Intended for healthcare professionals

Head To Head

Should the NHS strive to eradicate all unexplained variation? No

BMJ 2009; 339 doi: (Published 19 November 2009) Cite this as: BMJ 2009;339:b4809
  1. Richard J Lilford, professor of clinical epidemiology
  1. School of Health and Population Sciences, University of Birmingham, B15 2TT r.j.lilford{at}

    Variation exists in all aspects of health care. Stephen Richards (doi:10.1136/bmj.b4811) argues that it is damaging to both quality of care and finances, but Richard Lilford believes that imposing uniformity risks stifling medical progress

    I assume that most people would agree that variation is acceptable when patients make different personal choices—for example, whether to have screening for Down’s syndrome or prostate cancer. Likewise, I take it that variation is not acceptable when compelling evidence of cost effectiveness is available. These points I take as “self-evident truths” and turn to the interesting question that relates to the acceptability of eclectic practice when the evidence is not compelling.

    When I started out in practice, some clinicians recommended bed rest for threatened miscarriage while others advised women to continue with normal activities. Some mothers were encouraged to nurse their babies prone, others supine. Should mandatory compliance with one or the other practice have been imposed in each …

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