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Medicines - Can’t take, Won’t take - Unlocking the reasons

Blogger . 18/02/2011 14:49:50
By Dr Joseph Bush, Lecturer in Pharmacy Practice, School of Life & Health Sciences

You could be forgiven for thinking that adherence – or more specifically non-adherence – to prescribed medication regimes is a relatively minor problem for the NHS.  However, non-adherence is a huge problem in all healthcare systems.  According to the World Health Organisation (WHO), in developed countries, adherence to long-term therapies in the general population is around 50% and is even lower in developing countries.  In England, between one-third and a half of all medicines prescribed for long-term conditions are not taken as recommended.  Estimates for the cost of unused or unwanted medicines in the NHS vary from £100 million to £300 million annually.  The economic costs are not limited to wasted medicines.   Non-adherence has the potential to limit the benefit of prescribed medicines.  A lack of improvement or deterioration in health has a direct impact on the NHS, with increased demand on GP surgeries and hospitals, all at an additional cost.

What makes figures such as those quoted above seem so shocking is that it seems a quite stunningly simple process to take a medicine properly – medication is prescribed; the patient is informed how to take their medicines; the patient obtains their prescription at a pharmacy; the pharmacist informs the patient how to take their medicines; ultimately the patient takes their medicines as instructed; [hopefully] the patient’s health improves as a result of taking medicines as instructed.  It would appear counter-intuitive for an individual not to take a medicine as instructed – why would a patient not take a medicine as prescribed?  Surely a patient who didn’t adhere to a prescribed medication regime could be considered be stupid, reckless or both.  To use Ben Goldacre’s Bad Science maxim “I think you’ll find it’s a bit more complicated than that”.

First of all in the scenario described above there is an assumption that the patient is a passive recipient of medical ‘wisdom’ and that it would be remiss of them not to heed said advice.  This is however, a spectacular over-simplification of what is at times a complex process.  The factors that can affect adherence to medicine regimes are myriad and diverse.  They straddle psychology, sociology, physiology, economics, pharmacology and logistics (and I make no claims that this list is exhaustive).

Obvious examples of factors which make adherence problematic include an inability to obtain the medicine in the first instance (through supply chain problems or an inability to pay for the medication for example), an inability to swallow solid dosage forms (this can be a particular problem in patients whose condition(s) leads to swallowing difficulties), unpleasant side effects of a medication and simply forgetting to take a dose.  There are however much more subtle forces at play that can determine whether an individual takes their medicines as prescribed or not.  For example, there are suggestions that some diabetic patients of South Asian origin may reduce the prescribed dose of medication that they ingest as they believe that medicines supplied via the NHS are more efficacious than those available in their countries of origin.  What is logical to one may seem preposterous to another.

It is into this maelstrom that the Aston Medication Adherence Study (AMAS) Team must throw itself (sounds overly dramatic – it’s not like we’re going to be climbing the north face of the Eiger or anything!).  First up is an assessment of levels of non-adherence amongst our study population.  This data will be analysed alongside relevant clinical markers (such as blood glucose or cholesterol levels) and patient self-reports in an attempt to devise a systematic approach to identifying non-adherence in vulnerable groups at the earliest possible opportunity.  While this itself is important, we also need to examine why our population do not always take their medicines.  This presents a tremendous opportunity to explore these factors amongst an atypical UK cohort – a hugely diverse population drawn from areas of significant socioeconomic deprivation.  It is only by understanding why people do not adhere that we can make constructive efforts to tackle medication non-adherence.  Improving levels of adherence will not only benefit patients but also wider society via decreased expenditure on costs related to non-adherence – highly pertinent amid the Government’s drive to deliver £20 billion of NHS ‘efficiency savings’ by 2014.

For more information check-out the Aston Medication Adherence Study (AMAS).

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Can the new Local Enterprise Partnerships (LEPs) deliver economic growth?

Blogger . 05/11/2010 15:29:34
By Graham Pearce, former Professor of Public Policy and Management, Aston Business School

The task of boosting economic growth and tackling regional inequalities could be undermined by plans in the Coalition Government’s Regional Growth White Paper to transfer powers to sub-regional consortia of councils and businesses working through Local Economic Partnerships (LEPs).

There are considerable uncertainties and potential risks, I believe, arising from the current reshaping of responsibilities for securing sustainable economic development at the sub-national level. My conclusion, in a nutshell is this, below. And I invite you, the reader, to give your comment in a bid to gauge, as a region, our collective reaction:

• LEPs will replace England’s nine Regional Development Agencies (RDAs) but collectively will have far smaller budgets. The scale of resources available to RDAs has not been sufficient of itself to make a significant impact on regional economic disparities and without political clout and some financial incentive LEPs could prove ineffective.

• The loss of RDA funds will be felt most keenly in Northern and Midland regions and, despite reassurances that resources for economic development will be distributed in favour of the less prosperous regions; reductions in public expenditure will exacerbate the longstanding economic disparities between the Greater South East and the rest of the country.

• The Government expects LEPs to tackle a range of policy issues that contribute to creating the right environment for business and economic growth. But the task of effective partnership working requires a considerable investment of time and energy. Moreover, the new Partnerships will be reliant on multiple funding streams administered by a plethora of government bodies, whose own budgets are threatened. Their room for manoeuvre will be severely restricted.

• LEP boundaries should reflect socio-economic realities, rather than administrative units. Nonetheless, the willingness of authorities to put aside local interests and provide a collective voice on issues that have a strategic dimension cannot be assumed. As the current bargaining around LEPs has revealed, parochialism remains a potent ingredient and rather than ‘natural’ economic areas LEPs are being defined according to arbitrary administrative boundaries. There is also the risk of unproductive ‘place marketing’ between LEPs to attract mobile investment and jobs.

• There is an underlying assumption that the key groups representing business are both willing and able to engage in LEPs - factors that are highly variable across business organisations and geographical areas. As volunteers, business partners do not want to be part of bureaucratic ‘talking shops’. Nonetheless, granting business interests an equal status with local authorities in LEPs may lead to undue prominence being given to economic considerations and may be incompatible with local authorities’ remit to deliver sustainable development in a public and accountable setting. As such they are likely to replicate the weaknesses of legitimacy associated with the RDAs and unelected regional assemblies.

• LEPs are expected to provide strategic leadership for the coordination and integration of sub-national spatial and investment priorities, where certainty is vital for both private and public sectors. There is virtue in seeking to coordinate such policies to maximise the effectiveness of public and private expenditure but this will depend upon authorities and their business partners demonstrating a capacity to enter into collaborative and long-lasting commitments, with the risk of significant geographical variations. Furthermore, the need for statutory planning across sub-regions is not currently recognised.

• The legacy of economic development knowledge and expertise in the regions, I think, should not be dissipated. Indeed, because there are economic opportunities and challenges that cannot easily be dealt with either nationally or locally, there remains a compelling case for establishing region-wide partnerships of local authorities, business leaders and other key partners to deal with strategic economic issues.
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A positive message in difficult times

Blogger . 29/09/2010 10:49:03

By Dr Pat Tissington, Associate Dean Business Partnerships, Aston Business School

Having taken a short break from blogging, I'm returning to the fray with what I hope is an upbeat message - despite the frankly awful prospects of government announcements in October. So, to the awful bit first. I get the impression from the various polling and public opinion sampling that the general mood in the country is not completely opposed to government spending cuts on principle. But there does seem to be opposition when people are asked what they think about reductions in the services they personally get from government. Perhaps the whole thing is too abstract at the moment but it is going to become only too real come October when the announcements are due. Psychologically this seems to be a case of self interest with people being fine about pain so long as it involves other people but less enthusiastic when it affects us personally. Or maybe it has more to do with not yet knowing what the impact is going to be. It is some sort of economic phoney war currently which is likely to have it's Dunkirk moment soon.

Those of us involved in the running of organisations will have experienced this sort of thing before. In order to get change moving, you must gain some general agreement that change is necessary. A popular way of doing this is the presentation of a "burning platform" - alerting people to an imminent crisis. In a recent talk at Aston Business School, Justin King who has performed a remarkable turnaround as CEO of Sainsburys, preferred to say this was making people acknowledge the reality of the situation. The reasoning is the same though - people are naturally resistant to change unless and until they realise there is no alternative; whereupon they can adopt it enthusiastically. It is perhaps the other side of the personal survival instinct we see in current attitudes to spending cuts. If staff become convinced that the survival of the organisation (and therefore their jobs) is dependant on change, the job of change management becomes straightforward. If they feel the opposite (i.e changes proposed wick jeopardise jobs), heels will dig in and creative effort will be devoted to resistance rather than innovating.

So, where does my optimism come from? I recently met a group of senior public sector managers in a Work Foundation event. I was astonished at how upbeat they were about the future. Initially I thought they must be mad bearing in mind some were heading up departments which were planning for a 40% funding cut. But after a while it dawned on me that in fact they were relishing the challenge and with good reason. One told me "Actually I prefer a large cut. If you were told to cut by 5% or even 10%, I would be expected to deliver the same service. But when this becomes 25 or 30%, no sane person expects the same service level. What me and my management team have to do is work out what will continue to deliver and what to stop. We need to work out how to do this and make sure we take our stakeholders with us. It's difficult yes - but also very interesting." So, it is being regarded as an opportunity for serious thinking about what organisations are for, what their stakeholders want/need and of course a way of providing challenge for staff. I have found similar relish for the fight across the pubic sector.

Privately many senior managers have also been energised by the rash of early retirements since many who are burned out have decided they have no stomach for the fight and allowed new blood to take over. So, perhaps the Great Government Cuts of 2010 will be remembered as the time when a new dynamism came to public services.

To be fair, it is going to be pretty dreadful as well.

This post first appeared on Dr Pat Tissington's blog for the Birmingham Post on 23 September 2010

To read further blogs please visit the Birmingham Post's Business Blog

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Is public service interpreting the difference between life or death?

Blogger . 08/07/2010 14:46:09

By Elaena Wells, School of Languages & Social Sciences

We have a lot of asylum seekers and immigrants in the UK. We often think that they should all be able to speak English, or start learning the language, but why should tax payers’ money pay for them to have an interpreter? Because if an asylum seeker has a medical or legal problem, and they can’t communicate properly, this could put them at risk.

Public service/community interpreters play a vital and under-appreciated role in helping with an individual’s basic human right to medical or legal assistance. But it still happens all too frequently that family members perform interpreting in medical and legal settings instead of qualified interpreters. This can cause problems and even danger. A recent case, for example, highlighted that a victim of domestic abuse needed to explain her injuries and how they came about, but the perpetrator of the abuse was acting as her interpreter.

This and other issues in interpreting will be explored at the international Critical Link conference later this month, which is happening for the first time ever in the UK. Organised by the School of Languages & Social Sciences at Aston University and taking place between 26-30 July, this major event will bring together representatives from around the world, with delegates from 37 countries already attending.

Professor Christina Schaeffner, from the School of Languages & Social Sciences, explains:

‘This event is of world-wide importance and will provide a forum for researchers, trainers, and practitioners. We hope that it will provide a unique link between Aston University’s research in this area and wider professional practice and academic research. As such, we are inviting public service employees such as health professionals to attend this conference. We are particularly keen on having service providers, service recipients and policy makers at the conference. There is not enough training provision in the UK, let alone government support for training courses. The conference will therefore have a significant role to play in raising awareness of some of the key issues around community interpreting.’

It is time to stand up for the rights of immigrants and asylum seekers to communication services in these difficult financial times and forthcoming public service cuts.

If you would like to attend the Critical Link conference please visit the conference's webpages.

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