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Compliance, concordance and respect for the patient's agenda

By Paul Bissell

This article is based on findings from my doctoral thesis, which set out to explore lay and professional perspectives on compliance with treatment, focusing specifically on people of Pakistani origin with a diagnosis of type 2 diabetes. One of the aims of my thesis was to explore how patients and professionals conceptualised decisions to comply, or not to comply, with the treatment of diabetes.1 I also wanted to assess the role lay health beliefs (or what is more appropriately referred to as lay knowledge2) played in shaping decisions to comply. As a medical sociologist, I had been influenced by a body of social science research which questioned the paternalistic and authoritarian assumptions of the compliance model3,4 and I saw the report of the Concordance Working Party, which called for a sea-change in the culture of both prescribing and relating to patients, as taking this critique into health policy. The Working Party argues that “concordance is based on the notion that the work of the prescriber and patient in the consultation is a negotiation between equals and the aim is therefore a therapeutic alliance between them. . . . Its strength lies in a new assumption of respect for the patient’s agenda and the creation of openness in the relationship, so that both doctor and patient together can proceed on the basis of reality and not of misunderstanding, distrust and concealment.”5

It continues: “. . . the most salient and prevalent influences on medication taking are the beliefs that people hold about their medication and about medicines in general. These beliefs are often at variance with the best evidence from medical science.”

Given the political salience of this report, I modified the aims of my thesis to include an exploration of the idea of concordance (or health care relationships more generally) with the groups I was studying. What I want to do here is to describe in some detail the experiences of one lay person in order to highlight some pervasive problems with relationships between patients and professionals. In particular, I want to explore what “respect for the patient’s agenda” (explicitly referred to in the definition of concordance) means for relationships between patients and professionals.

I use here an extended case study design focusing on the experiences of one respondent. Mrs D was one of 21 English speaking people of Pakistani origin diagnosed with type 2 diabetes whom I interviewed and subsequently reinterviewed for my doctoral thesis. Mrs D and the other lay respondents were recruited from both primary and secondary care diabetes centres based in northwest England. A detailed account of how I recruited respondents and analysed the resultant data can be found elsewhere.1,6

Mrs D’s account

Although born in Karachi, Mrs D had lived in north-west England for most of her life. In her early 40s, she was married with four children and also took responsibility for the care of her elderly mother. Although her husband had experienced periods of unemployment, he was currently employed in a local factory.

When I first interviewed her, Mrs D had been diagnosed with diabetes for about six years and indicated that her treatment consisted of a combination of medication (metformin 850mg) alongside compliance with the diabetic diet and regular exercise. Her formal health care was organised between her general practitioner and a hospital. Mrs D had also been diagnosed with arthritis, hypertension and migraine headaches and also had a very high body mass index.

Download the attached PDF to read the full article.

Citation: The Pharmaceutical Journal URI: 10985923

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