Devi Shetty – nicknamed the Henry Ford of heart surgery – believes developments such as computerised diagnoses and technicians doing the work of highly trained medics are just around the corner. Ben Clover hears his ideas for the future of medicine.
“In five years’ time a computer will make more accurate diagnoses than doctors. In 10 years’ time it will be mandatory for a doctor to get a second opinion from a computer before starting treatment.”
Dr Devi Shetty is not afraid of bold statements. The founder of India’s Narayana Hrudayalaya hospital chain is famous for his high-volume surgical hospitals. He argument is that technology will be a major contributor to improving quality as demand for healthcare grows.
Dubbed “the Henry Ford of heart surgery” by The Wall Street Journal because of his drive towards standardisation and his focus on economies of scale, the surgeon says advances in IT will drive out variation whether clinicians like it or not. So why fight it?
Over 10 years Narayana hospitals have performed 50,000 heart surgeries. The chain now consists of 14 hospitals with 5,000 beds.
Asked how he can reconcile that throughput with quality and safety, the medic who studied cardiac surgery at Guy’s Hospital in London stresses their mutual reinforcement. He says the volume at which his hospitals operate and the information they collect means they can address problems very quickly – trends that could take longer to manifest themselves in smaller hospitals come to the fore more swiftly at Narayana.
“You see in a very short time [any] problems in the system,” he says. “You can’t address quality outcomes without using large numbers.”
Dr Shetty draws a parallel with aviation safety, a subject that saw a comparative paper from researchers published last year. The Millbank Memorial Fund report suggested recording all hospital phone calls, prohibiting the use of titles and using only first names in theatre, while providing anonymity and immunity for people who report critical incidents.
Dr Shetty believes there is a resemblance to the standardised checklists and IT regulation of procedures in a cockpit. “Computers do not fly the plane but a pilot only follows the protocols” he says, “That is why air travel is safer than travelling on Indian roads.
“When a patient is admitted to the intensive care unit of a hospital he will ask what the experience of the doctor is – the same is not true when boarding a flight.
“The standardisation of health is inevitable and it is better to embrace it.”
It is a trend he believes will eventually result in much of the work currently done by highly trained medics being taken over by well equipped technicians.
Growing demand will also force these changes and greater productivity from the clinical workforce, he said.
“With the time limitation [the doctor] doesn’t have a whole day to diagnose one patient‘s problem. He has to diagnose in 10 minutes, in half an hour. In a limited period of time a computer is always smarter than us. We have to accept this.”
- Born in India in 1953
- After training as a cardiac surgeon at Guy’s Hospital in London, Shetty returns to India in 1989
- Shetty and his team pioneer neonatal cardiac surgery, after operating on newborn babies with complex congenital heart disease (1989)
- Treats Mother Teresa (1991-97)
- Founds Narayana Hrudayalaya hospital in Bangalore in 2001
- In 2003 Shetty is named Ernst and Young entrepreneur of the year
- 2009 sees Shetty sign an agreement to build a hospital in the Cayman Islands
- Conceived of the concept of a “health city” – a 2,000-5,000 bedded conglomeration of multiple super-specialty hospitals in a single campus. The economies of scale achieved through these health cities enable the provision of affordable healthcare to thousands of people.
Some senior clinicians in the NHS believe Dr Shetty’s prediction is not fanciful, but others are more sceptical.
One tells HSJ there is already evidence that using algorithms can improve the accuracy of diagnoses, citing the Alvarado score, which helps surgeons to diagnose appendicitis. He says five years “probably isn’t unrealistic” in getting algorithms like that onto a smartphone. What might take longer are systems that perform a real-time analysis of a patient’s entire electronic medical record and compare it against millions of other patients.
In one development on this front, IBM announced in February that a hospital in California had reduced its mortality rate in cardiac surgery by using “predictive analytics” to reduce risk.
Critics might argue that Dr Shetty’s system is healthcare for a different country with a different set of public expectations and ask what it has got to teach the NHS. The answer? Probably something.
Jim Easton, head of the Department of Health’s quality, innovation, productivity and prevention programme, is interested enough in the parallels between Dr Shetty’s work and the challenges facing the NHS that he is hoping to speak to him soon.
Star question - Jim Easton, Department of Health national director for improvement, asks:
Q. Dr Shetty’s outcomes data looks impressive to me at first sight, but is bound to be challenged on the grounds of safety. What is his response to this?
A. International benchmarking data show the Narayana hospitals are achieving outcomes comparable to hospitals in the West, but Dr Shetty is cautious about suggesting that parts of the group’s practice could be adopted directly by the NHS, which he describes as “a great system” of which he is a “very, very proud product”.
But he does mention two things that go to the heart of the quality, innovation, productivity and prevention programme that Mr Easton is leading.
“We are now on a very ambitious journey,” Dr Shetty says. “Zero bed sores, zero nosicomial infections [healthcare acquired infections] and zero mortality after an operation.
“We have achieved zero per cent bed sores, now we are addressing infections and mortality. We believe it is possible.”
He adds: “I don’t think the NHS should worry too much about quality of care. I think the quality there is very, very good in some areas. What the NHS should do is know how much money it is spending for what it is getting. It should have a profit and loss account on a daily basis.”
Although Dr Shetty is cautious about suggesting practices the NHS could import from Narayana hospitals – citing the different regulatory regime and workforce picture – one comment he made at the Nuffield Trust’s annual summit in February caused a stir.
When talking about the group’s expansion plans across the subcontinent he mentioned as an aside: “England is such a small country, you only need two or three heart hospitals and two or three cancer centres”.
He now admits: “Three centres was a bit of an exaggeration. I believe there are 22 heart centres [in England at the moment]. I believe you could slim it down to seven or eight. That would improve outcomes and bring down costs. You could have angioplasty and angiograms at 22 centres but the complicated surgery you should concentrate.”
Dr Shetty says his biggest challenge running Narayana to date has been securing the capital for expansion. With the group planning to take its 5,000 beds up to 30,000 in the next five years, he tells HSJ: “Wherever possible we expect someone else to build the building and we are trying to get the medical equipment companies to sell it to us on a per-use basis.” This is the kind of thing that might be familiar to NHS leaders as private finance initiative and equipment-use deals.
In 2009 Narayana agreed a scheme that might one day be looked back on as a key moment in the development of a more globalised health economy. A new hospital complex in the Cayman Islands aims to treat not only locals but uninsured Americans, who are an hour’s flight away in Miami. This could be the first time healthcare systems and business models from the developed and developing worlds have been in direct competition.
Dr Shetty, who first found fame as Mother Teresa’s heart surgeon, has little time for the world’s medical associations, who he blames for restricting entry to the profession to protect their incomes.
“It is always the professional bodies that run the health system” he says. “Medical councils do not want more doctors to be trained. These are the clubs and they want to continue their premium. An association of cardiologists does not want more cardiologists to be trained. No government in the world has woken up to the reality that [medical associations] shouldn’t have the say on how many doctors we should have.”
Dr Shetty is looking to establish a training agreement with Ethiopia, which he believes to be the only country in the world without an overly powerful medical association.
He says: “We have been trying to set up something in Ethiopia. It has no medical council. The prime minister was a medical student and he said ‘do not allow these associations to be founded’. They will scuttle the growth of healthcare manpower.”
Dr Shetty is also forthright about the role of medical associations in restricting a truly global labour market for medical staff. “All these entrance exams are made to protect the jobs rather than control the quality,” he says. “Why can’t they allow a British doctor to work in Canada or America?”
His solution is a single university that sets the same standard across the world.
“We are trying to propose to world leaders that we just have one global university for healthcare,” he says. “This will create the curriculum. There will be some variation between countries but pain relief or a hernia [are the same everywhere].
“One university, with one curriculum, can conduct exams in any part of the world. I have been proposing it each time I meet somebody. But unless you are a doctor people don’t understand what we are talking about.”
After capital investment, Dr Shetty says workforce reform is the second biggest challenge he has faced in building Narayana. In 2006 the World Health Organization put the global shortfall of healthcare workers at four million. But Dr Shetty is pessimistic about this estimate: “We believe it is more than eight million,” he says. “That shortage will really start to manifest itself in the next two or three years.”
He is blunt about a solution: “We need to churn out thousands and thousands of doctors.”
The airline safety metaphor is also one he also uses for nurse training.
“Suppose we are training a pilot. When we train a pilot we spend all our time making sure he will take off and land safely. His entire training is about safely flying the plane, it’s not about how the engine works.
“Nurse training [now] is about how the whole system works. There is no point in [nurses] knowing everything about everything. In those areas where they are trained they should be experts. If [a nurse] is working on an ICU, he or she should know everything about the ventilator and what to do when the blood pressure goes up.
“We are training nurses to become nurse intensivists.”
But he admits it is not easy: “All over the world it is a problem that people are uncomfortable training other people to do their job.”
Star question - Jonathon Tomlinson, a GP in London, asks:
Q. Dr Shetty told the Nuffield Trust summit in February that the “cost of healthcare will not get reduced in the US and Europe unless Asia and Africa become healthcare markets”. Can this be explained further?
A. Dr Shetty tells HSJ that at the moment there are “very few” buyers for the big pieces of medical equipment. “As the Asian healthcare market expands it will become like buying a washing machine,” he claims, resulting in greater standardisation and lower prices.
He does not see the implications of his workforce system, or the introduction of checklists and greater medical procedure specialisation, as de-skilling the medical workforce in any way.
Asked if he explicitly conceives of his approach as industrial and his hospitals as factories he says his aim is simply “to democratise healthcare”. In return, he poses the question: why would you not configure the workforce as cost effectively as possible to achieve that?
The figures he produced at the Nuffield conference make this point – while India needs 2.5 million heart procedures a year, it performs only 90,000.
Dr Shetty tells HSJ: “I have the privilege of being a heart surgeon. Someone else is trained to repair a car and I am trained to repair a heart. That doesn’t make them any less intelligent or less smart. Most people can be trained to do most things.”
He made a similar point at his Nuffield summit appearance, where he spoke via video link, before finishing his talk by showing the assembled health policy experts a painting on his office wall. He said viewers might have thought it was a Monet or the product of another famous artist – it was actually the work of a trained elephant in Thailand.