This document summarizes and analyzes significant variation in diagnostic testing rates across different areas of England. It notes that overuse and underuse of diagnostic tests can negatively impact patients. There is an urgent need to better understand the causes of this variation, as commissioners in some localities order over four times as many audiology assessments or 170 times as many rheumatoid factor tests as other areas. The document examines possible reasons for the variation, including weaknesses in the diagnostic evidence base, "defensive medicine", and younger doctors' reliance on technology. Reducing unwarranted variation will require recognizing healthcare scientists' and pathologists' skills and allowing them to benefit more patients. The attached atlas covers indicators for imaging, endoscopy, pathology

1. The NHS Atlas of Variation
in Diagnostic Services
November 2013
Copyright 2011 Right Care

2. Unwarranted variation in the rates of diagnostic testing is of
the utmost relevance to individual patients with the overuse, as well as under-use, of diagnostic tests being
potentially serious issues.
There is an urgent need for work to improve our
understanding of variation in the rates of many diagnostic
services, and to understand whether the variation observed
is random, warranted or caused by other factors.
Why do commissioners in one locality commission over four
times the number of audiology assessments than
commissioners in another, and why is there 170-fold
variation in the usage of rheumatoid factor testing ?

3. “ Our work across the NHS through the
auspices of NHS England will be focussed
upon addressing the issues raised by and
described in this Diagnostic Services Atlas,
with the aim of ensuring that patients have
timely, equitable access to the appropriate
diagnostic tests and the reports generated.
”

4. The magnitude of variation for many of
the indicators in the NHS Atlas of
Variation in Diagnostic Services may
surprise some people. In a context of
evidence-based medicine and
guidelines, how is it possible that the
degree of variation in diagnostic testing
is so great?
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5. In this Atlas, the focus is on people with
symptoms who are in need of a diagnosis.
For people with a diagnosis, although there
are variations in treatment, there is some
consistency regarding what happens to
them. This is in direct contrast to people in
need of a diagnosis, who face a more
disorderly health service.
There are several reasons why such
variation in the use of diagnostic services
exists…

6. First, the evidence base is much weaker for diagnosis
than for treatment, a problem being addressed by the
National Institute for Health Research (NIHR).
Second, there is the practice of what is sometimes
referred to as “defensive medicine”, the practice of
testing “just in case”, a particular challenge in the context
of biochemical and other laboratory tests, which is why a
relatively large number of such indicators are presented
in the Pathology Services section.
Third, younger doctors, who perhaps were trained in a
shorter period of time, have become more reliant on
technology.

7. Of critical importance in tackling the problems
revealed by the Diagnostic Services Atlas is the
contribution that healthcare scientists,
radiologists, pathologists and the various subspecialties can make.
Healthcare scientists, pathologists and
radiologists need to be recognised as
professionals with immense knowledge and skill,
and to be given the opportunity to apply that skill
for the benefit of the whole population and not
just for those patients referred for tests.

8. www.rightcare.nhs.uk/atlas
In print
You can order free printed copies
using the online form on out website
Online
High and Low resolution PDFs are
available for download
Interactive
A fully interactive InstantAtlastm
is available online
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9. The Atlas of Variation in Diagnostics Services covers five
areas of diagnostic services: imaging, endoscopy,
physiological diagnostics, pathology, and genetics. We
attach a copy of the Preface and Contents, to show the
coverage of the indicators, of which there are 69 in total.
We regard this Atlas as being very important because it
highlights a phenomenon that we have observed in our
work for Right Care that, although there is concern about
variation in the management of diseases, the
management of symptoms and the use of diagnostic
services shows even greater variation, some of which is
likely to be unwarranted.

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