The authors of the Atlas of Variation in Healthcare say the dominant paradigm for the NHS for at least the next decade will be value. Bola Ajekigbe reports

There is growing evidence that the Atlas of Variation in Healthcare is driving major change in the NHS, as both commissioners and providers seek to maximise the value of their services.

According to Sir Muir Gray and Phil DaSilva, co-authors of the Atlas and joint national directors of the QIPP Right Care work stream, the dominant paradigm for the NHS for the next decade, and perhaps beyond, is value.

Value, the relationship between outcomes and costs, can be adversely affected by the myriad ways in which healthcare varies.

Mr DaSilva says “the production of the atlas itself is important, but the bigger prize is the use of the atlas to transform care and improve outcomes”.

Stimulating dialogue

The Atlas stimulates commissioners and providers to work together with their populations to understand how the allocation of their resources can benefit a greater number of patients.

In addressing unexplained variation, by highlighting outlier activity of a primary care trust’s activity and spend relative to others and stimulating dialogue on optimal resource allocation, the atlas has proved influential in maximising value for commissioners and providers, clinicians and managers, as well as benefits to patients.

We need to remember the great improvements made in the NHS and that things constantly change with technology and medicine

Indeed it is vital, say Sir Muir and Mr DaSilva, that commissioners and front line clinicians work together to drive QIPP. On this front, the Atlas has not only provided a strategic overview of potential areas for action, but also a narrative to engage clinicians to be backed-up locally with systems and processes to identify and tackle unexplained variation.

We need to remember the great improvements made in the NHS and that things constantly change with technology and medicine and as clinicians start certain activities and stop others”.

Encouraged by the level of interest from clinicians across primary and secondary care, Phil DaSilva believes the ability of all clinicians to effect change is underestimated. “That impetus is blunted if clinicians are not supported and where systems become overly bureaucratic”.

The Atlas is not designed to be used in isolation, but as a catalyst for change, and as part of a suite of tools to triangulate resource allocation and services achieving optimal care.

Warrington Clinical Commissioning Group (CCG)

When Warrington CCG gained full delegated authority from NHS Warrington in April 2011, it needed quickly to identify efficiencies, where benchmarking showed they ought to be made, and where changes would improve quality and productivity, leading to improved patient care.

The Atlas of Variation enabled the consortium to identify the service areas and pathways where its Office for National Statistics cluster peers collectively delivered more efficient, effective and/or appropriate pathways for a similar demographic population. 

The service reviews identified many opportunities for improvement and transformation and these are now being implemented

This initial benchmarking data – on outlier activity, expenditure, outcomes and quality – was then used to inform a full service review that determined the causes of overspends and sub-optimal performance.

The CCG was charged with delivering £20m of the £25m QIPP savings NHS Warrington needed in 2011-12. The first wave of reviews focused on mental health, trauma and injury, respiratory and musculoskeletal services, all areas that the Atlas of Variation showed significantly higher activity and expenditure than the norm.

The service reviews identified many opportunities for improvement and transformation and these are now being implemented. Clinical pathways have been redesigned, in collaboration with stakeholders, to deliver high quality and sustainable services for the future.

NHS Lincolnshire

In 2009/10 NHS Lincolnshire undertook a major review of its expenditure to identify potential cost-savings and areas for quality improvement from reducing unwarranted variation.

At a strategic commissioning level, NHS Lincolnshire has been working with the Right Care team using programme budgeting and the NHS Atlas of Variation as the initial level of detail. Starting from a broad overview of spending across disease-based programme budget categories and variation across primary care trusts (PCTs), variation was then examined down to a granular level with data from the East Midlands Quality Observatory.

Cancer and musculoskeletal conditions illustrate two programme budget categories where NHS Lincolnshire has been using data from the Atlas

At a local level, primary care and commissioning dashboards have been developed to monitor deviations from locally agreed targets. The dashboards are updated regularly and discussed in bi-monthly meetings involving CCGs and the PCT’s commissioning team. The CCG executives then feedback to individual practices. Results showed that Lincolnshire could realistically achieve £12-16m in efficiency savings per year.

Cancer and musculoskeletal conditions illustrate two programme budget categories where NHS Lincolnshire has been using data from the Atlas to understand identify unwarranted variation, and then has taken corrective action to remedy the misalignment of resources.


The Atlas highlighted high expenditure on cancer against poorer than average outcomes in terms of mortality. An in-depth review by the cancer team, focusing on major drivers of cost and activity, indicated several areas for action:

  • Chemotherapy regimens and spend: a review with the local cancer network showed multiple charging for treatment events, in particular four separate charges for chemotherapy. Contracting action is now underway to ensure appropriate payment.
  • High levels of emergency admissions, both at active treatment stage and end of life: new services including palliative care co-ordination and rapid response teams (commissioned from the third sector) have already had an impact on increasing the number of patients who are dying at home.

Musculoskeletal conditions

The Right Care programme identified large variations in rates of un-cemented hip replacement across Lincolnshire. Local clinicians cited high levels of trauma as being the explanation; despite lower levels of hip fractures shown in the Atlas of Variation. An in-depth review of activity was undertaken to understand variation against regional and national norms.

  • A review of waiting lists identified large scale non-compliance with prior approval processes, especially in spinal surgery and for other musculoskeletal conditions. This involved reviewing both procedures of limited clinical value, and the range of simple procedures already available in the community within primary care, and revealed significant duplication of services.
  • Clinical thresholds for all elective orthopaedics are now being enforced. Rigorous enforcement of prior approval now in place is expected to save £2m by the end of 2012/13. The trust has instituted a policy of non-payment for procedures of low clinical value not having prior approval.
  • Opportunities in the contracting process are increasingly used to influence provider behaviour. Reduction in variation has been identified as a potential commissioning for quality and innovation (CQUIN) payment for 2012/13 if no change is detected.

NHS Lincolnshire plans to expand action on unexplained variation through a specialty-wide focus in co-operation with the East Midlands Quality Observatory. Variation data in terms of secondary care activity will play a key part in the “tool boxes” being assembled by emerging CCGs and their commissioning support services.

Find out more

All of the atlases can be downloaded from the Right Care website