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Reducing variation in healthcare services in the UK

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Do people in England have equal access to the same quality evidence-based NHS services according to their needs and if not, what can nurses do about it?

I have been in nursing for over 30 years and witnessed many positive changes, but the fundamentals remain the same: we are here to provide the best possible care to individuals and populations. Yet we know there are differences in the way care is provided around the country and within organisations and we must constantly ask ourselves: “How do we know the care we are delivering is the ‘best’?”

“Why is it that some people receive optimal care while others receive standard care?”

Michelle Mello

Michelle Mello

Michelle Mello

Despite many of us giving our all, we still see wide variation in the care people receive while using NHS services. We see variation in quality, safety, equity, outcomes and spend as well as types of services used. So, why is it that some people receive optimal care while others receive standard or, even worse, sub-optimal care?

Some variation in healthcare is expected and normal, often linked to levels of illness or individual preference; so we can expect to see some variation in the way someone chooses to manage, for example, his or her long-term condition or reproductive health. However, much variation is unwarranted and this means it cannot be explained by the same causes and should be explored. To illustrate, if you live in England and have a learning disability you are four times more likely to die of preventable causes compared with the general population. This unwarranted variation could be due to many factors, including limited professional knowledge or the way organisations/systems work, including fair access to care.

“Unwarranted variation may be caused by underuse of care practices”

Some unwarranted variation may also suggest overuse of resources leading to waste and potentially harm. We may be doing things that have no or limited benefit, for example, over-prescribing antibiotics. Equally, unwarranted variation may be caused by underuse of care practices, such as Doppler in the management of venous leg ulcers.

The important thing about unwarranted variation is that it raises questions about quality, equity, effectiveness and value in healthcare. So as nurses, what is our role in exploring unwarranted variation and what can and should we do about it?

“It is in our hands to influence and change care processes”

Nursing sits on the front line of care and has a key role in the way resources are used, placing the profession in a position to identify and reduce unwarranted variation. It is in our hands to influence and change care processes, after all nursing is the leading profession that works with patients and individuals to plan and deliver most care.

There is help to support nurses achieve this through the NHS RightCare initiative. It helpfully focuses on individuals and populations as opposed to organisations, specialities or technologies, important though they are.

NHS RightCare uses evidence and intelligence to promote sound business processes to reduce unwarranted variation.

Some questions NHS RightCare will help you ask include:

  • Is care determined by historical referral patterns?
  • How many people are there in the population with this problem?
  • What proportion do we see in our service?
  • Are we not seeing those who would get great value from our service?
  • How good are our outcomes compared with outcomes in a similar population?

The RightCare approach has three steps that help health systems identify and reduce unwarranted variation - where to look, what to change and how to change, none of which can happen without involving nurses.

Step one uses robust data to identify the clinical areas where there is the biggest opportunity to improve outcomes, such as respiratory, cardiovascular or cancer or all three. This step is important to nurses because clinicians determine the pattern of spend within each programme budget.

Step two looks at designing optimal care pathways to improve experience and outcomes. This is where clinicians and especially nurses are key.

Step three future proofs the changes by ensuring the new ways of delivering optimal care are shared by everybody.

You can find out more at

Michelle Mello is deputy national director at NHS RightCare

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