Will reducing unwarranted variation stifle innovation?
Reducing variation in healthcare has become a driving force to optimise value and improve quality of the care provided, as well as being a mechanism to ensure equity of access and the availability of treatments. It is the philosophy underpinning Realistic Medicine, The Atlas of Variation, RightCare, Getting It Right First Time (GIRFT) and Prudent Healthcare. We have grown accustomed to funnel plots, shaded maps and tables demonstrating how different areas and units perform. Sometimes it is unclear which colour is ‘good’ or where one should aspire to be on the ascending/descending graph of activity. There is still much to learn and contextualise in this field but, at last, data is being gathered, shared and improved in the process – overall, reduction in variation is welcome, but, it needs to be better understood.
A question that frequently arises is ‘will this desire for commonality diminish innovation?’ As agreement is reached about acceptable limits of costs, practice and outcomes and more scrutiny is applied to individual performance, it is possible that once a standard is set, everyone will simply toe the line. This is a definite risk, especially at a time when clinical research has become more difficult to set up and front line clinicians are too busy to do any more than care for an increasingly large number of complex patients. The environment is one of less space for new ideas and fewer opportunities to enact them easily.
One of the Academy’s functions as an organisation is to help ensure that work common to all Medical Royal Colleges is developed in a way that promotes standardisation. In other words, to reduce variation that might develop if carried out independently by our 24 members. This has resulted in the efficient production of agreed policies and guidance on quality standards and post-graduate training and assessment that provide consistency for the profession. All guidance is reviewed and updated regularly – either by design or by a changing medical or educational environment. There is no suggestion that these are once-in-a-lifetime arrangements nor that they are not receptive to new ideas.
Medicine does not stand still. Everyone involved – including patients and the public – will ensure that curiosity of the informed alongside developments in technology and a need for constant advancement will produce new techniques and ways of working. Colleges intrinsically and actively support and promote research and service improvement, both of which inevitably lead to change, but in a controlled fashion. Curricula for post-graduate medical training are the living documents that assure new specialists are trained in relevant and up to date practices as does continuing professional development (CPD) for established practitioners.
In practice, Health Improvement Scotland (HIS) has recognised the need for change while promoting standardisation and emphasises that its quality frameworks must not be too rigid. HIS encourages ‘risk taking’ in the re-design of services, but, in a way that these changes are fully assessed in a prospective and honest way before becoming incorporated locally or more widely.
Identifying unwarranted variation will raise quality at the lower end of the spectrum but is unlikely to inhibit the drive for continued improvement at the upper end thus acting as a mechanism to help raise the level throughout.
Professor Carrie MacEwen
Chair, Academy of Medical Royal Colleges