Is the NHS delivering enough of the right things?

Last week I wrote a blog about the problem of overuse in the NHS: where people get services they don’t want or need, which can lead to unnecessary harm and wasted resources. But this is only part of the story. The flipside is that the NHS faces the problem of underuse too.

Underuse happens when effective care isn’t delivered when it’s needed. It can lead to people needing more complex care as their conditions get worse – for example, if they end up in hospital because their condition isn’t managed properly at home. This means that tackling underuse can sometimes save money for the NHS, by keeping people well and reducing use of costly services. In other cases, reversing the problem of underuse is more likely to increase costs – particularly in the short term – as a result of investment in new services or improved access. In either case, tackling underuse is fundamentally about improving care for people who need it.

So, where might the NHS not be delivering enough of the right things?

One example is diabetes care. While the National Institute for Health and Care Excellence (NICE) sets out clear guidelines for what good diabetes care looks like, data from 2012/13 tells us that only around 60 per cent of people with diabetes treated by the NHS receive eight of the nine recommended care processes that could improve their health. Even fewer – only 36 per cent – achieve all three of NICE’s recommended treatment targets. Failure to provide people with the right care can make their health worse – and around 24,000 people die from avoidable causes related to their diabetes every year. It also costs money: estimates suggest that around £170 million a year could be saved through better management of diabetes in primary care, reducing the need for people to go into hospital.

Another example is when people become ill but their conditions aren’t diagnosed, leading to missed opportunities to intervene early and stop them getting worse. Take chronic obstructive pulmonary disease (COPD), where Department of Health guidance suggests that around one in eight people over the age of 35 has COPD but doesn’t know about it – and more than 15 per cent are only diagnosed after turning up to hospital in an emergency. It’s thought that many opportunities to diagnose COPD are missed, and that better diagnosis and treatment could improve people’s health while saving the NHS money.

Other examples of underuse include a range of early intervention services, and the provision of drugs and treatments. We set out some of these examples in our report, Better value in the NHS. In many of these cases – such as the use of drugs to reduce the risk of stroke – high levels of overuse and underuse exist together, resulting in large variations in clinical practice.

Doing more of the right things to improve people’s health also means looking outside the NHS, to services like education, employment and housing. This is because health care services on their own can only do so much to improve the health of the population, which is influenced by a wide range of social, economic and environmental factors. While there’s a growing evidence base about the benefits and return on investment from services that address these wider determinants of health, finding money to invest in them is challenging when already cash-strapped local authorities are seeing their public health budgets cut – something my colleague David Buck has described as the falsest of false economies. This in turn is likely to have an impact on demand for NHS care, as other public services designed to keep people well fall away around them. Wider cuts to local authority budgets and the funding crisis in social care provide more lines in the same story.

Overuse and underuse are two sides of the same coin. They can be found together across the health system almost everywhere you look, highlighted by the dramatic variations in clinical practice and health outcomes across the country. Taken together they contribute to a single problem for people served by the health system: worse health. We set out a broad agenda for overcoming these problems in our recent report on achieving better value for money spent on health services. In the case of underuse, rather than thinking simply (or medically) about how we can tackle these problems in the NHS, we need to think more broadly about the underuse of a wider range of services that affect people’s health too.

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#544447 Irene Stratton

The variation just in foot checks for people with diabetes is a topic worth a whole blog in itself. Just looking at QOF tables it's clear that there's a vast difference in the number of people 'exception reported' and then in those with foot risk check. Also there are CCGs where they do not have a multidisciplinary foot care team despite this being advised a decade or so ago. Easy to see why there are 135 amputations a week in peple with diabetes thought to be unnecessary by Diabetes UK.

#544459 Dr Umesh Prabhu
Medical Director
Wrightington Wigan and Leigh FT

It was Anthony Robinson who said 'If you always do what you have always done you always get what you always got. Sad reality is NHS is good at doing the more of same old thing over and over. NHS appoints Board level leaders for technical skills and not for values or leadership skills. Many come from private industry, lawyers, accountant, business background and they bring business ethos to the NHS working. Most of them want NHS to run like a business and give top priority to the finances.

NHS also works in silos. Primary care, secondary care, community care, mental health and social care. Different leaders working in their own little organisation looking at their own priorities and in the middle of all these what really patients want or need is totally lost. Demand is increasing, elderly patients with multiple co-morbidities are sent to hospital many times to have many unnecessary tests, unnecessary interventions and heroic surgeries when all they need is tender loving care in the community or nursing homes or at home. But there is no support for GPs or families or nursing homes.

We got to change NHS radically and vanguard and devomacn and integrated care gives us brilliant opportunity provided we have right leaders. If not this will be one more initiative without any real benefit to patients, staff or NHS.

Let us get the basics right in our NHS. Our values, culture, value based leaders, good governance and integrated care right with common IT and common leaders who put patients at the heart of everything they need and transform NHS working with patients and their families.

#544461 Merron Simpson
Housing and Health Lead
NHS Alliance

Great blog Hugh, and good to see housing mentioned as part of the solution. Here's an example of how New Charter Housing and Tameside GP Federation are working together to identify and address NHS overuse and underuse by over 75s You can find more similar case studies on NHS Alliance Housing for Health website - click

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