Widespread variations in rates of surgery are unfair and inefficient, new study finds

A new report, Variations in health care: the good, the bad and the inexplicable, from The King's Fund has found persistent and widespread variations across England in patients' chances of undergoing surgery for common medical conditions.

This suggests that many patients are not being given surgery they need and that some may be undergoing operations they do not benefit from.

Even after allowing for legitimate factors that affect rates of surgery between areas, such as differences in need, significant variations were found between primary care trusts (PCTs) in the rates of common operations. Researchers found that, for example:

  • in 2009/10, rates of patient admissions for routine operations such as hip and knee replacement varied by as much as 400 per cent, between the highest and lowest PCTs
  • rates of coronary artery bypass grafts varied from 34 per 100,000 in Westminster PCT to 197 per 100,000 in Berkshire PCT
  • surgery rates for cataract replacement – one of the most commonly performed operations in the NHS – varied by 300 per cent between some PCTs.

Even for some operations whose effectiveness has been questioned, variations in treatment between PCTs are widespread. The removal of tonsils in children has been queried since the 1930s, yet the rate of tonsillectomies in Coventry PCT in 2009/10 was ten times higher than the rate in Kingston PCT for example.

Some variations also seem to disproportionately affect people in more deprived PCTs. Researchers found that patients from more deprived areas were less likely to have hip replacements – an operation with a strong evidence base for being effective – compared to patients from more affluent areas.

Certain variations also have implications for NHS efficiency and for delivering the £20-billion in productivity improvements the NHS needs to find by 2015. For example, operations such as varicose veins can often be done as a day case rather than requiring an overnight stay, which can be better for patients and less expensive for the NHS. But day case rates for varicose veins vary from around 90 per cent in some PCTs to as little as 30 per cent in others. 

The researchers note that variation in treatment offered for the same conditions can be justifiable, for example, where patients have opted to undergo a specific treatment rather than to take other options. The report recommends the increased use of shared decision-making about proposed treatment between doctors and patients, to incorporate the patient's assessment of their needs and reflect their tolerance of risk.

To incentivise this, the researchers suggest that local providers of care and commissioners should also be required to publicly justify key indicators of variation in care – both between individual practitioners in their area, and as compared to their neighbouring PCTs.

John Appleby, Chief Economist at The King's Fund said:

'This report confirms research over decades, both in the UK and internationally, which has shown persistent and unwarranted variations in use of and access to even the most common surgical procedures. This is unfair to patients and inefficient for the NHS. Remedying this is urgent given the need to improve quality of care while the NHS grapples with the biggest financial challenge in its history.

'We know broadly the reasons for variations. These include differences in local PCT decisions about their priorities, differences in clinical judgement between doctors, historic differences in the level of provision of some services, variations in the choices made by patients between surgery and alternative treatments and so on.

'The key to reducing 'bad' variation and encouraging 'good' variation is to engage patients in key decisions about their treatment by supporting them in understanding the risks and benefits of treatment, in relation to their own attitudes to their health.'

Read the report: Variations in health care: the good, the bad and the inexplicable

Notes to editors: 

For further information, or to request an interview, please contact the Press and Public Affairs office at The King's Fund on 020 7307 2585 (if you are calling out of hours, please ring 07584 146 035).

The report Variations in health care: The good, the bad and the inexplicable, outlines differences in admission rates for several routine interventions by analysing the geographical variation in health care provision in the NHS in England. Thirty-six different procedures were selected for analysis because they were either:

  • generally recognised to be clinically effective, or
  • there is uncertainty regarding their intervention, and/or
  • there are cost-effective alternatives available for conducting surgery – for example, treatment as a day case, rather than being admitted as an inpatient.

Evidence suggests that medical opinion and/or doctor preferences and attitudes have a substantial influence over which treatment patients will receive and are a major source of variation. Studies have also found that patients, if fully informed about their options, will often choose differently from their doctors and are less likely to elect for surgery than control groups.

The King's Fund is a charity that seeks to understand how the health system in England can be improved. Using that insight, we help shape policy, transform services and bring about behaviour change. Our work includes research, analysis, leadership development and service improvement. We also offer a wide range of resources to help everyone working in health to share knowledge, learning and ideas.