Chapter 5 - Tackling Unwarranted Variation, Harm And Waste
How do we intend to tackle unwarranted
What is Unwarranted Variation?
In Realising Realistic Medicine, we made it clear that one of the main aims of Realistic Medicine is to tackle unwarranted variation. Variation occurs for a number of reasons. Healthcare systems are complex. Regional differences may arise due to differences in recording information, or due to the needs of the local population. In some cases there may be a range of approaches to treatments, all of which add value, but the best methods have yet to be determined.
However, some variation cannot be explained by the characteristics of the people being treated. Unwarranted variation, a concept developed by Professor John “Jack” Wennberg at Dartmouth, is variation in healthcare that cannot be explained by need, or by explicit patient or population preferences.  Recognising unwarranted variation is of vital importance because it allows the identification of:
- Underuse of higher value interventions – i.e. under treatment.
- Over use of interventions which should be used less frequently.
- Over use of interventions which may result in harm.
Data which show variation in interventions do not tell us whether services are good or bad. No one knows the right rate of hip replacements, cataract operations, MRI examinations or antidepressant prescriptions, for example. The right level of an intervention, sometimes called the “warranted level”, must be determined by clinicians discussing variation to understand the reasons for it. Only by discussing variation together can we decide whether that variation is warranted or not. Where clinicians agree that the variation is unwarranted, they must seek to find, agree and implement solutions to tackle it.
How do we intend to tackle unwarranted variation?
We know that demand for health and care services is increasing and in order to meet that demand we must consider how to make optimal use of the resources we have to ensure the best possible care for our patients.
Allocative value: allocating resources to different groups equitably, in a way that maximises value for the whole population. This might relate to either a condition or a characteristic e.g. respiratory medicine, which might further be broken down to e.g. asthma, COPD, sleep apnoea etc. Once this has been done, those who manage the service must get together with patients to identify where best value is achieved and how resources are distributed across prevention, diagnosis, treatment, rehabilitation and long term support.
Technical value: improving the quality and safety of services to increase the value derived from resources allocated. This may involve reducing the waste or inefficient processes associated with a particular service or improving safety. 
Personalised value: basing decisions on the best current evidence, careful assessment of an individual’s clinical condition and what matters most to the patient. These may include the value they place on good and bad outcomes as even the highest quality healthcare has the potential to do harm.
Realistic Medicine aims to ensure that all treatment offered to patients is able to add value. When we talk about “harm” in healthcare we tend to focus on harm from missed diagnoses or under-intervention. Although this is very important, we must not lose sight of the fact that there may be “hidden harm” involved in over treatment and excessive interventions. Focussing on better value care will therefore involve a change in mind-set for many health and care professionals, including, at times, becoming comfortable with the “gentle art of doing nothing”.
Value Based Healthcare Work Programme
In order to help ensure that everyone is practising Realistic Medicine by 2025, we need a co-ordinated programme of work that focuses on supporting the delivery of Value Based Healthcare across Scotland. We need strong and committed leadership if we are to fully embed Realistic Medicine principles and values across health and care. Realistic Medicine Leads will be appointed across Scotland in spring 2018. They will be trained in the use of Value Based Healthcare principles and techniques and provide leadership and support to clinical and management teams on Realistic Medicine.
The Leads will develop, co-ordinate and promote a Value Based Healthcare Work Programme for their area, drawing on the tools and support programmes that we will develop nationally. They will engage with their local colleagues to promote Realistic Medicine in practice and will support each other to develop, promote and embed good practice across their region. As a group, they will also oversee improvement projects that will focus on triple value and change the way we deliver care. The Leads will be required to:
- Complete training in Value Based Healthcare principles and techniques.
- Promote Value Based Healthcare and support colleagues with training.
- Engage with local and regional Clinical, Quality and Management teams to deliver Value Based Care and evidence progress against objectives.
- Create the culture and conditions for Realistic Medicine to thrive.
- Champion initiatives that support shared decision making.
- Evaluate local applications for Value Improvement project funding and advise which projects to support.
In Realising Realistic Medicine, we committed to commissioning a collaborative training programme on unwarranted variation for clinicians. This programme will be rolled out in spring 2018 and will offer training to our Realistic Medicine Leads and others in the concept of triple value. A modest amount of funding will be available to support value improvement projects and the Realistic Medicine Leads will help to agree the criteria by which staff can apply for funding for projects that will aim to tackle unwarranted variation.
The Realistic Medicine Leads and those who have completed the Value Improvement training will also be trained to use the Atlas of Variation, identifying variation for further local understanding and, where this is found to be unwarranted, to generate and implement solutions that will help to eliminate it.
How will an Atlas of Variation for Scotland help tackle Unwarranted Variation?
An Atlas of Health Variation shows variation in the health of the population, in health and care, and in health outcomes experienced by people in different geographical regions. The production of a publicly accessible Atlas of Variation for Scotland, supported by an engaged cohort of clinicians trained in understanding variation and influencing change, will be an essential tool in practising Value Based Healthcare.
An Atlas of Health Variation does not suggest an ideal level for procedures, tests or treatment, nor does it suggest that high is bad or average is ideal.
The aim of the Atlas is not to provide answers but to provoke questions and dialogue. These questions will not only lead to a better understanding of the reasons for variation, but will help to identify variation that is unwarranted and potentially harmful. Questions that the Atlas might stimulate include:
- Does the variation matter?
- Are we doing things the same way as in other parts of the country?
- Do we need to change what we are doing?
- Can we learn from successful innovations or best practice guidelines elsewhere?
- Can we share our expertise?
The Atlas will initially focus on helping to identify over treatment and under treatment across Scotland and support clinicians to address this. Month on month we aim to build the Atlas, adding more maps. We will continue engaging with clinicians to identify which indicators to add to the Atlas, ensuring it reflects the needs of the population, is relevant to clinicians and evolves as innovation emerges.
It is expected that the Atlas will, over time, support the development of healthcare provision that is appropriate to the needs of all people across Scotland. We are working with Public Health Intelligence of NHS NSS to ensure that the beginnings of an Atlas are delivered by spring 2018.
The desire to identify and tackle unwarranted variation is clear within Scotland and mirrors that which we see internationally. This work has begun across many countries and we can learn from their experience as we introduce this work here. It can only happen if we have useful, accessible data, presented and interpreted in a way that provides insightful knowledge for clinicians, supported with training and education, to discuss locally within a receptive culture. This is the intention of our Value Based Healthcare programme and we look to you for your support to enable it to flourish in order that we provide better health outcomes for our public.
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