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Observations Body Politic

The safety and quality agenda could smother genuine innovation

BMJ 2015; 350 doi: (Published 20 February 2015) Cite this as: BMJ 2015;350:h561
  1. Nigel Hawkes, freelance journalist, London
  1. nigel.hawkes1{at}

How can local freedoms be reconciled with the desire to reduce variation in service provision?

The history of NHS management could be summarised as the pursuit and elimination of unwarranted variation wherever it raises its head. What else are all those guidelines, targets, audits, reviews, league tables, benchmarking, and patient pathways for? Their aim is to standardise practice and eliminate wasteful differences. For every right way of doing something there are many potential wrong ways that need to be corrected to achieve the best possible results for the least possible outlay.

Yet for all this effort variation persists. Its pursuit is as frustrating as the hunting of the Snark; just when it seems on the verge of capture it makes its escape. Chase it down here, and up it pops there. Finally lay a collar on it and somebody will argue that in this case the variation isn’t unwarranted at all but a perfectly justifiable reflection of clinical judgment or local circumstance.

Reducing variation is one way to achieve the ambitious productivity targets that NHS England laid out in its Five Year Forward View.1 Since 2008, says a report written for the …

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