Mapping variation to prioritise areas needing improved outcome, quality and productivity

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An “atlas” of unwarranted variation in healthcare for children is informing commissioners and empowering parents, writes Ronny Cheung.

Variation in the NHS is well recognised. Put simply, the consequences of variation in healthcare are that patients are not receiving the most appropriate care, and the NHS is not getting the most from its resources.

Following the seminal work of Dartmouth professor Jack Wennberg on healthcare variation in the US, the NHS Atlas of Variation in Healthcare has highlighted levels in England across a range of indicators.

The NHS Right Care programme has commissioned a suite of themed atlases, starting with a collaboration with the Child and Maternal Health Observatory on variation in healthcare for children and young people.

Why variation matters

Variation occurs because healthcare is a complex business influenced by a plethora of social and interpersonal factors. Indeed, a great deal of variation may not only be expected but desirable. It may, for instance:

be due to factors outside the control of healthcare services, such as socioeconomic deprivation, differences in population age or gender mix;
reflect a service that is tailored for the specific needs and preferences of individual patients or populations;
result from a local innovation which improves the quality of service.

What is more important for service improvement is to identify “unwarranted” variations, which Professor Wennberg defines as “variation that cannot be explained by patient illness or preference”.

This may be because we are deviating from evidence-based clinical standards and guidance for high quality and high value care, whether as a result of variation in clinical performance and skills or wider system shortcomings influencing access, flow and productivity.

The supply of healthcare resource may influence its utilisation irrespective of its value – for instance, there is much evidence to suggest that where local healthcare capacity is greater there are higher admission rates or more outpatient appointments, with no demonstrable improvement in overall outcomes.

Finally, where there is more than one treatment option for a particular condition, clinician preference is often the final arbiter, where an approach of shared decision-making with fully informed and engaged patients has been shown to result in fewer, less invasive treatments being used.

The purpose of the Child Health Atlas is to illustrate the magnitudes of variation in quality, equity of access and outcomes across 27 indicators of child health.

For the first time, variations across the breadth of child health services provided by NHS England are presented together to allow clinicians, commissioners and service users to identify priority areas for improving outcome, quality and productivity.

While the unit of analysis (primary care trust) will soon be superceded by clinical commissioning groups, the overriding purpose of illustrating and tackling variations will not change. The Child Health Atlas allows patient groups and families to identify and challenge commissioners and clinicians as to the appropriateness of any geographical variation in quality, access and outcomes.

Key findings

The degree of variation demonstrated in these 27 indicators is significant. For instance, after removing the five PCTs with the highest and lowest values in order to reduce the effect of outliers, the magnitudes of variation for emergency admissions among PCTs in England for diabetic ketoacidosis are threefold, for epilepsy over fourfold, and for asthma nearly fivefold.

Lengths of stay for bronchiolitis and epilepsy vary by 2.5-fold and threefold. Needless to say, including outliers magnifies the degree of variation enormously (click on the purple maps, above right).

Indicators of community child health and primary care show similar degrees of variation. For instance, after removing outliers, perinatal mortality varies twofold among PCTs in England and breastfeeding rates threefold.

Outside health, variation is equally marked – rates of “statementing” of primary school children vary sixfold among local authorities in England (click on the purple graph, above right).

It is difficult to explain such stark variation between any two PCTs purely on the basis of warranted variation. The key is for local services to understand their own outcomes in context. Local populations may derive greater value from certain services than their neighbours, and the aim must be for commissioners to ensure the variation illustrated is warranted by difference in local need.

Practical steps

Illustrating the magnitude of variation can highlight priority areas for change. For these areas, the key questions that follow for local commissioners and clinicians are:

Is the variation warranted or unwarranted?
If unwarranted, what are the causes?
What can we do to address the causes?

Local commissioners can use the Child Health Atlas to improve the quality, access and outcomes for local services by:

Prioritising areas of high variation: Local commissioners and clinicians in consultation with patient groups must decide which of the highlighted areas require most urgent redress in terms of improving outcomes, productivity, quality and equity of access.

Using tools for improvement: Variation in outcomes must be seen in the context of the relationship between local need and expenditure. Many tools exist for commissioners to identify the variables and benchmark performance against similar PCTs.

Of particular relevance to child health are the spend and outcome tool, which allows comparison in expenditure and outcome between similar PCTs, and the disease management information toolkit, which models the effect of commissioning decisions for long term conditions in children and young people.

Redesigning systems of care: Unwarranted variation is primarily a symptom of system design failure. Redesigning pathways of care that are responsive to local needs, facilitate evidence-based clinical practice and that are sensitive to the influence of supply-and-demand and shared decision-making will be more effective in reducing unwarranted variation than trying to impose behaviour change within an existing imperfect system. Clinical leadership is a vital ingredient in implementing such changes.

Identifying further indicators: The 27 indicators included in the Child Health Atlas are by no means comprehensive, and should serve only as a starting point to identify areas of high variation. In order to maximise value for their populations, variation in other areas of high local priority should be identified, measured and the causes tackled in the same way.

Interrogating variation in different dimensions: Many variations are dependent on local factors such as clinician preference or existing pathways of care, which are therefore persistent and can be highlighted by longitudinal analysis of variation. Variation in outcomes depending on timing of admission or intervention has also been demonstrated.

Local commissioners may also be able to identify reasons for variation at a population level by changing the unit of analysis from populations down to individual services, providers or even individual clinicians.

Many local providers and commissioners have already used variation analysis to great effect, as a starting point to identify and tackle the reasons for variation.

In future, greater changes will be required to reduce unwarranted variation in healthcare for children and young people.

Data: To reduce variation, we must first be able to measure what we are doing. For child health, the relatively smaller numbers involved means a coordinated approach to data collection is essential, particularly to facilitate new CCGs in accurate benchmarking and comparisons of quality. Improved accessibility and linkage of record-level data would allow for more sophisticated and granular measurement of outcomes.

Child health does not exist in isolation. Analysis of child health services should encompass other endpoints such as educational attainment, readiness for employment and transition to adulthood, impact on families and outcomes in social care. The work of the recently launched Children and Young People’s Health Outcomes Forum will be instrumental in identifying meaningful outcome measures by which commissioners and clinicians can be held accountable.

Networks and clinical integration: Services for children, particularly those with long term and less common conditions are often fragmented. Consequently, these children are at the greatest risk of variation in the quality of their care and in their outcomes.

Commissioning care through an integrated clinical network can play a powerful role in reducing variation in healthcare for children and young people, where the populations are relatively small. Quality can be enhanced through centralised upskilling of staff and the creation of seamless pathways of care delivered close to home where possible. Access is equitable, based on clearly defined need. Sharing of resources means greater value to commissioners and patients, while peer review and data collection for benchmarking, both among and within networks, is facilitated.

Tackling unwarranted variation can reap rich rewards for the NHS, and is part of an ongoing process of improvement to achieve better outcomes for the children and young people we serve. The Child Health Atlas should start commissioners and clinicians on the path to investigate variation, routinely and continuously, to maximise quality, outcomes, productivity and value.