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. 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. Mapping variations presents some clear directions of travel. For instance, if there is variation in rates of admission to stroke units, it is obvious that the rate of admission needs to increase in those populations in which the rate of admission is low. Unwarranted variations offer health services in every country the opportunity to obtain greater value from healthcare resources.

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

2. The NHS Atlas of Variation 2011
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
2

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

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 - with an introduction by Sir Muir Gray September 2011
4

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
5

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. …….. 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/healthsystems/medicalpracticevariations.htm
8

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.
9

10. Frame and re-frame narrative…
10
..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. unexplained
unjustified
random
unacceptabl
e
Classification of Variations – Who decides?
unwarranted

14. www.rightcare.nhs.uk

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!
15

16. Online Learning Series
Right Care for Populations
Find the full series at:
www.rightcare.nhs.uk/resourcecentre
16
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