Healthcare, says Simon Stevens, chief executive of NHS England, is the world’s largest cottage industry. This is illustrated by the enormous variations in practice that occur all across healthcare. Ten and twenty fold variations are common: imagine if the time of your plane from London to Sydney varied between one and 20 days depending on who you flew with; your car, depending on the manufacturer, broke down once every five years or four times a year; or your packet of Weetabix cost £1 or £20. Such variations would not be tolerated, and probably they wouldn’t either in healthcare if the broader public knew about them.
Academics and doctors have known about them since the 1930s, and Jack Wennberg from Dartmouth College who brought unwarranted variation to the fore began his work in 1967. Medical audit was introduced in the early 1990s and supposedly became compulsory, ensuring that all doctors reviewed their outcomes and continually sought to improve the care they deliver. The NHS even published the NHS Atlas of Variation in Healthcare in 2010, but so far there has been little progress in reducing variation. Could that be about to change across the NHS?
This week’s Cambridge Health Network meeting discussed reducing variation in the NHS and heard from Professor Tim Briggs, an orthopaedic surgeon; former president of the British Orthopaedic Association; and chair of Getting It Right First Time (known inevitably as GIRFT), an NHS programme to improve the quality of care and reduce cost by reducing variation. To look at, Briggs is the stereotypical orthopod, a big man dressed in a suit and tie who made frequent references to rugby. It was easy to imagine him in the front row. Yet he was atypical in that he spewed forth data from the beginning to end of the meeting, belying the old joke that if you wanted to hide something from an orthopod you’d put it in a statistics textbook. Briggs is as interested in data as he is in bones, and data are one of the main tools he’s going to use to reduce variation across the NHS. Listening to him you felt that if anybody could reduce variation he could, and he’s already done it to some degree in orthopaedics.
Briggs began his work in orthopaedics with a grant of £250 000. He recognised that the NHS needed to improve its performance and reduce its costs in order to be sustainable. He gathered data on all aspects of orthopaedics for all the hospitals in England and found, as expected, big variations—for example, one London hospital had a 15% infection rate after hip and knee replacement when some hospitals are close to having no infections. The data showed as well that surgeons performing more than 20 hip or knee replacements a year had lower rates of reoperation, and yet, as the report he produced shows, nearly a quarter of surgeons were doing less than 10 hip replacements a year and 16% of those doing knee replacements did fewer than 10. Remarkably, he then personally visited every hospital in England, showed the orthopods data on their performance in relation to other hospitals, and discussed what they could do to improve their performance.
The result was many improvements including reduced lengths of stay, fewer inappropriate arthroscopies, and a reduction in the number of surgeons doing low numbers of operations—and a saving of £100m over two years. Another improvement has been a drop in claims against the NHS. Such claims, which totalled £1.95 billion for the NHS in 2017/8, show the same variation as everything else in healthcare but with the same pattern for all categories of claims—with a few trusts accounting for many of the claims.
Briggs’s work in orthopaedics led to the Getting It Right First Time programme, which now has 37 work streams, all with a respected clinical lead, and a method that Briggs is convinced will work: the programme is clinically led, data driven, has implementation teams, and is externally scrutinised. The programme has already produced six reports, all on surgery, but it is extending to medicine and general practice. Some questioned that it was so hospital based, but Briggs pointed out that of the £16 billion spent on the NHS in London more than half goes to hospitals: hospitals, like banks, are where the money is.
But “How do you get the money out? asked one old hand. The answer seemed to be that the savings will lead to more “value” (better outcomes, more throughput) rather than cash savings. Indeed, with payment by results more throughput could lead to more expenditure on hospitals. Because about three quarters of NHS expenditure is on staff, cash savings usually mean fewer staff.
Briggs said how he had thousands of metrics on the performance of hospitals, and he showed rapidly a succession of slides filled with data showing wide variations. But these data are not public, and the reports from Getting It Right First Time give data on, for example, numbers of surgeons performing small numbers of operations, relatively innocuous data, but not on the huge variations. Those who have access to the data know where they would choose to go for an operation, but the public doesn’t have access to the data. (I’m about to have an eye operation, and I have no idea whether the hospital where I will have the operation has high or low postoperative infection rates.) Those in the room felt that these data should be made public and would have to be eventually.
There was also much discussion about the difficulty of achieving change in the NHS, where local people are very attached to their local hospitals and some clinicians reluctant to change. One answer was to work with the two thirds of clinicians open to change and leave “the laggards” to follow on in their own time. The evidence is that improving overall performance is more effective than concentrating on outliers, but Briggs is impatient with laggards. He insists that people must improve, and he wants to aim for the best, not the average (raising thoughts of Lake Woebegone, where all the children are above average). Getting It Right First Time has also been meeting with MPs to try and head off political protests that might arise around reforms that would be clinically beneficial.
Somebody asked whether commissioning shouldn’t have achieved what Getting It Right First Time hopes to achieve. There seemed to be agreement in the room that commissioning had failed and should be abandoned. “CCGs [clinical commissioning groups] don’t know what they are buying,” said one person, giving an example of a CCG requiring of a hospital simply car parking, quality of food, and targets for 30 day readmissions and deep venous thrombosis. There was also conviction in the room that regulation had not worked either in reducing variation.
Briggs argued that another benefit of Getting It Right First Time should be that it could identify doctors like the disgraced consultant Ian Paterson, who was found guilty of intentionally injuring patients. He became a consultant in 1998 and began harming patients in 2003 but wasn’t suspended until 2012. Metrics like his follow-up rate and the recurrence rate in his patients with breast cancer showed him to be an outlier and could have detected his misconduct much earlier.
Most people at the meeting knew that previous attempts to reduce variation have been unsuccessful and that change can be hard to achieve in the NHS, but, nevertheless, the meeting ended with the audience thinking that Getting It Right First Time could achieve the much desired goal of raising quality and reducing costs.
The Cambridge Health Network holds their events under the Chatham House rule, meaning that people cannot be reported by name. Professor Briggs has seen this blog and approved what is attributed to him.
Richard Smith was the editor of The BMJ until 2004.
Competing interest: None declared.