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

Produced by:

This guidance is about enabling patients to make informed choices by involving and supporting them in decisions about prescribed medicines. It explains guidance (advice) from NICE (the National Institute for Health and Clinical Excellence) to the NHS in England and Wales.

Key recommendations

Developing effective, equitable interventions to support adherence to appropriate prescriptions

What are the most clinically effective and cost˗effective methods for identifying and addressing the perceptual barriers (such as beliefs and concerns about medicines) that influence motivation to start and continue with treatment, and the practical barriers (such as limitations in personal capacity and resources) that limit an individual's ability to implement intentions to adhere to medicines?

Why this is important

The Guideline Development Group identified a priority for the systematic development of effective, realisable, efficient and equitable interventions to facilitate informed choice and optimal adherence to appropriately prescribed medicines.

Systematic reviews of adherence interventions show that although adherence can be improved, the effects were generally modest and there is considerable room for improvement. Few previous interventions have been developed systematically using appropriate theoretical models, and they have not been modelled and piloted with assessment of process variables as well as outcomes.

Interventions should be developed using an appropriate theoretical framework with a phased approach to testing that includes assessment of process (that is, the things that are targeted for change) as well as outcomes and a need for an individual approach.

Informed choice and shared decision-making

What are the most clinically effective and cost˗effective ways of communicating the potential benefits and risks of medicines to promote informed choice and optimal adherence?

Why this is important

The principles of informed choice and shared decision˗making have largely been developed from theoretical and conceptual models. The competencies listed for shared decision-making consist of a number of different skills, and patients have shown that they may value different aspects of shared decision˗making. Although the right of patients to be involved in decision˗making in regard to their own healthcare is accepted, the practice of shared decision-making may mean that healthcare professionals and patients play different roles than they have to date in healthcare consultations.

This may have implications for legal and professional responsibility and accountability. Patients and professionals enter decision˗making with very different levels of knowledge and access to information. Improving patient knowledge and information may require structural changes to health services and their delivery. Patient˗reported outcomes also need to be included.

Support processes: prescribing˗related consultations and medicines review

How can practitioners and patients be supported to improve the quality of prescribing-related consultations and medicines reviews so that they facilitate informed choice and optimal adherence to medicines?

What are the effects of medicines reviews by healthcare professionals other than the prescriber on patients, prescribers and outcomes? How can the process of medicines review be enhanced or improved to address issues of informed choice and adherence?

Why this is important

Non˗adherence is often a hidden problem. Many patients are reluctant to express doubts and concerns about medicines because they fear that it will displease the healthcare professional. We need better methods for overcoming this problem and promoting honest and open discussions about medicines and adherence.

There are an increasing number of non˗medical prescribers (such as pharmacists and nurses) This is a key context issue and there are a range of questions relating to patient perspectives on new prescribers and to new and existing prescribers' perceptions and skills. The effects of new prescribers on patient adherence to medicines should be included in any studies designed to evaluate new prescribers. The inclusion of formal procedures for medicines review within the Pharmacy Contract in England provides an opportunity for improved support for patients. We need a better understanding of the effects of non˗prescriber reviews on medicines usage and outcomes, and how reviews might be improved to benefit patients and society.

It is thought that between a third and a half of all medicines prescribed for long‑term conditions are not taken as recommended. If the prescription is appropriate, then this may represent a loss to patients, the healthcare system and society. The costs are both personal and economic.

Adherence presumes an agreement between prescriber and patient about the prescriber's recommendations. Adherence to medicines is defined as the extent to which the patient's action matches the agreed recommendations. Non‑adherence may limit the benefits of medicines, resulting in lack of improvement, or deterioration, in health. The economic costs are not limited to wasted medicines but also include the knock‑on costs arising from increased demands for healthcare if health deteriorates.

It is thought that between a third and a half of all medicines prescribed for long‑term conditions are not taken as recommended.

Non‑adherence should not be seen as the patient's problem. It represents a fundamental limitation in the delivery of healthcare, often because of a failure to fully agree the prescription in the first place or to identify and provide the support that patients need later on.

Addressing non‑adherence is not about getting patients to take more medicines per se. Rather, it starts with an exploration of patients' perspectives of medicines and the reasons why they may not want or are unable to use them. Healthcare professionals have a duty to help patients make informed decisions about treatment and use appropriately prescribed medicines to best effect.

You can read the guideline on NICE's website.