How behavioural factors affect the response to medication

Behavioural factors influence the “the whole issue of how patients engage with treatment and the issue of adherence”, explains Professor Horne. “Our psychology influences how well a pharmacologically active treatment works for us, but also our beliefs influence whether or not we get side effects – and these are some recent findings from our group”, he continues.

“Patients don’t come to the encounter with the pharmacist …. as a blank sheet that we can write the instructions on;  they come with pre-existing ideas about the nature of their condition and about pharmaceuticals and whether that medicine is the best thing for them”, says Professor Horne. Understanding “what is in the patient’s head” and finding ways to discuss it can be critical for improving adherence.

Reviving the apothecary role and updating the remuneration model

Published evidence demonstrates the value of behavioural approaches. A case in point is the New Medicine Service (NMS) that was inspired by a study showing how a brief phone call from the pharmacist, designed to address belief barriers and practical difficulties, led to a significant Improvement in adherence.

However, Professor Horne believes that community pharmacists could be  embracing a wider role to support the safe and effective use of medicines. They could also play a bigger role a bigger role in prevention of ill health, he says.

“We need to have a remuneration model that is fit for a 21st century public need and a 21st century pharmacy capability.  I think I’m probably talking more in the realm of the ‘apothecary role’ than the pharmacist as a person who is limited to safe supply [of medicines]”, he explains. “Just funding pharmacy on the basis of safe supply is, in my view, a missed opportunity for governments and society”, he adds.

Computer-assisted triage to improve consultations

Some additional training may be required to enable community pharmacists to use behavioural approaches to improve outcomes for patients and a computerised triage tool could help to make consultations more efficient.

“We’ve developed digital tools that can triage patients by identifying concerns and doubts about treatment, addressing them not in a way that replaces the pharmacist but can prepare the patient for a discussion with the pharmacist ….. so that the pharmacy interaction becomes more efficient”, Professor Horne explains.

The use of such tools breaks down one of the barriers to constructive discussion between clinician and patient.

Reflecting on his work, Professor Horne says, “I believe that pharmacy is really, really underutilised all across the world – there’s much more that we can do”.

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In order to incorporate behavioural approaches to patient consultations community pharmacists might need some additional support and training although, as Professor Horne points out some undergraduate courses include “a substantial input on behavioural medicine”. Some post-graduate training might also be needed for pharmacists who have been in practice for longer, he acknowledges. Partnerships with the pharmaceutical industry might be one way to deliver such training. There is a growing recognition of the underdeveloped role of community pharmacy and innovative partnerships could be established to bring behavioural medicine training to community pharmacists, he suggests.

Digital triage tool

Another approach is through the use of technology. “In my own group we’ve developed digital tools that can triage patients by identifying concerns and doubts about treatment, addressing them not in a way that replaces the pharmacist but can prepare the patient for a discussion with the pharmacist and cover some of the ‘low-hanging fruit’ so that the pharmacy interaction becomes more efficient”, he explains.

The triage tool that has been developed is called Persignia and is based on a questionnaire. “We’ve demonstrated it works to address beliefs and improve adherence in a proof-of-principle study in inflammatory bowel disease and we’re developing it further through our spin-off company with UCL Business. It’s really quite simple – it’s based on my 20 odd years-worth of research in this area. So, it profiles people, it asks them some simple questions based on validated tools that identifies their perspective on the medicine. It identifies any doubts or misunderstandings that they have about the necessity for the medicine and it identifies common concerns and practical barriers. Then, based on what they select as their particular doubts or concerns it gives them a …. brief story to address that concern or that doubt.  What we find is that it can help people develop a more positive attitude towards their treatment, overcome concerns which would have been hidden and act as a barrier to them taking the treatment and align them with the treatment. Now, that doesn’t replace what the clinician does – it’s not meant to do that – but it can be a preparation.” Given that consultations are always short – perhaps as little as five minutes – this can be a useful foundation for discussion.

Professor Horne explains: “It breaks the barrier …. that many patients have to discussing concerns about their treatment with a pharmacist or doctor because of that thing I mentioned earlier where they have two [conflicting] ideas at the same time – ‘I like and trust the clinician but I don’t like and trust the treatment – but I can’t tell the clinician that I don’t like and trust the treatment because they might interpret that as a lack of trust in them and I don’t want to compromise that relationship’. So it can break down that initial barrier that makes adherence and patient’s concerns about treatment often something that’s hidden in the consultation”

“I think this is the area that we need to move more into and I believe that pharmacy is really, really underutilised all across the world – there’s much more that we can do”, he concludes.

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A number of studies have demonstrated the value of applying insights from psychology and behavioural medicine to pharmacists’ day-to-day practice.  More than 10 years ago Professor Nick Barber from the School of Pharmacy (at UCL) and a team from Nottingham University led one of the landmark studies.  More recently, a group in Belfast, led by Professor James McElnay, showed that it was also possible to apply these approaches “with significant improvements in patient adherence but also in other outcomes such as reduced readmission to hospital”, says Professor Horne.

In order to tailor the response appropriately the pharmacist needs to know what doubts and concerns a patient has about their medication. Professor Horne recommends an approach that can give the patient the opportunity to ask questions and air concerns in a low-key, conversational way.  When handing out dispensed items, instead of asking, ‘Have you had this before?’ he advocates a different approach. “I would suggest a very simple alternative to that which is first of all to say, ‘Hello, I’m your pharmacist. I’m looking after your medicines. Can I ask if you have any questions or concerns about this medicine?’. What I found in my practice, and in the research studies we’ve done, is if you just say that to people, they will often tell you what is on their mind.” Most people will say they are fine but, often, when the person does have concern, they will say so.

Professor Horne continues: “Now there are lots of other initiatives that I think one could develop for community pharmacy which would encourage the public to see [that] the type of support that they can get from the Community Pharmacy is maybe a lot more than they might expect.”

The next question that arises is whether it is realistic for community pharmacists to work in this way within the framework of the current business model. Professor Horne addresses this in two parts. First, he considers the evidence for effective services, noting that the New Medicine Service (NMS) is a good example of a service based on evidence.

He says: “You only need to look at the New Medicine Service in the UK as an example that was based on an earlier study that we did,  applying these approaches, at the School of Pharmacy led by [Professor] Nick Barber. What we did was to apply the idea of understanding the patient’s beliefs as well as their capabilities.  …… Then, in a brief phone call from the pharmacist, typically about 10 minutes, we were able to address those belief barriers and practical difficulties in a way that led to a significant Improvement in adherence – engagement with the treatment. That was a ‘proof of principle’ study that showed that you can apply behavioural interventions through a pharmacy channel; it was the inspiration for the New Medicine Service.”

Most health economies today are facing a situation in which there is a shortage of access to doctors, a need for more preventative care and better self-management of conditions within the community. “I believe that pharmacists could have a much greater role in this – they are well-trained scientifically, they’re accessible and there’s lots of them and I think it’s amazing how little we use pharmacies. If you look, for example, at musculoskeletal pain control and the huge societal impact of that, I believe that pharmacists could be more involved and, using the tools that they have at their disposal on the ‘P’ (pharmacy only) medicine shelves, could probably do a lot more to support pain control. That includes not just the medicines but other psychological tools and techniques that you should be able to access in your pharmacy”, he says.

Out-dated remuneration model

The second part of the answer involves taking a wider perspective.  If community pharmacists are to embrace a wider role, then this has further implications for the business model. Professor Horne says: “It really seems to me that we have a rather old-fashioned and, dare I say, outdated, way of remunerating pharmacy through the NHS which is based on the volume of prescriptions. That, I have to say, is so ‘last century’. It’s almost beyond the last century and it emphasizes a role of the pharmacist which is about the safe supply of medicines”.  Focussing on safe supply in this way is important but much of this could be automated in the near future, he argues. More seriously, “it fails to recognize the huge contribution that pharmacists can make in how medicines are actually used by patients”, he says. In addition, community pharmacist could be taking a bigger role in prevention of ill health.

“We need to have a remuneration model that is fit for a 21st century public need and a 21st century pharmacy capability.  I think I’m probably talking more in the realm of the ‘apothecary role’ than the pharmacist as a person who is limited to safe supply [of medicines]. As soon as we say ‘safe supply’, it implies a clinical role – they have to engage with clinicians, [asking] ‘Is this the right prescription?’ and they have to engage with patients [asking] ‘Are they able to take the treatment the best effect?’ – so the apothecary role is, in a way, an extension of safe supply but it goes wider. Just funding pharmacy on the basis of safe supply is, in my view, a missed opportunity for governments and society”, he concludes.

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Professor Horne originally trained as a pharmacist and practised as a hospital pharmacist for 10 years before embarking on PhD studies (into the psychology of medicines and understanding patient perspectives of treatment) supported by a Department of Health Pharmacy Enterprise scheme.  His research in this field has continued and he now leads a research group that is looking at the psychological and social factors that determine the outcomes of treatment. His teaching – on the M. Pharm course and post-graduate courses – is about understanding “behaviour as it relates to pharmaceuticals and [using] that understanding to improve the quality of care and support that we give to patients”, he says.

Why HCPs need to know about behavioural science/approaches

Behavioural factors are important for the effective use of medicines because they influence the “the whole issue of how patients engage with treatment and the issue of adherence”, explains Professor Horne. The other important area where psychological factors come into play is in determining the direct effects of a medicine. This is related to phenomena such as the placebo effect, where a physiological response is achieved using a substance that has no pharmacologically active ingredients, and the ‘nocebo’ effect, where patients experience side effects from placebo.

Professor Horne explains: “The element that we’re researching is how these non-specific effects – the psychological aspect of the treatment – are also relevant for active drugs. So, our psychology influences how well a pharmacologically active treatment works for us, but also our beliefs influence whether or not we get side effects – and these are some recent findings from our group. In summary, there are two effects, one is what we do – our behaviour – and the other is a direct effect of our psychology on physiological responses and treatment outcomes.”

Understanding of these factors can be used to help patients to get the best from their medicines. Many patients do not take prescribed treatment and that is particularly relevant for community pharmacy, says Professor Horne.  In fact, WHO estimates that half of medicines prescribed for long-term conditions are not taken as directed.  “From our research we can see that there are two main reasons why people don’t take medicines – they can’t or they don’t want to – it’s a lack of ability but also for many people a lack of motivation”, he says.

Some people want to take their medicines but they can’t because of barriers beyond their control; this could be because they are forgetful, they haven’t understood, they are unable to access the medicines, the medicines are too complicated to use or they simply cannot afford the medicines. “Pharmacy is traditionally very good at helping patients by making taking the medicines as simple and as easy as possible -and those things are very valuable, but the thing that’s often neglected is the ‘don’t want to’ [group]”, he says.

Professor Horne explains: “We know from our research that many patients ….. don’t come to the encounter with the pharmacist or the medicine as a blank sheet that we can write the instructions on;  they come with pre-existing ideas about the nature of their condition and about pharmaceuticals and whether that medicine is the best thing for them. The problem is those beliefs are often hidden because we don’t ask about them and patients are reluctant to tell us that they have a doubt [about] the treatment …. or that they’re not taking it, because they think that will offend the healthcare practitioner. So, what we’ve shown is that by having a better understanding of what the patient brings to the encounter with a medicine….. can be used to explain in a different way that overcomes doubts about whether they need it.” The doubts and concerns that a patient could have include whether the drug is still needed and fear of long-term side effects. “Once we understand what is in the patient’s head, if you like, what they’re thinking about the medicine, we can address misplaced concerns or doubts that are based on the mistaken understandings of the condition or the treatment”, he says.

Read and watch the full series on our website or on YouTube.