Emergency department attendances and heart disease deaths vary fivefold across England

BMJ 2015; 351 doi: (Published 18 September 2015) Cite this as: BMJ 2015;351:h4993
  1. Nigel Hawkes
  1. 1London

People in some English local authorities lose 20 times as many years of life as those in other areas as a result of chronic liver disease, shows a new edition of the NHS Atlas of Variation in Healthcare (

Variation is a fact of life in the NHS in England. For example, babies 6-8 weeks old are nearly five times as likely to be enjoying the benefits of breast feeding in some places as in others, while death rates from coronary heart disease among people aged under 75 vary by a factor of more than five. Attendances at hospital emergency departments show a similar degree of variation, ranging from 159 per 100 000 population to 823 per 100 000.

The atlas, the ninth and biggest to be published, aims to help healthcare commissioners, providers, and doctors to deliver the best care they can by eliminating unwarranted variation. Bruce Keogh, NHS England’s national medical director, said, “The atlas exposes some inconvenient truths about the extent of clinical practice variation in care for some common conditions. The good news is that—at a time of financial pressure across the service—hospitals, GPs, and mental healthcare providers have substantial opportunities to unleash greater value from their existing NHS budgets.”

Examples of where care might be improved cited by Public Health England are in prescription by GPs of antibiotics (which shows 2.5-fold variation), in monitoring diabetes (1.7-fold), and in the assessment of dementia (2.7-fold).

The variations are smaller when the top and bottom few areas are removed. Variation in breast feeding comes down from 4.8-fold to 3.2-fold, a gap that has persisted despite strong encouragement to mothers to breast feed. The atlas blames factors such as social deprivation, ethnicity, and maternal age for some of the difference but says that considerable unwarranted variation still exists and should be tackled.

The prevalence of obesity among people aged over 16 varies by more than threefold across the country, from 11.2% to 35.2%. Deprivation is once more cited as a factor, together with ethnicity and age. London is a microcosm of England, judged by the weight of its citizens. It has boroughs in the lowest and the highest categories and all the others in between.


Cite this as: BMJ 2015;351:h4993

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