There are a number of examples of unwarranted variation in healthcare, both in the UK and globally. Unwarranted variation has the potential to divert resources to areas where they are uncalled for, and is a source of concern, as it suggests that the care women are receiving may depend upon where they live. It also implies that NHS resources are not being used in the most efficient way (Royal College of Obstetricians and Gynaecologists, 2016).
The term ‘postcode lottery’ is often used in the UK to describe unwarranted variation, and midwives are aware of these often unjust variations in care provision. Some variation in care is normal and to be expected; yet, there is much that is ‘unwarranted’ and cannot be explained, justified or even defended. Identifying the variation in care settings can provide opportunities for improvement. As the NHS continues to face challenges, understanding where variation in care and outcomes occurs, and what this variation means, is needed more than ever if the quality and safety of maternity services and the experience of mothers are to be improved (National Maternity and Perinatal Audit, 2017).
Leading Change, Adding Value
The Leading Change, Adding Value framework (NHS England, 2016) is a guide for all midwifery, nursing and care staff, building on the success of Compassion in Practice (Department of Health, 2012), which sets out the ‘6Cs’. The 6Cs have been used extensively in a number of health and care settings (including maternity care), and have since become the foundation of health and social care values. The Leading Change, Adding Value framework has the potential to transform the future of midwifery care, with the overarching aim of supporting staff in addressing unwarranted variation, and driving change in care.
The framework is well suited to any organisation that is implementing, or thinking of implementing, a public health model of care that keeps women's health and wellbeing central, while also aiming to maximise every opportunity and contact that midwives have with women and their families. When there are better outcomes, better experiences and better use of resources, this will lead to improvements in population health—a key focus for midwives as they carry out their public health role.
At the core of the framework is a determination to tackle unwarranted variation. There are three areas where work is needed:
There are 10 ‘commitments’ within the framework that will support staff in ensuring better experiences for women and their families and improve outcomes (NHS England, 2016: 13). These commitments have been designed so that they are suitable for use in any setting, whether locally or nationally.
The Chief Nursing Officer for England, Professor Jane Cummings, has urged everyone, wherever they work and whatever their role, to use the framework to develop approaches to close the three gaps that have been identified in the Five Year Forward View (NHS England, 2014). Previously, Compassion in Practice (Department of Health, 2012) confirmed the values at the heart of midwifery care, and Leading Change, Adding Value develops this; supporting staff to apply as much importance to quantifying and measuring the outcomes of their work as they do when demonstrating the quality and the core value base for which they are renowned. The framework supports midwives to think about how they can narrow the three gaps described in the Five Year Forward View by reducing unwarranted variation in efforts to achieve the triple aims of better experience, outcomes and use of resources (Berwick et al, 2008).
The ten aspirational commitments set out in the framework will help midwives to achieve the triple aim outcomes.
The RightCare programme
The UK health and social care system is undergoing dramatic changes that are set to continue. There are a number of approaches underway that aim to achieve the triple aim (Moore and DeBuono, 2013).
In England, the NHS RightCare programme (NHS England, 2018a) is a national initiative that is committed to delivering the best care to patients; making sure that the NHS' money goes as far as possible and improves patient outcomes.
Ensuring that women and their families can access the right care, in the right place, at the right time means that the NHS can treat more women effectively, now and in the future. It is unacceptable to witness inconsistent differences across the country regarding the type of care that women and their families receive. NHS RightCare's work is central to ensuring that the best possible care is delivered everywhere. To achieve this, NHS RightCare advises local health economies to:
‘As the NHS continues to face challenges, understanding where variation in care and outcomes occurs, and what this variation means, is needed more than ever if the quality and safety of maternity services and the experience of mothers are to be improved’
Call to action
Midwives and other healthcare providers often face challenges in quantifying the contribution they make to patient outcomes. Leading Change, Adding Value emphasises the need for each health professional to focus on unwarranted variation, differences in health and care outcomes, experiences of women and their families, and the use of resources that cannot be rationalised by reasons of geography, demography, or infrastructure.
It is important to know where to look for unwarranted variation, what it is that needs changing, and how to change it—and then those changes need to be made. Using the RightCare methodology and tools, for example, the ‘Commissioning for Value’ packs (NHS England, 2018b) and Clinical Commissioning Group packs (NHS England, 2018c) and Atlas of Variation (NHS England, 2018d) series is a good way to start.
The leadership contribution that midwives make is key to maintaining high standards of maternity care and delivering change. Leading Change, Adding Value sets out shared ambitions and commitments across health and social care, and demonstrates the leadership potential that midwives have, and the role that midwives can and must play.