10 reflections on...

Reducing 'unwarranted' variation and the GIRFT programme

Getting it right first time (GIRFT) is a national programme designed to improve patient care and increase efficiency by reducing variation in the NHS. The latest report from the programme generated significant media coverage last week. The GIRFT programme lead, Professor Tim Briggs, was reported as saying that the NHS should not receive additional funding until the savings available from GIRFT have been realised.

In this blog, NHS Providers chief executive Chris Hopson reflects on the media coverage of the report and the issues it raises:

1. Variation is a feature of all international health care systems. The evidence shows that it is an endemic part of healthcare provision. The NHS is no different, as evidenced by the CQC. It therefore makes sense for national and local health leaders to focus on how we can tackle variation and we should all support national programmes like GIRFT that are designed to help frontline NHS services in this task. But, as other international health systems have found, reducing variation is complex, difficult, time consuming and depends on a range of different factors.

2. A critical first step is to identify the difference between warranted and unwarranted variation. Some variation is legitimate, inevitable, and not capable of, or appropriate for, elimination. In short, it is warranted. Unwarranted variation - “differences that cannot be explained by illness, medical need, or the dictates of evidence-based medicine” – is susceptible to reduction and is therefore a sensible focus of management activity. But the difference isn’t always clear cut. Take a geographically isolated hospital that finds it difficult to recruit experienced consultants in a certain specialty and which lacks access to step-down beds, but which still needs to undertake certain procedures. This hospital will likely experience worse clinical outcomes and longer lengths of stay for a patient than a hospital with access to experienced consultants in that specialty and higher access to step-down beds. Is that warranted or unwarranted variation? Case mix is also a well known driver of variation – a DGH doing basic casework in a specialty is likely to have a different clinical outcome and staffing profile to a tertiary hospital whose case mix includes very rare, complex, cases. Averages and aggregate data, even among cohorts of similar peers, can be deceptive.

3. Having access to data and evidence is fundamental to the process. The more rich and detailed the data, the better. The GIRFT programme is helpfully producing initial, top level, benchmarking data. This shows, in a relatively crude way, where differences in outcomes (e.g. infection and rework rates) and inputs (e.g. number of types of staff matched to case load and costs of supplies) exist between trusts. However most of the data, in and of itself, does not show which variation is warranted and unwarranted or how the unwarranted variation can be reduced. Trusts report that while the GIRFT data is a good starting point for a conversation, a whole load more work then needs to be done to actually identify why the variation exists; establish what is warranted and what is unwarranted; agree what needs to be done to reduce the unwarranted variation; and then actually deliver the changes to clinical practice to secure the desired reduction.

4. Trusts tell us that another key to the process is high quality, deep, rich, detailed, iterative conversations involving the relevant clinicians and managers. They tell us two factors are important here. First, a high degree of clinical engagement is needed, including a real willingness amongst clinicians to interrogate and develop the initial data, seek solutions and then actually change what are often long and deeply held clinical practices and preferences. Second, time and space is needed to have the deep, rich, conversations that are required. Trusts tell us that while they welcome the GIRFT data as a good starting point, they are working in an increasingly pressured, unstable and fragile environment with “once in a generation” levels of operational and staffing challenge. They are therefore finding it difficult to consistently enable the frequency, quality and depth of discussions and follow up work needed, given the time and complexity involved (e.g. gathering all the clinicians and key managers in a specialty together in one place for an extended time on a number of different occasions). Given the scale of other pressures and other priorities, senior leaders are also finding it difficult to devote sufficient time to this process – a key requirement to secure clinical buy in and ensure effective delivery.

5. Any identification of unwarranted variation needs to be followed by a rigorous and well-resourced change programme that enables the required changes in clinical practice to be consistently and effectively implemented and then bedded in. Trusts tell us that they often lack the analytical, change management and clinical liaison resource needed to deliver this complexity of change programme. They tell us that much of this type of resource - which is not involved in direct frontline care provision - has been stripped out in previous rounds of continual annual cost improvement programme (CIP) savings that NHS providers have been required to make over the last decade. They also tell us they are struggling to identify sufficient investment to create this resource afresh.

6. If the NHS is to consistently reduce unwarranted variation we need to be realistic about how long this will take and what support trusts need. System leaders need to support trusts to deliver. Giving trusts crude top level data and then having a large arm’s length body team intrusively and impatiently monitor speed of change won’t get us very far. It will be much more effective to ask trusts what support they need to tackle this difficult, complex, task and ensure they then receive that support.

Last week’s media coverage left four misleading and unhelpful impressions that need correction.

7. The first of these was that trusts are not actively engaged in efforts to reduce unwarranted variation and that GIRFT is, by itself, a brand new magic key. Trusts have been looking to eliminate unwarranted variation in key areas for some time – the consistent reductions in length of stay and improvements in theatre utilisation over the last decade are testament to this. GIRFT is a welcome, first, national level, specialty-based programme in this space and, as such, deserves our support. It is producing helpful top level benchmarking data. But, as outlined above, in and of itself this data will not produce any of the changes required on the ground.

8. The second mistaken impression is that significant amounts of savings can be delivered quickly. We need to be careful about making crude financial extrapolations of possible savings levels from top level benchmark data. Some variation is warranted. Some unwarranted variation may not be reducible given local circumstances. And all the international experience suggests that consistently realising actual savings is a long, complex, process.

9. A third mistaken impression is that the NHS is inefficient and wasteful and is not trying hard enough to realise efficiency savings. There is a multitude of evidence to suggest this is not the case. The recent Commonwealth Survey showed that the NHS is the most efficient health system in the advanced Western world. The OECD has shown that the NHS has one of the lowest levels of administration and management cost in the Western world. The NHS delivered around £20bn of savings in the 2010-15 parliament. In 2016-17, NHS trusts delivered a record £3.1bn worth of savings through CIPs, £200m more than the previous year. NHS trusts are now being asked to realise another 4% savings this year – a savings level that no other advanced Western health system has ever consistently achieved. Some would like to inaccurately portray the NHS as an inefficient, wasteful, system led by incompetent bureaucrats who aren’t trying hard enough. This is nonsense and we need to challenge this hoary old chestnut every time we see it.

10. And, finally, perhaps most damaging of all, is the mistaken impression that the NHS is not worthy of future funding increases until GIRFT has been delivered. As outlined above, it will be impossible to eliminate all variation. Reduction of unwarranted variation will take time and it’s impossible at this point to calculate how big the savings might be. The highest estimate we have seen is £3.6bn, which seems very optimistic and ambitious to us. Meanwhile, the independent Office for Budget Responsibility has estimated that the NHS is facing a £15bn funding gap in 2020/21. So a brilliantly effective GIRFT will only go a small part of the way to cover the rapidly growing NHS funding gap. We shouldn’t pretend GIRFT can do more, more quickly, or we risk sinking it under an unrealistic weight of expectation. But that shouldn’t stop the NHS from doing all it can to eliminate as much unwarranted variation as possible, as quickly as it can. And GIRFT has an important role to play in that process.