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.
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.
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
- 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.
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.
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.