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Keywords:

  • adherence;
  • compliance;
  • concordance;
  • ethics;
  • health beliefs;
  • medicine management

Aims and objectives

To demonstrate that concordance can be operationalised to the benefit of patients. Concordance can be understood as a composite of knowledge, health beliefs and collaboration.

Background

In discussing any clinical decision, it would be ideal if different views could be incorporated to reach the most coherent decision. This is a definition of concordance, a widely agreed ideal in nursing. There are limits, however, that make the practice of concordance problematic. Sometimes there is little time or willingness to discuss issues in depth. Some views of the world are considered more worthy than others. As a consequence, clinical guidelines currently prioritise easier to measure outcomes of negotiation, such as adherence.

Design

This discursive article argues that prioritising adherence is a fundamental error, incoherent with current strategic rhetoric such as the Department of Health's ‘no decision about me without me’.

Methods

The impact of prioritising concordance is contrasted with adherence-based interventions.

Results

Where adherence is a goal of treatment, non-adherence is considered problematic. This value judgment is not useful and does not occur in a consultation that prioritises concordance. However, concordance is difficult to translate into clinical practice. This article shows that concordance can be operationalised by considering it a composite of health beliefs, knowledge and collaboration.

Conclusion

The main thesis is that different behaviours can always be incorporated into a concordance framework. This negates the necessity for adherence as an endpoint in itself.

Relevance to clinical practice

Fifty per cent of people do not take medicines as prescribed. Interventions focused towards improving adherence are only ever partially successful. This is because it presupposes the clinician is right. Concordance by contrast is more coherent with person centred care and thus more likely to generate clinically meaningful outcomes for patients.