1. Supporting medicines adherence:
Developing the pharmacist contribution
Graham Davies | Professor of Clinical Pharmacy and Therapeutics
King’s College London

2. ProfessorGraham Davies,
Institute of Pharmaceutical Science
King’sCollege London

3.  South London project – supporting patients
with diabetes
 Supporting community pharmacists to
deliver adherence support
 Key challenges to future care – the
Southwark and Lambeth IntegratedCare
initiative
 Summary

5. Richmond
174,400
Wandsworth
269,300
Kingston
150,000
Merton
192,300
Sutton
180,900
Croydon
336,600
Bromley
335, 914
Lewisham
284,746
Lambeth
329,174
Southwark
298,073
Greenwich
262,145
.
Bexley
233,33311
2
6
5
9
14
12
3
4
15
5
8
7
17
13
1
10
2
4
5
9
8 6
1
10
7
3
16
2
3
4
5
6
7
8
9
10
1
11
12
13
14
15
16
17
Bethlem
Bolingbroke Hospital
Epsom Hospital
Guy’s Hospital
King’s College Hospital
Kingston Hospital
Lambeth Hospital
Maudsley
Mayday Hospital
Oxleas
Queen Mary’s Hospital
Royal Marsden – Sutton Hospital
South London Healthcare
St Helier Hospital
St Thomas’ Hospital
Tolworth Hospital
University Hospital Lewisham
1 Greenwich University
2 King’s College London (The Strand)
3 King’s College London (Waterloo)
4 King’s College London (Guy’s)
5 King’s College London (St Thomas’)
6 King’s College London (Institute of Psychiatry)
7 Kingston University
8 Lambeth College
9 London Southbank University
10 St George’s University
Four key
priorities:
• Mental
health
• Diabetes
• Stroke
• Infection

6.  Estimated that there are 3.1 million people with diabetes in England. 800,000 of
these are not diagnosed (1)
 By 2020 an estimated 3.8 million adults, or 8.5% of the adult population, will have
diabetes and by 2030 this is estimated to rise to 4.6 million or 9.5% (1)
 The NHS in England spends more than £2.3 billion a year on inpatient care for
people with diabetes.That’s 11% of NHS inpatient care expenditure (2). Length of
hospital stay is 2-3 nights longer than those without diabetes.
 Anti-diabetes medicines cost the NHS £725 million/year.
 30 -50% of medicines prescribed for long-term illnesses not taken as directed
 For diabetes, we can estimate at least £200 million/year waste
(1) APHO Diabetes Prevalence Model, http://www.yhpho.org.uk/resource/view.aspx?RID=81090. Last updated 28/09/2010
(2) NHS Diabetes report November 2011. www.diabetes.nhs.uk

7. 0%
10%
20%
30%
40%
50%
60%
%obese
Schools - % Obese Southwark average London average England average
Schools
Reducing UnwarrantedVariation
Fourfold variation in the rate of hospital
admissions for diabetes in London PCTs
Fivefold variation inY6 childhood obesity
rates across primary schools in Southwark
Tenfold national variation in the % of type 2
diabetics receiving all 9 NICE key care processes
Threefold variation in uptake of structured
education across South London with best at 29%

8.  Key stakeholders from across south London
invited to discuss how community
pharmacists could be more specifically
involved in supporting people with
diabetes.
 Participants included representatives from
national diabetes organisations, patient
representatives, academics, commissioners
and healthcare professionals.

9.  Supporting patients’ use of medicines
 Identifying concerns and facilitating goal setting
 Screening for undiagnosed diabetes
 Risk assessment using trigger drugs
 Supporting use of glucose meters and test strips
 Communication skills to promote inter-
professional working
 Signposting
 eye and foot checks; access to support groups and
structured education (DESMOND)

10. “…I’ve been going to the same place for the past 3 years and they
understand my history and if my medication has run out they will
phone me to remind me.”
Patient 3
“...I ring up the pharmacist, supplies are getting a bit low, tell
them what I want...he will ring the surgery and I will go in about 2
days later and it’s all waiting for me. He will do a delivery service
for those who need it.”
Patient 14

11.  Raise awareness of common beliefs about
illness and treatment held by patients
 Enhance consultation skills
 Provide systematic approach
 Examples of good behaviours
 Develop a proactive versus reactive approach

13. Endorsed by the Royal Pharmaceutical Society

14.  Increase awareness about adherence and
challenges
 Underpinned by evidence:
 Perceptions and Practicalities model1
 Focus on consultation skills using validated
framework (MRCF)2
 Highlights patient-centred approach to better
understand their medicine-taking behaviour
 Demonstrates good consultation behaviours
which can lead to behaviour change
 Motivational interviewing
1 Horne, R. &Weinman, J. (1999) Patients' beliefs about prescribed medicines and their role in adherence to treatment in chronic
physical illness. Journal of Psychosomatic Research, 47 (6), 555–567.
2 Abdel-Tawab R et al (2011). Development and validation of the Medication-RelatedConsultation Framework (MRCF).
Patient Education and Counseling 83 (3): 451-457.

15. Interactive
Videos demonstrate different levels of
effective practice
Work at your own pace
Reflect on your own practice
Techniques explained in full
Rating exercises to reflect on level of practice
Features & Benefits

16. PRE-MODULE ASSESSMENT (Clinical Knowledge)
PART 1:
Assessing and addressing adherence in diabetes
PART 2:
Identifying and consulting with non-adherent patients with diabetes
PART 3:
Using consultation skills to identify and address patient non-adherence
in diabetes
POST-MODULE ASSESSMENT & REFLECTIVE EXERCISES

20. Low concerns
High concerns
High necessityLow necessity
Sceptical
AcceptingIndifferent
Ambivalent
Mann et al. (2009)

26. No of
Conditions
per patient
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
People(%)
Age Groups (Years)
Morbidity (number of LTCs) by Age Group
0
1
2
3
4
5
6
7
8+

27.  Co-morbidities with ageing
 Engagement of different health care
professionals
 Silo approaches
 Poor transfer of information
 Lack of consistency in messages
 Medicines adherence
 Not routinely assessed or documented
 Agreed plan or intervention not documented
 New Medicines Service and MUR a start

28. Citizens will feel that their health is also their responsibility
and will be supported in self management by building
community assets, capabilities and skills.
We will provide the right care in the right place, at the right
time, reliably and proactively by the professional(s), peer
support workers or volunteers most suitable to provide care.
Ensure we are treating the whole person with integrated care
centred around empowered individuals.
Ensure professionals are best able to deliver this new
approach, ensure better professional lives for the staff we are
working with.
This requires behaviour change by all professionals, citizens
and communities.
1.
2.
3.
4.
5.

29. We need to shift the LTC
care paradigm from
people being dependent
recipients of care to
enabling and supporting
people with LTCs to live
independently and
optimally with their
condition.
Doing more of the
same better will not
be enough
Must do better:
• LTCs are under-diagnosed
• Too many people with LTCs die
prematurely
• QOF scores for LTC management are
well below London average in 7 of 17 LTC
diagnoses
The ‘Scissors of Doom’ - Growing demand
with less funding
• Population in S&L expected to grow by
18% in next 10 years
• Aging population
• People live longer with LTCs
• Funding for NHS, Public Health and
Social Services is falling well behind
growth in demand

30. Undertaking healthy behaviours
• Not smoking, Exercising, Healthy eating, Drinking alcohol in
moderation
Keeping home environment safe
• Impaired mobility and physical ability to take care of all activities of
daily living
• Cognitive decline with impaired ability to run a household
independently
• Epilepsy with frequent seizures and risk of injury
Optimising medicines use
• Taking medications as prescribed or knowing how to take PRN
medications
Detecting and addressing risks early
• Detecting people at risk and stratification
• Early effective interventions
• Care management

31.  Scoping the key issues, problems and
successes
 Developed medication adherence screener
 Piloted in hepatitis C out-patient clinic
 Adoption byThrombosis Centre (KCH) - focus on
transfer of warfarin patients to NOAC (time in
range <50%)
 CCG backing to use screener in GP cluster.

32. Pilot in 40 patients – over 20% admitted to missed doses in
week before clinic
The majority of patients (70%) had concerns about their
medicines
Frequency (%)
Possible side effects 23 (62)
How the medicines may damage my body in the long term 9 (24)
Taking too many medicines 9 (24)
Whether the medicines will be of any help 4 (11)
Whether their effectiveness will wear off over time 4 (11)

33. • Preliminary results suggest that the screener can be integrated
into routine care to identify non-adherence
• Non-adherence appears to be associated with:
• Low motivation (as conceptualised by the Modified Morisky
i.e. forgetfulness and carelessness)
• Perceptual barriers (only took their medicine when they felt
the need)
• Practical barriers (poor planning of medicine-taking
behaviour )
• Used by MDT to target inform consultation during clinic visit

34.  Capture medicines adherence data routinely and
make available to:
 Aid provision of consistent messages
 Facilitate patient self-management
 Training for all HCPs is key
 Opportunity within Lambeth and Southwark to
design and test a system for LTC which draws on
expertise of pharmacists
 Need to measure impact of approach on health
care outcomes/utilisation/satisfaction

35. ProfessorGraham Davies,
Institute of Pharmaceutical Science
King’sCollege London