Are there generic factors that improve the quality of care in the settings of the NHS? This talk set out to explore the factors in several NHS settings:
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There are many competing pressures in the setting of medical education with patients having priority. The reduction in working hours of the team as a result of the European working time regulations has disrupted the contact time with trainees.
The key is the relationship between the trainer and trainee. When this is strong the trainee can manage with even the most difficult experiences in their training post. This face to face contact is frontstage continuity. Backstage continuity is adequate records of training to allow other trainers to pick up and move the trainee onto the next stage in their education. This is often provided by electronic or paper educational portfolios. The organisation of the team is also crucial with a clear departmental lead educator who can oversee the educators, trainees and processes such as appraisal, induction and teaching.
Trainers should be professional in their approach. This means reflecting on their role and trying to improve what they and their team do. They should set up local feedback on the quality of education and use any regional or national comparative feedback available.
Patients have said to me “superb care, crap delivery” ,by which they mean that every individual tries hard but the system does not always provided a smooth pathway of care. The worry in the next few years is that a culture of cutting back and “handle quickly then return” to primary care will reduce the standard of secondary care.
When the NHS works well there is a clearly co-ordinated pathway of care with proactive professionals checking that the patients get treated as soon as possible. Examples include stroke care and anticoagulation treatment which lead nurse co-ordinators. Comunication within the team is essential and this includes computer records. In secondary care the use of computer records still seems basic when compared to primary care. Linking and using records effectively could be one of the biggest advances in healthcare over the next decade
Primary medical care is expected to be taking on more with less resources and this may well become a threat to quality of care.
Proactive healthcare is about covering all the aspects of one patients care. This includes the patients problems, the doctors knowledge of all other patient problems and the external documentation required by government. This can’t all be done in seven minute of a consultation so has to be viewed over the year.
Frontstage face to face continuity of medical care is important with complex medical problems. The doctor is working from an existing understanding of the patients problems as well as an implicite understanding of the patients personality and what they perfer to do. Backstage continuity of records ensures any member of the team can efficiently build on from what has been done. This saves time and improves safety of care.
As we move forward we should be talking of integrated care rather than secondary and primary care