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.
- Hugh's blog on overuse: Is the NHS delivering too much of the wrong things?
- Hugh's blog on misuse: Is the NHS delivering enough things right?
- See our report: Better value in the NHS