1. Copyright 2011 Right Care The need to understand variation in healthcare: When is variation unwarranted? Phil DaSilva National Lead NHS Right Care November 2013 Online Learning Series Right Care for Populations

2. 2 Reducing unwarranted variation to increase value and improve quality “ A good map is worth a thousand Words… … cartographers say, and they are right: because it produces a thousand words: it raises doubts, ideas. It poses new questions, and forces you to look for new answers. ” Franco Moretti (1998) Atlas of the European Novel 1800–1900 The NHS Atlas of Variation 2011

3. 3 Four things Understanding Variations Defining Variations Identifying Variations Not all Bad What is it? Who names it? Who defines it? Who decides what is and isn’t variation? Tools are needed to search for variations Variation can be good

4. 4 Variations are not a new phenomenon Variation in healthcare remains endemic, with many articles published in the past 40 years identifying the existence of variations in health care across demographic groups, geographic areas, institutions and even individual health care providers within a single institution and in hospital treatment rates. J Allison Glover, 1938 10-fold variation in tonsillectomy 8-fold risk of death with surgical treatment Essential Reading: Unwarranted variation in health care Essential Reading: Unwarranted variation in health care - with an introduction by Sir Muir Gray September 2011

5. 5 There is also evidence of variations in general medical practice and between general practitioners (GPs) and practices, with variations identified in areas such as the frequency of contacts, registration of diagnoses, diagnostic test ordering, referrals, prescription rates, and return visits

6. Ensuring measurement and publication of information for both NHS England’s direct commissioning and CCG commissioning (outcomes and value for money) including inequalities and unjustified variation Mandate paragraph 9.3 (page 61)

7. Researchers, academics, clinicians and other observers are still discovering wide variations ( Reid et al; 1999, McPherson, 2008, Wennberg 2010, McBride et al; 2010, Appleby 2011 ). Reid, F.D.A., Cook, D.G. & Majeed, A., 1999. Explaining variation in hospital admission rates between general practices: cross sectional study. BMJ British Medical Journal, 319(7202), pp.98-103. McPherson, K., 2008. Commentary: James Alison Glover (1874-1963), health care variations research then and now. International Journal of Epidemiology, 37(1), pp.19–23. Wennberg J,. 2010 Tracking Medicine: A Researchers quest to understand healthcare. Oxford University Press McBride, D. et al., 2010. Explaining variation in referral from primary to secondary care: cohort study. British Medical Journal, 341(7784), p.c6267. Appleby, J., et al., 2011. Variations in Health Care: the good, the bad and the inexplicable: The Kings Fund; London

8. 8 …….. many years later, we can still observe variations in health care in England, NHS Atlas of Variation series, (DH; 2010, 2011, 2012) …….and many countries are facing the same puzzle of understanding variations in their health care system …….. http://www.oecd.org/els/health- systems/medicalpracticevariations.htm

9. 9 ….and yet the management of variations in health care remains an elusive management concept… …….the conundrum is whether the NHS in England is primed to understand and explain, or to tolerate and justify known variations in healthcare.

10. 10 Frame and re-frame narrative… Patients Clinicians Managers Researchers..common understanding of variation

11. Mulley (2009) comments that if all variations were considered as good or bad, then dealing with them would be easy and he urges clinicians and policy makers to find the courage and curiosity to confront variations in health care. Mulley, A.G., 2009. Inconvenient truths about supplier induced demand and unwarranted variation in medical practice. British Medical Journal, 339(oct2).

12. unwarranted unexplained unjustified random unacceptable Classification of Variations – Who decides?

14. www.rightcare.nhs.uk

15. 15 Summary Variation exists The NHS needs to be primed to deal with it and needs to have leadership Explain and understand variation A strength to build on is that clinicians are keen to understand variation Start now!

16. 16 Online Learning Series Right Care for Populations Follow Right Care online Subscribe to get a weekly digest of our blog alerts in your inbox, Receive occasional eBulletins Follow us on Twitter @qipprightcare Find the full series at: www.rightcare.nhs.uk/resourcecentre