Tuesday, 12 November 2013

Indian Health: Money and Doctors Cannot Solve It - Get the Engineers Out There

India's recent mission to Mars seems to have provoked questions mainly from non-Indians on the need to prioritise development in other areas such as healthcare. Most Indians seem to be proud of the Mars mission and live on hope that the great successes seen in space exploration may somehow be replicated one day in other areas. Many non-Indian commentators and overarching international organisations have asked for India to raise healthcare spending.

The numbers seem to be all over the place. For the purpose of this blog discussion we will assume the following for Indian healthcare expenditure:

Percentage of GDP spent on healthcare 4%

Percentage of government expenditure on healthcare 8%

Per capita spending on healthcare $60 (if you believe wikipedia its $124)

Out of pocket expenses is around 60%

This is when the arm chair commentators, the ones who have never been bitten by a mosquito in an area where malaria is prevalent, should get out of the discussion and get a dose of reality.

What can you get in western healthcare for $60? Not a lot. 

This $60 per person per year spent on Indian healthcare is mostly accounted for by the 20% of people who represent the middle class and above. Many of the middle class get much more than $60 spent on them leaving in theory and in practice, a large proportion of the population to have nothing spent on their healthcare $0 per year. A friend recently had a colonoscopy in a frightfully expensive hospital in India and spent Rs 70000 ($1111) this may mean this friend has used up 17 other Indians' annual healthcare spend. You get the picture.

70% of the Indian people live less than $2 per day (33% of people are below the official poverty definition of $1.25 per day). You get the bigger picture.

By how much should India raise its healthcare expenditure? Doubling it to $120? What would that get? Nothing in reality. Doubling that to $240? You would not even scratch the surface. If the entire per capita income of an Indian which averages $1100 is spent on healthcare India will still have a healthcare expenditure less than Lithuania. Even at that level no one can predict if healthcare benefits will be equitably distributed across the population. It may well be possible that the rich will get healthier and the rest may get unhealthier.

The US example is relevant here where 18% of GDP is spent on healthcare at nearly $9000 per person yet 40 million US citizens do not have healthcare cover and US has poor outcomes for many chronic conditions. Throwing money at problems does not necessarily solve problems. 

Ask for a better system. Ask for a different system. If that system costs a little more, then the money follows, do not ask for more money to be spent on the existing system - it just goes down the drain.

Copying the current western systems of the 21st century for healthcare delivery in India straightaway  is expensive. This means the benefits of any copied western systems will reach the small proportion of the wealthy population. Well worth remembering the Jaguar in India costs the same as in England and obviously the only wealthy get to use it.

Alternative medical systems (ayurveda, siddha, homeopathy, etc) are still unable to provide comprehensive answers at a population level.

So what is missing? What are the potential avenues to explore?

Cannot Escape Evolution

There can be no doubt health improvement at population level has evolved gradually over time from the early 1900s. Interestingly the earliest foundations of population level health improvement happened not by direct personal medical based interventions but by infrastructure based social living conditions improvement. I am talking about covering the drains, separating animals from human beings, providing clean drinking water and so on. Direct intervention based healthcare followed much later.

In India in 2013 there are still many areas even within all the cities greater boundaries where there are open sewers. In 2013 in one of the poshest areas of a very major city there are contaminated water supplies. The healthcare budget cannot not solve this; yet solving it will improve the health of the people.

A healthy population is the greatest boost to an economy but the population cannot be made healthy by primary, secondary or tertiary care based direct personal medical interventions - i.e. doctors, clinics, hospitals. Populations can be made healthy only by political will and civil engineers. That is the trick India is missing. Building more primary and secondary care centres with open drains around them is the opposite of a decent healthcare solution. India cannot hope to improve the health of the population by avoiding a well established evolutionary pathway.

It seems India and its well wishers may be looking for the magic injection that will solve major health problems. There may be magic injections for diseases but we will do well to remember that there are no magic injections for health.

Under the given current conditions, doctors cannot solve the healthcare problem of India. Get the engineers out there. Get them to cover the drain, clear the puddle, provide clean drinking water and keep the roads clean. You will find the population becomes healthier contributes effectively to the economy. Then and only then we can spend more on healthcare and expect to benefit from it.

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I have blogged previously about great areas of Indian healthcare which you may want to check out.
Dr Bang's remarkable achievement in rural India which gets the same results as cities

My conversation with the Chairman of Aravind Eye Care a low cost superior quality system about their culture

Tuesday, 22 October 2013

Are doctors paid well?

Are doctors paid well? 

Or are they normalised to the lack of a major motivator?

Young Bankers

A person known to me did an internship with a bank/financial services firm during the summer break at the end of the first year of a three year degree course. For those two months this bank intern was paid including allowances which works out pro-rata to about £21000 per annum. The hours were very long, typically from about 8.30 am to 10.30 pm the work was very demanding including working on live projects. The output was measured and critical developmental feedback was provided very frequently with no tick box exercises or euphemistic language. The allowances included dinner and taxi back home if the intern worked after 8 pm. On the first day the Managing Director of the firm set aside time to meet the intern before the start of the internship. Just before leaving the team gave the intern a farewell lunch at a Michelin starred restaurant.

All this for an intern with one year university education doing a summer job for eight weeks.

I know reliably that internships in banks after the second year in university is much more common and those youngsters are paid a little bit more.

The starting salary for investment banking and other higher profile areas in banking after a bachelors degree are $100000 to $150000 after bonuses. Starting salaries with an MBA ranges between $120000 to $220000. In the UK for a first year analyst in investment banking is £60000 without bonus (I learn that a few first year analysts make more than £100000 after bonuses). For other areas of banking the first year pay ranges from £40000 to £60000.

Young doctors

I looked at my junior doctors, house surgeons (now called Foundation Year One trainees) in the UK. After five to 6 years in medical school they are first responders to many critical situations that could involve risks to life and limb - their pay is £22636. They get no food from their hospitals even if they worked through their lunch/dinner breaks which many often do. They do not get any allowances. I am informed by quite a few house surgeons from many hospitals that they had not seen their consultants for up to five days and not seen their clinical directors for longer. When these house surgeons leave after four months of work (it used to be six months) it is not always they get a send off dinner and never in a Michelin star restaurant.

Hull York Medical School has recently required their senior medical students to do night duties which involves more than simply shadowing, possibly actual work such as clerking etc; these medical students are not paid for it. I am sure HYMS are not alone in this. I know of no medical student who worked in a hospital or GP practice doing supervised clinical work for which they got paid.

Some/Many India private medical college house surgeons see and treat patients without pay after having paid lakhs of rupees as capitation fees to enter medical school and then lakhs of rupees as course fees for 5 years.

Young doctors and young bankers, both need to have consistent excellent academic record and great CVs. They need to perform under high pressure situations within very narrow time constraints. The number of newly qualified doctors more or less matches the number of young graduates who enter the banking industry. Doctors work shorter hours, banking analysts do 100 hour weeks; however I have many years ago as a young doctor before the EWTR worked 80 hour weeks for many years and the pay was not equivalent to young graduate analysts in banking. Surely someone is bound to come up with the emotional argument of public money, please give it a rest for at least two reasons, junior doctors working with private healthcare providers do not get any higher pay and we constantly hear from the BBC and other public sector bosses about the need to pay themselves competitive rates when compared to private sector.

There is no question that doctors especially young doctors are not paid well. Add to that the longer very demanding education, the stress of dealing directly with individual members of the public's health in often resource constrained circumstances and the very restrictive regulatory atmosphere - the mix is quite a downer for most doctors. Having made a choice to do medicine most people switch to serving the public, relieving pain, noble profession type of thinking to validate their thinking and keep their sanity.

Any doctors in the rich lists?

Four out of 400 in the Forbes USA rich list have medical qualifications. Of these four only Gary Michelson ranked at 328 seems to have made his money from his practice as a doctor - he is an orthopaedic surgeon with 250 patents. Thomas Frist Jr is a medical doctor who made his money by running hospitals. Two other doctors made their billions by their involvement in pharma.

In the Forbes world rich list there is only one person who has made his billions through healthcare. Thomas Frist Jr of HCA  comes in at 262 in the world rich list, as already said he owns hospitals.

In the UK's list of billionaires there is no one who made their cash through healthcare (unless you include Branson who owns Virgin Health but I am not sure he made his billions from it).

Considering the fact that the need for healthcare is universal and eternal (as opposed to cola drinks or branded retailing being a non-essential option) it is very unnatural, strange that there are no doctors in the rich list.

Financial motivation is normal. Are doctors normalised to the abnormal?

Being a hands on doctor treating patients does not pay great.

So, not only a junior doctor is paid a fraction of what their banking colleagues are paid, they do not have a hope of every making it rich by treating patients as a clinician. Our reward systems do not seem to rate the direct saving of life, direct relief of pain and other direct clinical forms of patient contact very highly. There is no financial case for young highly intelligent, hard working high achievers to be doctors. Further, there are no future financial opportunities for doctors.

We may or may not want to or be able to remedy it. However when we look at the big picture and recognise that doctors are also normal human beings with normal emotions but have adjusted to the low finance reality there may be a certain element of hidden, difficult to explore, difficult to understand, motivational deficit which may be impossible to resolve. After all doctors may not be paid as much as bankers but they are paid much more than the rest of the working people; so any doctor who argues about not being paid well could be seen as greedy, unethical and unprofessional - so it is not the done thing. 

One major motivation in life, a normal wish that rewards are linked to effort, especially for the young does not exist for doctors. The medical profession will have this permanent cloud, this eternal chain to its feet in the form of direct financial or motivational levers which are unavailable. That will have its impact on society. The profession is now normalised to it hence unable to argue forcefully or think of innovative means to break through.

The medical profession is fighting the phenomenon of normalisation of the abnormal by confronting a large number of bad practices to improve patient safety (hand washing, routine catheterisation for surgery and many others come to mind). Will they be able to do the same for generally superior financial rewards for the whole of the profession?


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Selected sources:

Thursday, 26 September 2013

In search of immortality

The media screams out relentlessly on excess deaths, avoidable deaths, harm, on how many lives can be saved if healthcare did this, that or the other right. In fairly cynical mood I thought, if I added up all the number of lives the media says we could save the people in UK could become immortal. Thus started my quest for immortality.

Here is the list and total of how many lives the media thinks healthcare can save.

Preventable DVT deaths 25000
Kidney function tests 42000
Addiction deaths 150000
Child deaths 2000
 Learning disability 1200
Cancer deaths 11500
 Maternal deaths 50
Not taking tamoxifen 500
Dehydration in the elderly 130
10  Wrong medication deaths 11
11  Sepsis 15000
12  Flu jab 7000
13  Trauma admissions in hospital 600
Total  254991

I am sure you the reader can add a few of your own categories to this list.

The total number of people dying every year in UK 428367. If we can save 254991 that means we will be 60% of our way to making UK immortal.Obviously there are undefined overlaps between the categories and I sure double or triple or multiple counting makes all that number attract attention.

Let us get a little real now. No one thinks they are going to to be immortal. Everyone knows there is avoidable/preventable mortality in healthcare delivery. The point is to try to admit, then identify avoidable deaths, followed by measures to reduce avoidable deaths to zero or awfully close to zero.

Would that be possible? 

The above media based list includes untimely or early deaths due to life style and behavioral choices. While solving that would also be possible, I am not talking about that. I am talking about deaths that can be avoided by delivering the healthcare in a way that we intended it to be delivered. 

United Kingdom has an amenable mortality of 102 per 100000 population (which works out to an approximate 65000 people) compared to France's 64 per 100000. It seems like a 40% reduction in amenable mortality should be possible. Since France's 64/100000 mortality is also amenable to healthcare it means we will have a lot of smart work to do for quite some time to come.

Can it be done?

We have already set the background by talking about HSMRs as an indicator, we have discussed the broad ideas around methodology in Hemadri's Four Fundamentals (, the issue of learning facts yet practising opinion and how to over come it in Letter to my nieces (

The current argument in UK is on how to actually identify the avoidable deaths. Individual case note reviews is thought to be the method. It may well be. There is a specific way of performing these individual case note reviews. 

Watch this space. The blog with some ideas on performing case note reviews will be here soon.

The quest for immortality - no that does not continue. The quest for eliminating avoidable deaths continues.................................


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Weblinks for each of the 13 headings which are listed above:


Sunday, 22 September 2013

NHS Hospitals with Doctors on the board of directors have better outcomes

NHS Hospitals with Doctors on the board of directors have better outcomes

Amanda Goodall has shown that hospitals with doctors as chief executives have 25% better clinical outcomes (statistically significant) in US hospitals. This is seen in other areas where 'expert leaders' have better outcomes. Kirkpatrick and Veronesi have looked at the board composition and found that in general boards of directors having more clinicians have lower HSMRs. Very specifically they found that boards of directors with more doctors in them clearly have a lower HSMR, higher CQC rating (actually their predecessor the healthcare commission's ratings) and higher patient satisfaction.

This prompted me to look at the Keogh 14 NHS Trusts that have been identified by the Department of Health and others as having problems mainly as a result of higher SHMI. The findings are of course compatible with the published research. 

All the 14 Keogh Trusts put together have only 3 doctors in their boards apart from their medical directors. Since medical directors on boards are statutory they are a common factor in all boards anyway.  So if medical directors are excluded from the calculations then the 

Keogh 14 trusts have 3 doctors (excluding Medical Directors) out of  184 board directors 1.63% of the board are doctors excluding MDs

Compare that to the 14 hospital trusts  with the lowest SHMIs (as of 2011) who have 15 doctors (excluding medical directors) out of 195 board directors 7.69% of the board are doctors excluding MDs

If we looked at HSMR (as of 2011) and compared high 14 and low 14 HSMR hospital trusts (the 14 is simply a number to match Keogh - there is no real logic or magic on the use of the number 14 here) a similar picture emerges:

NHS Hospitals with highest 14 HSMRs - 5 doctors (excluding Medical Directors)amongst 189 board directors  2.64% of the board are doctors excluding MDs

NHS Hospitals with lowest 14 HSMRs - 16 doctors (excluding Medical Directors) amongst 191 board directors. 8.37% of the board are doctors excluding the MDs

Medical directors as already mentioned are a mandatory appointment. Any other doctors appointed to the board is a sign of the value and recognition  by the trust and the appointment committees either on the basis of what the trust thinks that doctors bring to the table or as a recognition of research findings that expert led organisations do better. It is very clear that more doctors on the board of directors is associated with better outcomes.

It may not be politically correct to say so but it simply makes sense to appoint more doctors to the board of directors. 

What is important is that increasing the number of doctors in the board in the high SHMI or high HSMR hospitals must not be done as a matter of ticking the box - that will be very disrespectful to the concept. It should come out of a recognition of the value that the medical profession brings to the system as borne out by the findings above. 

It is also possible that when we cynically manipulate the undeserving into boards or when all boards have a higher number of doctors there will still be a difference between low and high performing hospitals. That is a different and new issue to be dealt with as it emerges. However in the meanwhile if as a result of increasing doctors in the boards we get better results we should respectfully and gratefully accept that.

It makes sense to have doctors on boards - let us do it.

Additional information added on 25 May 2015 - The difference in doctors in the board of directors between the Keogh 14 trusts and low SHMI trusts mentioned above is statistically significant with a p value 0.0081 (significant at p < 0.05 ) using a chi-square test

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The trust boards listed above were identified from their respective websites accessed on 21 September 2013

Kirkpatrick and Veronesi's article on Clinicians in Boards:

2012 low 14 SHMI trusts list is quite similar to 2011. I used 2011 since it was easier to access.

There were 7 BME board directors in Keogh 14 trusts and 7 BME board directors in 14 lowest SHMI trusts  

Keogh 14 Trusts
Basildon and Thurrock
Dudley Group
East Lancashire
George Eliot
North Cumbria
Sherwood Forest
United Lincoln

14 Low SHMI Trusts (2011)
West Middlesex
North West London Hosp NHS FT
James Paget
Chelsea & Westminster
St Georges
Royal Free

14 Highest HSMR trusts (2011)
Morecambe Bay
Isle of Wight
Hull & East Yorks
North Cumbria
George Eliot
Dartford & Gravesham
University Hosp of North Staffordshire
Northampton General Hospital
Dudley Group
Shrewsbury and Telford
Sherwood Forest

14 lowest HSMR trusts (2011)
Chelsea & Westminster
Kings College
Guys and St Thomas
Frimley Park
St Georges
Royal Free