Coordination needed between primary and secondary care for chronic diseases
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《英国医生杂志》
Systems that improve coordination between primary and secondary care are essential to improve the management of chronic diseases, a report published in the United Kingdom last week said.
The report was compiled jointly by the Royal College of Physicians, the Royal College of General Practitioners, and the NHS Alliance to assess how to optimise provision of care for long term conditions such as asthma, arthritis, chronic obstructive pulmonary disease, diabetes, dementia, and heart failure, which are all increasing with the ageing population.
The working party considered that optimal care would require new models of service provision, championed by clinicians and working in partnership with patients. It suggested that joint approaches should be developed at local level, including primary care trusts and local hospitals, to improve coordination of patient care.
Setting up "joint clinical directorates"—:clinical directorates that spanned primary and secondary care—:should be considered as a way of facilitating the development of the infrastructure and clinical governance requirements for services across different sectors.
Professional training should also be reviewed. The report proposed that the Postgraduate Medical Education and Training Board should encourage royal colleges to develop training programmes and modules for doctors to support chronic disease management across primary and secondary care. Training should include team working and the development of the skills needed to work effectively in partnership with others—:including patients.
Ways of sharing information should also be developed. The report recommended that primary care trusts and acute trusts should develop local shared information pathways, including electronic transfer of pathology results.
Professor Carol Black, president of the Royal College of Physicians, said: "As we live longer, the amount of chronic disease in society will almost certainly increase. Such a challenge requires all members of healthcare teams to work together to make their own particular contributions at the right time and in the right place. In the patients?best interests the locus of care will sometimes be in the hospital setting and sometimes in the community. What we professionals should strive to provide is appropriate unity of care.
"To provide seamless care for patients with chronic diseases, GPs and hospital consultants have got to work together. PCTs and clinicians working in hospitals must agree jointly what care is best for patients and how to provide it. We need to get rid of some of the boundaries that currently exist between primary and secondary care." She added: "Services need to be commissioned jointly by PCTs and acute trusts, taking account of local factors including resources and social factors."
The report reviewed several examples of innovative schemes of shared care in the NHS, including the Ladywood diabetes project in Birmingham, in which three local secondary care providers work with 90 general practices to provide diabetes care. The service is led by a specialty diabetes multidisciplinary team, which includes a consultant diabetologist, consultant nurse, dietitian, podiatrist, and lead GP. Specialist diabetes clinics to which GPs or practice nurses can refer patients are held on a regular basis in local health centres. Outcome measures have shown improved HbA1c concentration, blood pressure, and cholesterol control.(London Susan Mayor)
The report was compiled jointly by the Royal College of Physicians, the Royal College of General Practitioners, and the NHS Alliance to assess how to optimise provision of care for long term conditions such as asthma, arthritis, chronic obstructive pulmonary disease, diabetes, dementia, and heart failure, which are all increasing with the ageing population.
The working party considered that optimal care would require new models of service provision, championed by clinicians and working in partnership with patients. It suggested that joint approaches should be developed at local level, including primary care trusts and local hospitals, to improve coordination of patient care.
Setting up "joint clinical directorates"—:clinical directorates that spanned primary and secondary care—:should be considered as a way of facilitating the development of the infrastructure and clinical governance requirements for services across different sectors.
Professional training should also be reviewed. The report proposed that the Postgraduate Medical Education and Training Board should encourage royal colleges to develop training programmes and modules for doctors to support chronic disease management across primary and secondary care. Training should include team working and the development of the skills needed to work effectively in partnership with others—:including patients.
Ways of sharing information should also be developed. The report recommended that primary care trusts and acute trusts should develop local shared information pathways, including electronic transfer of pathology results.
Professor Carol Black, president of the Royal College of Physicians, said: "As we live longer, the amount of chronic disease in society will almost certainly increase. Such a challenge requires all members of healthcare teams to work together to make their own particular contributions at the right time and in the right place. In the patients?best interests the locus of care will sometimes be in the hospital setting and sometimes in the community. What we professionals should strive to provide is appropriate unity of care.
"To provide seamless care for patients with chronic diseases, GPs and hospital consultants have got to work together. PCTs and clinicians working in hospitals must agree jointly what care is best for patients and how to provide it. We need to get rid of some of the boundaries that currently exist between primary and secondary care." She added: "Services need to be commissioned jointly by PCTs and acute trusts, taking account of local factors including resources and social factors."
The report reviewed several examples of innovative schemes of shared care in the NHS, including the Ladywood diabetes project in Birmingham, in which three local secondary care providers work with 90 general practices to provide diabetes care. The service is led by a specialty diabetes multidisciplinary team, which includes a consultant diabetologist, consultant nurse, dietitian, podiatrist, and lead GP. Specialist diabetes clinics to which GPs or practice nurses can refer patients are held on a regular basis in local health centres. Outcome measures have shown improved HbA1c concentration, blood pressure, and cholesterol control.(London Susan Mayor)