Richard Smith: Impressions of Devi Shetty’s hospital city—bringing surgery to the masses

richard_smith_2014I’m standing with Devi Shetty, a cardiac thoracic surgeon in his surgical gear, between two paediatric intensive care units with around 40 cots. All the cots are full apart from those ready for children who are undergoing surgery. The units are tremendously busy, full of activity, but at the same time calm. I remarked on the calmness to Shetty: “They all know what they are doing,” he responded. The nurses, at least one for every bed, are in blue and green, and I can see some of the children with their endotracheal tubes, catheters, and intravenous lines. I’ve been in many hospitals, but the scale of this activity makes me gasp. Shetty knew it would.

High volume, high quality, low cost

Shetty took me to the corridor between the intensive care units because it’s the best illustration of the huge scale of the work that the Narayana Hrudayalaya (“Temple of the Heart”) health city does. There are 37 cardiac surgeons—some adult surgeons, some paediatric, and some, like Shetty himself, both—and they operate six days a week from 6am to 10pm and often later.

There are 360 intensive care beds, half the beds in the hospital. I asked Shetty if they ever have to cancel operations because of a shortage of intensive care beds, as happens regularly in the NHS. “Never,” he answers, “We just open more beds.” The result is that the hospital does more heart surgery than any other and achieves high quality at a lower cost than anywhere else.

This is one of the achievements that has made Shetty globally famous. Patients come from 76 different countries, and an Indian friend described how he took his brother to Shetty’s hospital for an angiogram partly because it would be cheaper but mainly because the hospital can be trusted to advise the right treatment. Unfortunately that’s not true in much of India where medicine is driven by money.

With this model of scale and specialisation Shetty anticipated the advice of Michael Porter, the American strategy guru, who advised hospitals to specialise and do one part of healthcare exceptionally well rather than try to do everything, as most hospitals do.

Treating the poor

Another reason that Shetty is famous is that the hospital treats patients who could otherwise not afford treatment. It does this by charging high fees to the very rich. I visited the 8th floor of one of his hospitals (there are many, as I will explain) and saw the luxurious suites where the very rich are treated. All but one of perhaps 40 suites was occupied, and these patients have their own ultrasound and X-ray machines and need to mix with other patients only if they need an MRI or CT scan. The poor patients are processed in a room at the bottom of the hospital before proceeding to the same outpatients consulting rooms as the “average patients.”

Development of the company

Narayana Hrudayalaya was started with the heart hospital, which was built on land in Bangalore (one of the world’s most innovative cities) given by the State of Karnataka, and more floors have been steadily added. Then Shetty, an accomplished businessman, added a cancer hospital that potentially could follow the same model as the heart hospital. This was not so successful—perhaps because of the variety of cancers, their presentations, and their treatments—and so the cancer hospital became a multispeciality hospital with a substantial component treating cancer. There is also an eye hospital doing operations for cataracts on an industrial scale.

Then the group took over or merged with other hospitals in India; there is also a hospital in the Cayman Islands, serving patients from the Caribbean and the US. Last year the group, which is now the fourth largest in India, went public, with its shares being oversubscribed 19 times. Because Shetty wants to keep operating he is the chairman rather than the chief executive of the group.

A hospital for Bangladesh?

Something like a third of the patients who come to the hospital from outside India are from Bangladesh. As I have a special attachment to Bangladesh, I ask him if he might open a hospital in Bangladesh. He says that his model won’t work there as there aren’t enough rich people. He could be wrong, but he’s a much more astute businessman than me.

A gifted surgeon

The group is built around Shetty, who is not only charismatic, but a highly gifted surgeon. Other surgeons described to me his great skill with that mixture of admiration and envy that I’ve seen in other surgeons describing outstanding surgeons. His reputation brings patients from across the world, creating work for other surgeons. Shetty continues to operate most days when he is India.

Preferable to the NHS

I meet two doctors, one a surgeon, who worked in the NHS for many years. Do you prefer it here, I ask after we’ve been talking for a while because I feel that they do, and they both laugh. They tell me they do, although they have to work much longer hours, six days a week. One tells me that it’s the patients, who are always grateful, whereas many NHS patients complain. (While in India, however, I hear several references to doctors being beaten up when things don’t go well with patients.)

Beyond hospitals

Shetty recognises that hospitals alone cannot bring healthcare to all Indians, and he would like to create what a colleague called “a hospital in the cloud.” Many, even most, people in India have smart phones, and you can get a signal almost everywhere (unlike in Britain). Healthcare needs to be delivered through smart phones, but one thing that holds this vision back, says Shetty, is inability to access the patient’s records, which are on paper and kept by the patient. The response of Narayana has been to devise an app that allows patients to photograph their records with their smart phones and then file them on the phone. The vision still has some way to go.

It did strike me as odd that a hospital that had such high tech intensive care and offers robotic surgery did not have an electronic record system. Evidently they are rare in India.

Reducing maternal deaths in India

There is one thing that irritates Shetty greatly: the way, he believes, that the Medical Council of India stands in the way of reducing maternal mortality. A woman dies in childbirth every 10 minutes in India, and India has got stuck with reducing maternal deaths. The facilities, says Shetty, are available, but the doctors and nurses are not. Politicians like to build hospitals and be photographed in front of them. The problem is that the tens of thousands of “MBBS doctors,” as everybody in India calls them (doctors who have graduated but not entered specialist training), are very restricted by the Medical Council in what they can do. In particular, they can’t do Caesarean sections or give anaesthetics, although, as Shetty points out, nurses do both in some countries. Instead of serving patients, many of the “MBBS doctors” cram for exams to enter postgraduate training in very expensive colleges, which were described to me as “being like concentration camps.”

After the chair of the Medical Council of India was arrested on charges of fraud the Government of India appointed Shetty one of five senior doctors to reform medical education. But after a year he left in frustration.

Beyond India

Very aware of the shortage of specialist doctors in Africa, Shetty has begun a project of aiming to train thousands. The curriculum is available on the web, and the clinical training is provided in hospitals across India. So far a hundred specialists have been trained.

Although Shetty’s focus is on India and low income countries, he did postgraduate training in Britain and has spoken often in Britain. He has lessons for Britain, not least in how high volume surgery carried out for 18 hours a day six days a week with careful attention to every detail of the process can improve outcomes and dramatically reduce costs.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: RS visited Narayana Hrudayalaya primarily to teach on how to get published in scientific journals. He was not paid a fee, but his expenses were paid by the hospital. They were much cheaper than a flight from London as he had already had his fare paid to Dhaka by icddr,b, where he is the chair of the board. RS has not visited the hospital before, but he has written an earlier blog on the achievements of Devi Shetty