The Scottish atlas of variation presents a range of indicator-based maps at health board of residence and local authority of residence level, by financial year.

The atlas aims to highlight any geographical variation that exists in the provision of health services and associated health outcomes.

It is designed to facilitate discussion and raise questions about why differences exist and help to promote quality improvement through this conversation.

As the Scottish atlas of variation develops, it will become an important tool to support Realistic Medicine by helping to identify and eliminate unwarranted variation, and the reduction of harm and waste within healthcare.

Realistic Medicine puts the person receiving health and social care at the centre of decisions made about their care and aims to ensure that all treatment offered to patients is able to add value.

We know that demand for health and care services is increasing and in order to meet that demand we must consider how to make optimal use of the resources we have to ensure the best possible care for our patients.

One of the main aims of realistic medicine is to reduce harm and waste, and tackle unwarranted variation.

Variation in healthcare exists because health systems are complex and the population has differing needs.

Identifying and tackling unwarranted variation is essential to improving outcomes derived from healthcare across Scotland.

Unwarranted variation is variation in healthcare that cannot be explained by need, or by explicit patient or population preferences.

Persistent unwarranted variation in health and health care affects equity of access to health care.

Understanding variation (random, warranted or unwarranted), through the engagement of clinicians, users and service providers, is key to providing value based healthcare within NHSScotland.

Recognising unwarranted variation is of vital importance because it allows the identification of:

• underuse of higher value interventions – for example, under-treatment
• overuse of lower value interventions
• overuse of interventions which may result in increasing harm.

It will also inform discussions on how to shift resources from where there is little or no benefit to clinical outcomes, to areas which will provide the greatest value.

We know that over investigation and overtreatment can cause harm as well as being wasteful of NHS resources.

When we consider 'harm' in healthcare we tend to focus on harm from missed diagnoses or under-intervention.

Although this is very important, we must be aware that there may be 'hidden harm' involved in overtreatment and excessive interventions.

The Scottish atlas of variation shows variation in the provision of health and care services, and healthcare outcomes across different geographical areas.

The atlas will initially focus on helping to identify over-treatment (unwarranted medical interventions) and under-treatment (insufficient treatment) across Scotland, supporting clinicians to address this by providing information in an accessible and informative way.

The atlas will highlight areas where access to health and care services differ and stimulate questions and debate about the health and care needed by people in those areas.

It is hoped that the atlas will support clinicians and healthcare teams to generate solutions that will reduce waste and harm and develop healthcare provision that is appropriate to the needs of all people across Scotland.

It’s important to note that the strength of the atlas is not to provide answers, but to prompt and stimulate questions that lead to better understanding of the reasons for variation and help identify variation that is unwarranted.

Atlas maps do not suggest an ideal level of service, or rate of procedure or treatment, nor do they suggest that high is bad, or average is ideal.

This is important, as atlas maps cannot be used as a tool to judge performance of one area against another. Instead, they are intended to facilitate debate and reflection on equity, effectiveness and value, and for this to be used by clinicians to drive improvement.

The 'fold-variation' value identifies the difference between the highest and lowest standardised rates for the procedure and geography level selected.

For example, if the highest rate of procedures per 100,000 population is 400 and the lowest rate is 200, this would be a 2-fold variation.

Differences in the population structure between regions can strongly affect the numbers of procedures that will be carried out.

For example, an area with an older population will have higher rates of hip replacements.

Standardising for age and sex is a way of making the rates comparable between regions despite these differences.

For one month prior and three months following the release of the initial set of 'proof of concept' maps in September 2018, there was a formal consultation period. 

Feedback was sought from individuals (including members of the public) signed up to the ScotStat website who had registered an interest in Health and Community Care statistics, from clinical networks (particularly targeting Realistic Medicine champions, Chief Medical Officer specialty advisors, Discovery clinical champions, and the PHS clinical team), and from staff in health and care management roles with improvement, planning or efficiency responsibilities.

In autumn 2019, there was a 'call for maps' giving the service the opportunity to steer development of maps during 2020/21.

The feedback from the formal launch consultation, the call for maps and from informal conversations at other events has been used to develop and expand the atlas.

We would encourage people to leave comments or questions using the feedback page, or email the atlas development team at phs.scottishatlasofvariation@phs.scot

Over the next few years, we will continue to publish maps that show variation in the health of the population, the provision of services and outcomes.

We expect these maps to support healthcare teams to have informed conversations that will seek out and reduce unwarranted variation and generate solutions that will reduce harm, eliminate waste and free up resources for higher-value healthcare.

Development of the atlas was overseen by the Realistic Medicine Atlas Development (RMADS) subgroup from autumn 2018 to summer 2019. 

A new Scottish atlas of healthcare variation governance group was set up in October 2019, with a focus on supporting decision making around what maps to release.  

In January 2020, this group signed off a release schedule for 2020/21, which had been developed from proposals received from the service.