The Aggressive Patient

Why are we intimidating and beating up our doctors ever so often these days?

Every other day one see’s newspaper headlines where doctors find themselves facing angry patients and their attendants who believe that misbehaving with hospital staff and doctors is no big deal at all. That breaking furniture and maybe a few bones will get them better service or perhaps the hospital will waive off a portion of their bills. Doctors and hospitals today are quite scared of such hooligans, who create a nuisance in the hospital demanding better treatment for their patients without realizing that their behavior is putting other patients at grave risk.

Part of the reason for this I suppose is that we are becoming a more aggressive nation. The road rage that one witnesses on the roads in Delhi everyday, the ugly fights among neighbors usually for parking spots, the crazy honking even on a red light are perhaps all a manifestation of this malaise. The medical profession too I suppose cannot escape its share of problems in a society becoming louder, more aggressive and more demanding. Everyone seems to be on a short fuse.

In hospitals, where life and death situations are routine, people are perhaps a lot more stressed and express their frustrations by mishandling the folks right in front of them. These are mostly doctors and nurses, who bear the brunt of their anger. Little do they realize that beating up the doctor won’t help them get better care. And that beating-up anyone is no solution to any problem.

The other reason that I find for all this anger in the hospital is a lack of communication between doctors and the patient’s attendants. Usually, the clinicians are very busy folks who have very little time for patient’s attendants. They believe that their primary duty is to look after the patients, without realizing that in today’s world they also have an equal duty towards addressing the attendant’s fears and concerns regarding the patients. Hospitals spectacularly fail in impressing on the clinicians that they must meet the attendants regularly and address all their queries as honestly and as transparently as possible. This must be a part of a process and not a random meeting in a corridor or when a patient’s attendant catches hold of a doctor fortuitously. Better communication will help reduce these unsavory episodes far more than more security guards manning the hospital doors.

I also look upon these incidents as reflective of a loss of respect and trust between patients and doctors. With the media awash with stories of profiteering hospitals and grasping clinicians engaged in dubious practices, no wonder that the relationship between patients and doctors have almost broken down. The noble profession has been reduced to no more than a transaction. There is no longer the old world courtesy and respect that clinicians commanded not so long ago. No longer are they the Gods of their realms. This is rather sad. The relationship between a doctor and a patient and their care givers has to be a a bond of great trust. The patient willingly allows the doctor to treat and operate upon him believing that he will do so to the very best of his skills and ability. The doctor on the other hand accepts this as a huge and crushing responsibility and does his best to ensure that the patient comes to no harm, while under his care. This is the covenant that has always existed between doctors and patients. This sacred bond is now stretched almost to the breaking point.

What is it that we can do to get back from the brink??

As hospitals and clinicians we have to understand that the patients are increasingly getting impatient and we must learn to deliver all that we commit. We must find more time to address their concerns and not just fob them off with some sarcastic remark about their limited understanding of medical matters. We must engage with them more, learn to treat them as equals and partner them in their treatment. A dialogue is essential.

As patients and their attendants we must understand the tremendous pressure and responsibilities each clinician carries. We must also have an unshakable faith in their good intent, skills and abilities. This has to be a given. We must also have the wisdom to realize that in medicine an adverse outcome is not necessarily the fault of the doctor or the hospital. Actually, at times it is no one’s fault. We must treat our doctors and nurses as fallible humans, just like ourselves.

Finally, there will always be those who believe that creating a ruckus helps get things done in the hospital. In my view the hospital must deal with them firmly and take whatever action is required to ensure orderly conduct.

Violence can not be justified, whatever the reason or the grievance. Beating up ones doctor is almost the most stupid thing imaginable that one can do.

The views expressed are personal

 

 

 

NHS and the dilemma of Outsourcing

A few months ago, a friend who lives in London visited his GP with a complaint of persistent headache. The GP advised him some medicines and asked him to follow-up in a week’s time. The head-aches continued and appeared to be getting worse, my friend visited the GP again, who referred him to a Neurologist. My friend managed to get an appointment with the Neurologist after 3 weeks. The neurologist examined him and suggested that he needed a MRI of the brain. A routine appointment for a MRI was given after another 3 weeks.

While waiting for his appointment, my friend had a seizure in his office. He was rushed to the A&E of a tertiary care hospital, an MRI was immediately conducted and a large vascular tumor was visualized. He was hospitalized and his family was informed that the he needed immediate surgery in a delicate part of his brain. The risks of the surgery included death because of uncontrolled bleeding or paralysis. Not operating meant certain death. They had little choice.

If, this would have been in India, my friend would have undergone an MRI the day after he had been advised by his neurologist. The tumor would have been diagnosed right-away and not after he had a seizure. His family would have been given some time to seek another opinion before deciding on surgery. They would also have had the time to visit a hospital of their choice and decide on a surgeon that they would have been most comfortable with. Essentially, this would have been an elective surgery rather than an emergency.

In England, the service was of course cashless at the point of delivery, in India, it would have been cashless as he would have been covered by an insurance policy.

With private healthcare extremely expensive and insurance premiums being very high my friend had no choice but to rely on National Health Service (NHS). This is just one case out of probably thousands who have no choice but to access tertiary healthcare in England through the A&E. The thought itself is scary.

With the issues facing NHS being well-known (and we are again in the middle of a winter when horror stories mount) it is quite a shame that the NHS mandarins haven’t considered outsourcing some of the work to hospitals abroad. The least they can do is offer patients a choice. Something like, ”you can get your bypass surgery done in the local NHS Hospital in 6 weeks or you can travel to a hospital abroad and get the same surgery done the next week. Waiting entails some risks, traveling abroad entails some risks as well and the you can decide what you want.”

The reason that NHS is chary of outsourcing is largely because of the fear regarding the local backlash, which will follow if something ”goes wrong”. And than there is of course false pride that comes in the way as well.

In matters related to healthcare sometimes things will certainly go wrong, the outcomes will not always be the desired ones. This happens in every healthcare organisation including NHS. The key is of course working towards minimizing medical errors. Good hospitals everywhere in the world pay great attention to patient safety and reducing mishaps. They have stringent processes, multiple checks and now great technology that helps bring down medical errors. At Max Healthcare in New Delhi, India, where I work we have an ambitious program called ”Chasing Zero”, which aims at reducing medical errors to zero (or as close to zero as possible!!!). I am sure other hospitals elsewhere too have such process controls, which eliminate errors systematically. NHS can pretty safely outsource some of their work to hospitals, which report clinical outcomes similar to NHS. Additionally, they can set up an oversight mechanism for this outsourced network of hospitals pretty much like what Care Quality Commission (CQC) does to supervise and regulate healthcare services in England.

The NHS will also find that the cost of sending patients abroad for treatment is far less than providing similar services in England. This will be an add-on benefit in times where most Clinical Commissioning Groups (CCG’s) are running deficits and the government has limited funds to pour into NHS.

While, this is a sensible solution the biggest problem in implementing something like this is the lack of courage on the part of both NHS as well as the Clinical Commissioning Groups (CCG’s) and ultimately the political leadership in England. The fear of the unknown and the belief that hospitals outside of Britain/Europe do not offer high quality care (mis)informs such thinking.

In a connected world where patients can be monitored and even operated remotely, this is bizarre. The NHS needs to create an expert group that should evaluate hospitals across the world for their clinical quality, cultural affinity to England, languages spoken, easy connectivity to England and the regulatory environment prevalent in the remote country. It should reach out to these hospitals for collaboration in treating NHS patients, who may opt to travel outside of England for their treatment.

Once the hospitals are identified, NHS should set a tight regulatory frame-work, which allows them complete visibility regarding the care protocols for their patients in these hospitals. If need be they can even post ”care officers” in these hospitals to monitor the care being provided. The MIS related to clinical outcomes should be transparently shared with the CCG’s/NHS. A quarterly review involving NHS/CCG officials and the hospitals should help in smooth operations of the program.

This is quite doable. All it needs is courage, will power and some leadership to effect a change.

PS: My friend had his surgery and a reasonably good outcome. The surgery was quite challenging, took more than 8 hours and was fairly eventful. He had to spend many days in the ICU and a long stay in the hospital. He has no complaints regarding the quality of care he received. His only regret being that this need not have been an emergency.

The views expressed are personal

Medical Trafficking and Medical Value Travel are very Different

I was recently in Kenya and learnt about a new term called “medical trafficking”.

This came up in discussions with a member of the Kenyan parliament, who is also an eminent clinician of Indian origin. The MP is a prominent citizen of Kenya, owns a chain of hospitals and believes that what passes for medical travel in Kenya is mostly medical trafficking.

Well, I wouldn’t agree entirely but there is more than a grain of truth in what the lawmaker is talking about. Essentially, he defines medical trafficking as dubious agents persuading gullible and sometimes desperate Kenyan citizens looking for the medical treatment to countries like India. He believes that many of the problems for which the Kenyans are travelling can be treated in his own and other hospitals in Kenya. However, ordinary Kenyan citizens, when faced with a medical crisis are lured away by unscrupulous medical travel agents with promises of magical cures at jaw-dropping prices in faraway places. This is largely achieved through an unholy nexus between local clinicians, hospitals, medical travel agents and hospitals in India and other countries.

The Hon’ble MP believes that Kenyan government should take steps to prevent exploitation of Kenyan patients in this manner. He is sponsoring a private member’s bill in the Kenyan parliament, which will regulate medical travel from Kenya and allow only patients, who have serious medical conditions and for which treatment is currently not available in Kenya to travel abroad.

I believe this is good.

However, there are a few caveats.

More than restricting patient travel for better medical care, Kenya needs to invest a lot more in building capacity and appropriate skills enhancement in the medical centre. The hospitals in Kenya, while making progress are still far behind those in India and elsewhere. The government hospitals are overcrowded, filthy and struggling. The hospitals in the private sector, barring a few are at best secondary care centres equipped to handle only routine surgeries. There is an all-pervasive shortage of clinicians, nurses and para-medical staff. The problem is a lot more acute outside of Nairobi. Unless, Kenya bridges this gulf, patients will always seek to travel abroad in search of better care.

This cannot be done overnight. Building new hospitals and finding highly trained and experienced clinicians will take years. In the short run, some gains can be made through collaborations with foreign hospitals, who might be willing to share their expertise with local Kenyan hospitals. It might also be possible to import a team of highly trained clinicians and allied technicians to be able to work in Kenyan hospitals for short periods. This will help Kenyan patients get access to high-quality care closer home and the local clinicians will be able to learn while working together with foreign experts.

Sure enough, some clinical work, particularly for higher-end tertiary care specialities, may still not get done with-in Kenya. Patients for these conditions will still need to travel abroad. These patients must be guided through proper well-established medical travel operators governed by suitable rules and regulations. These need to be framed urgently.

The medical travel industry continues to be largely unorganized not only in Kenya but in almost all parts of the world. Small-time operators with very little understanding and knowledge of the patient’s needs or the capabilities of the hospitals that they are being referred to continue to thrive. This is the soft underbelly of medical travel that the Kenyan lawmaker referred to as ”medical trafficking”.  This, of course, needs to be rooted out. It will be possible only when well-established medical travel operators employing doctors and other experts come into play. The government of Kenya should establish guidelines on who can be a medical travel operator, give them incentives to set up their offices in Kenya and let them effectively collaborate with Kenyan Hospitals, the NHIF and other large public sector undertakings for patient referrals. Only authorized medical travel operators should be allowed to facilitate patients for treatment abroad.

Finally, I must make a point about patient choice. The fact that a particular treatment is available in Kenya should not mean that the patient must be treated in Kenya. This will be clearly wrong. Availability of treatment does not guarantee quality. If a patient prefers to go abroad for her own treatment, she must be allowed to do so. After all, it is a matter of her own health and if she has the necessary wherewithal to pay for the treatment at a place of her choice, she must be allowed to do so.

Medical Trafficking is a result of unorganized, mercenaries masquerading as medical travel operators being allowed to work unchecked in Kenya. It must be curbed through effective legislation. However, patients genuinely needing high-end medical care or those who wish to travel abroad for treatment must be allowed to do so. They should be guided to bonafide and licensed medical travel operators who may help them seek the best possible care anywhere in the world.

A Day in Khiva

272Pahalvan Mahmood is perhaps the only wrestler in history who has a beautiful mausoleum built for him, which he shares with his king. The Pahalvan apparently was a man of extraordinary talents. Apart from his herculean strength and skills as a wrestler he was a polyglot, philosopher and a poet. He was also known to be a Sufi and the patron saint of the city of Khiva in Khorezm (Khorasan) region of present-day Uzbekistan. As I stand agape at the beautiful monument, our guide Umeeda tells me that the most famous wrestling match that Pahalvan Mahmood had won was with a renowned Indian pahalvan in the city of Multan. Pahalvan Mahmood beat the Indian wrestler and was cleverly able to free over 500 Uzbek prisoners as a reward for his efforts.

The Pahalvan’s mausoleum is carefully kept in Khiva, has a magnificent tiled courtyard and a turquoise dome, which gleamed in the sun. The aquamarine dome is striking and the tiling on the walls and the sarcophagus are marvellous. The tomb was built-in 1326 and has been very well-preserved. Pahalvan Mahmud has the honour of sharing the mausoleum with the 13th-century ruler of Khiva.

224Khiva has a history going back to over 1000 years. The city is located on the banks of Amu Darya in the Khorezm region of Uzbekistan, west of the modern Uzbek capital Tashkent. The region is also famous as the birthplace of Al Biruni, arguably the finest scholar of the medieval Islamic era. Al Biruni knew physics, mathematics, astronomy and natural sciences. He was also a historian and linguist familiar with Khawarzemin, Persian, Arabic, Sanskrit, Greek, Hebrew and Syriac. Al Biruni travelled to India and published a famous study of Indian culture after studying Hinduism. In Khorezm, he is a national hero.

Fortunately, travel to Khiva is a lot easier in today’s time. Direct flights connect Tashkent to Amritsar and Delhi. The nearest airport to Khiva is Urgunch 70 minutes flying time from Tashkent. Khiva is a 40 minutes drive from Urgunch. A 4 lane modern highway took us from Urgunch to Khiva. The road on either side was lined with fields of cotton, sunflower and peach orchards. The land is fertile and well fed by a network of canals visible everywhere.

190Stepping into the walled city of Khiva is like entering a living and breathing medieval Islamic city. The inner part of the city called ”Ichan kala” is well laid out with beautiful madrasas, mosques and lovely minarets. The Kalta Minor, which is a huge blue and green tiled tower in the centre of the walled city is an incomplete minaret, which the Khan building it could not complete and his successors chose not to finish. Today, it is the most distinguished landmark of the walled city of Khiva.

We strolled across the thoroughfares of the lovely city on a mild afternoon. The streets were lined with shops selling curios, beautiful ceramic plates and fur huts made from authentic minx fur. We walked onto the roof of the king’s palace to have a great view of the city spread out beneath us. This is a city steeped in history and so well-preserved that it appeared as if we had actually travelled a few centuries and were looking at a real medieval city.  The silver throne of the king though was a disappointment. This is apparently a replica, the original one is now a part of the National Museum in Moscow.

242Opposite the King’s Palace stands a madrasa with a beautiful tree-lined courtyard and the rooms of the students around it. There is a museum there as well, where I came face to face in a painting with Pahalvan Mahmood standing victorious after his famous ”dangal” in Multan!!!

257A little later we walked into the Djama Masjid, the Friday prayer mosque. The mosque is now a monument with hundreds of carved wooden pillars supporting the roof arranged in rows. The mosque was built in the 10th century and rebuilt in 1788-89. Umeeda showed us some original columns taken from the earlier structure. From the place, where the imam stood, Umeeda pointed out to us that all the columns were clearly visible. With the sun filtering into the mosque, it almost looked divine.

277A small turn towards the right took us to the mausoleum of the famous pahalvan and the king Rakhmat Khan. Abutting the mausoleum is a tall minaret. Umeeda challenged us to climb to the top for the most magnificent views of the city. We accepted the challenge and entered the dark minaret through a flight of stairs leading to its entrance. Soon we were on a treacherous, winding, ancient staircase with polished wooden steps. We soon realised our folly but decided to continue up through the minar. A little light seeped through the openings cut into the wall of the minaret and we used the torch-light from our mobile phones. The journey up the minaret is arduous but the views from the top well worth it. I imagined seeing the Amu Darya glinting in the sun, far away to our east. We learnt that the minaret also served as the ancient gallows, with the condemned being flung to their deaths from the top.

The return to mother earth was even more treacherous. The stairs are uneven, slippery and there is just nothing to hold on to. We negotiated each step with a great deal of caution, holding on to the step above while taking the next step down. To make matters more difficult, we encountered people going up the same time. Stepping out of the minar, I took a deep breath and resolved never ever to try scaling a medieval minaret, whatever the reward!!!!

PS : The melons of Khurasm are something to die for. Pristine white slices dripping with the sweetest nectar, they are just out of the world. We saw these piled high up on the roadside, each melon the size of a football. Actually, they come in two shapes, oval like a rugby ball and round ones like a football. We had them for dessert that evening.

Pics by the author

The Patient’s Charter and some Questions

The National Human Rights Commission (NHRC) of India has developed a Patient’s Charter, which has also been released by the Ministry of Health and Family Welfare, Government of India, for comments by various stakeholders. The document enshrines 17 patient rights including the right to information regarding one’s medical condition, emergency care, informed consent, confidentiality, a second opinion, patient safety, and quality care. The charter also tries to establish a multi-layered grievance redressal mechanism involving a grievance redressal officer in the treating hospital, an external Patient Rights Tribunal or the necessary authority to be established under the Clinical Establishment Acts.

The Patient Charter actually puts together various patient rights, which were earlier scattered across multiple documents such as the MCI Guidelines, various court judgments, and extant laws. The charter allows patients to know about their rights in a single document, which in itself is commendable. This document once finalized needs to be vigorously publicised and patients educated about their rights.

While the Patient’s Rights Charter has laudable aims and is couched in lofty language, what is not clear is how will this be implemented. Healthcare in India is largely unorganized, unregulated and mostly in the hands of the private service providers. The majority of patients view their doctors as demi-Gods (yes, even in this age!!!) with miraculous powers to cure. The government institutions suffer from chronic overcrowding, creaking infrastructure, and perennial shortages. I am not sure as to how a harried doctor with hundreds of patients waiting to see him through the day will ever be able to provide complete ‘information’ to a patient about his condition, plan of treatment, likely prognosis etc. To make matters worse, even if the doctor was to attempt this, there would be a great fear in his mind of the patient not fully comprehending the problem or worse misunderstanding leading to completely unintended consequences.

It is nice to have the ‘right to confidentiality, human dignity, and privacy, however, how is one to reconcile this with the reality of many of our hospitals, where patients are often forced to share beds because of lack of adequate infrastructure.

Similarly, it is great to have a ‘right to a second opinion’, it is not clear how will this right be exercised. Should, the primary physician informs the patient to exercise his right to get a second opinion from another expert, should he facilitate this and what happens if the two opinions do not converge. Does the average Indian patient has the ability to fully evaluate the nuances of both the opinions and make up his mind about the treatment options on the table? I have seen even highly educated patients to struggle with this.

I find the ‘right to choose the source for obtaining medicines or tests’ particularly difficult to understand. The patients while in a hospital can choose to bring in medicines from any source of their choice and get tests done from any laboratory. In India, where we have over 30000 drug manufacturing units with many operating from people’s garages and sundry sheds, it is extremely hard to ensure quality clinical outcomes if patients were to get their own medicines. The same applies to unregulated labs thriving on almost every street in the country. While I can understand and appreciate the intent of this direction (to ensure private hospitals do not fleece patients by forcing them to buy expensive medicines and tests), how on earth will we have clinicians and hospitals take ownership of clinical outcomes under these circumstances?

The right to seek discharge from a hospital is indeed welcome. The hospital cannot detain a patient against her wish is simple enough to understand and agree with. However, what happens if a patient insists on leaving the hospital without settling her dues. This happens most often when the clinical outcome is adverse and the patient feels that she has not received adequate care in the hospital. Maybe defining a set of responsibilities for patients along with this Patient’s Charter will be a good idea.

The right to be referred to a higher clinical establishment or to a super-specialist without any commercial consideration is clearly the way it should be. The referring doctor/institution must only be guided by what is good for the patient and not by any other external considerations. This has been on the statute books for long. The million dollar question remains, how will this ever be implemented and monitored.

On the issue of grievance redressal, my view is that hospitals must have an ombudsman or a committee of external experts to be able to address patient grievances. The committee should consist of eminent individuals and experts who can evaluate the patient grievance without bias and address the patient concerns in a timely and just manner. The external appellate mechanism being sought to be established either through the CEA or an empowered quasi-judicial committee works just as well. However, patients must be educated on the nature of grievances that should be raised in these fora. Otherwise, they run the risk of being inundated by sundry patient complaints and fail in their primary duty of addressing genuine grievances.

The Patient’s Charter in itself is a great step forward. All the stakeholders, which includes medical establishments, government and patients must ensure that the charter in its final form is implemented both in letter and spirit.

An educated, well-informed and aware patient is after all in everyone’s interest.

The views expressed are personal.

 

 

 

 

The Doctors who Communicate Better, are Better Doctors.

Communication with patients is perhaps the most important component in the overall patient experience at the hospital, yet it is a rare hospital that gets it right. The communication with patients largely involves the clinicians. The nurses, front-office executives, the house-keeping staff and even the security guard manning the elevator too can help deliver a wonderful experience by reaching out with kind words. However, it is really the doctors, whose words make the biggest difference in a patient’s life.

A few years ago, a friend’s husband needed a kidney surgery. The patient was to be wheeled into the surgery at around 10 am in the morning and the surgery was to finish in 4 hours. He was wheeled in for surgery from the hospital room at around 0930 in the morning. When I met the friend’s family a couple of hours later the attendants sat huddled together in the cafeteria, anxious and hopeful in equal measures. The time went by rather lethargically and their anxiety kept mounting. When 6 hours had gone by, the frantic family members approached the doctor’s secretary, who assured them with great panache that the surgery has gone without any hitch and they will soon be able to see the patient. Much relieved, the family members decided to have a celebratory coffee as they waited to see the patient in the recovery.

While they waited to hear from their surgeon, a couple of hours went by. The helpful doctor’s secretary by now had finished work and gone home. The surgeon was no-where to be found and there was just no one who could give them any information about the patient. Again frantic with worry the friend reached out to me to get some information about the patient’s well being and also when can they possibly see him and their surgeon.

Concerned, I made inquiries with the team in the OR and learned that the patient’s surgery had been delayed by a few hours as the previous surgery in the same OT had lasted longer than planned. The surgeon had been busy operating his scheduled cases and did not have the time to step out and explain the delay to the anxious patient’s relatives. The surgeon’s secretary had not heard anything untoward from the OT either and just assumed that everything would have gone as planned.

The patient’s surgery was uneventful and he made a full recovery. However, for the patient’s attendants, this was a harrowing experience. This is a true incident, and we know that something like this happens every day in our hospitals.

I have often pondered over the stark difference in the situation between the surgeon and the patient. Consider this for a minute. For a surgeon, a surgery is something that he does every day (maybe multiple times every day!!!), for a patient it is a frightening and hopefully once a lifetime experience. The surgeon, while operating in his theatre, surrounded by a team that he has perhaps worked with for years is usually confident of his skills and the ability to help the patient. The patient and his family are on the other hand in an alien environment. No one likes to be in a hospital and surgery is scary. The outcome in the patient’s mind is always uncertain. Given a choice, he would be anywhere but the hospital. Such is the power imbalance and asymmetry in the equation between the doctor and the patient, that it is imperative that we use clear communication to keep things on as even a keel as possible.

Patients will always see doctors who communicate well as better clinicians. Patients and their families like their doctors if they step down from their pedestals and treat them as friends. They will readily narrate stories about their interaction with their doctors and tell all their family and friends on how approachable and wonderfully transparent their doctor was. They will readily recommend the doctor to their family and friends and ultimately restore the doctor back on the pedestal!!!

It is very hard for the hospital administrators to mandate processes that define when and how should the clinicians meet their patients. Afterall, this is really a matter between a doctor and his patient and the hospital management isn’t usually welcome as a participant in this relationship.

However, hospitals must encourage their doctors to spend more time with patients and their families and not just fob them off with brusque briefings in the corridors. They must provide infrastructure, where patients and their families can meet their doctors and spend time together.

Doctors who communicate well with their patients can easily transform the hospital experience for a vast majority of patients.  Hospitals will do well to remember that.

The views expressed are personal

 

 

The Need for a new Healthcare Model and some Concerns

The organized private healthcare in India needs to urgently evolve a new business model.

The present model faces challenges as the government goes about changing the healthcare landscape of the country in a ham-handed manner. The price controls that are being put in place essentially mean that private healthcare players will have to develop a new business model, which is ultra low cost and allows them to accept patients at the government mandated low prices.

The Ayushman Bharat Scheme and its different versions being developed by the state governments appear to be a precursor to some kind of Universal Healthcare system in India. The government in itself is not in a position to significantly increase its own healthcare spending on badly needed public healthcare infrastructure. Thus, it will willy-nilly rely on private healthcare, which in any case caters to a majority of the citizens of our country. This is likely to see the emergence of a low-cost health care system, which will serve the needs of the masses.

The Contours of the New Model

Going by the prices on offer from the government for various medical procedures, the new model will have to be quite bare bone. Essentially, this would mean less number of people employed in the hospital, very little by way of ”support services”, no private rooms, generic medicines (my fear is of inferior quality as well, as India has over 30000 pharmaceutical companies with poor regulation in place) and very little by way of patient comfort. The model can only work on large volumes of patients and high patient throughput.

The Concerns

While the model can be developed, the biggest concern will have to be the quality of care that will be delivered. The model’s cost-driven approach completely ignores the minimal clinical quality standards that must be delivered. Presently too, this is a nebulous area as the quality of health care services vary widely and there are no comparative acceptable benchmarks. Large private corporate hospitals have their own standards often comparable to global standards and they have systems in place to monitor the quality parameters and clinical outcomes. Small, private nursing homes have fuzzy standards not clearly defined and stated. No one publishes there outcomes.

To make matters worse, in India we do not have a clinical quality watchdog, which keeps an eye on medical processes and outcomes. Thus, hospitals can report their outcomes and clinical data as they wish. This is clearly a recipe for disaster.

While the implementation of National Health Protection Scheme (NHPS) may lead to better access to medical care to a large number of citizens, the large private healthcare players may get deluged with patients far beyond their capacity. When the payor will be the government through insurance companies, everyone would want to access the highest level of care possible. This in itself is fine and laudable if the care available in the country is of a uniformly high quality. However, in India, the quality of care varies tremendously and therefore the private healthcare players with high standards of care may find themselves unable to cope. Sadly, they may end up compromising on these very clinical standards to manage the patient volumes, thus blunting the competitive edge that they had to begin with.

The third big concern is the ability of the government agencies to be able to effectively implement this ambitious scheme. While the mandarins in Niti Aayog are burning the proverbial midnight oil to get the scheme off the ground, the challenge is indeed enormous. The best-planned schemes come to naught if the execution is tardy. That sadly has been the fate of almost all such similar schemes implemented earlier in different states. The government’s track record is hardly inspiring and the stakes this time around are truly high.

The private healthcare players, however, have their task clearly cut out for them. They have to find a new business model, which delivers world-class care to a very large number of people at a cost which is impossibly low. The sooner they get on with finding the right business models for themselves, the better off they will be.

The views expressed are personal