence. Seeing theimprovement will maintain patient moti-vation when they are taking treatment tomodify risk in a long-term condition, egCHD or diabetes.

Excellent adherence arises when thepatient takes responsibility for self-moni-toring their treatment and the treatment

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Table 1. Building, marketing and implementing adherence support services: support functions and serv-ices that will enable adherence support services to become established

Marketing• social marketing – to raise awareness of important benefits/patients as partners • patient and public involvement – IT platforms such as ‘crowd sourcing’– use of social mediato change prevailing attitude and culture toward medicines and their vital role in improvinghealth outcomes and improving productivity of healthcare services

• marketing to create awareness of the need at practitioner, practice and NHS commissioner(CCG/CSU) levels – improved efficiency, effectiveness and economy

• development of thought leaders and knowledge management, to evolve the understanding ofthe barriers to adherence and how to effectively overcome them

Implementing practice change• training – building a clinical infrastructure through training that embeds an understanding ofthe barriers to adherence and how to manage them

• resources – development of patient-centred adherence materials • evidence-based education – focusing on specific aspects of medicines administration thatchallenges the achievement of optimal treatment outcomes

• patient peer support for adherence – assuring the quality of peer support in long-term condi-tions

• training of pharmacists – how to become adept at influencing attitude and behaviour changein an adherence consultation

• matrix working opportunities – workshops that encourage collaboration to improve adherence– systems for linking databases that can provide new insights into problems that patientsencounter with medicines, eg the ‘pill burden’, which is the amount of time managing medi-cines takes each day

Implementing process change• programme management – experience of systems to support phased roll-out and valuestream mapping to identify process barriers to adherence

• development of local clinical partnerships – opening up referral pathways between doctorsand pharmacists to drive the uptake of care pathways

• equity and excellence – working with academic health science networks (AHSNs) to build anew strategy for adherence at national level

• business case writing or business planning – medium- to long-term sustainability• project management of specific objectives of the roll-out of adherence support services• building the clinical infrastructure – pathways/referral• performance development – Action Learning Sets• knowledge management – extend the methodology to support safe, phased and targetedmanaged entry of innovative medicines based on intensive pharmacist-led pharmaco-vigilance

• developing a programme to support all levels of competence at all levels of the NHS, ie a com-missioning competency matrix

• measurement metrics for medicines optimisation dashboard – QOF metrics measured byHealth and Social Care Information Centre (HSCIC)

plan includes a range of techniques target-ing those factors that will diminish adher-ence if not addressed. This is supportedwith readily accessible professional sup-port from the prescriber (or pharmacist).

For example, once excellent adher-ence is achieved, patients can share theirexperience and provide peer support toother patients so that they too can achievethe transition toward similar control.

Addressing poor adherenceThere are six steps to a successful strategyfor addressing poor adherence.

1. Start a different conversation aboutmedicines adherenceThis may involve uncovering failingstrategies and replacing them with lessorthodox approaches that are moreeffective, eg reframing the question dur-ing a consultation from ‘Are you havingany problems with your medication?’ to‘In the last month, did you miss takingyour medication either partly or com-pletely?’ and, to support future assess-ment, encourage patients to use anadherence diary to estimate how manydoses are being missed.

2. Importance of review and reinforce In preparation for a medication review, pre-scribers may consider undertaking a snap-shot audit to determine whether thenumber of repeat requests correspondswith the number of months that thepatient should have taken their medicines,or whether there is a discrepancy thatuncovers significant underuse.

If a new medication has recently beenprescribed for which there is predictableclinical response, prescribers can chartthe patient’s response against theexpected response trajectory for the treat-ment concerned: any separation between‘actual’ and ‘expected’ response providesa basis for further investigation focusingon adherence.

The new concept of medicines optimi-sation sets an aspirational level ofresponse and treatment outcome that canbe achieved if all confounding factors toachieving excellent levels of adherence areadequately addressed.

Additionally, ‘checking in’ with signifi-cant others in the patient’s home may help

to validate a patient’s response anduncover whether personal motivation is anissue.

Asking the patient to share their ownunderstanding of the need for treatmentand its role in affecting the course of theirdisease may provide some insight into apatient’s expectation and hence theirlikely levels of motivation. Helpingpatients reach a better understanding ofthe role of their treatment may be a slow,incremental process; however, it will ben-efit patients hugely by dismantling anymisconceptions they have about what thetreatment will achieve, and reinforcing apositive perspective.

3. Explore outcomes that are importantto patients From ‘What’s the matter?’ to ‘What mat-ters to you?’. This can uncover powerfulincentives to improve adherence.

The importance of acknowledging out-comes that are important to patients is a‘game changer’ for a patient’s motivationlevels. For example, living on into frail oldage is often of far less interest, and there-fore has much less motivational potential,to a middle-aged person than staying asfit and healthy as possible so that they canenjoy time with their grandchildren.

Another potential area for closerexamination is to offer patients rewardsand incentives for patient compliancewith a treatment plan. Pilots of exerciseprogrammes that offer subsidised/freegym membership provide a precedent forthis. Though this can be very controver-sial, there may be some circumstanceswhen this is justified if it avoids significantdownstream costs associated with non-adherence resulting in treatment failure.

4. Advocacy for medicines optimisationThe prescriber should set high standardsfor adherence with their patients, aligningprocess goals (ie daily recording of med-icines administration) with performancegoals (ie achieving long-term conditiontargets and setting these with each indi-vidual patient). Patients trust their doctor,and if doctors strongly advocate the valu-able outcomes that medicines canachieve this will drive consistency ofpatient behaviour. Prescribers need tofocus on what they have done right to

improve adherence as this is more likelyto reproduce improved adherence ratesin future.

Medicines optimisation can beembodied in a quality statement that pre-scribers can adopt and display openly, onbehalf of all patients who are prescribedmedicines by them: ‘All patients will begiven access to information and adviceabout their prescribed medication so thatthey can become active partners in theirtreatment and so that they share our ambi-tion to achieve treatment goals that areamong the best in the world.’

5. Teamwork to deliver medicines optimisationPsychologists confirm the importance ofmaking use of different types of goals. Theseparation of outcome and performancegoals opens the opportunity for collabora-tion with pharmacists who are trained toachieve improve performance of pre-scribed medicines. They can set ‘SMART’performance goals (specific, measurable,achievable, relevant and time based) astheir training provides them with in-depthknowledge of pharmacology and the rolethat different delivery devices can play inaddressing physical barriers to medicinesadherence.

Pharmacists will also effectivelyaddress patients’ concerns about side-effects and provide valuable advice topatients to help maintain their motivationlevels. The relationship between thepatient and pharmacist is key and by work-ing together they can develop strategies toaddress adherence issues, such as thepatient keeping a diary to monitor theirdaily usage of medicines.

The pharmaceutical industry too canoffer valuable support for the roll-out ofadherence support services (see Table1). The Association of the BritishPharmaceutical Industry (ABPI) will pro-vide a governance platform for NHSorganisations to work in partnership inthese areas with pharmaceutical compa-nies. In the future, precise diagnosticswith predictably effective therapeuticswill dominate the market and so theneed to build adherence support solu-tions will become even more importantto the success of treatment and achieve-ment of excellent patient outcomes.

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There are already a range of non -promotional adherence support servicesfrom pharmaceutical companies, like theOneHeart Programme (see Figure 1),which patients should be directed towards.

6. Keep the adherence issues alive:making every prescriber contact countPrescribers need to build time to talkabout medicines into their consultationsor work more closely with other healthcareprofessionals who can spend time toexplore the issues and suggest options foraddressing and overcoming adherencebarriers with individual patients.

Working closely with pharmacists andother healthcare professionals, like com-munity nurses, can provide a valuablereal-world perspective for prescriberswishing to gain insight into the generalattitudes and behaviour of patientstowards medicines.

Poor monitoring of disease parame-ters accompanied by minimal adherenceto medicines can allow symptoms to grad-ually manifest leading to treatment fail-ure, sometimes resulting in emergency

treatment in hospital. Recovery fromthese emergency episodes provides anideal opportunity for prescribers to re -inforce the reason for treatment and theimportance of achieving and maintainingexcellent levels of adherence to pre-scribed medicines.

SummaryAchieving and maintaining excellent adher-ence to prescribed medication is notsomething that prescribers can take forgranted. Patients need continual person-alised professional advice and support toovercome barriers to adherence and tomaintain their personal motivation. It hasto be clear to them that prescribing is aprecise process that will treat disease in asafe and effective way, and that achievingexcellent adherence presents the bestopportunity for them to achieve the bestfrom their prescribed medication and agood outcome.

Pharmacist expertise can be har-nessed very effectively to deliver an opti-mal treatment response by engagingpatients early in their treatment journey

and reinforcing the individual treatmentgoals agreed with their prescriber.

But commissioners need to recognisethat the behaviour change needed toachieve good outcomes can present a sig-nificant hurdle, especially when the con-sequences of nonadherence in chronicdisease are deferred. The cost of treatingthe resulting morbidity can be consider-able, which makes the case for recognis-ing adherence support services as a keylocal improvement driver and a commis-sioning priority.

The NHS wants to ensure patients feelsupported to manage their condition, andNHS England have made this an indicatorin the NHS Outcomes Framework 2013/2014. Pharmacists are ideally placed tomanage this and they can make adher-ence support services a game changerthat drives quality, significantly improvespatient outcomes and reduces healthinequalities.

Andrew Riley, regional partnership manager, Association of the BritishPharmaceutical Industry

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