Private healthcare in India: 3T MRIs, super-specialties and valet parking

Featured

Ask people what they imagine healthcare in India to be like and images of over-crowded wards and shortages of doctors may spring to mind. However for those who can afford it, this is far from the case.

Max Healthcare is one of the largest private hospital chains in India and were kind enough to host me in their flagship hospital in Delhi – Max Saket. I’d like to thank Brigitte and the team there for organising such an amazing time learning about the organisation. Max formed only 16 years ago but now runs 14 hospitals with over 2500 beds across North India. The majority of patients seen are self pay followed by those that are insured.

maxsaket
Max Saket, New Delhi

 .

Technology and specialities

Saket is in the South of Delhi with around 500 beds and has a dizzying array of technologies and medical specialties. For a start they have a completely electronic patient record across the hospital including e-prescribing – something we’re in the process of implementing at Yeovil. They have a Da Vinci robot with surgeons trained initially in the US and now in a centre in Chennai. They have 3 MRIs one of which is a 3T MRI – again something that many NHS hospitals won’t be able to boast having. They have two linear accelerators.

In terms of clinical specialties, the caché amongst private hospitals in India appears to be able to hold the title “Super Specialty Hospital”. To be categorised in this bracket private hospitals compete to provide the most cutting-edge and specialised services possible. Max Saket provides specialties ranging from neuro-surgery to lung and liver transplant just as a starter. One of the challenges of intense competition for private work is the duplication of specialised services and increasing costs as hospitals compete to attract the most talented surgeons. To develop a new super-specialty, a team must be persuaded to jump ship to a new provider thus increasing costs. Something we’re lucky, generally, to avoid in the NHS.

Screen Shot 2018-07-22 at 08.37.55
Some of the specialties at Max Saket

 .

Quality

When discussing the amazing array of technology and specialties available in private health facilities in India with an NHS colleague they commented “but is there really any assurance around quality?”. I met Dr Arati, Vice President of Quality for Max and discussed in detail their approach to quality. Dr Arati had previously been Associate Director of Quality for Avon, Gloucestershire and Wiltshire SHA and so gave a great comparison of the NHS and Max approach to quality. As an organisation Max identifies two types of quality: service quality which includes patient satisfaction and cleanliness, and clinical quality which Dr Arati oversees with a team of four other doctors. The chief executive’s remuneration and organisation-wide metrics embed quality centrally. The three organisation-wide metric areas are:

– Patient satisfaction

– Clinical quality

– Financial performance

Quality standards in Max are very similar to those we measure in the NHS and a number of doctors I met proudly cited current performance against, for example, door to balloon time. Other key indicators monitored by department and consultant included:

  • Surgical site infections
  • Mortality
  • Readmission rates
  • Return to theatre rate
  • DVT prophylaxis

Whilst I haven’t conducted a detailed outcome comparison, the level of awareness of clinical standards was impressive as was the level of data available.

 .

Doctors in management

A particularly striking point I observed during my meetings in Max were the number of doctors in full time management or leadership positions. An example of these medical leaders is Dr Amrita Gupta, the Medical Superintendent of the hospital. This role is similar to a Head of Operations in the UK. Amrita studied for her MBBS before moving into management roles for the variety it offered. A recent graduate of the Advanced Healthcare Management Programme at the Indian Business School she is a focussed and driven leader responsible for day-to-day oversight of the hospital. Amrita talked through her reasons for moving into management explaining she’d chosen it “because it’s a specialty in itself, has a good career path and offers so many challenges”. She went on to explain how she could use her medical background to formulate health policies and was accepted by fellow clinicians as a decision-maker in the organisation. I asked Amrita and others why there were so many doctors in leadership positions at Max compared to the UK. They explained that firstly there’s less pay disincentive on going into management in comparison to the UK and secondly clinicians are often seen as a useful mediator bridging the view-points of professional managers and clinicians.

The range of clinicians in full time management posts is a real contrast to the UK where leadership positions for doctors are often ‘bolted on’ to existing clinical roles. I suppose in a context where doctors are already in short supply (as is the case in most countries), then large numbers leaving medicine to go into full time management positions may worsen the situation. However their presence in Max undoubtedly strengthened leadership arrangements and bridged the management/clinician distinction and divide.

image1
Dr Amrita Gupta, Medical Superintendent

 . 

Connections to UK

As I met doctors around the hospital I was struck by how inter-connected India is with the UK. I met doctors moving to take up jobs in the UK (I’ll post a video interview with one later) and doctors returning from the UK to be with family. Almost every doctor I met appeared to have either been to the UK for a fellowship or conference or had worked there for a time. Before going I worried I would see hospitals struggling with doctor recruitment due to western countries tempting staff away with higher salaries or other opportunities. Whilst this clearly has been an issue (see here), it’s more nuanced than that with experience in the UK being seen as a positive asset for doctors in India. A worrying trend I found in conversations was a feeling from doctors that the UK was losing its attractiveness or becoming less welcoming and so the US was being seen as a more positive place to go for education. I asked one senior doctor I met near the end of my time at Max why he’d sent his children to study in the US and not the UK. He replied that the level of education offered at British universities seemed of lower quality and that “the UK isn’t as appealing a destination to send our kids to now as it once was, you need to ensure the UK remains welcoming and open”.

 .

 

Great care, but what if you can’t afford it?

A key concern I had during my visit to Max was how these fantastic services were only available to a small fraction of the population. Also, despite insurance, families often have to contribute a significant amount themselves for treatment and the financial pressures are real. I discussed these concerns with staff there who were at pains to explain how all hospitals using government land are required to use at least 10% of their beds for patients who would otherwise be unable to pay. In addition, anyone arriving in ED regardless of means must receive emergency treatment if needed. As I was shown around ED there were a number of patients there who were uninsured and being cared for.

In India those earning less than Rs13,800 a month (roughly £140) are categorised as ‘Below Poverty Line’ and qualify for free treatment at hospitals which they can then claim back from the state. Despite this support for the very poor, funding healthcare is a real issue in India – estimates suggest only 20% of people have any form of health coverage and out-of-pocket health expenses drive over 60 million Indians a year into poverty. For a good discussion of these challenges and the current government’s strategy to extend health cover read this Commonwealth Fund summary.

 .

Final thoughts

As I left Max for the last time I noticed a valet parking desk at the front underlining the affluent demographic being served. Undoubtedly Saket provides world-class services in Delhi with an amazing array of specialities and supporting technology and is run by a group of talented and committed leaders. I hadn’t realised the extent to which they were still required to treat some patients without insurance but was increasingly interested in how this top-tier hospital compared to healthcare available to the majority of Indians without insurance. From Delhi I set off two hours west to Haryana state to see how public hospitals run and what challenges they face – more on that next week.

 

maxsaket

Blog 2. Talking to people about healthcare in India

Dear everyone

As you’ll have seen from Twitter the first country I’ve travelled to for the fellowship is India. I owe Dr Parag Singhal, Consultant Endocrinologist at Weston NHS Trust and National Secretary for BAPIO, the British Association for Physicians of Indian Origin, for making the introductions that made this trip possible. Thank you Parag!

Before going I’d read up about healthcare and I’d particularly recommend Mark Britnell’s book In search of the perfect health system. If you have a limited attention span like me its brief chapters provide an ideal introduction to each country’s health system including its challenges and innovations. The picture below was taken whilst re-reading it whilst stuck in an epic hour-long Delhi traffic jam.

Britnell’s ‘in search of the perfect health system’

In order to get an insight into what people think about healthcare I ran a focus group in Delhi with a group of students and professionals thanks to the amazing Delhi Toastmasters club. I have to say I was blown away by the passion the group had in discussing healthcare – a seriously impressive bunch! The four themes I picked out from this focus group which I’ll explore further were: equity, sanitation, prevention, and resources and organisation.

Equity
Britnell’s India chapter is entitled one country, two health systems and this was clearly evident from discussions and (as you’ll see in my next blog) in visits to hospitals. Bharat in the focus group described the inequity between excellent private provision that is available to the richest part of society compared to little or no healthcare available to those uninsured. He said “what you call a birthright in the UK may not be a birthright here because everyone doesn’t have medical insurance”. In fact only about 10% of Indians have any insurance and healthcare is the leading cause of people falling back below the poverty line with families often having to sell their property or possessions to fund what they need (see here for stats and current government plans to address this). This inequity is also split between cities and the countryside with medical facilities largely centralised to urban areas meaning little provision is available in rural areas.

Bharat discusses how the UK’s birthright to healthcare for all isn’t yet available in India

Sanitation
Numerous people discussed the importance of sanitation with me and emphasised both how important this was but also concern that it wasn’t improving. I recognise my sample was biased being largely urban but there was a lot of concern voiced about poor sanitation, let alone healthcare, in rural areas. According to the World Bank over 300,000 children a year die from diarrheal diseases and a whopping one in ten deaths in India are due to poor sanitation (See the economist for a good summary here). Whilst driving between cities I saw people queuing to collect fresh water from lorries as we were in the middle of an acute water shortage (see Reuters article here).

Prevention
Discussion of healthcare in the UK is often based around hospitals with typical questions focusing on do we have enough beds, doctors or nurses. My discussions in India were significantly different with the majority of discussion not focusing on treating ill people but on the importance of prevention. A number of people highlighted the impact they’d seen from the Bill and Melinda Gates Foundation in reducing infectious disease particularly in poorer states such as Bihar (for a good summary of their work see here). In the focus group there was a great deal of discussion about attitudes to early diagnosis and the fact that there were minimal check up programmes to identify the early stages of disease. In a discussion about cholesterol for example, Yagit talked passionately about how “the first time people find out they have high cholesterol is when they have a heart attack”. The group also discussed the importance of price as a disincentive to seeking early diagnosis with one explaining that unless check ups were free, people would be unwilling to seek help. This made me reflect on the discussions often raised in the UK about introducing payments to access ED or GP appointments. The issue of price discouraging preventative healthcare for those with little funds is real.

Animated discussions in the focus group

Resources and Organisation
I’ve grouped these two as they were always connected when I discussed levels of funding in India. Before going to India I expected it’s incredibly low health expenditure to be a prime topic of conversation. India currently has public expenditure of just 1.2% of GDP on healthcare making it one of the lowest funded systems in the world. With the UK already struggling with around 9% compared to many European countries at more than 11% (see this article for a good King’s Fund summary of health funding) I thought this would be highlighted as the key issue that needed to be solved. I was seriously mistaken. I reckon only about half of people I spoke to saw the funding level as an issue at all. People often referred to there being not enough doctors but didn’t link this to funding. When I pushed people the response I often got was “of course we need more funding, but the most important thing is a clear strategy/a primary care service/better sanitation”. Instead of funding the key point made was there was a need for a clearer and more focussed strategy to improve healthcare across India, improve prevention and tackle inequity. Despite having read about the current government’s health reforms (summarised here), many of those I spoke to felt that health strategy needed a stronger central direction to improve things such as standardised and affordable pricing and the development of a comprehensive primary care system.

Reflections
These discussions made me rethink my beliefs around Indian healthcare but also about health more generally. Coming from what I increasingly recognise is a hospital-centric system it was eye-opening to see discussions so focussed on public health and equity. It made me recognise firstly that we are lucky to have such an equitable system with some great achievements in preventable disease in the UK. But it also made me reflect that we need to focus more effort and funds on prevention rather than just treatment.

Final thought
Finally, as I had a day spare in Delhi decided to do a short walking tour to see some of the sights. This was a serious mistake for a soft British person – at the middle of the tour temperatures reached 47 degrees and I thought I might pass out as I lumbered down some steps. While I was thinking this, a man ran past me carrying what I saw was a 100kg bag of spice. I was in total awe of the resilience and strength of people working in such conditions but also recognised the unique health context posed by such extremes. I’ll post some videos from the focus group over the next few days. Next week’s blog will focus on Max Healthcare – one of India’s leading private healthcare providers.

Man carrying 100kg bag of spice downstairs in 47 degrees heat