Use of the term ‘quality‘ needs definition before it can be interpreted in any critique of the health service. I propose a definition of a quality as one which can be measured by the extent to which the person with the problem feels that s/he has been seen and heard by a healthcare professional with the requisite expertise. It has resonance with business where if the customer feels that she is not valued she takes her custom elsewhere. However as is sometimes illustrated by some aspiring healthcare providers they understand business but have no clue about medicine. There is a burgeoning of primary care providers, offering something akin to fast food outlets but these are likely to disappoint their clients.
Quality has four benchmarks:
There is no ‘quality’ if the patient has no prospect of consulting the person best placed to assist and especially when need is greatest. There are many examples of disastrous outcomes for people who have not been able to access the required expertise in time. In healthcare that may be a surgeon but it could also be a dentist, a physiotherapist, a pharmacist or an allied health practitioner. On that basis it is telling that in Australia access to general practice may be challenging in some communities but so is access to allied health practitioners. For this reason alone these communities have a diminished quality primary care service regardless of any other benchmark.
However ‘access’ alone is a poor proxy measure of quality although it often seems as if the public believes it is the only one that matters. It certainly makes very bold headlines when it fails. On the other hand there is little point in a very accessible service which is not effective. Once the access issue has been addressed the focus shifts to effectiveness. The Royal Australian College of General Practitioners offers a useful list of indicators that might guide a medical practice. Each discipline or organisation is likely to have its own list of ‘quality’ indicators for effective care.
The integration of care providers is a sensitive marker of quality in health care. There are many healthcare issues where a team approach is of critical importance to timely diagnosis or rehabilitation especially when transitioning from another setting. Practitioners in different disciplines rarely work as an effective team not because they don’t wish to, but because team work is inhibited by funding and or organisational structures. This may be the one area where collaboration could improve quality for modest investment.
Finally, and crucially, continuity of care is a vital component of quality. Simon illustrates the point well. He has been admitted to three different hospitals in the same town over the past three years. He usually finds his way there in an ambulance or via the emergency department. He has two different problems which have been diagnosed as ‘alcoholism and neurosis’ or ‘epilepsy’ and ‘stroke’ or ‘migraine’. Simon has certainly enjoyed access and on every occasion he has consulted someone who is suitable trained but there has been no integration of providers and the only hope for a good outcome is continuity of care. By any standard, eight CT scans later, he is at risk of iatrogenesis. After three years he has been told he is fit to drive and not drive in the same month by practitioners with the same specialist qualifications. He has been commenced on antiplatelet medication by one and advised to discontinue all medications by another. The only hope is that he has the same general practitioner and that continuity of care might be the light in an otherwise dark and it seems radiated tunnel.