I am not sure it’s feasible just to use “length of stay” and “avoidable admissions” together only as yardsticks.
Imagine if the only metric you had of how effective the provision of weekly groceries was was how much time you spent in a supermarket.
But that’s actually the level of the argument.
Or, in the alternative, imagine for a moment if a lot of effort was put in, by external advisors, into drawing up lists of how to avoid inappropriate trips to the supermarket; or screening for members of the public who might be at high risk for running out of provisions that week.
If you shut down all the local smaller shops, admittedly people would be forced to go to their local supermarket. And the customer would be assumed to be able to make it to the supermarket, even if it were miles away.
A particular type of customer might have a big shopping list, where the only sensible option would be to go to a supermarket rather than a local smaller shop.
And yet we have a situation where that particular type of customer might be tending to have to shop for ever longer lists in their shopping basket – but simply cannot avoid going to the supermarket when needs must, for example one has run of toilet roll.
This week, I attended a ‘quality improvement clinic’ for the Royal College of Physicians’ annual conference here in London, at the ExCeL centre. A newly appointed consultant took her problem to the ‘clinic’; and explained how she was leading a proposal for a newly engineered frailty service.
The ‘clinic’ expert then asked – “But what are you actually trying to achieve?’
The consultant replied, “For frail persons to spend the least time in hospital.”
I offered to the ‘clinic’ expert at the end, just after the meeting had ended, that the issue all depends what question is being framed, for you to judge whether a quality improvement project is worthwhile.
The project appeared to me like saying it is desirable for ‘us’ to force shoppers to spend least time in the supermarket, when it is clearly not the case that it will necessarily be safe and desirable for such patients to negotiate their long shopping lists while running down the aisles at high speed.
Frail older people tend to have complex needs, due to a plethora of issues, like comorbidity and polypharmacy. The danger in making the length of stay so short is that the long list of problems don’t actually get sorted out. The supermarket is basically saying to the shopper ‘here – have one of the items on your shopping list, but please don’t come back unless you run out of it or you really do need the other items‘.
It might also not be possible to expect all customers to have all their needs serviced in a small shop where the time frame is limited.
The customer (and I hate this analogy too) should be in the right shop at the right time. Keeping people away from the supermarket by actively trying to manage their shopping demands at home may not always work.
Making people educated enough to produce complex meals from limited ingredients may work, and may indeed stop the need to buy more complicated stuff from the supermarket. But that assumes people have the resources and skills to ‘self manage’ their shopping, and this is a big demand. Having successful self-managing ‘shoppers’ at supermarket conferences butters no parsnips.
And then again – some shoppers may never go home after going to the supermarket, as what happened in the supermarket really put them back (e.g. a change of surroundings or inappropriate medications may put a frail older person with dementia fully into a state of delirium, so that, once successfully ‘deconditioned’ in bed, he or she might have to go to a care home.)
If your time is overall running out, would you want to spend most of it in a supermarket?
We are in a relatively good place now compared to where we were before – where we can now raise our heads above the parapets and say openly why sometimes what happens in supermarkets really isn’t good enough.
How do you ‘measure’ how good the supermarket is? In addition to the speed with which its customers are “processed”, it could be whether the supermarket meets the needs of customers, or whether the products are safe in the first place, as well as whether the supermarket is running at an overall loss or the time spent by each customer is at a minimum.
The whole construct, furthermore, assumes that shopkeepers never become customers. I indeed am on the GMC medical register, and regularly have to go shopping on behalf of my mother because she is frail and lives with dementia. Sometimes, I find that on-line shopping with the best will in the world is not enough.
But as a ‘secret shopper’ it does give me insight into the big picture. Shopkeepers think very differently to customers.
I think we need to invest in community resources, and to think rather more carefully about that question asked in ‘clinic’: “But what are you actually trying to achieve?’
Can this all be summarised with something so trite as, “Would you recommend my supermarket to your friends and family?”
At no point was I left with a clear idea of what the patients wanted from this new innovative shiny service, and more. All I was left with was an elaborate list of excuses to why the shopper might spend the least time in the supermarket, how the supermarket could see more shoppers, but not at all addressing why the trip to the supermarket was necessary and what could be done by all to get the most out of it. Quality improvement cannot be an elaborated game simply ‘to save money’.