From autonomy to standardisation: one response to clinical variation

24 February 2016

Earlier this month Lord Carter published his final report on the operational productivity of England’s acute hospitals. The report finds there is “significant unwarranted variation across all of the main resource areas”. In procurement, for example, some hospitals pay £800 for a hip prosthesis while others pay £1,500. Eradicating this variance, Carter suggests, could save the NHS £5 billion a year.

In primary care there is a related problem: clinical variation. In 1948 general practitioners were incorporated into the NHS as independent contractors. Today there are approximately 7,500 surgeries in England and autonomy remains their hallmark. According to a 2002 editorial in the British Journal of General Practice: “Each practice has – to some extent – its own sub-culture:…behaviour patterns…internal organisation…and ways of delivering healthcare”.

Variation was a key theme of the King’s Fund’s 2011 inquiry and recent indicators suggest challenges persist. Last year’s independent cancer strategy identified geographical variations in cancer diagnosis: in some places 37 per cent of people are diagnosed via an emergency presentation, in others 15 per cent. In diabetes care, the Public Accounts Committee recently found similar variation. The number of people receiving NICE’s three treatment standards for blood glucose, blood pressure and cholesterol ranges from 28 to 48 per cent.

This is bad for patients and the wider healthcare system. Late diagnosis raises the cost of treatment and complications from long-term conditions can lead to patients needing hospital care. Complications from diabetes – amputations, blindness, kidney failure and stroke – cost the NHS almost £4 billion a year.

Standard operating procedures could be one way to bear down on clinical variation. The work of Intermountain Healthcare, based in Utah USA, illustrates their potential. Intermountain has developed an array of “clinical practice guidelines”. While guidelines require tailoring to each patient, they provide “shared baselines” for clinicians. The savings from just one guideline, for caesarean sections, are estimated at $50 million a year. Intermountain now has over 100 guidelines covering the bulk of their activity.

Medical advances strengthen the case. As Atul Gawande, the surgeon and writer, has argued, today the knowledge of how to treat patients is generally available. The proliferation of medical knowledge, however, makes it difficult for clinicians to be conversant with best practice – let alone apply it consistently. Standard operating procedures could help.

The NHS is tasked with finding £20 billion of productivity savings by 2020-21. Carter’s call for operational consistency in hospitals is one part of the effort to deliver this. Clinical standardisation in primary care could also help by keeping people well and reducing costs. Clinical autonomy may have to give way.

Leo Ewbank, Researcher, Reform  



John Davies

26 February, 2016

Of course they have their own individual sub cultures -that is how organizations work- they are not machines with interchangeable parts.

Greg Wood

25 February, 2016

You're referring to clinical protocols, which have been around for years. They have a very chequered reputation: the problems with NHS triage and advice lines like NHS Direct and 111 largely stem from the protocols used, which are highly risk-averse. You might think that means they are very safe, but life ain't like that. Sending lots of people to A+E unnecessarily slows down the treatment of real emergencies and so causes real harm to patients. It's an example of something that works in theory not working in practice - something that happens a lot in our over-centralised country!