This is a global problem; in the US, a 2023 report from the American Medical Association stated that, ‘every year in the US, there are about 125,000 deaths that could have been prevented if patients had been taking their medications correctly.’

The same report notes that medication non-adherence leads to between $100 and $300 billion in avoidable healthcare costs annually.

A 2013 study in Prescriber found that non-adherence costs the NHS in England more than £930 million per annum across five disease types – asthma (£130 million), type 2 diabetes (£100 million), high cholesterol/coronary heart disease (£120 million), hypertension (£390 million) and schizophrenia (£190 million).

Medicines are the second biggest spend for the NHS; £17.4 billion a year, or one in every seven pounds.

The 2003 World Health Organization report on adherence estimated that patients do not take between 30 and 50 per cent of medicines prescribed for long-term conditions. However, the report noted that, ‘no methodological gold standard exists to measure the range of non-adherent behaviours.’

According to Statista, community pharmacies dispensed over a billion prescribed items in England in 2023-24, an average of 20 items for every person.

So, we are taking the horse to water, but seemingly unable to make it drink. Non-adherence burdens health systems with increased ill health, medicines waste, hospitalisation and emergency admissions.

Non-adherence is particularly dangerous when medicines must be taken at specified times. Yet, even in hospitals, time critical medication (TCM) is not always administered on time, sometimes with fatal consequences.

In December last year, a report by the Health Services Safety Investigations Body found that a patient in a hospital emergency department should have received 18 doses of his Parkinson’s TCM over three days, but seven were not given and three were given late. He died four weeks later.

An ageing population, due to improvements in public health, medicine and the understanding of disease mechanisms, means that older people are more forgetful, adding to the problem of unintentional non-adherence.

However, unintentional non-adherence is not restricted to the elderly; lifestyle-related factors, such as a busy schedule or religious/cultural conflicts, affect people of all ages.

Intentional non-adherence remains widely misunderstood. It is a head-scratching problem – why would someone deliberately not take the medication prescribed for them? Common reasons include – concerns about side effects, misunderstanding dosage or timing instructions and lack of belief in their effectiveness.

Meanwhile, fear of dependence, difficulty in administration and even feeling better, and not completing the course, are among other significant problems.

Human nature being what it is, we must accept that some patients, for sometimes very good reasons, simply ‘misspeak’ to their doctor. It can appear much easier to say you forgot to take your meds than to admit you don’t want to.

A particularly distorting variant of this is when patients say they have taken meds when they haven’t. This can have far-reaching consequences; alternative drugs could be prescribed, adding cost and feeding false data on efficacy back into the system.

A May 2023 report in The Pharmaceutical Journal noted that, in England alone, over 5.7 million items were ‘not dispensed’. This may be due to patients no longer requiring prescriptions or being unable to pay the prescription charges.

In England, almost 10% of people surveyed in March 2023 couldn’t afford their prescriptions. A survey of community pharmacists conducted at the end of 2022 by the Royal Pharmaceutical Society showed that half saw an increase in patients not collecting prescriptions due to cost.

In short, non-adherence is a major global health problem that impacts public health and costs an enormous amount of money.

Improving the effectiveness of adherence interventions may have a greater impact on the population’s health than any other global health measure.

A 2023 systematic review reported in the Electronic Journal of General Medicine noted that ‘the three most reported practices of medication non-adherence are prescription abandonment, non-conforming and non-persistence.’

The review considered the main factors that lead to non-adherence, the top three being socioeconomic-related, healthcare system-related and patient-related. The conclusion was that ‘medication adherence is a multidimensional and complex matter that needs to be addressed at different levels.’

The review found that ‘improving patient medication adherence can be achieved when healthcare providers, physicians, pharmacists and nurses interact more with patients through regular follow-up visits and appointments.’

These findings support the conclusions from a major European review of intervention studies, which noted that “electronically-monitored adherence feedback is potentially an effective approach to enhancing medication adherence.”

In 2009, the National Institute for Health and Care Excellence (NICE) concluded that no single intervention could solve intentional non-adherence but stressed communication, increased patient involvement, better understanding of patients’ beliefs and concerns, and providing information.

This suggests there is a job to be done to better inform and engage with patients throughout their medication journey.

Given the constraints GPs and pharmacists face, technology may be part of the solution. Monitoring patients at home, every time their medication is due, has been shown to dramatically improve adherence rates.

In Liverpool and Knowsley, such an approach has demonstrated improvements in adherence from around 30% to 97%. Both local authorities reported significant cost savings and improved quality-of-life indices.

Following up, meeting, checking on progress, resolving issues, communicating with patients and monitoring their medication-taking is transformative.

Non-adherence is a huge, largely hidden and often forgotten problem. Perhaps it falls into that class of problems that aren’t immediately visible or causing immediate pain, so they don’t get the attention they desperately need.

It is also a complex, multidimensional problem, one that demands a better understanding of human psychology; on the face of it, it’s a problem that shouldn’t even exist – why would anyone not take the medication that’s designed specifically to help them?

But it happens, so it is incumbent upon government, health and social care services, local authorities, pharmacies and all stakeholders to work together to better understand what’s going on and to take steps to address it.

It has been shown in multiple studies that simple measures can make a big difference, and that technology can play a major role in supporting patients through their medication journey, increasing adherence and delivering all the benefits that accrue from that.

One day, in the not-too-distant future, perhaps doctor’s orders really will be much easier to follow.

Norman Niven is CEO at Paman. Go to paman.org.uk