Matthew Cripps and John Newton explain how the NHS Right Care model is designed to help drive service improvement and avoid unwarranted variation

It has been more than five years since the publication of the first NHS Atlas of Variation in Healthcare, and yet inconsistencies in treatments and services are still a widespread challenge for the NHS.

Much of this variation is unwarranted, in that it does not involve differences in illness, patient preferences or population needs and can therefore be avoided. Unwarranted variation wastes valuable resources and may even do more harm than good.

Unwarranted variation wastes valuable resources

By addressing this type of variation the NHS can greatly increase the value of healthcare – the balance between the resources put in and the benefits realised (for both individual patients and the population).

The Atlas has more than 100 maps and is a key part of the new NHS Right Care model designed to help clinical commissioning groups, NHS trusts, local authorities and NHS area teams tackle variation.

The NHS Right Care approach

The NHS Right Care model follows a three stage approach and uses the Atlas of Variation, along with other tools to help the NHS drive service improvement.

The first step, “where to look”, identifies areas with the greatest potential for improvement through direct comparison with similar parts of the NHS. Because of the variety and comprehensiveness of its data, the Atlas is key to this approach. It represents an ideal starting point for identifying quickly which local services are outliers and therefore sub-optimal.

It involves a deep dive into a particular care pathway to gain more detailed insight

In this way the Atlas indicates where more detailed investigation should be focused. NHS Right Care’s Commissioning for Value packs for each clinical commissioning group are also designed for this purpose.

The next step, “what to change”, is supported by NHS Right Care’s Pathways on a Page tool. The tool identifies exactly which aspects of services can be improved locally.

This typically involves a “deep dive” into a particular care pathway to gain more detailed insight into what is working well, and what is not.

The final stage, “how to change”, is about proving the credibility and viability of the proposed change and then implementing it. This requires the disciplined use of reliable processes, including programme management, stakeholder engagement, analysis of the potential impact on service providers and a sound business case.

Shared ownership

There are five essential ingredients for creating the right conditions for achieving increased value. Encouraging clinical leadership is essential.

Clinicians are the right people to recognise, articulate and drive the case for change. Encouraging this becomes easier where CCGs and providers have strong relationships.

Clinical engagement is key to this and direct involvement of a suitable range of clinicians in pathway redesign creates shared ownership of any change.

The model focuses on talking about what is wrong

Indicative data, like that provided by the Atlas of Variation and other insight tools, helps direct further inquiry. Evidential data or “deep dives” also provide detailed justification of local change, while impact assessments are important for understanding what happens to costs and patient flows.

Finally, improvement can only be ensured if implementation is robust and there is a sound business process. 

Successful adoption of this NHS Right Care approach establishes the collective positive mindset needed to achieve effective change. The approach aims to get everyone discussing the same issues and agreeing to priorities.

This creates momentum and a common purpose.

The model focusses on talking about what is wrong as opposed to whose fault it is or the cost involved in fixing it and remaining confident that the right action is being taken and is achievable.

The RightCare Approach: A Case Study

Using the NHS Atlas and other tools mentioned, Blackpool and Fylde and Wyre CCGs identified unscheduled care as a key area for improvement.

Analysis of the local ambulance service database showed 1,100 999 calls in three months came from just 100 individuals.

An advanced paramedic was assigned to contact them. Many were found to have emotional, financial or family problems rather than ill health, indicating that understanding and guidance were needed rather than enforcement.

In the first 15 months among the cohort:

  • 999 calls to the ambulance service fell by 89 per cent and to the police by 44 per cent
  • Accident and emergency attendances reduced by 93 per cent
  • Hospital admissions were down 82 per cent
  • There was a 98 per cent reduction in incidents of self-harm

The change has delivered sustainable clinical and financial benefits. Patients have been supported to maintain a better quality of life, while an investment of £70,000 achieved a saving of more than £2.7m in 15 months.

Blackpool CCG has embedded the model into primary care, offering coaching to vulnerable and high service users.

Healthcare can vary in different ways: in its quality, the outcomes achieved, the money spent, the types of service and levels of activity. It can involve both the under-use and over-use of services and treatments.

There are three aspects to value. Firstly, value-based healthcare is about making services personalised. In this, shared decision making is crucial because it can help with deciding when intervention is not benefiting a patient.

Secondly, value needs to be allocative, with optimal distribution of resources among all the sub groups in need in the population. Data indicates there is currently a 1.6 to 2-fold variation in resources assigned to different programme budgets, such as those for people with musculo-skeletal problems or mental health needs.

This is further complicated by the fact that many patients have more than one condition.

Lastly, leaders also need to think about the productive use of resources such as the proportion of surgery done as day cases or hospital length of stay.

Next steps

Right Care’s focus on healthcare value is now firmly centre stage and a full rollout is getting underway. Ten new delivery partner posts have been created and from February 2016, CCGs will be recruited in waves of 60 to adopt Right Care practice, with all 211 CCGs expected to take part over the next two years.

Commissioning support units will be offered development alongside an accreditation framework, to enable them to support CCG clients (such as through service ”deep dives”).

This is not just a matter for commissioners; NHS providers will also be encouraged to use the Right Care approach. Patient groups can help to enhance public knowledge of what constitutes high value care, and engage with clinicians in this debate.

The identification of variation is an opportunity to improve, not to explain it away

There will be a strong focus on partnerships, with NHS England and Public Health England working closely with regulators and other agencies (for example, to embed Right Care principles within professional training). PHE will further develop its variation and value function with analyses to provide additional insight as fresh data sets become available and new requirements emerge.

Some colleagues will need persuading that this whole approach is the right one. Evidence that other parts of the NHS are doing it better is not always welcomed by those for whom the comparison is less favourable – although many do respond positively.

Major challenges

Good leadership will be needed to drive this change in culture. It will be important to promote the idea that the identification of variation is an opportunity to improve, not to explain it away. In fact, understanding the Right Care philosophy will help financial professionals to engage with clinical issues, and clinicians to embrace matters of finance.

The potential benefit is considerable – both for patients (better prevention, care and outcomes) and for the NHS (hospital avoidance, cost savings, greater efficiency). The Right Care approach is not a panacea, but it can help the NHS to meet the major challenges set out in the Five Year Forward View.

The 2015 Atlas and others are at www.rightcare.nhs.uk/atlas – both as downloadable PDF files and in interactive form, where the numbers underlying maps can be seen. This website also provides access to other NHS Right Care tools, including Commissioning for Value packs for all CCGs (www.rightcare.nhs.uk/index.php/commissioning-for-value/)

Matthew Cripps is national director for NHS Right Care and John Newton is chief knowledge officer at Public Health England