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Marketers invest time and effort in working out how to get medicines into patients' hands, but what should they do to ensure that drugs are not then discarded?

A pair of ballerinasAs an industry, we spend many millions of pounds chasing new patients who might benefit from our products.

From GP advertising to huge salesforces, expensive symposia to extensive medical education programmes, disease awareness campaigns to supporting patient action groups.

Yet, here's the strange thing: once we have them in the net, we let as many as half of them go again, very quickly. Have we not heard of the expression 'A bird in the hand... '? If we could just approach the effectiveness of our market acquisition activity in our market retention strategies, the returns could be huge.

I'm talking here about compliance; actually, I'm talking about adherence, and I'll explain the difference presently.

Too often, the industry wrings its hands and complains that the healthcare 'system' is not doing enough to ensure that patients prescribed drugs do actually take them - and that the same system is ignoring pharma when it comes to initiatives to tackle the problem. My contention with this is that it is drastically wrong.

The problem is the total lack of proactivity (with a few honourable exceptions) within the industry to take a leading role in developing such partnerships.

There are many examples of stand-alone industry initiatives to improve compliance, but why does the pharmaceutical industry seem to want to go it alone? Is this a case of pharma looking introspectively once again, regarding compliance as its own problem which it must solve single-handedly? Does the industry truly believe that it isthe only party concerned with the problem, and so it must press on, unaided, to find a solution? If so, it is deluding itself.

The industry's own self-interest actually coincides with everybody else's (including the patients' and the funders'). Patient compliance is something that affects the government, doctors, pharmacists, funders, insurance companies, the industry, and not least, the patients themselves.

Why, then, is there so little collaboration between these stakeholders to combat 'health illiteracy', changing the way that patients view their therapy, which would give long-term healthcare cost savings, brand retention and better consumer relationships - as well as boosting industry's return on investment?

Why are we leaving it to the 'system' to boost adherence? Why aren't we doing more? What should we be doing to build really effective partnerships to keep hold of those patients on which we spend so much trying to acquire?


Sticking to it
Much has been written on the subject, especially with the emergence of the concept of concordance in recent years; but concordance is only part of the solution. We should get our terminology right first.

What we're addressing here is 'adherence' and that, according to the World Health Organisation, is the extent to which a person's behaviour - taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider.

Adherence is very close to compliance, which is a measure of patient behaviour - the extent to which patients adhere to the agreed 'treatment' approach, which is larger than (but also includes) how they take the medicines they have been told to take; according to the prescribed instructions, in other words.

The concept of concordance is a different part of the solution to the same problem (ie, adherence). Concordance, according to the Medicines Partnership, concerns shared decision making about medicines and other treatments between a healthcare professional and a patient, based on a partnership where the patient's expertise and beliefs are fully valued.

This is an important partnership, then, and one from which the industry appears to be excluded. To realise just what is at stake for the industry here, let's take a look at just how big the problem is.

Despite the cynical views of 'lies, damn lies and statistics', the figures are pretty clear. At any one time, 70 per cent of the UK population is taking medicines to treat or prevent ill-health or enhance well-being. The fact that many long-term illnesses are now tackled with prescription medicines has led to a growth in prescription drug spending in the UK from £3.4bn in 1994 to £6.1bn in 2001 (more than 10 per cent of the total NHS spend); so it's an important part of our country's healthcare strategy.

Studies show that 28 per cent of people do not adhere to their prescription within just 10 days of taking a new medication - that discounts those who don't fill the first prescription but includes people who stopped of their own accord, those who intentionally missed a dose, and those who unintentionally missed a dose.

These distinctions are important because different approaches are required for each category.

When it comes to medicines prescribed for chronic conditions, the Medicines Partnership estimates that 50 per cent are not taken as prescribed, with some conditions such as asthma experiencing a staggering 80 per cent non-adherence rate.

What's more, while patients simply forgetting to take their medicine or renew their prescription will always be a problem, a worrying 61 per cent of all non-adherence is thought to be 'intentional' - ie, mainly fears about side-effects, worries over costs, or a simple disbelief that they actually need the drug.


Far reaching problem
This is a worry for the pharmaceutical industry because patients not taking their medicine, especially for those with chronic conditions, means fewer sales and the need to spend marketing resources finding new patients. On that basis, funders should be quite pleased! (But of course it's not as simple as all that).

The consequences of non-adherence are far-reaching and end up being a concern to everyone. For the patient, it can lead to ill-health and reduced quality of life, and ultimately reduced life expectancy.

This in turn can lead to increased costs elsewhere in the NHS, as it's much better to have a condition controlled via medication than treated in an expensive hospital bed; ultimately the arguable short-term financial gain to the healthcare system ends up being a longer-term drain on resources.

Wider society also loses out if a healthy, economically-active person managing their condition so that they can get on with their everyday life suddenly becomes inactive through illness, constituting an economic 'double-whammy' - of expensive treatment-seeker and ex-contributor to the wider economy.

In addition, the pharma company takes a hit in terms of lost revenues, especially for chronic conditions, and just as importantly, negative perceptions emerging about the efficacy and tolerability of its product(s).

When you start to look at the reasons given by patients in research as to why they don't use their medicines optimally, the weakness of the go-it-alone option that many in the industry seem to be adopting is revealed.

The fact of the matter is many patients start from the point where they believe that the potential harm from any medicine outweighs the benefits. The balance between the belief in the necessity of the prescribed medication - especially long-term - and concerns about the long-term effects and possible dependence is tipped towards non-adherence.

Yet, it's difficult to see what the industry can do to turn this perception around on its own. Only better communication between healthcare professionals and patients can allay these fears, so pharma needs to engage with HCPs, as well as all those who influence them, to build real partnerships that give doctors the tools with which to tackle these patient issues.

As long as communication directly with patients is forbidden - and realistically, even if it were not, given the poor reputation for self-interest that blights our industry in the eyes of the general public - we need the collaboration of all healthcare professionals to drive up adherence.

This is a complex scenario; from not filling the initial prescription, through refusal to make behavioural changes, incorrect dosing, forgetting or skipping doses, to self-termination of the medication for whatever reason, each problem needs to be addressed separately. The widely hailed concordance concept is one good tool to tackle this, but how can this work if there is not similar concordance between all of the stakeholders involved in providing patient care?

We should be pushing at an open door, given that the agenda of healthcare professionals, or at least its objectives, is pretty similar to our own.


The Industry's Role
The main role of the pharmaceutical industry in any society should be to develop safe and efficacious therapies. Full stop.

Your shareholders might disagree, preferring instead to concentrate on profit alone, but in any stakeholder partnership, developing good therapies is the pharma industry's primary role.

So developing drugs that work, have fewer side effects, and which are easy - or at least easier - to administer would go some way to playing a useful role in promoting adherence. However, because medicines are for patients, and patients only benefit if they use them optimally, the industry's role needs to go further than that, and needs to step into the area of information.

What should our role be in these partnerships? The industry can have a hand in ensuring that the dialogue taking place between the patient and their doctor, nurse, pharmacist or other healthcare provider achieves the best outcome for everybody involved.

If we agree that concordance, where there is a real consultation process between a patient and their healthcare professional, is an effective way to go, or at least more effective than simply expecting the patient to do what they are told, then increased and broader patient knowledge is vital to make this process work.

All patients want to be more involved in decisions about treatment. Even within the older generation who have traditionally accepted that 'doctor knows best', there is a majority demanding more involvement; and this proportion rises dramatically among younger age groups - only a third of patients want no involvement in treatment decisions.

Pharma understands this well, but it is not getting the message across to the healthcare providers. Studies have shown that doctors underestimate the degree to which they instruct patients, and consistently overestimate the degree to which they consult and elicit their views.

Like it or not, doctors are listening less to the industry. So an industry-led compliance campaign will only ever have limited effect; which is why the industry should be driving true stakeholder partnerships by demonstrating shared goals, shared concerns and a win-win mindset.

Come together
Healthcare practitioners participating in true partnerships with patient groups, funders, the government and industry, are more likely to listen to the message.

Why isn't it happening? Perhaps, following the Health Select Committee inquiry, the industry is still reluctant to open itself to accusations of self-interest in promoting such partnerships.

Yet, are we really so unconfident that we can't persuade other stakeholders of the confluence of interest?

Let's leave the last word to Asta Moller, of the International Council of Nurses, who addressed a recent conference on adherence, pleading with the industry to get more involved.

Seek out the guidance of nurses' organisations and their leaders. Work with these organisations and with individual nurses. Bring training, useful tools for their patients, resources for their community initiatives. Get as close as you can to those whom you seek to help. Draw from the knowledge and experience of nursing to help shape your goals and strategies.

Healthcare stakeholders are crying out for us to drive partnerships, and partnerships which will ultimately increase our return on investment. What are we waiting for?

The Author
Dr Paul Stuart-Kregor is director of the MSI Consultancy. He can be contacted at; alternatively, visit the MSI Consultancy website at 

2nd September 2008


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