by Laura Schang

Evidence of geographic variations in health service performance challenges the core goal of health systems: to provide equal access to safe and effective health care for equal need. Although healthcare funders in England and many other countries including the US, Canada, Germany, Spain, the Netherlands and New Zealand now have unprecedented access to data concerning variations in health service performance, there is little research on how funders might actually use this data to improve resource allocation and outcomes.

Our study, recently published in Health Policy, examined how and to what extent Primary Care Trusts (PCTs) in England use the NHS Atlas of Variation in Healthcare, which highlights variation in expenditure, utilisation and outcomes across PCTs.

The study involved a nationwide survey (total response: 53 of 151 of PCTs, 35%) and 45 in-depth interviews with local PCT managers. Our findings suggest some general lessons for users of evidence of geographic variations:

1. Provide appropriate tools to help decision makers understand what variation is unwarranted and address barriers to evidence use.

The NHS Atlas has great merit as a visual tool prompting engagement with variations and facilitating communication with clinicians. Many PCTs, however, struggled with the inherent ambiguity of classic variations research, which does not allow drawing direct inference from relative rates of activity to ‘good’ or ‘bad’ performance. To achieve an impact on resource allocation, decision makers should be able to define and operationalise which part of the observed variations, if any, is unwarranted.  In addition, just under half of the respondents (25 of 53 PCTs) in our study reported that they do not use the NHS Atlas due to a lack of awareness, staff capacity, or applicability of the data. Such hurdles in using research evidence need to be tackled as a matter of priority.

2. Agree responsibilities for action and ensure high-level leadership.

Local agreements on responsibilities for action and high-level leadership by the PCT Board emerged as critical factors in moving beyond the data. All 53 participants in the study emphasised addressing unwarranted practice variations as an opportunity to reduce waste within increasingly tight economic constraints. Only 18 of 28 PCTs who had reviewed the NHS Atlas, however, were also able to coordinate further analysis and action. This is a missed opportunity. Advocates of variations data should support decision makers to build capacity in order to understand data on health service performance and translate that understanding into action.

3. Move from an overemphasis on individual outliers towards a more systemic view of variation and its management.

Respondents in our study tended to focus on the top and bottom ‘outliers’ of the Atlas of Variation. Although an ‘outlier’ position can be a powerful trigger for further scrutiny, national regulators and local commissioners should avoid seeing the national average as an implicit reference point or even a target – the danger being complacency. The publication of Atlases of Variation should be linked to efforts in understanding patients’ pathways across all health care settings. It should also enable decision makers to prioritise remedial actions on the basis of their contribution to population health.


For the full article, see Schang L, Morton A, DaSilva P, Bevan G (2014) From data to decisions? Exploring how healthcare payers in England respond to the NHS Atlas of Variation in HealthcareHealth Policy, 114, 1, 79-87.

The article was published in a special issue of Health Policy on Geographic Variation in Health Care – 40 Years of “Small-Area Variation”.

About the author

Laura Schang is a doctoral student in the Department of Management at the London School of Economics and Political Science.