Zip Code Lottery: Addressing Unwarranted Variation in Health Care

Research | Ian Peate| February 28, 2018

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Health care variation, often referred to as the zip code lottery, is present in a number of healthcare systems globally. Learn about different types of variations and some reasons behind them from Ian Peate OBE FRCN, Editor in Chief, British Journal of Nursing.

Everyday clinical practice is characterized by wide variations that are unable to be explained by illness severity or patient preference. Incidence of these wide variations can be found in the UK, and this is equally present in a number of other healthcare systems globally. In the UK media, variation is often referred to as the “postcode lottery” or “zip code lottery.” The “postcode lottery” means that in some parts of the UK more people may receive a certain intervention, such as eye surgery, than people living in another part of the country (Cripps, 2017).

In the UK and US, there are several types of variation and in some instances there are good reasons for this, in other cases the causes for variation are more difficult to justify, if at all. It is this type of variation that offers opportunities for improvement as we strive to provide effective health care for all.

In the US, patients with long term conditions, for example, respiratory conditions experience unwarranted variations in care in different US regions. For example, people with diabetes should have blood lipids (a type of blood fat) monitored regularly, yet in some regions, patients are 50% less likely to receive these tests than patients in other parts of the US.

Most wounds in the UK are managed mainly by nurses and doctors in the community or the patient’s own home. The most commonly treated wounds are leg ulcers, which are wounds that the patient may have had for a long time (chronic) occurring in the lower leg. While leg ulcers are distressing and painful, leaving the patient susceptible to infection and potentially impacting their mobility and their quality of life, there are variations across the country in how leg ulcers are treated. Improved wound care that includes effective appraisal of the wound and the person’s needs, making a definitive diagnosis, deciding on treatment and prevention of complications has the potential to minimise treatment costs as well as improve patient outcomes and experience. There are a number of opportunities available to reduce variation, but this requires organisation and knowledgeable practitioners.

There is a particular approach in the UK called NHS RightCare. This focuses relentlessly on increasing value in healthcare and addressing unwarranted variation at every stage of any contact with the health care system, and ‘every contact counts’ is the mantra. This approach is underpinned by intelligence and robust scientific evidence, demonstrating to those who buy services ‘where to look’ i.e., where variation and low value exists. The NHS RightCare approach supports health economies through ‘what to change’ and ‘how to change’ (NHS RightCare, 2017).

In England, Leading Change, Adding Value (LCAV) (NHS England, 2016) is a framework that can be used by all nursing, midwifery and care staff and others regardless of where they work and the role they are performing. The framework comes from staff on the shop floor, developed with a wide range of organisations nationally, staff representatives, patients, care-givers and the public. The LCAV framework considers unwarranted variation, the differences in health and care outcomes, patients’ experience and use of resources that are not able to be justified by reasons of geography, demography or infrastructure.

The largest group of staff in the health and care workforce are nurses, midwives and care staff. These staff have a key leadership role in bringing about a positive impact on care outcomes, user experience and more effective use of resources. Nurses, midwives and care staff focus on value, and they provide care that is compassionate, courageous and competent. They can only do this if they are knowledgeable, equipped with data and information required to make decisions that can address unwarranted variation.

The health care librarian is key in assisting health care providers to access resources and data that will help eliminate unwarranted variation, through scientific endeavour as opposed to the ‘we have always done it this way’ approach. This could be by enabling mobile/cell phone access or other electronic resources across an organisation, or promoting resources that are available to healthcare providers to support their lifelong learning. That is an important message regardless of where the patient lives or where the health care provider practices.

Healthcare variation is important in determining the care that patients receive or that they do not receive. Addressing unwarranted healthcare variation can contribute to more equitable access to, and better value, health care for all.

Cripps, M. (2017) “What do we mean by ‘variation’ and when is it ‘unwarranted’? last accessed January 2018
NHS (2014) “Five Year Forward View” last accessed January 2018
NHS England (2016) "A Framework for nursing, midwifery and care staff, Leading Change, Adding Value”. last accessed January 2018
NHS RightCare (2017) “NHS RightCare Scenario: The Variation between Sub-optimal and Optimal Pathways” last accessed January 2018

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