The National Institute for Health and Care Excellence (NICE) has recommended that patients should be put at the “centre” of drug prescription decisions. The guidelines could have a big effect on how diabetes medication is prescribed.
Patient-centred approaches have benefits and drawbacks, advocates and critics. But how will it affect you?
What do the recommendations mean?
The guidelines call for greater doctor-patient interaction regarding prescriptions. All the options should be discussed so the patient feels comfortable. Data on each patient should be carefully collected and evaluated so that prescriptions can be tailored to the needs of the individual.
NICE identify key priorities in their report. They include:
- New systems to evaluate medicine: Essentially, this means establishing things like patient surveys and health record reviews.
- Sharing of relevant information between care settings when a patient moves: Contact details, allergies, details of medicine currently being taken etc. Between 30 and 70 per cent of patients have “an error or unintentional change to their medicines” when they move to a different care setting, according to the guidelines
- Medication reconciliation: “Medicines reconciliation (MR) is the process of obtaining an up to date and accurate medication list that has been compared to the most recently available information and has documented any discrepancies, changes deletions and additions”
Why has NICE made these recommendations?
It’s estimated that between 30 and 50 per cent of medicines prescribed for long-term conditions are not taken properly, according to the World Health Organisation (WHO). And, as more and more people have long-term illnesses, – about 15 million people in England now – the problem is getting worse.
Between 2003 and 2013 the average number of prescriptions per person grew: from 13 to 19.
NICE is recommending that the principles of patient-centred care be applied to prescriptions.
How would this affect people with diabetes?
But how might this affect you, specifically? Let’s take an example: if you have type 2 diabetes, there are several approaches to managing your blood glucose levels: dietary changes, doing more exercise, medication, or perhaps even insulin.
With a non-patient-centred approach, the decision would be made largely based on the broad facts of your case. Perhaps you’ve had type 2 diabetes for x number of years, and your blood glucose control hasn’t improved. Because of this, and based on no other information, you might be prescribed a certain kind of medication.
With a patient-centred approach, the doctor would have more detailed information about you. They could use this to evaluate your situation, and work out what you need. Then they would discuss the possibilities with you, making sure you’re aware of all the options and approaches that could be taken to get the best results for you.
Finally, you and your doctor would – at least in theory – reach a mutual agreement about the best way to treat your specific problems. And if this did mean medication, you would have a far better understanding of why this has been prescribed for you over other treatments. As a result, you’d be more inclined to take it properly.
What are the benefits of NICE’s new guidelines?
NICE’s new guidelines address the problem of improperly taken medication. Theoretically, the measures will improve the effectiveness of medication and the management of long-term illnesses. Patients will have a better understanding of their medication, because the options have been carefully discussed.
A patient-centred approach to prescriptions should mean that patients are happier, more conscientious about taking their medication, and generally more in control of their condition(s).
What’s not to like?
Critics suggest that patient-centred care is dangerously close to customer service, a situation in which the patient essentially decides their own treatment. But then “patients are not always right.”
Doctors, who are keen to differentiate between a “transactional relationship” and an “interactional relationship”, often echo this concern. Transactional relationships are about quickly satisfying a consumer with whatever it is they think they need. This is obviously not helpful.
So a patient with type 2 diabetes might be determined to take medication, rather than changing their diet or doing more exercise. At what point does the mutual discussion end, and the doctor make a decision not to prescribe the medication? Or does the doctor prescribe a possibly unnecessary medication?
Interactional relationships – the kind that doctors should aim to develop with their patients – require “time for narratives, the stories patients tell about their lives, that give their symptoms context and meaning. One meeting is rarely enough, especially when caring for patients with complex or long-term conditions.” Is this really feasible? Can the current infrastructure of the NHS handle this kind of in-depth interaction?
Some critics argue that the term itself is unclear: “no one knows that patient-centred care really is because there is no common definition.” But NICE’s guidelines have gone to great lengths to propose concrete changes rather than rhetoric.
So what to make of the new NICE guidelines?
The problem posed by prescribed medication to the NHS is apparent: the amount of improperly taken medication not only suggests that patients aren’t getting the treatment they need, but that NHS resources are being wasted.
The guidelines address some of the fundamental prescription problems facing the NHS, as well as fostering an environment in which patients are happier and healthier. But they have been criticised as being too idealistic. How to avoid “transactional relationships” in which patients become customers? How to find the time and resources to develop the kind of doctor-patient relationships that are needed?
What do you think of the proposed guidelines? Do they suggest a much better attitude? Or is this the wrong solution to the prescription problem?
