25 - Improving the quality of primary care mental health: what does and does not work?

Summary

What do we mean by quality of care?

Campbell et al (2000) have usefully defined two principal dimensions of quality of care for individual patients: access and effectiveness. In essence, do users of services get the care they need, and is the care effective when they get it? Within effectiveness, they define two key components – effectiveness of clinical care and effectiveness of interpersonal care.

The effectiveness of clinical care depends on the effective application of knowledge-based care. Knowledge-based care refers to both evidencebased medicine (Sackett et al, 1996) and care that is regarded as legitimate (Donabedian, 1990). The latter relates to aspects of care that may be widely accepted without necessarily having scientific evidence of effectiveness. Knowledge-based care incorporates the extent to which a treatment or service is consistent with patients’ reasonable expectations and contemporary professional standards of care, reflecting both societal and professional norms. Care is described as ‘evidence based’ only when there is good scientific evidence of a link between process and outcome.

However, effective care also requires appreciation of the quality of interpersonal care, the patient's personal experience of illness (Stewart et al, 1995) and the perceived quality of the communication with the health professional. Care should be planned for and agreed with individual patients through negotiation with the doctor; such ‘shared decision making’ (Elwyn et al, 1999) means that truly ‘patient-centred care’ (Stewart et al, 1995; Mead & Bower, 2000) may sometimes seem to be at odds with the implementation of ‘evidence-based’ care (Bensing, 2000).

Coordination or integration of care for individual patients is also an important attribute of effectiveness of care, and is particularly relevant to primary care (Starfield, 1998). Coordination refers to the effectiveness with which health professionals deal with other organisations, or other professionals within the same organisation, which directly or indirectly affect patient care. Relational continuity of care, that is, the existence of an ongoing therapeutic relationship with a health professional, is also of key importance to people with mental health problems (Haggerty et al, 2003).