The Department of Health has for the first time laid bare the huge regional variations in healthcare across England.
The first NHS Atlas of Variation in Healthcare, published today, shows dramatic differences in wellbeing, health outcomes, spending and service provision across England. Much of the variation cannot be explained by population health need and highlights shortcomings in the quality and value of services, the atlas says.
Even after the five biggest outliers have been removed from both the top and bottom of each area analysed, the 34 maps reveal significant variations. This includes a 12-fold difference in the rate of bariatric surgery between primary care trusts and more than a 10-fold variation in the proportion of high risk transient ischaemic attack cases treated within 24 hours.
The report was overseen by Sir Muir Gray and Philip DaSilva, the co-leads on the right care strand of the DH’s quality, innovation, productivity and prevention programme.
In the report’s foreword they state: “Our aim is to put variations in activity, expenditure, quality, outcome, value and equity firmly on the health service agenda for the next decade, and to stimulate the NHS to search for unwarranted variation and, by extension, to tackle the causes and drivers of that variation.”
The report calls for a “move towards a health service focused not only on its great institutions but also on the health and healthcare problems that persist despite reorganisation and structural change”.
Mr DaSilva, a former PCT chief executive and regional commissioning director, told HSJ there would be some “oh my god moments” when PCTs look at their position.
He said: “I suspect some people are unaware of the levels of variation they [are] operating in. Some will be surprised by it.
“Publication of this [data] cannot be underestimated. It shows just what we’ve got to do and how we’ve got to operate.
“[It is] a defining moment for the NHS because it will move discussion to allocation of resources to increase value, as opposed to contracts and bureaucracies.”
King’s Fund chief economist John Appleby said: “It is great [to] have in the public domain the fact, for example, that in some parts of the country it is very easy to get a hip replacement and in other parts it is not.”
The atlas reveals a six-fold variation in the rate of hip replacements. It also confirms that patient reported outcome measure results published this year showed wealthier populations “are receiving hip replacements much earlier in the course of their arthritis”, compared with more deprived populations.
Professor Appleby said: “People at the bad ends of variation need to be put on the spot and asked to justify what is going on.”
Levels of variation across service areas
| Map indicator | Variation between regions |
| Cancer inpatient spending rate | 2-fold |
| Major amputations among type 2 diabetes patients, by strategic health authority | 2-fold |
| Diabetes patients receiving nine key care processes (%) | 5-fold |
| Bariatric procedures rate | 12-fold |
| Suicide mortality | 5-fold |
| Incapacity or severe disablement benefit claimants with mental or behavioural disorders, by local authority | 4-fold |
| Elective admissions among epilepsy patients | >4-fold |
| High risk transient ischaemic attack cases treated within 24 hours (%) | >10-fold |
| Emergency admissions among asthma patients aged 18 and under | >3-fold |
| Average patient reported pre-operative health for knee replacements | 2-fold |
| Hip replacements among people “in need”, by local authority | 4-fold |
| Spending on anterior cruciate ligament reconstruction | 9-fold |
| Caesarean section (without complications) spending | 2-fold |
| Diagnostic referral rate among newborn hearing screenings | 4-fold |
| Magnetic resonance imaging activity | 2-fold |
Figures are rates among the relevant population except where stated, adjusted for age and sex and where possible by need. Variation is among PCTs except where specified otherwise
Causes of variation identified
Community and ambulatory services
Different access to and quality of out of hospital and outpatient services are the most common factors behind the variations featured in the atlas. It is highlighted as a significant issue in 11 of the 34 topics.
For example, variations in cancer hospital stays - the largest single area of cancer spending - “cannot be explained by differences in the incidence of cancer”, the atlas says.
However, it says bed days and spending can be cut by “increased use of ambulatory care services”. Best practice in hospitals, such as advanced recovery techniques - can also reduce length of stay.
Elsewhere, the atlas says hospital admissions among people with epilepsy can be avoided through community based epilepsy services with links to acute specialists, and GPs reviewing patients more often.
Clinical thresholds
Differences in clinical decision making, affecting referral and activity rates, are linked to 11 of the 34 topics. These include elective epilepsy admissions, bariatric surgery rates, cataract surgery rates, and referrals for scans.
It also influences variation in the rate of hip and knee operations and, linked to both of those, the average self-reported health of those undergoing the procedures. This judging was drawn from the recently introduced collection of patient reported outcomes measures.
The atlas says: “Areas with the highest rates of total knee replacement have PROMs with the lowest pain and disability scores. Areas with greatest need and the poorest access to knee replacement tend to be more deprived.”
It says one reason for this is simply variation in clinical practice, with some orthopaedic consultants recommending knee replacements for patients their peers would not view as needing the operation.
Hospital best practice
Following best practice guidance in hospital is linked to eight topics of variation, including spending on Caesarean sections, hospital bed days associated with chronic obstructive pulmonary disease, and length of stay for fractured neck of femur patients. Another topic, the proportion of stroke admissions spending 90 per cent of time on a designated stroke unit, requires “redesigning whole systems”, the atlas says, so hospitals have units meeting well known standards such as 24 hour physiological monitoring.
Diagnosis, checks and screening
Better diagnosis, checks and screening, generally by GPs, is a significant factor in variation in five topics, including the ratios of reported to expected prevalence of epilepsy and chronic kidney disease, and emergency admissions of people with epilepsy. Another area susceptible to better diagnostics is major amputations in people with type 2 diabetes, 80 per cent of which are potentially preventable. The atlas says primary and community care should establish multidisciplinary foot teams.
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