Chief medical officer calls for rewards to improve clinical practice

BMJ 2006; 333 doi: (Published 27 July 2006) Cite this as: BMJ 2006;333:216
  1. Caroline White
  1. London

    The chief medical officer for England, Liam Donaldson, has said that financial rewards and penalties could be introduced in a bid to root out unacceptable regional variations in clinical practice.

    Professor Donaldson was speaking last week at the launch of the latest issue of his annual report on the state of public health, which draws on data for 2005 from the former 28 strategic health authorities.

    He said that despite great improvements in medical education and the growth of an evidence base to inform practice “there is still far too much clinical variation” that cannot be justified by medical need and that is “not acceptable.”

    Not only do such discrepancies result in inappropriate care and health inequalities, they also expose patients to unnecessary risk and cost the NHS “billions” every year, he added, citing as one example the use of 574 different hip joint and socket combinations for broadly similar operations.

    The report shows that inexplicably wide geographical variations exist in prescribing patterns, numbers of hysterectomies, treatment of coronary artery disease, and use of tonsil removal among children.

    Numbers of hysterectomies for excessive menstrual bleeding among women aged between 40 and 59 years have fallen by 64% in North Central London strategic health authority but by only 15% in Northumberland, Tyne and Wear. Professor Donaldson said that if hysterectomies were performed more appropriately 6000 operations could be avoided and £15m (€22m; $28m) saved.

    Similarly about 8000 tonsillectomies are needlessly done—particularly among children from poorer families, among whom the procedure is more common—at a cost of more than £6m.

    Professor Donaldson said that better dissemination of the latest evidence under the new NHS information technology programme and guidance on ineffective interventions from the National Institute for Health and Clinical Excellence would help narrow the gaps and ensure that all patients received the best available treatment.

    But adjustments to the current tariff system, which would give incentives for effective practice and penalise its opposite, was another option, he said.

    “It's possibly a win-win situation,” he said, adding that serious discussions about it would be held over the next few weeks.

    Paul Miller, chairman of the BMA's consultants' committee, said that such a scheme was “certainly achievable.”

    He said, “If you stop funding a hospital to do certain procedures it will stop doing them.” But clearcut evidence for change was essential, he added.


    • Annual Report 2005:The Chief Medical Officer on the State of Public Health is available at

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