Unwarranted variation in health care service delivery was the subject of Connect Health‘s latest Change webinar on Wednesday (17 November).
The session highlighted the current prevalence of unwarranted variation (or geographic variation) in patient care – defined as differences that cannot be explained by personal preference, illness, medical need, or the dictates of evidence-based medicine – which has been exacerbated by COVID-19 and the resulting impact on patient waiting lists.
Professor Tim Briggs CBE, Chair of GIRFT (Getting It Right First Time), National Director of Clinical Improvement for the NHS and Consultant, Royal National Orthopaedic Hospital, called for “a relentless drive” to use data to help minimise variation. He explained that healthcare providers must “change the drumbeat” of care delivery if patient outcomes are to improve as standard.
Professor Briggs said:
….We’ve got to change the narrative… instead of saying ‘it can’t be done, it’s too difficult’…we need to say ‘it can’…We did it before [cleared the backlog – referring to 2007, when there were 587,000 patients waiting over a year for procedures] and we can do it again.
Fiona Ottewell, Delivery Partner North East North Cumbria ICS Locality Team, North East and Yorkshire Region Improvement Lead, NHS England and Improvement, was the first speaker at the event, chaired by Dr Marwan Al-Dawoud, Director of Clinical Delivery, Connect Health. Fiona highlighted patient inequalities across a variety of treatments, from spine MRI scans to opioid prescriptions.
She agreed with the sub-title of the webinar, which asked if unwarranted variation provides opportunity for productivity.
[It does], as it helps to ask the right questions when considering areas that could be improved.
Outlining how patients in deprived areas “present later in the [care] pathway”, affecting outcomes, Fiona said that variation data can prompt conversations about why such inequalities are happening, potentially leading to cost savings, increased productivity and improved patient care. She also pointed to the importance of shared decision making between patient and provider, underlining how variation can be warranted when providing personalised care. Fiona said:
It’s about understanding that different horses will run on different courses, and we really need to be as flexible as we possibly can.
The importance of accurate, current data was further emphasised by Professor Briggs, who said it is critical if “squeezing out” unwarranted variation from the system is to become a reality.
Talking through the HVLC (High Volume Low Complexity) Programme, he outlined how measuring care performance in operating theatres, for example – with data refreshed every two weeks so it can be thoroughly tracked – is a “complete gamechanger” in transforming the care offer.
When asked if there’s a danger of promises of transformation being ‘rhetoric’ only, he asserted a need for accountability:
there must be a structure, and we need to hold people to account – we can’t accept poor performance anymore.
Andrew Bennett, National Clinical Director Musculoskeletal Conditions, NHS England and Improvement, Consultant Physiotherapist Sutton Health and Care, Epsom and St Helier NHS Trust, gave an update on the BestMSK Health programme – focused on restoration and improvement across MSK patient care – and underlined how services were already stretched pre-COVID.
Highlighting that ‘whole pathway transformation’ is needed to reduce unwarranted variation, Andrew said there are resources available and ways of working that can be adopted, such as making the best use of digital technology.
We need to mitigate risk, we need to control demand and we need to make best use of capacity – but they are all quite cold words. [Alongside this], we have to have a constant focus on high quality care and optimal patient experience.
He also emphasised the role of MSK leads at ICS level in co-producing strategy to help drive change.
We want to enable MSK leads at ICS level to co-produce their MSK strategy, adopting over-arching principles… to meet local need…they have the best understanding of population and resources [locally].
Fredi Cavander-Attwood, Policy Manager (Health & Care), MS Society, provided a patient perspective, describing “the sense of injustice” felt by MS patients in dealing with the “postcode lottery” of the care offer, and a subsequent feeling of “having to fight the system” to obtain approved treatments.
Fredi said:
It has an emotional but also a physical impact, where people are struggling with symptoms like fatigue. Fundamentally, it’s not knowing what you’re entitled to, what you should expect, because national bodies say one thing and the local reality is different.
The final speaker at the event, Dr James Hopkinson, Joint Chair and Clinical Lead Notts and Nottinghamshire CCG, provided an integrated care system viewpoint.
He argued that the system needs to get away from working through waiting lists in date order, instead prioritising clinical need. Like Fiona, he emphasised the need for shared decision making, asserting that
[this doesn’t mean] the completion of tick boxes or forms by a surgeon…to make sure they’ve explained the risks [to a patient before an operation]… [instead] it needs to lead to a better clinical conversation at all points in patient pathways…[to] empower our patients…and help them make informed decisions.
Echoing Professor Briggs’ call for accountability, when asked about the main thing that needs to change to improve patient outcomes, Dr Hopkinson said:
There’s something about education and culture, so that we all actually start to believe it’s all of our problems, so that we’re all looking at the data… and we’re all engaging with patient conversations…This is everybody, across all parts of the system [who must be held to account].
Watch the webinar recording
Read our speaker biographies
Q&A Summary
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