The president of the Royal College of Paediatrics and Child Health tells us what the new NHS atlas reveals about variations in care
When I was growing up in the 1960s, there were over 200,000 operations a year in England to remove children's tonsils. Fifty years on, we can safely say that this represented about six or seven times the number of tonsillectomies there should have been on medical grounds.
While the numbers have fallen dramatically because of medical advances and the recognised health risks of too readily removing a child's tonsils, there is still (at best) a three-fold variation in tonsillectomy rates across England. In other words, if the highest rates were replicated across the country, this would equate to around 55,000 operations a year – compared to 9,000 a year if the lowest rates were replicated. And we don't know whether the lowest are missing some children who should have their tonsils out (eg for obstructed breathing during sleep) or the highest taking out more than is necessary.
So, why the variation? It's a question that we as healthcare professionals up and down the country should be asking ourselves following last week's publication of the NHS Atlas of Variation in Healthcare for Children and Young Adults. The atlas maps for the first time the extent of variation in child healthcare across all primary care trusts in England. It's based on 27 key indicators including immunisation, treatment of diabetes and emergency admission rates for epilepsy and asthma – and the number of tonsillectomies. It reveals that for some conditions, there is at least a seven-fold variation in the healthcare children receive and for one indicator – admission rates for children with mental health disorders – the gulf between highest and lowest is a huge 48-fold.
In some cases, there is good reason for variation and it's to be expected. Socio-economic and cultural factors – levels of deprivation, geography, ethnicity – are proven causes of what can be described as "warranted" variation which is difficult for the healthcare system to overcome. But the Atlas also suggests there is a significant level of unwarranted variation. In other words, the variation in healthcare cannot be solely explained by socio-economic factors and there's something we, as healthcare professionals, can do about it.
Take one of the atlas indicators – hospital admissions for children and young people with bronchiolitis – where the data reveals a five-fold variation across England. A glance at the map shows there are significantly greater admissions in areas of the north-east, north-west and West Yorkshire than elsewhere in the country. An immediate explanation might be that there are higher rates of passive smoking and poorer general health due to deprivation in these regions. However, closer analysis of the data reveals that, in fact, some of the poorest areas of the country are performing better than more affluent ones. Clearly something else is at play. Variations such as this and others could be due to a failure to adhere to guidelines in one area; perhaps it's down to a highly innovative use of clinical networks in another – or perhaps, even, professional expertise is particularly high in one region and less developed elsewhere.
Also interesting is the atlas's revelation that such variation cannot always be solved by simply injecting more money. Increased spending on a service does not necessarily result in better quality – among providers of childhood diabetic services for example, there is no clear correlation between greater resource and improved clinical outcomes.
The challenge now for healthcare commissioners, practitioners and government is to use the atlas data to minimise this unwarranted variation. A good map is worth a thousand words and as NHS chief David Nicholson said, to improve results, we need better metrics. We've got the metrics, now we have to use them to begin the urgent of task of bringing the worst up to the standard of the best; ensuring guidelines are followed, using clinical networks more effectively and sharing best practice. Only then can we provide the highest standards of healthcare for all of the 11 million children in England.
• Prof Terence Stephenson is the president of the Royal College of Paediatrics and Child Health.
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Read the complete post at http://www.guardian.co.uk/healthcare-network/2012/mar/20/childrens-health-nhs-atlas-data
Mar 20 2012, 09:21 AM
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