Liverpool activist Greg Dropkin has weighed the claims of the RightCare initiative, and found them wanting.  (RightCare: wrong answers Journal of Public Health November 2017). RightCare is an NHS England programme that identifies opportunities for savings and quality improvements and describes itself as ‘a proven approach that delivers better patient outcomes’.

Greg Dropkin’s challenges the modelling assumptions made by RightCare (which have a flavour of a corporate consultancy about them), and the misinterpretation of dissimilar outcomes as opportunities for improvement. The difficulties of measuring unwarranted variation are well documented by Appleby and others in a 2011 Kings Fund report (Variations in health care: the good, the bad and the inexplicable). Unwarranted variation is a slippery notion, even though it appears to be endemic in clinical practice.

The RightCare approach has advantages for the NHS, giving NHS England, the DoH and the Treasury the results they want – the appearance of better quality care with the impression of lower costs. It contributes to the current magical thinking about NHS finances. Sadly, Dropkin’s argument is unlikely to dent this magical thinking much, the NHS being a centralised hierarchy within which conformity is highly valued.

Worse, from our point of view, is that faulty RightCare judgements may result in misallocation of resources through the allied CROC (Co-ordinated Reallocation Of Capacity) programme. For example, if the solution to unwarranted variation in cancer outcomes seems to be proton beam therapy, the NHS will have to invest in plant and machinery, or buy treatment time in the small but growing network of commercial proton beam treatment centres.

However, if RightCare did not exist we would have to invent it. It attempts to address variations in the five tractable conditions that drive secondary care use (heart disease, hypertension, COPD, CKD and atrial fibrillation), and it is interested in under-use as well as over-use of services. Given that pathway standardisations introduced by QOF seem to have only limited impact on clinical outcomes or service use, this makes sense.

An example is RightCare’s Falls and Fragility Fractures Pathway, which defines the core components of an optimal service for people who have suffered a fall or are at risk of falls and fragility fractures. The NHS claims to be working on this, but other priorities have overshadowed falls and fractures, despite their huge cost. The Royal College of Physicians 2010 report Falling Standards, Broken Promises, documents the neglect of this problem. RightCare is right to pick up the problem, and its proposals for a pathway are appropriate and overdue.

The 2011 King’s Fund report recommended changing the focus of initiatives against unwarranted variation from achieving outcomes to fixing care processes (especially shared decision making). This favours pathways, which may be picked up by the Get It Right First Time initiative (GIRFT) as much as by RightCare. (Digression: Why does the NHS have two organisations trying to tackle unwarranted variation? Because they have both evolved from different NHS fiefdoms!)

Shared decision-making is a noble enough idea, but in the NHS’s current toxic climate it too can be warped. ‘Choosing Wisely’ is a programme that aims to discourage doctors from using interventions that are not supported by evidence, free from harm and truly necessary. (Malhotra A et al Choosing Wisely in the UK  BMJ 2015;350:h2308). The NHS in North West London recently asked the public their views on Choosing Wisely, a scheme which it said was “to help reduce waste”. Its proposals for consideration were: encouraging patients to buy medicines over-the-counter when they could; GPs to avoid prescribing medicines that could be purchased; and patients to collect their own repeat prescriptions rather than let pharmacies collect them. What begins as an attempt to improve the quality of care ends as a means to transfer costs to the user.

An incoming Labour administration should change RightCare without abandoning it. Duplication of effort is usually unhelpful, so RightCare and GIRFT should be merged. The emphasis on outcomes and the optimistic claims of savings could both go, to be replaced by evidence-based pathways that regulators could audit and evaluate. And campaigners could harry those in NHS middle management who try to sneak in service reductions or co-payments as part of a quality improvement drive.

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10 Comments

  1. adrian mercer says:

    You may be interested in my recent article on warranted care variation:

    http://www.cost-ofliving.net/making-a-virtue-of-variation-the-fragmentation-of-the-english-nhs/

    1. Steve Iliffe says:

      The delegation of health service management to region-like STPs or geographic health maintenance systems will push the NHS towards a Scandinavian-style organisation of health care, but one not (yet) aligned with local government. This certainly changes the function of the national management structure of the NHS, but since “geographic variation…remains a persistent and ubiquitous problem” despite efforts over decades to reduce it, this shift is rational. The risk, as I see it, is that alignment with regional government will not occur in parts of England (We have it already in Scotland, Wales and Northern Ireland, and are getting close in some English metropolitan areas). It is this democratic deficit that might shut down argument and marginalise debate in the future (as it has in the past), not the act of devolution itself.

      The national bit of the NHS has a mythological value that glamourises its nature as a centrally-run, hierarchical command and control structure that attempts to bring its peripheral parts under control, whether they be 20th century Regional Health Authorities or 21st century Foundation Trusts. The NHS has been and remains a national service locally administered, but it has never been democratic and its national bodies have always had to negotiate with the powerful fiefdoms that make it up. Ironically, those who favour even more centralisation have been best served by the Coalition and Conservative governments; command and control has never been so powerful as now.

      1. Anonymous says:

        The direction from my perspective is not to scandanavia but to American style ACOs, aided and abetted by the american style IT systems, contracting packages , support organisations, teams of management consultants etc.
        see https://en.wikipedia.org/wiki/Accountable_care_organization

        The problem is that too many doctors are quite happy to see the drift to american style professional control and salaries. The average pay of a consultant in the US is between $200-600,000.
        The historic compromise is between the interests of the medical profession and the Managed Care Industry; at the expense of the poor (who are marginalised) and the average citizen (who pays through the nose).

        1. Steve Iliffe says:

          So we should surrender, I think. If the forces of darkness are so pervasive and attractive rational people will go home and leave the romantics and fanatics to fight to the last ditch. Of course all the anti-political conspiracy theories around the NHS are hopelessly simplistic. The NHS is more complex than they can grasp, and there is plenty of political work to be done. John Kennedy’s comments (below) shows how RightCare can be challenged, but also improved on. If we could understand the type of variation he describes we might be in a better position to reach sound judgements and take action.

          1. Anonymous says:

            Suggest you read https://www.researchgate.net/publication/255625570_Fads_in_Medical_Care_Policy_and_Politics_The_Rhetoric_and_Reality_ofManagerialism
            All the UK is doing is following in the slipstream of the USA. Where there is precious little to show for their efforts to “integrate” care apart from a healthcare system which simultaneously costs 17.9% of its GDP and leaves over 40m uninsured and many underinsured.
            No one is saying surrender. But you need to know where this all leads.
            If you are not careful.
            Fact is the inverse care law explains most variability. The NHS is not as complex as you think.

  2. John Carlisle says:

    “The 2011 King’s Fund report recommended changing the focus of initiatives against unwarranted variation from achieving outcomes to fixing care processes ” This is a nonsensical statement.

    Does the Kings Fund or Carter have any idea what unwarranted variation could mean? Is it too much variation in the process? Is it variation that exceeds control limits of normal variation. Do they mean, as Right Care wrongly uses it, variation between sites and services?
    Until they get it right the data they give out will be unhelpful, as The NHS Atlas of Variation is. A colossal waste of money.

    1. Steve Iliffe says:

      No, there are two reasons why it is good sense. The first is the tactical need to proclaim professionals as the source of energy, innovation and leadership in improving services whilst also attributing much of the unwarranted variation to their evidence-lite behaviour. Focusing on process renders this conflict less personal. The strategic reason is that an interest in processes can lead to an interest in inputs . Investments in specific services – say oncology – vary between CCGs up to two fold, and not all of this variation is attributable to population factors. Some, perhaps much, of it seems to come from the variable abilities of specialists to lobby for resources. This thought is uncomfortable, but reinforces the need for RightCare or something like it. Of course the notion of ‘unwarranted’ variation is a slippery one, but it can only become firmer and more tractable if engaged with rather than being avoided.

  3. John Kennedy says:

    Steve Iliffe is right to question the use of Right Care to assess variability across STP’s. To illustrate consider the relationship between the rate of non-elective (emergency) admissions to hospital for COPD to the number of patients diagnosed with COPD and the level of compliance with the scores on COPD QOF clinical domain. COPD emergency admission rates are known to be related to ‘patient experience’ as measured in QOF by the proportion of patients who were ‘able to obtain an appointment in two working days’ and the proportion who were ‘able to book an appointment’ and deprivation measured by Index of Multiple Deprivation 2010.
    The relationship between these various indices is highly complex and not expressible within framework used within Right Care. More specifically in an unpublished study GP practices were classified on the COPD QOF clinical domain in terms of whether they were continuously in the top 30% of practices, the middle 30% of practices or the bottom 30% of practices between 2004-11. Membership of these practice categories has a substantial effect on emergency admission rates between 2001-3 to 2009-11.

    Typically COPD emergency admission rates rise with increasing deprivation and fall with increasing patient experience. However these relationships are reversed in practices that were continuously in the top 30% of practices between 2004-11. Within continuously high scoring GP practices emergency admission rates fell with increasing deprivation and rose with increasing patient experience. More specifically the most deprived continuous High QOF practice had 14 fewer admissions per thousand than the least deprived in 2009-11. In contrast in the same period practices which were only in top 30% of practices within the years 2009-11 had 194 more admissions per thousand than the least deprived. Similarly continuous High QOF practice with the least patient experience will have 98 fewer admissions per thousand patients than a practice with the maximum patient experience in 2009-11.While in the same period practices which were only in top 30% of practices within the years 2009-11 had 22 more admissions per thousand patients.

    Unfortunately as is the case with practically any type of variability although it can be described it is not understood. Worse this form of variability cannot be expressed within Right Care leaving any inferences as to how treatment could be enhanced or costs of treatment reduced open to qualification. As Steve Iliffe suggests Right Care provides an “appearance of better quality care with the impression of lower costs. It contributes to the current magical thinking about NHS finances”

  4. “Our patients are different –they are older, sicker, more deprived ..etc “ is the usual response when variations in healthcare outcomes and processes are discussed .
    There are of course differences in populations –and these can be corrected for, though imperfectly. But there is also variation in clinical decision making, and in provider provision. This may be legitimate –taking into account patient preferences – but another possibility is that variation may be provider /practitioner led .There can be perverse incentives in the system –such as item for service payment, or non adherence to known best practice guidelines or arbitrary decisions about allocation of resources. Wennnberg’s work in the USA has shown how provider power can lead to over treatment, with no improvement of outcome.
    Unless we believe there is no underuse or overuse of resources, and everything is currently perfect, it is surely worth looking at comparative data at a CCG level, where the commissioning power lies. Whether CCGs then make the right decisions after looking at their data is another issue. We can debate if Right Care is currently working well –but Steve Iliffe is right to say we need something like it. .
    Similarly, using shared decision making to justify shunting of costs to the user is wrong but shared decision making/supported self management can lead to better outcomes for patients.
    Let’s not throw too many babies out with the bathwater.

    Dr Linda Patterson

  5. Anonymous says:

    Nobody argues that healthcare costs need managing and that comparative data is important in doing that.
    The issue is whether sub-contracting this to amercican style ACOs is the way to do it.
    All the evidence suggests not.
    HMOs (and that is what an ACO is) have existed in America since 1973. The GDP spent on health has risen from 7.1% to 17.9%.
    The pay of the CEO of United Health was $66m in 2016.
    The HMO industry is bigger than Amazon, yet all it is is a middleman in the healthcare system.
    The promise huge savings yet they add costs of at least 15%.

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