What can the NHS learn from the theory of marginal gains?

By Dr. Peter A. L. Bonis, Chief Medical Officer, Clinical Effectiveness, Wolters Kluwer Health
There are many management theories on how to turn systemic failure into sustained success. Some are complex, others remarkably simple. One that’s capt...

There are many management theories on how to turn systemic failure into sustained success. Some are complex, others remarkably simple. One that’s captured the imagination in recent years is the theory of marginal gains, famously used in track cycling.

Back at the London 2012 Olympic Games, the British cycling team reasoned that if each element of competing on a bike – including kit, aerodynamics, diet or components – could be improved by just 1 per cent, the combined effect could make a winning difference. Over time, these marginal gains notched up the team’s performance to the point that they became virtually unbeatable.

Like many of the best ideas, the principle was simple enough for almost anyone to apply. Soon, luminaries of business management like the Harvard Business Review were espousing it and it quickly became a darling of management theory.

But what about healthcare? A healthcare system, like a large business, is a complex machine of many moving parts – human, mechanical and technological – contributing to overall performance. Could a focus on marginal gains help the crisis-ridden NHS improve quality and/or costs?

Imagine if each decision made by a clinician on the medical frontline – in primary or acute care – could be slightly improved, one by one, over time. 

Perhaps it’s a GP deciding not to refer a patient to hospital. Or a hospital consultant deciding against an unnecessary test. Or a junior doctor making the right call on a drug prescription. On one end of the spectrum, the better decisions have the potential to improve the effectiveness of care. On the other, they could help avert errors.

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We should take a moment to consider the cumulative cost of errors. A 2016 report by the British Medical Journal concluded that medical errors should rank as the third leading cause of U.S. deaths.As well as costing lives, mistakes are also putting health systems under intolerable financial strain.

In the UK, health service leaders warn that pay-outs to victims of medical negligence are becoming “unsustainable” for the NHS. Worryingly, a fear of litigation is now said to be creating a culture of exaggerated cautiousness (sometimes referred to as “defensive medicine”) among clinicians, worsening the bottlenecks in patient care.

So, what can we do? Cyclists can change their helmets and skin suits. Where are the marginal gains for the NHS? They may lie in addressing the millions of daily decisions made by front-line caregivers. Cumulatively, helping them to arrive at better decisions can make a massive difference.

We need to equip frontline clinicians with the evidence and tools to help, such as clinical decision support (CDS), software tools that assist clinicians in making the best decisions. Does it work? Many studies have demonstrated that CDS can improve decisions, potentially leading to better patient outcomes.

A recent study published in the International Journal of Medical Informatics found a significant association between use of a popular form of CDS (UpToDate) and reduced diagnostic errors. Physicians who used UpToDate® had a diagnostic error rate of 2% compared with 24% in a control group without UpToDate

Clearly, there is real progress to be made – some decisions may lead to small mistakes, others are potentially life-threatening. Added together, improvements in the myriad of clinical decisions made each day could surely start to make a difference. There are no gold medals in health, but perhaps there is a big win on the horizon if we can gradually make healthcare work better, one decision at a time.


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