Copyright 2011 Right Care

The need to understand variation in healthcare:When is variation unwarranted?

Phil DaSilvaNational Lead NHS Right Care

November 2013

Online Learning Series

Right Care for Populations

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Reducing unwarranted variation to increase value and improve quality

“A good map is worth a thousand Words…

… cartographers say, and they are right: because it produces a thousand words: it raises doubts, ideas. It poses new questions,

and forces you to look for new answers.”

Franco Moretti (1998)Atlas of the European Novel 1800–1900

The NHS Atlas of Variation 2011

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Four things

Understanding Variations Defining

Variations

Identifying Variations

Not all Bad

What is it?Who names it?

Who defines it?Who decides what is and isn’t variation?

Tools are needed to search for variations

Variation can be good

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Variations are not a new phenomenon

Variation in healthcare remains endemic, with many articles published in the past 40 years identifying the existence of variations in health care across demographic groups, geographic areas, institutions and even individual health care providers within a single institution and in hospital treatment rates.

J Allison Glover, 1938

• 10-fold variation in tonsillectomy

• 8-fold risk of death with surgical treatment

Essential Reading: Unwarranted variation in health care - with an introduction by Sir Muir Gray September 2011

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There is also evidence of variations in general medical practice and between

general practitioners (GPs) and practices, with variations identified in areas such as the frequency of contacts, registration of

diagnoses, diagnostic test ordering, referrals, prescription rates, and return visits

Ensuring measurement and publication of information for both NHS England’s direct commissioning and CCG commissioning (outcomes and value for money) including inequalities and unjustified variation Mandate paragraph 9.3 (page 61)

Researchers, academics, clinicians and other observers are still discovering wide variations

(Reid et al; 1999, McPherson, 2008, Wennberg 2010, McBride et al;

2010, Appleby 2011). Reid, F.D.A., Cook, D.G. & Majeed, A., 1999. Explaining variation in hospital admission rates between general practices: cross sectional study. BMJ British Medical Journal, 319(7202), pp.98-103.

McPherson, K., 2008. Commentary: James Alison Glover (1874-1963), health care variations research then and now. International Journal of Epidemiology, 37(1), pp.19–23.

Wennberg J,. 2010 Tracking Medicine: A Researchers quest to understand healthcare. Oxford University Press

McBride, D. et al., 2010. Explaining variation in referral from primary to secondary care: cohort study. British Medical Journal, 341(7784), p.c6267.

Appleby, J., et al., 2011. Variations in Health Care: the good, the bad and the inexplicable: The Kings Fund; London

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…….. many years later, we can still observe variations in health care in England, NHS Atlas of Variation series, (DH; 2010, 2011, 2012)

…….and many countries are facing the same puzzle of understanding variations in their health care system……..

http://www.oecd.org/els/health-systems/medicalpracticevariations.htm

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….and yet the management of variations in health care remains an elusive management concept…

…….the conundrum is whether the NHS in England is primed to understand and explain, or to tolerate and justify known variations in healthcare.

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Frame and re-frame narrative…

Patients

Clinicians

Man

ager

s

Rese

arch

ers

..common understanding of variation

Mulley (2009) comments that if all variations were considered as good or bad, then dealing

with them would be easy and he urges clinicians and policy makers to find the

courage and curiosity to confront variations in health care.

Mulley, A.G., 2009. Inconvenient truths about supplier induced demand and unwarranted variation in

medical practice. British Medical Journal, 339(oct2).

unwarrantedunexplained

unjustified

random

unacceptable

Classification of Variations – Who decides?

www.rightcare.nhs.uk

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Summary

• Variation exists• The NHS needs to be primed to deal

with it and needs to have leadership• Explain and understand variation• A strength to build on is that

clinicians are keen to understand variation

• Start now!

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