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A tale of two halves

The National Director for NHS RightCare looks at what overuse and underuse mean for people and patients; and how they are tackled for the benefit of the person, patient, taxpayer and the NHS:

Overuse and underuse are two of the key themes underpinning the NHS RightCare programme implemented across all Clinical Commissioning Groups Sustainability and Transformation Partnerships and emerging Accountable Care Systems in England.

Overuse in the provision of health services has come to prominence in recent years and is one of the themes underpinning NHS RightCare.

Although the phenomenon has existed for decades, it has received much greater attention with the ramifications of the global economic crisis, including the need to find efficiency savings in the NHS.

The Institute of Medicine’s definition of overuse is: “Care in the absence of a clear medical basis for use, or when the benefit of therapy does not outweigh the risks”.

This definition highlights two important points:

  • Overuse has the potential to harm patients, through unnecessary, inappropriate, or low-value treatment.
  • Overuse represents opportunity costs to the NHS and to other patients who may be denied, or experience a delay in the care they need, due to unnecessary expenditure elsewhere.

Thus, overuse is a waste of resources that has harmful consequences, and ultimately signifies poor care.

The most obvious example of overuse is the prescription of antibiotics. Antibiotic consumption is one of the major drivers for antibiotic resistance in bacteria, which has serious consequences, including increasing treatment failure for commonplace infections, and a decrease in the treatment options available in situations when antibiotics are vital.

On the flip side is underuse – a failure to deliver effective and affordable care that a patient would have wanted. This definition underlines two consequences of underuse:

  • It denies an improved quality of life to some patients, because underuse could increase disability and co-morbidity.
  • It removes the possibility of increased life-expectancy for some patients.

Underuse has serious consequences for the NHS: if patients are not given effective treatment when they need it, there is a likelihood that they will present at a later date with more serious symptoms, which may entail more complex care incurring greater costs.

There are many examples of underuse of effective care in the NHS, including the lack of timely access to care on a stroke unit for people with acute stroke, and the variation in quality of care people receive from stroke services. Another example is the proportion of people with diabetes who do not receive all NICE-recommended care processes which help to prevent microvascular and macrovascular complications.

Underuse can signify a misallocation of funds leading to a lack of care, the provision of ineffective care, or a lack of capacity where patients could benefit from effective care but are unable to access it. Underuse not only causes harm to individual patients, but its cumulative effects harm the population, reducing the level of health and well-being across society.

Overuse and underuse in the NHS affect us all. The cost to individual patients is clear, especially when they do not receive the effective care they need or when they are given treatment they did not need or would not want; both can lead to physical or mental harm.

The cost to the NHS, and accompanying opportunity costs, affects other patients in need; clinicians; service providers and commissioners responsible for stewardship of treatment resources; and the taxpayer, who ultimately funds the NHS. The cost to local populations across England is a loss of health and wellbeing, resulting in a shrinking of economic sustainability and community viability, which becomes a drain on civil society.

So how do we tackle the issue of overuse and underuse?

All patients in need should be given the “right” care: effective care at the appropriate time in line with the seven principles, six values, and series of patient rights in the NHS Constitution for England.

The RightCare approach is designed to help entire health economies take action to increase value in healthcare provision and to reduce unwarranted variation. This approach is broken down into three stages: where to look; what to change and how to change

One of the easiest ways to identify overuse and underuse in clinical practice is to look for variation, for instance, in activity, cost, quality, safety, equity and the quality of interventions. NHS RightCare’s Intelligence packs and NHS Atlases of Variation are useful starting points. Once the potential for variation has been identified, it is possible to investigate whether the variation is warranted or unwarranted.

NHS RightCare tackles overuse and underuse of effective care in several ways:

  • Promotion of shared decision-making, whereby clinical expertise is combined with the patient’s knowledge and preferences during consultation; patients receive  unbiased and clear information regarding treatment options and the possible benefits and harms – this leads to better informed treatment decisions and better outcomes.
  • Partnerships with other NHS England programmes such as Medicines Optimisation, which adopts a patient-focused approach to medicines use, changing the way that patients are supported to achieve the best possible outcomes from their medicines.
  • Supporting the development of the Nursing, Midwifery and Care Staff Framework – Leading Change, Adding Value – which describes how this group of healthcare professionals can help to increase value for patients and populations while reducing unwarranted variation.
Matthew Cripps

Professor Matthew Cripps is National Director of NHS RightCare, a part of NHS England that focusses on population healthcare improvement and helping the wider health service to identify and use techniques, tools and methodologies to increase value in healthcare.

Its focus on increasing value at system level, for individuals and the population, is seen as integral to the delivery of financial sustainability for the NHS.

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