As a doctor who has spent his entire professional life practising in the United Kingdom, it would be presumptuous of me to lecture an Indian audience on what plagues Indian doctors. But I was invited to discuss this and what I tried to do was draw on my experience of what troubles doctors in the UK face, and let the audience decide if this resonates with their experience of health services in India.
I drew on my experience as Dean of a Medical School, President of the Royal College of Paediatrics and Child Health, and as Chair of the GMC (General Medical Council), but these were my views as a practising clinician.
There may be more in common than at first glance. Spending on health as a percentage of gross domestic product has fallen in the UK from a peak reached before the global recession of 2008. By 2012, health spending had declined to around 9 per cent of GDP and has not recovered since. A similar decline in healthcare spending is true of India too, though from a much lower starting point.
When the UK is compared to other Western European economies, we also have fewer doctors per thousand population and fewer hospital beds per thousand population. Again these are problems India faces and to a greater degree. The UK also struggles with rising demand as the population demographic becomes older and more people survive but with long-term diseases.
But there are also big differences in the problems confronting doctors in the UK and India. India continues to have a much higher infant mortality rate of 40 deaths from every 1,000 live births, around ten times that in the UK. Vaccination against preventable childhood diseases in India remains lower than the UK. In adults and children, tuberculosis, malaria, HIV and dengue are causes of death in India; we rarely see these now in the UK.
The solutions open to the UK and India also have much in common. Both countries need to invest in prevention as well as cure, both need to recognise the huge benefits of primary care in the community as well as hi-tech hospitals and they both need to disinvest in treatments which don’t work. Both countries need to ensure that the private sector supplements the government sector, rather than being a substitute for it.
The greatest threat to India is that a health sector dominated by a fee-for-service system will drive unnecessary expenditure on needless tests and treatments. In health systems where a hospital or doctor can charge money for each test, each drug, each operation or each time the patient is seen, there is actually a financial incentive for patients to be over-investigated and over-treated.
For example, antibiotics will tend to be prescribed more freely even when it is likely the patient has a viral infection; X-rays are done for common, low-back pain when there is no evidence this alters treatment; patients are admitted to a hospital for observation when they could be sent home and reviewed the next day. India can ill afford such unnecessary health expenditure and poorer Indian people may be deterred from seeking care when they need it by prohibitive, upfront charges.
The UK’s NHS is based on a different system. The confusingly named Commonwealth Fund (actually based in the US) makes international comparisons of healthcare systems and regularly scores the UK NHS highly on value-for-money and equity of access.
The UK NHS is free at the point of delivery of care, funded from direct taxation. Essentially this approach relies on the population all contributing and pooling their risk, recognising that they may pay taxes but may not need the health service when they are young and fit but that the health service will be available and affordable to them if and when they need it as they age or become ill. Principles which might serve India well.