A hip operation is like buying a cardigan

I’ve only just started following Roy Lilley’s nhsManagers.net email newsletter. I would recommend it. Interesting, sharply written and relevant.

But I have to disagree with his latest column entitled, “Not like buying a cardigan”. In it he argues that difficulty in contacting your GP, bad hospital food, poor attitude of staff and collecting a hospital acquired infection are not quality issues. His point is that all these should be done anyway. Hence the only thing that is a quality issue is if your hip replacement is successful and lasts. To be clear, I don’t think Roy is arguing that the other things are not important, but that they should be gotten right anyway, so the focus of “quality” is on the core purpose provided. From the article,

Having an operation and collecting a hospital acquired infection is not a quality issue. It is entirely avoidable and actual bodily harm. It is an assault. A bed sore is neglect. Are we to say if you manage to escape from hospital without an infection or a bed-sore that is a quality experience? No! There is no virtue in virtue; you are not supposed to be left hanging on the phone, suffer and infection or collect a bedsore. The absence of any of these is not a quality measure. You might just as well argue they were lucky.

In a way he is right, but he is missing the point that there are levels of quality. Let’s call them core, essential, expected, nice to have and luxury. Think about a trip on an aeroplane:

  • Core – get me from A to B
  • Essential – the plane must not fall from the sky
  • Expected – a seat on the aircraft
  • Nice to have – local airport and a free in-flight drink
  • Luxury – seats that turn into beds or a gym on board the plane

To generalise:

  • Core – The reason I am taking this service or product
  • Essential – Safety factors
  • Expected – Things you don’t think about when there, but would really annoy you if they are missing and you tell people when they are broken
  • Nice to have – Little extras that make you smile
  • Luxury – Big extras that make you tell your friends and family about what happened

So let’s classify some of the things Roy mentions:

  • Ease of calling the GP – expected – this should be easy, it is annoying when it isn’t
  • Hospital food – expected – a reasonable quality is expected; cold, tasteless food is bad; but caviare and champagne is not necessary
  • Bed sores and infections – essential – like the plane falling out of the sky we think that everything should be done to prevent these
  • A new hip that works and lasts – core – this is why we underwent the procedure in the first place

So Roy is right and wrong. These other factors are important, and some are essential, but only the hip is core.

But the interesting thing is that from the perspective of providing the best care we should be getting all the core, essential and expected things right. We should do it firstly, because it serves the patient best if they have decent food and don’t get infections in hospital. Secondly, the beneficial outcome is that giving good food helps people recover faster, preventing infections means fewer bed days and antibiotics, all of which means we save money. So better care saves money too.

Roy is half-right, we should do these things anyway, but my point is we need to understand where they lie in the above classification and what they consequences are of getting them right and also of getting them wrong.



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