Firstly, we looked at the perceived need for further support for these patients in terms of improving knowledge and rectifying errors or poor adherence. We also discussed perceptions around existing services and their ability to support these patients.
The need for support in medication adherence
Using the information collected on patient knowledge and adherence to their prescribed medication, we explored the need for further support for these patients. Patient understanding of their medication was mixed, with patients demonstrating some broad knowledge about their medications, for example, the anti-angina medicine nicorandil was described as “for the heart” (P5) when it would have been more accurate to state that it was for treatment of angina. However, 11 out of the 15 patients did not know what at least one of their medications was for. Two patients used a community monitored dosage system (dosette) both of whom reported not knowing what the majority of their medication was for. Two patients had misunderstood what at least one of their medications was for (for example, the cholesterol-lowering medicine atorvastatin described as a “blood thinner” P4).
Nearly all patients reported good adherence to their medication, but when asked for specific details about how and when they took each medicine, discrepancies were noted. Three patients were not taking their medicines as described on the prescription labels, with a total of 5 medications being taken incorrectly. For example patient P10 had been prescribed the diabetic medicine metformin ‘1 tablet 3 times a day’ but was actually taking 1 tablet at breakfast and 1 at night. Four patients were choosing not to take some of their medications, or taking it sporadically (without informing their GP) and still collecting it on repeat prescription (P2 was being prescribed the nutritional supplement Adcal D3™ and the painkiller tramadol but had not taken them for the last 3 years). Only 3 of the 15 patients admitted to forgetting to take their medications, but during the interview nearly all patients recalled incidents where they had forgotten to take some doses and having to take it at a later time when they remembered. In summary, the majority of wrong medicine taking was unintentional with only 4/15 patients reporting intentional non-adherence that had not been discussed with either a GP or pharmacist.
The interviews explored GP and pharmacist perceptions on how well patients manage their medication regimens. Most practitioners felt that some patients experienced difficulties with medication management. It was also felt by most that this would therefore impact on adherence:
Not as many people as I’d like to, understand why they should take what they take, so I’d say more than half don’t. And, I think the fact that they don’t then does make a big difference to their adherence. GP1
I’m well aware that it’s not as clear as you would sort of assume and there is quite a lot of misinterpretation around dosing schedules and other things that they have. Again, I’d have said probably half of those patients won’t take it correctly, if not more. Ph1
The Universal Medication Schedule (UMS)
To explore views on the UMS, patients and practitioners were given an example chart (Table 2). The interviews explored views on: usefulness/usability, how it might be delivered and feasibility of implementing it in the UK care system.
Attitudes towards UMS
Practitioners generally expressed positive views about the UMS, with all GPs and most pharmacists thinking that it could be of benefit to particular patients:
I think the ‘what it’s for’ is a really good idea. Because I’m forever sending out patients, with their repeat prescriptions, and I’ll write on what they’re all for. GP2
Three of the pharmacists did not feel that the chart would add much to current practice. However, these views may have been affected by their perceptions around the services they provided themselves:
I don’t think it’s going to be of massive benefit in terms of that chart there where it’s all laid out, there are some sort of poorly educated patients, and I don’t think it would necessarily help all them. I think looking at that could be a bit over-facing actually. Ph1
Patients also had mixed views on how beneficial the UMS might be for them. When asked if they thought it would be useful for them, on the whole patients liked the simplicity of the chart - preferring having all the information to hand when taking their medications:
It’s short and sweet and you don’t have to sit and read through all that [PILs], because I don’t know people that read it anyway P1
Yeah, it would be, because that way I could just pin it…well, tape it in the cupboard and as I open the cupboard I can see it as I’m doing my tablets as well P10
Patients often felt that they understood and managed their medicines well and therefore did not need further support such as that provided by the UMS chart:
I know what’s in the box and I know what it’s for. Well, the information’s there so I know what it’s for, like, you know…I don’t think it would be any more helpful than what I’ve got already, to be honest with you. P7
However, as described earlier many patients, even those who thought they managed their medicines well, were not taking them exactly as prescribed and were unclear on what their medicines were for.
How it could help
The ‘Special Information’ column providing details on what medications are for and any further instructions was thought to be particularly helpful for patients:
I think what’s helpful is so they know what they’re taking these tablets for. So that last column is very helpful. Very helpful indeed, because not only would it tell them when to take them, but it would tell them why they do need to take it. GP4
The majority of GPs thought that improved health literacy would facilitate discussions with patients about their medications and therefore help patients make informed decsions:
These special instructions, or what it’s for, that’s the bit that really matters, because once they know what it’s for, then they can start to challenge and question, and say, “well actually you’ve given me this, and you say it’s for my cholesterol, but I thought my cholesterol was alright doctor?” GP3
However, this seemed to raise an issue for some GPs who expressed that improved understanding might not always be beneficial to adherence:
There’s one danger though, and I think this probably refers again to my specific community here, some patients may take the decision as to whether they want to take a medication or not into their own hands, because they know that this is for blood pressure, they may say, well, today I feel really well, I’ve checked my blood pressure on my home machine today and it was normal, so I probably don’t need that tablet. GP8
Although this view was only expressed by a couple of GPs this may have implications for delivery of the UMS.
Practitioners also identified that the UMS could be a useful tool for communicating between settings so between general practice, pharmacy, hospital and the patient, with everyone having access to the same information. One pharmacist who also worked in a hospital pharmacy stated that:
With my hospital hat on it’s really useful to have a list of all the medication the patient is on in case they get admitted and they can take it with them. Because when we used to do the medicines reconciliation it was a nightmare, they’d come in with bags and bits and drabs and stuff and you wouldn’t know what they were on. Ph1
GPs also thought that consistency throughout the service was a key issue for patient care:
This will allow consistency of message from us as well as from the pharmacist, and I think it’s the consistency that’s probably more important than anything else. GP3
Patients thought that the UMS would be of use but were less clear in how it would help them. Unlike the practitioners interviewed, who did not identify that they thought it would reduce errors, some patients thought that it would help them prevent errors:
Oh that would be a good idea that…Because I get that mixed up sometimes, you know, and I think, oh God, and then I look through the tablets and think, oh, I’ve got two of them, oh, I’ve got three of them, so the one that I’ve put extra I throw away! P10
Some patients thought that the UMS alone would not be sufficient to help them because it doesn’t act as a reminder to take the medication or provide any visual evidence (such as an empty container) that they have taken their medications that day. However, it was suggested that if used in conjunction with a self-filled dosette box, it may improve adherence to medicines. One patient who raised this used her own self-filled dosette box to illustrate:
But, as I say, just something in print isn’t as good as the physical thing of having the tablets there [in a dosette tray] P9
Delivering the UMS
When asked who they thought should deliver the UMS to the patient, there was evidence of role conflict. The majority of GPs thought that in terms of time and practicalities, it would be best delivered in pharmacies. Conversely some pharmacists thought the chart would be best delivered by the GP.
However, most GPs and pharmacists stated that it would have more impact if delivered by multiple sources:
So hit it home at discharge [from hospital] and then the GP can do that but so can the pharmacist, we can all sing off the same message but at different points of the process, and if somebody’s missed at one there’s a likelihood to be caught in the net later on. Ph4
Suggestions were made as to how the UMS chart could be best implemented. There are a number of GP and pharmacy services already in place in the UK (See Additional file 3- The Community Pharmacy Contractual Framework (CPCF)), with the aim of improving knowledge and supporting medicines adherence in patients. However, these were not always well perceived. Integrating the UMS into the existing services to provide enhanced support seemed to be logical, and suggestions were made for linking it to a number of these services:
In general practice, consultation time and medicines reviews are the main vehicle to support medication use in patients, but limitations with this system were acknowledged:
Because they often…they’ll have some [medications] and then get more added and more added and it’s…you might tell them what the new one is but then it’s reminding them again of what the older ones were and it can get…I’m sure it gets very complicated. GP5
Some GPs suggested that a tool which can automatically add new medicines on to an existing chart could help support this process:
So, what would be nice, is that something like this [UMS] sits allied to the GP prescribing element, it recognises everything that’s on repeat prescription, you press a button, and out it comes. GP3
Medicine Use Reviews (MUR)
MURs are an incentivised scheme delivered by pharmacists. Time pressures and targets to complete the maximum number of reviews per year (400) were perceived to have a negative impact on the value of MURs and on targeting the right patients. As a result of this, most GPs stated that they saw little value to MURs and that they viewed them as ‘tick box’ schemes that rarely raised important issues:
I think the Medicines Use Reviews were entirely without purpose and benefit and should have been not done, and we in fact didn’t even read the stuff the pharmacist sent us we used to throw it straight in the bin. GP1
Patients who had been offered a MUR were generally positive about the service although only 4 had actually taken part in a review. It was thought by most practitioners that this would be a good place to introduce the UMS as it would allow time for discussion. However, issues around targeting and the small numbers of patients receiving these services would remain.
I think talking through it would be quite a good process, it is quite a good lead into an MUR, to be quite honest with you, or a medication review with the doctor…I wouldn’t just have it as a bag stuffer, I think people sometimes ignore the things that are just stuffed in the bag. Ph4
Monitored Dosage System (dosettes)
The dosette system provides selected patients with their medications already divided into daily, timed doses. GPs and pharmacists reported both benefits and problems associated with using the MDS/dosette system. Two patients in the sample were currently using the MDS system and both had very poor knowledge of their medications. However, they both felt that it had improved their adherence to some degree:
I tended to take them all at once rather than splitting it up. And it’s only because they’ve been split up on this system [dosette] that I started following that, to some extent, P3
Dosette boxes do have a list of the medicines included but would not usually indicate what health conditions the medicines are for. It was also commented on that this information was not presented well and would be difficult for some patients to read. The potential for including the chart in the dosette tray was suggested:
Well, very often with the [dosette] pack, you know, when you lift the lid it has that written inside, doesn’t it? I must say it’s not very well presented in some of them. It’s like it’s come off a computer from the 80’s or something, but at least it’s there. You could upgrade that. GP7
Again the majority commented that introducing the UMS throughout the system from secondary care to primary care creating more consistency and improving patient care would be the most efficient use of the chart:
What we want, and I think what’s really important for patients, is that if you have the same system all the way through, because that’s where confusion comes in otherwise, you know, different formats? So, it would be really nice, because we’re always talking about integrated care these days, and lack of fragmentation of care, and having a consistent message. Well, this is one of those examples. It should be adopted right the way through. GP3
Feasibility of implementing UMS
All practitioners thought that the chart would have to be linked into existing computer packages and to be self-populating, otherwise it would place too much strain on GP or pharmacist time:
Otherwise it won’t get done, you know, there just isn’t time in consultation to be producing something like this. So it needs to be, sort of, effortless to produce. But you could have a C side [to a prescription form] which you’d produce…you know, you’ve got your B side on your prescription, and you have a C side which are printed out like this, yeah GP6
Most practitioners agreed that the paper format was the most practical with the current population. However, issues around keeping the document up-to-date and ensuring a patient is using the correct version are a consequence of using hard copies which become historic soon after printing:
But they like paper, and the other thing about paper is that if there’s any question about it, they can pick it up, they can take it to the hospital with them, they can show it to their relatives. So, I think paper is the way forward. But, I guess my concern about paper is, is it always up to date? GP2
Another possible limitation of using hard copies is that if a patient had only one copy it is unlikely they would have it with them all of the time:
Even if you don’t lose your bit of paper, it might be upstairs when you’re downstairs, and it could be time for your medication, so it’s not going to be with you all the time is it? GP3
Thinking about feasibility of delivering the UMS chart in the future, many practitioners thought that it may need to move to a digital format. The point was also made that as the population ages more people will be used to electronic devices to support their health care:
I think as people who are like my age, you’re not going to stop using your smart phone and your computer just because you get to 65. The current generation of 65 to 75 year olds probably don’t use computers much although I do come across patients that do. In the future, if you’re going to plan something for the future, then there must be scope. Ph6