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Time to stop playing the variation game


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Friday, 19 March 2010

Time to stop playing the variation game

The NHS Confederation has published its manifesto for the NHS, a readable and sensible analysis of where we find ourselves and the situation a new administration will inherit.

Among its recommendations is ‘for the NHS to be much less tolerant of variation that is not

supported by evidence, and for professional leaders and clinical managers to take a more active role in challenging this’.

Variation in the NHS takes a number of forms. Some are good. Some are bad. They are easily confused and sometimes willfully confused by individuals and organisations seeking to defend their own interests.

Among the forms of variation we consider good are patient choice and commissioning that reflects different demographics or health needs. 

Bad variation is the kind that arises though inadequate management, dysfunctional relationships between commissioners and providers, variations in clinical ability or standards of care, funding inequities, poor leadership, misaligned systems and so on.

There is no shortage of evidence to measure variation and no shortage of excuses to explain it away. Local enhanced services were designed to allow good variation – funding for services to meet particular local needs that were not covered by existing provider contracts. Some of these are excellent but in other cases services are effectively being paid for twice, once via the core contract and again through what amounts to a discretionary top up.

Recent surveys have shown that the true variation between what the least and best rewarded general practices receive can be a factor of almost two. Sometimes the discrepancy is justified; often it is not. There is no clear correlation between the highest performing providers and the highest paid ones, and the evidence suggests strongly that many of the traditional defences of variation are spurious or cynical. An overpaid, underperforming provider will point to the difficulty of making like for like comparisons or the unique health needs of the population.

Better evidence is exposing some of these arguments as false. Like for like comparisons are possible and while health needs vary according to a range of factors they are not beyond the scope of analysis.

The Confederation’s prescription is right. Some people will object that it creates an NHS by numbers, but that’s a worn-out argument. Nobody benefits from beancounting but everyone benefits from accountability.


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