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INSÄNT AV Pam DEN 12 :e NOVEMBER, 1996 vid 22 - tiden


See my earlier discussions on "DebattForum" 3 weeks ago!
Now I am back from Sweden.

After spending a most enjoyable two weeks in Sweden studying
models of diabetic care it seems appropriate to reflect on
"lessons from abroad" and to commit my impressions to paper
e.g. holistic patient care, effective communication networks,
output of bakeries at Alingsas (effective and delicious)..
etc.! The study was based around Stockholm and Gothenberg
where I had the opportunity to meet with many people involved
in the provision , purchasing, R&D and educational aspects of
diabetic care. My interpretation is against the context of
integrated services at Airedale NHS Trust described in a
television series in the UK as a " Different Country Practice".

In contrast to the UK, Sweden hosts a wide range of regional
models of diabetic care with variable success in access,
equity and political lobbying. Care in some council areas
approaches the "gold standard" objectives of the St Vincent
declaration delivering high quality, "seamless" services to
the diabetic patient through the constructive use of information
and through collaborative partnerships. In contrast some city
locations are subject to the challenges of scale, fragmented
professional networks, and of variable incentives and expertise
within primary care.

In common with the UK, there is a climate of economic
constraint which demands decision making based on knowledge of
both clinical outcomes and of relative costs. The purchaser-
provider split and the power of GP Fundholding in the UK have
introduced a focus on detailed costing emphasising quality
issues and customer satisfaction. In comparison, the Swedish
systems based on block financial allocations or DRG contracts
do not seem to have generated the cost awareness of different
models and interventions. The limited collation and standardisation
of information on a national basis also tends to delay the
acquisition of "evidence based knowledge" which supports objective
resource allocation.

The implementation of the current budget reductions in Sweden
poses major problems in maintaining
(or increasing) the quality of care through an increase in the
efficiency and effectiveness of current systems and processes.
Unfortunately, political control introduces an emphasis on the
short term which which may cloud the longer term economic savings
which result from reduced incidence of complications. At one site
evidence was presented which indicated that a 1 SEK investment in
early preventative measures ( primarily related to eye and foot
care) could translate into a long term saving of 10 SEK - a
significant payback.

Significant variations in clinical practice and in the composition
of the "diabetic team"became apparent. Some teams included social
workers and physiotherapists whilst the role of dieticians and
chiropodists in both primary and hospital settings was very
variable. There appeared to be no consensus on the provision of
specialist foot care teams, the acute treatment of the diabetic
ulcer and on the appropriate personnel to deliver dietetic advice.

There was however a consensus on the key role of the diabetic
specialist nurse and the increasing scope of their contribution.
Wide support for the " 10 point training schemes" has the
potential to introduce a level of expertise throughout the chain
of patient care which can enhance care partnerships and foster good
communication. Education and continuing professional development
also plays a major role in improving competence, and in opening up
debate and discussions to agree on " best practice". Educational
initiatives, audit and evaluation, registration of family doctors
in each primary health care centre with a special interest in
diabetic care, and good communication networks have all generated
a new confidence in the expertise of the family doctor.

No common pattern emerged of investment in Information Technology
nor in an understanding of its real potential in improving the
quality of patient care. This was well demonstrated in one council
area where all Primary Centres use the same systems and software
is compatible with the hospital site. Timely , electronic transfer
of patient information is planned and achievable - a rare
combination. Contrast this with a city clinic where all records
are paper based and specific to the professional groups and the
scale of the problems with integration and team working are multiplied
significantly. Several sites have also achieved an electronic
system to support the National Diabetic register which introduces
mutual benefits including the analysis and evaluation of population
data, treatment regimes and practice specific, confidential audit.

Effective diabetic care is difficult to define and I am only an
inexperienced observer. From my discussions I would however
several key factors which appear to support a patient focused
climate :-

Effective networks of primary care and hospital based professionals
with regular meetings and open, collaborative discussions.
Agreed guidelines on patient care and checklists to support
A system of continued education to further enhance competence
Comprehensive IT systems which facilitate shared information and
serve many functions.
An agreed programme of care organised as a single system within
a council area with one funding stream (if possible).

Many problems remain within the UK although we also demonstrate
considerable success. From my many visits and discussions within
Sweden there are a number of issues which I will follow up and
"lessons to be learnt" from your initiatives and experiences.
Our problems and interests are similar and there are common
reserach initiatives into "seamless care" with the aim of
maximising the quality of patient care within limited resources.
I am confident that we will succeed and I thank you all for your
support and interest in my work and for the considerable time
invested in this study.

From Pam



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