Connect Health “Change” brings you the latest in a series of webinars to make and embed transformation in healthcare. Aimed at system leaders and clinicians across the NHS, the webinars provide practical solutions to the challenging issues we are all grappling with.
Unwarranted variation (or geographic variation) in health care service delivery refers to differences that cannot be explained by personal preference, illness, medical need, or the dictates of evidence-based medicine.
Unwarranted variation is widespread throughout the UK, affecting patient outcomes, service costs and overall productivity. Lord Carter highlighted an opportunity to save up to £5bn in his 2016 report.
Delegate feedback included:
- The delegates enjoyed the range of speakers and clarity of cases made
- Really informative and helped me understand the changes happening within the NHS
- Access to high level speakers leading national strategy
Watch the Webinar in Full
Chaired by:
Dr Marwan Al-Dawoud, Director of Clinical Delivery, Connect Health
Q&A
Fiona Ottewell, Delivery Partner North East North Cumbria ICS Locality Team, North East and Yorkshire Region Improvement Lead, NHS England & Improvement
Question 1: How do individuals get access to this data for their own patch?
Answer: Every CCG or locality team will have business analysts with access to this data and who will be able to share this information. It’s in their best interest to be working in collaboration with you to look at this data and if you’re still hitting barriers then my contact details are in the webinar video and I’d be very happy to signpost you.
Question 2: Does that conversation between CCGs who are outliers actually happen, in order to learn from each other?
Answer: Yes it is happening. It happened more pre-COVID than post-COVID because there are so many other significant conversations happening post-COVID but that conversation is definitely happening at CCG level. Even as we move into ICS’s that sort of conversation is very much live in terms of managing the demand that we’ve got at the moment.
Question 3: This is clearly a big opportunity for spotting inequality. What should we all be doing about it in our individual domains?
Answer: In my opinion we should all be thinking about how do we make sure that we personalise the offer. I think we do have an ability to personalise the offer to individual populations, to individual patients. It’s a case of understanding that different horses will run on different courses, we really do need to be as flexible as we possibly can in terms of our healthcare offer.
Question 4: If this is such a huge opportunity for spotting inequality and access issues, what should we all be doing about it?
Answer: We should be using the data, we should be using shared decision making, we should be seeking to make every contact count. We should be seeking opportunities to change that conversation and to enable patients around self-care, as well as knowing what’s happening within their population, knowing what the data is saying.
Professor Tim Briggs CBE, Chair of GIRFT and National Director of Clinical Improvement for the NHS; Consultant, Royal National Orthopaedic Hospital
Question 1: We have known about variation for many years, but it is only now that we are starting to address it. What has been the catalyst for this and is it sustainable?
Answer: It’s the GIRFT programme with 60 national leads etc. It started off in orthopaedics, it’s now 40 specialties, we’ve got 60 national leads, 31 national reports. Second thing is, getting that data together, getting it refreshed regularly, getting into the model hospital with GIRFT, defining where we want to be and getting data so we can look at outputs, quality, efficiency, productivity and theatre uses, using this data to work smarter. Then looking at how we involve the independent sector, this elective recovery, using this data to drive real change.
Question 2: Why is London so far ahead of the rest of the country in respect of the 7% improvement in 52 week waits?
Answer: London got hit hardest by wave one. In April 2020, I was asked by Sir David Sloan, Regional Director, and Dr Vin Diwakar, Regional Medical Nurse, as the National Director of Clinical Improvement and GIRFT lead to help them transform their surgical service. We developed this model together and trialled it in London. On the basis of our outputs, we’ve now got the go ahead to deliver it nationally, so that’s why London is further ahead than the rest of the country. We also developed hub sites, we’ve got 43 hub sites in London, and so we’ve demonstrated that model works as well. That’s why we’ve got the go ahead to take it national.
Question 3: Where do you see unwarranted variation in 10 years’ time?
Answer: Change the narrative, get this to be the drumbeat. If we get this right, we’ll see significant improvement in patient outcomes, patient care and we know that outcome over cost is value, we’ve got to make sure that we spend every pound of NHS money as wisely as we can. The variation shows that we can make significant inroads into that, that’s the problem across the whole system. We need to change the narrative, we’ve got the data now to do it and we’ve got to change the drum beat, we’ve got to have a relentless drive of using this data so that we have a whole system-wide approach or model health system which is regularly updated. We are now in a completely different space to where we were, we have invested huge amounts of time and money to develop these data sets and it’s not going to be acceptable not to look at and utilise the data to drive change.
Question 4: It may be useful to gather data from private providers as often they pick up some of the weaknesses within the system. Is this going to be approached too?
Answer: Yes it is, data on volume and data in the NHS is now going to the model health system. We then want to get into the theatre data because what we want is a level playing field so we’re producing the best outcome. From being a consultant to the tertiary level hospital if the knee replacement patients are very unhappy when they come for a second opinion and the causes are multifactorial either the surgery hasn’t been done particularly well or it shouldn’t have been done in the first place. We’ve got to work together to make sure we operate on the right patient at the right time. We need to get a consistency across the country using pathways so we don’t have unhappy patients that we do see because of inappropriate decision making or poor surgical performance.
Question 5: You also mentioned rural and deprived areas of the country are worse. I’m not sure it’s as simple as where you live of course but surely there are some quick wins we can put in place to help?
Answer: The neurology report and all the national reports talk about the workforce and using the variation. One of the biggest things we can do is get individuals who, where Trusts are struggling to recruit, have joint appointments for teaching hospitals so that they bring those skills from the teaching hospital into the DGHS. The other thing we need to do, not just with consultants, but with all staff is to have training staff in the teaching hospital, the DGHS, so that we have shared appointments and we get the skill set and drive up standards.
The whole program is regionally led, system-delivered and GIRFT enabled but what we’ve got to start doing is making sure we hold people to account to deliver. Too much in the health service has been failure to deliver. There has got to be a relentless focus for the next three years because that’s what our patients want, that’s what our patients would expect and that’s what the taxpayers would want us to deliver. We cannot accept poor performance anymore by either clinicians or our managers/our managerial structures. We all own the problem, we’ve got to understand that we’re all accountable to deliver this.
Andrew Bennett, National Clinical Director Musculoskeletal Conditions, NHS England and Improvement, Consultant Physiotherapist Sutton Health and Care, Epsom and St Helier NHS Trust
Question 1: What are the key enablers to deliver impact in reducing variation in access outcomes and experience locally?
Answer: Firstly, we can build on the work that’s being done with regard to pathways but also ensure that the right resources are in place, aligned with those in primary and community care, both at the front end of the back end. Working with CQC and working to optimise commissioning, we then have the evaluation piece and, with regards to data, we have good data in the secondary care space. We don’t have good data in the primary and community care space so we need to look at how we can evaluate the whole system better, integrating the dense data across these different spheres. We need to focus on leadership because to bring those things together we need to enable those who are MSK specialists in local lead roles, who have the best understanding of population and resources, to adapt and adopt these strategies to meet local leads. We’ve got areas working very well, we’ve got areas that are challenged. We don’t want to hamstring one the ones working well at the expense of those who are challenged. It’s about creating this leadership community and learning system to deliver and then at the heart of that is co-production. We are trying to offer the best value care for patients and to do that we need to ensure that patients are engaged just like everybody else.
Question 2: Community providers often lack the quality of data seen in hospitals; do you see this as a challenge to the type and rate of transformation? How will you drive change with that deficit?
Answer: This is a massive challenge that we have in the primary/community care space. We’ve got the Best MSK health programme, we’ve got a work stream focusing on primary/community care and a work stream focusing on data and metrics led by one of our analysts, Neil Parkinson. They are working with all the stakeholders involved in the project including right care and GIRFT to co-produce a robust primary care and community care data set. As part of this, we need to make best use of the model health system to align with the secondary care plan and we need to ensure that we are relating primary and community care data with secondary care data so we can measure the quality of the whole system, the productivity and performance.
In order to do this, we’ve got to look at commissioning at place level through ICSs and the PCN end level, focus on the collection of the right data and measures using that data. We’ve got to focus on working with CQC to make sure that we are looking at quality of services aligned with that data and we’ve also got to enable local leadership. It all comes back to leads, the majority of leads in the MSK world want to be collecting this data and we need to bring down the barriers to enable this to happen.
Question 3: You also mentioned rural and deprived areas of the country are worse. I’m not sure it’s as simple as where you live of course but surely there are some quick wins we can put in place to help?
Answer: The excellent work that we are doing in the AHP space with regard to frameworks capability, not only for FCPs, but for advanced practice consultant practices, aligning the work and the workforce strategy can help us look at things in a different way.
We need to enable a leadership structure to enable this to happen which is one of the things we’re working on. We’re looking at a network for MSK through the regions and ICS that is appropriately resourced, funded, has the right analysts around it, right project managers who can hold to account about what’s going on. We’ve got to find a balance here, the risk if we don’t is we try and put square pegs in round holes.
The database is so important and the ability to evaluate where we are now and the impact we can provide along with a leadership framework to enable that accountability.
Fredi Cavander-Attwood, Policy Manager (Health & Care), MS Society
Question 1: How should the NHS involve patients and communities in efforts to tackle unwarranted variation?
Answer: I touched on the integrated care systems and the need to involve patients there, it’s really important that, at all levels, those bodies have representation from different types of community groups. The guidance has been drafted around those changes and is reflecting them. It’s not optional to involve patients and patient groups, and particularly engaging with those communities that carry the highest burden of ill health and disability that may not be the ones who put themselves forward for opportunities, to be involved, so we need to proactively seek those voices out.
Question 2: You mention the feeling you have to fight the system. A lot of people don’t have the ability to do this. What can they do?
Answer: Just involving patients, engaging with patients, the ICS level is important but actually in the voluntary sector too. Those patient organisations can speak on behalf and represent people who can’t do that directly, it’s really important to make sure that the patients are involved in the system at local level. There are some patient organisations which develop patient champions because some people may not feel like they have a voice. We need to be supporting people to develop their voice as well.
Question 3: You also mentioned rural and deprived areas of the country are worse. I’m not sure it’s as simple as where you live of course but surely there are some quick wins we can put in place to help?
Answer: On neurology the GIRFT report has some good ideas around workforce, where it’s difficult to recruit.
Dr James Hopkinson, Joint Chair and Clinical Lead Notts and Nottinghamshire CCG
Question 1: What do you think would make the most difference to reducing unwarranted variation?
Answer: I would like to see a much greater focus on shared decision making. I, personally, hate the term shared decision making because it’s become a thing rather than a process. By shared decision making, I don’t mean the completion of tick boxes or forms by the surgeon when they’re consenting to make sure we’ve explained the risks, I mean the development of a better clinical conversation by all people who are involved in patient care, at all points in patient pathways. Too often, patients arrive at surgeons having been told that they need a new knee or a hip and we’ve already preconceived an outcome. We’ve got a responsibility to help patients understand their condition, understand their options, including what will happen if we don’t do anything. We need to empower our patients to make informed decisions about their own care. We need to change the entire narrative at all touch points of patient care.
Question 2: Do you think that primary care is doing what it can to support self-care and to enable within chain decision making?
Answer: I think this goes across the entire spectrum, we can do better at every level. Self-care is not a primary care owned domain, in secondary care specialist clinics, self-care is still a key part of what I would be expecting people to do and I see myself as an enabler to do that. There are issues of resource time in primary care and across the system but there’s also understanding education. People genuinely believe that when the x-ray comes back and it says severe osteoarthritis that that means they need a knee replacement, we need to educate, we need to understand, we need to be in a position where within our systems each part of the system talks to each other. The data is absolutely key but it needs to be live, it needs to be meaningful, it needs to happen in a timely way so that the interventions that happen at certain levels, the outputs are visible and somebody’s able to say that actually what’s happening right now isn’t right so change the dial and learn from it. In the last 25 years, primary care and secondary care have been divided and conquered by people in the political spectrum and actually we don’t talk to each other in the ways we used to. I think we need to get back to that place where we’re honest and talk to each other and give each other proper feedback so that we do a better job.
All speakers – What is the one thing you would change to improve outcomes for people experiencing unwarranted variation?
Fiona: If we really get shared decision making as effective and as robust as possible, I believe that that will make a sustainable difference that we are seeking in our productivity challenges.
Andrew: Self-management has got to be adapted to local population needs and local resource availability. It needs to be underpinned by a population health approach which, of course, ICS is designed to enable that but it’s about the local leadership to co-produce the strategy.
Fredi: Involving patients, not making assumptions about the reasons for variation or how to solve them without asking patients. People are feeling this burning injustice and we need to find a way to not shy away from that. Making patients aware of what their entitlements are at that local level because often people don’t know what they should be entitled to.
James: There’s something about education and culture, we all need to be looking at the data and engaging the patient conversations. It’s too hard to pick out a unit or a particular group of people to be responsible for this. That’s what the conversation needs to be, it needs to be big, it needs to be bold and it needs to be across all parts of the care system.
Watch the webinar again, which includes further insight from the speakers including a full Q&A session, and read more about the speakers here:
Wednesday 17 November 2021
View our speakers’ biographies
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