Imagine you are responsible for healthcare in a country where 30 million people are in poverty because of healthcare costs, where you are contending with communicable diseases eradicated in many parts of the world as well as the rising prevalence on non-communicable disease, where the number of hospital beds and doctors per head of population is half the international average and the numbers of nurses and midwives a third.
What would you do to deliver the highest quality care at the lowest possible cost?
Having just had the privilege of visiting some of the most innovative healthcare systems in India as part of the IPIHD study tour, the following would be my top five:
1. Make affordable healthcare a noble purpose
Tapping into intrinsic motivation is often used to improve quality. Yet efficiency is the one domain of quality that we seem to fail to connect to people’s hearts.
Not so in the health systems we visited.
Here, the relentless reduction in waste was pivotal to their mission of improving equity, access and safety. This goal was referenced frequently – whether Narayana’s value of ‘continuously reducing costs’ or Lifespring’s mission to ‘maintain lower healthcare costs’ – these goals were displayed throughout their buildings.
Discussions were replete with phrases such as ‘the solution can’t cost more than the problem’. There was none of the unease that we associate with the ‘cost-cutting’ agenda, the case was simple: reduced unit costs means more people can receive the care they need.
2. Be explicit about the quality of care that can be provided
In a context where there is often very little care available and ‘something would be better than nothing’, it would be easy for healthcare providers to overstretch themselves in terms of the breadth and complexity of care they attempt to provide.
Securing world-class outcomes in care was dependent on setting clear and visible parameters for the care that could be provided in any given setting. The clearest example of this was LVPEI’s pyramid model, where there was explicit recognition that this may mean that people would need to travel further to receive more complex care.
3. Harness all the available assets
The healthcare systems we visited amply illustrated that necessity is the mother of invention. A drive to embrace innovation was evident, whether in Narayana’s decision to put all their data in the cloud to facilitate access and sharing between sites, or the move to a paperless bedside by using iPads in place of notes.
In the face of crippling attrition, making best use of their workforce was a priority. Staff training focused not just on the clinical skills but also on quality improvement approaches and business management.
Equally significant was the use of ‘assets’ outside the formal healthcare system, such as training relatives to act as ‘care companions’ at Narayana or the development of Vision Guardians – members of local communities trained to support early detection and diagnosis – at LVPEI.
4. Embed continuous quality improvement
If there was one unifying feature of the four healthcare systems we visited, it was the way in which quality improvement approaches were integral to their management systems.
Standardisation was universally seen to be a critical factor in ensuring affordability. Whilst standardisation in the UK tends to be built around the evidence – and in the absence of clear-cut evidence there is a failure to reach consensus – standardisation in the four health systems we visited had greater emphasis on cost control.
Any risk of this having an adverse effect on outcomes was mitigated through rigorous (and often real-time) use of data to track process and outcome measures. Protocols weren’t straightjackets and there were systematic approaches to study and learn from any deviation from the standard process.
5. Listen to your service users
With the friends and family test only up and running for a few months in England, it was humbling to see the extent of user feedback in the Indian health systems we visited, whether through follow up phone calls, text messaging or visits from community teams post discharge.
Of course, in a market-based system an element of this was driven by the need to keep ahead of competitors, but the motive doesn’t detract from the impact on maintaining and improving standards.
Now imagine you are responsible for a healthcare system in an economy where the level of public debt is unsustainable, where the population is rapidly aging and where co-morbidities mean that health care demands will become increasingly complex. Wouldn’t these ideas make equal sense?
Jo is Director of Strategy at the Health Foundation, www.twitter.com/JoBibbyTHF
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