Getting it right first time –a catalyst for change

There are few clinical staff in the NHS who would not concede that care does not always get delivered at the same high standard for all patients – the phrase often used is the ‘post code lottery’. There is also enormous frustration that we do not seem to learn lessons from good practice, practised elsewhere. Why would we not improve our care if we read the research, understand the rationale and have the authority to make the changes. Are we just lazy and demoralised? It is likely to be nothing to do with that, and far more to do with the quality of the data which we use. It is often presented in a mystical way that is hard to decipher and comparisons with our own practice are far from easy to make. There may also be costs involved in making change, and without doubt it requires effort. Effort to bring the whole team along, effort to get the chief executive on board as well as other colleagues. There is not much capacity around for extra effort although every one of us would like to do the very best for the patients in our care that we possibly can. 

Some aspects of variation can be good, but when it is written of, it usually means, not so good. We certainly need a gap analysis, such as was undertaken for the Five Year Forward View where there will be many activities launched to reduce the “health gap”, the “quality gap” and the “financial stability gap”. These actions were identified as improvement opportunities. The next steps review of progress, published in March 2017,1 recorded successes in the health gap where there has been action such as plain packaging for cigarettes, the first national diabetes prevention programme, a sugar tax agreed to reduce childhood obesity and one million infants vaccinated against  meningitis. All of which will have good long term outcomes for public health. How was progress on the quality gap described? Some of the identified successes are cited as better clinical outcomes – i.e. cancer survival at a record high, first ever waiting time targets for mental health treatments introduced and met as well as improving adult inpatient experiences of care. meningitis. All of which will have good long term outcomes for public health. How was progress on the quality gap described? Some of the identified successes are cited as better clinical outcomes – i.e. cancer survival at a record high, first ever waiting time targets for mental health treatments introduced and met as well as improving adult inpatient experiences of care. 

The concern surrounds what is known as ‘unwarranted variation’, much of this can be put down to differences in local funding, the complexities of healthcare and its application to highly variable people, their lifestyles and choices. Some of it is about clinical decision making and differing priorities. Tackling some of the unwarranted variation is on the current agenda for the Department of Health and NHS RightCare is leading the work. They have provided an NHS Atlas of Variation2 which some clinicians have heralded as the first useful local data on their speciality they have seen and they have ever had to work with. With Clinical Commissioning Groups, local health plans and transformation plans as well, the local context is becoming more and more relevant whilst national support for large change projects is also critical to their success and spread. One of the key features of the redesign of clinical care to work out the unwarranted variation, is credibility and leadership. It is also important to acknowledge that not all variation is bad and not all of it can or should be managed away.