Medicines adherence: the challenge

In order to answer this, we need to address another question: what is the purpose of a consultation about medicines? We suggest that the value of a consultation lies in helping patients get the best health outcome from their medicines and this requires more than education. We are told that up to half of patients do not to take their medication as intended.5 In reality, this means that every other patient we see will not be taking his/her medicine as we expect or have advised which can result in suboptimal outcomes for his/her health. As use of medicine increases as a therapeutic intervention, so does the imperative to consider how we use consultation time with patients more effectively to help them get more from their medicines, a process known in the UK as medicines optimisation.6 ,7 In the UK, recent government policy embraced the approach to move from compliance, where we tell patients what to do about medicines, to concordance, which requires agreement and this is embodied by the phrase ‘no decision about me without me’.8 There is an urgent need to act: economic modelling estimates that suboptimal compliance contributes to enormous waste. For example, for patients with type 2 diabetes, it is estimated to cost the National Health Service (NHS) over £100 million per year in avoidable treatment costs in England.9 In a report published in 2015,10 commissioned by NHS England, these costs are still considered relevant and increases between 2010 and 2014 are estimated at 11%.

We need to work with patients to create engagement in improving health, increasing patient awareness of their role in managing their health, supporting patients to become active participants in their care and take responsibility for their health. When patients take more active responsibility for medicines choice, we will reduce issuing medicines to patients who do not want to take them and can improve adherence through concordant consultations.

In order to do this, we argue that pharmacy teams need to think differently about the way in which consultations are undertaken in order to improve effectiveness of medicines.

Training opportunity

With this in mind, London North West Healthcare NHS Trust pharmacy dispensary staff, based at Northwick Park Hospital in North West London, UK decided to take the opportunity to improve their consultation skills through the use of health coaching.

Health coaching has been defined as: ‘A behavioural intervention that facilitates participants in establishing and attaining health-promoting goals in order to change lifestyle-related behaviours, with the intent of reducing health risks, improving self-management of chronic conditions, and increasing health-related quality of life’.11 Developed from the Goal, Reality, Option, Will (GROW) model used in business coaching, health coaching is being introduced into NHS practice for a wide variety of clinicians to support patient self-care and self-management.12–15

In April 2014, London North West Hospitals NHS Trust pharmacy department commissioned the largest provider of Health Coaching in England, The Performance Coach, to deliver a 2-day training course to a cohort of 18 pharmacists from the two hospital sites. The course was delivered by Dr Andrew McDowell, a health psychologist and leader for design and delivery of health coaching courses for the NHS, and Professor Nina Barnett, a consultant pharmacist for older people, an experienced health coach and trainer, who has designed health coaching interventions for pharmacy practice.16 Recognising that we could not train all pharmacy staff in the health coaching, we sought to introduce aspects of this discipline into the everyday consultation for all pharmacy staff in a dispensary setting. To this end, all dispensary staff attended a 2 h introductory session which focused on small changes in practice. This included considering what staff would want if they were patients, considering the current consultation from the patient perspective and including moving from telling to asking approach.17 This was reinforced at weekly dispensary meetings with staff sharing successes and challenges of interventions. In order to support further skill development, the full course has been recommissioned for 2016.

Ensuring safe practice

Delivering medicines to patients through safe process is critical to dispensary practice and good governance is required around all changes to established practice. Therefore, prior to any changes, an audit of the technical steps of the existing process for giving medicines to patients was undertaken to confirm adherence to minimum safety standards. The audit demonstrated that safe practice was in place and the team, therefore, felt secure in the decision to review consultation style, integrating health coaching into consultations. A flow chart was created detailing the steps required to support the journey towards more patient-centred consultations (see online supplementary appendix 1). This included the principles of the 4Es (Explore, Educate, Empower, Enable; see online supplementary appendix 2), a pharmacy-based model for short consultation16 which uses health coaching principles to support patient-centred conversations.

Dispensary health coaching process

In order to provide consultations appropriate to our patients, three categories patients are considered:

1. Patients who do not wish to have a conversation about their medicines. This may be because they already have enough information or because they are in a hurry to leave. Our experience is that attempting to give patients information in this situation causes frustration for both patient and pharmacy team member.

2. Patients who are receptive to information about safe use of medicines and have no immediate concerns or questions about their medicines.

3. Patients who are receptive to information about safe use of medicines and have questions or concerns about their medicines.

Using these three categories, trained pharmacy staff tailor their consultation to patient need. The process is described in the flow chart (see online supplementary appendix 1).

Patients in the first group receive a very short consultation, focused entirely on safety. A typical conversation includes checking who the medicines is for, confirming allergies and highlighting the contact number for the organisations' medicines information patient helpline and information in the medication patient information leaflets provided by law with all dispensed medicines.

Patients in the second group are offered the opportunity to ask questions and if they have no questions are provided with appropriate information within our safety checklist.

Patients in the third group are offered an opportunity to ask questions and if they have questions, the consultation proceeds using a coaching approach, supported by the 4Es model.

Our findings

In the first few weeks of the pilot, advantages observed so far from both staff and informal patient feedback include:

• Improved staff satisfaction. Staff has said that they prefer to be able to tailor consultations for patients, focusing on what they actually want/need to know.

• Reduced patient and pharmacy team member frustration having ‘permission’ to focus on patient safety where time was short.

• Improvement in using and optimising skill mix where pharmacy technicians and pharmacists were empowered to have the same type of conversations.

• Patients have told us they were happy with our consultations directly.

The main perceived disadvantage of using the above consultation style was the fear of increasing the time for consultations, however, this appears unfounded from our experience. We have identified a need for a dedicated counselling area to improve privacy in consultations.

Now that we have demonstrated the practicality of implementing this intervention, we intend to review our work with patient involvement and assess the intervention formally through patient and staff feedback questionnaires. Planned modernisation of the pharmacy dispensary will include provision of a consultation area.

How could this apply more widely?

It is now accepted that patients should be at the centre of their healthcare. Recognising that there is patchy patient-centred practice in pharmacy, we hope this work will contribute to our vision that all pharmacy consultations will be patient centred. We are using coaching approach to consultations in a variety of ways and we encourage everyone to consider how their processes can be improved to ensure the patient is at the centre of the consultation and to make changes, large and small, in the direction of patient-centredness. Provision of a patient-centred consultation framework in our dispensary, using a coaching approach, has improved our focus on patient needs. This balances our previous focus on health professional needs from consultations and will continue the journey towards patient-centred care.