title: If the NHS introduced a '50 procedures a year' policy, what proportion of consultant firms would be affected?
abstract: BACKGROUND
  Governments, insurers, quality assurance agencies and others have used the higher volume = better quality relationship as a basis for health policy. This relationship is probably real enough to justify these policies. However, even if it were not real, there are other reasons why these and other organizations such as the National Health Service (NHS) may favour high-volume providers. This paper attempts to answer the question: 'If, for common elective procedures, the NHS instituted a high-volume purchasing policy that requires consultant firms to perform a minimum of "50 procedures a year", what proportion of consultant firms would be affected?' The aims of this study were to estimate the proportion of NHS consultant firms that perform common elective procedures less than 50 times a year and to estimate the proportion of firms that would have to stop providing these procedures if a '50 procedures a year' purchasing policy were introduced.
  
  
  METHODS
  A descriptive analysis was carried out and modelling was performed on data stored in an NHS health episode statistics database of patients treated in West Midlands NHS facilities. For each of 12 common elective procedures we assumed that a volume threshold of at least 50 a year were set, and calculated the proportion of NHS consultant firms undertaking each procedure who performed less than 50 of those procedures each year and the proportion of firms who would have had to stop providing each procedure.
  
  
  RESULTS
  All firms performing some procedures, e.g. cataract extraction, did so at least 50 times a year. By contrast, no firm repaired more than 50 recurrent inguinal hernias a year. If a volume threshold of at least 50 procedures a year were set for a basket of 12 common elective procedures, then about 40 per cent of firms would no longer be eligible to provide a procedure. Even if a lower 'one a month' threshold were set, about 20 per cent of firms would still not be eligible to provide that procedure.
  
  
  CONCLUSIONS
  Introduction of a high-volume policy would affect a considerable number of firms, as many NHS consultant firms perform some common elective procedures infrequently. Some consultants would see the introduction of a high-volume policy as an opportunity to further specialize and super-specialize. Others would see it as a policy that restricts them to providing a narrower range of procedures, makes their professional practice less interesting, and reduces their professional autonomy. Postgraduate training institutions need to consider the possibility and implications of high-volume policies, as many junior doctors would probably need to learn to provide a narrower range of skills than at present.
authors.affiliation: Department of Public Health and Epidemiology, University of Birmingham, Edgbaston. RouseAM@hrsrc1.bham.ac.uk
authors.forename: A
authors.initials: A
authors.lastname: Rouse
authors.forename: R
authors.initials: R
authors.lastname: Wilson
authors.forename: A
authors.initials: A
authors.lastname: Stevens
mesh_terms: D017558:Elective Surgical Procedures / Q000592:standards* / Q000706:statistics & numerical data*; D006291:Health Policy; D006801:Humans; D011050:Policy Making; D011785:Quality Assurance, Health Care / Q000379:methods*; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D013222:State Medicine / Q000592:standards*; D006113:United Kingdom; D014600:Utilization Review