Ronald Reagan once famously quipped that the nine most terrifying words in the English language are ‘I’m from the government, and I’m here to help’. But that doesn’t, for one moment, stop Michael Horrocks, Professor of Postgraduate Surgery at the University of Bath and a former President of the Vascular Society of Great Britain and Ireland, relaying precisely that message to a room full of vascular surgeons and interventional radiologists. ‘We are here to help,’ he says. ‘We are not the Care Quality Commission. We are here to serve. …There will be plenty of chance to comment as we go through,’ he says as the team [of clinicians and managers] wants to provide answers to what they can see are their less-good figures. ‘We are not here to catch you out. We are here to help.’
This quote opens a new report, variations in clinical care, by Chris Ham, a veteran of the London health think tank, The King’s Fund, about a National Health Service (NHS) program designed to link data about clinical practice and variations, patient outcomes and costs.
The variation in frequency of some medical and surgical treatments raises questions that require answers from the doctors providing those treatments and from the hospital managers behind them. When rates of treatments vary widely from one hospital to another, or between surgeons in a large specialty unit (even when variations in disease severity are accounted for), the basic question is this: which clinicians have it right? The answer to that question is important for getting the best deal for patients and also for making the best use of money allocated for health care.
Studies in Australia have confirmed large variations in clinical practice. The rates vary by region (urban versus rural), by hospital type (public versus private) and by specialty. With constantly improving electronic systems capturing performance data in the health system, these variations are now readily documented. If the clinical and financial data can be brought together, a complete picture of clinical practice can be drawn.
But what is it that Michael Horrocks is doing?
Ham tells of watching Horrocks meet with a group of surgeons in a hospital. He presents to them 60 slides of information about different conditions, comparing the performance of different surgeons, examining variations in clinical practice and cost:
The suggestions for improvement come from both Horrocks and the consultants themselves, who recognise that the way the theatres are used needs to be improved; that so many patients these days are older people for whom the surgeons need to work more closely with their medical colleagues to get their length of stay down; that to get the service’s infection rate down, the vascular surgeons need their beds ring-fenced so that emergency medical patients do not introduce infections that get to the surgical wounds.
The NHS has started a program called Getting it Right First Time. The aim is to use all available data to show where performance variations are out of line with best practice. Effort is then applied to stop wasting money on clinical activity that deviates from best practice with no explanation.
In Australia, Anne Duggan and colleagues at the Australian Commission on Quality and Safety of Health Care published a second edition of The Australian Atlas of Healthcare Variation in June 2017. It is hugely comprehensive and stacked with fascinating data, for example, nearly 14 million PBS prescriptions for opioid medicines were dispensed in 2013–14, and the rate in the area with the highest rate was 10 times that of the area with the lowest rate.
The way that Horrocks uses similar data with the clinical groups in the UK is a fine example of what can be done. Similar approaches are used in excellent centres in Australia.
The message? If you can assemble the diverse data sets on cost, clinical practice and outcome that are increasingly available in the health system (although often unlinked), and exercise expert management of clinicians examining those data, new efficiencies and improved standards of care will follow.
This is one more argument in favour of ensuring that the health system adopts top-rate information systems. It would be good to hear much more about resourcing this development and less about yesterday’s solution to health care improvement such as privatising inefficient systems in the pursuit of lower costs without concern about patient outcomes.
Stephen Leeder is an emeritus professor of public health and community medicine at the University of Sydney. He is currently director, Research and Education Network, Western Sydney Local Health District and Editor-in-Chief of the International Journal of Epidemiology.