Reducing unwarranted variations in healthcare in the English NHS

The Health Atlas was published amid expectations that it will result
in improves in the quality and efficiency of care: Lord Howe expects that
it will be 'commissioners and patients' who will 'identify and address
unwarranted variations'.1

Lord Darzi referred to 'unexplained and unacceptable variations' in
clinical practice which lead to poor quality and inefficiency.2 Little has
changed since Glover's analysis of the variation in tonsillectomy rates in
England in 1938,3 whilst Glover's successors, Public Health Specialist
involved in commissioning who are acutely aware of the differences, have
no place in the new NHS. NHS commissioners in their various guises have
been aware but unable to do much about it being constrained by the levers
available (or denied) to them.

The profession jealously guards its clinical freedoms, citing the
differing individual needs and circumstances of patients as justification.
It does so in the face of this overwhelming data that demonstrate that it
is variations in clinicians' behaviours, not patient characteristics,
which determine what care any patient will receive: the populations served
by Primary Care Trusts (PCTs) simply do not differ to the extent that
would explain the Atlas variations.

Events at Bristol Royal Infirmary in the 1980s and 1990s, culminating
in the Enquiry into paediatric cardiac surgery, triggered the development
of Clinical Governance structures and processes within the NHS. Events at
Oxford earlier this year, also in paediatric cardiac surgery, suggest that
those structures and processes within Trusts are inadequate and unfit for
purpose, at least in some hospitals.4 It is a necessary part of any system
-wide approach to dealing with clinical variation that Providers be given
a mandatory responsibility to tackle clinical variation.

Should not Foundation Trust (FT) contracts include a requirement that
unexplained and unacceptable ('bad') clinical variation be reduced and
that a report produced each year to demonstrate progress? Initially the
requirement could be simple to show reduction but specific targets could
and should be set in future years. Commissioners should demand through
contracts that variation is constrained towards the delivery of their
contracted (evidence based) pathways of care. The GMC expects doctors to
'take into account the priorities set by government and the NHS or ...
employing or funding body'.

The Medical Director, supported by their Clinical Governance team
should carry Board responsibility in each Trust, whilst Clinical Directors
should be charged with that responsibility in their respective
specialities, with a similar role for the Chair of the Drug and
Therapeutics Committee. These clinicians should be appraised on their
success in reducing bad variation: the justifiably maligned Clinical
Excellence Award process should be realigned to success in these areas.

However Foundation Trust (FT) status and the need to meet Monitor's
requirements bring some perverse incentives, with FTs who do indeed
constrain this bad variation at risk of losing business to other FTs.
There needs therefore to be structures above FT to manage this problem.
The Care Quality Commission should be required to focus on this bad
variation but the process needs strengthening through a national
initiative. The Lord Darzi Quality Observatories (QOs) represent a lost
opportunity. The production of information was always a relatively simple
task: doing something effectively with it was the real challenge. These
QOs could have had a governance structure attached to them, indeed it
could have been the principle function of the QOs. Clinical Networks could
have been established in each Region to cover all clinical activity and
each could have been led by a clinician tasked with comparing Trusts and
all clinicians in the region, with the intention of eliminating bad
variation and thus providing a level playing field for competing FTs.
Again this difficult work could be important grounds for CEAs, especially
national ones which should then be recommended not applied for.

Members of the newly established Faculty of Medical Management and
Leadership should have the knowledge and skills to tackle clinical
variation. Training in population health and distributive justice must be
an important requirement for membership if its members are to properly
appreciate their roles in improving quality and efficiency in a NHS tasked
with serving the whole nation, not simply a series of needy individuals
each in isolation.

There are within the NHS some talented and committed clinicians
capable of doing this demanding and difficult work but they are in a small
minority and probably already unpopular with colleagues. The NHS needs to
identify, nurture, protect and reward this rare breed, and it needs to do
so urgently to survive. Indeed, if self-regulation is to survive then the
profession must be seen more clearly to regulate itself on this key
indicator of clinical quality.

And General Practice should not be excluded from both the analysis of
variation and structures to facilitate its reduction.

References:

1 Wise, J. Health atlas shows large variations in care in England BMJ
2010; 341:c6809

2 NHS Next Stage Review Final Report: High Quality Care For All. The
Stationary Office;June 2008:CM 7432

3 Alison Glover J. The incidence of tonsillectomy in school children.
Proceedings of the Royal Society of Medicine. 1938.31 p. 1219-36.
(Reprinted Int J Epidemiol) 2008;37:09-19.

4 Mayor S. Oxford hospital suspends paediatric cardiac surgery after
four deaths. BMJ 2010; 340:c1303

5 http://www.leadership.londondeanery.ac.uk/news/establishment-of-a-
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