EYE ON INDIA

India has one of the highest rates of preventable blindness in the world. Of the 12 million blind people in India, 50 per cent could have their sight restored with a simple cataract operation. A further 17 per cent simply need an adequate prescription for glasses.

[caption id='attachment_5201' align='alignright' width='200'] James Wawrzynski BA[/caption]

In 1976, Dr G Venkataswamy, a retired ophthalmic surgeon from Southern India set about creating his first eye hospital in Madurai, Southern India. He would fund a free eye hospital for poor people by offering a for-profit eye care service to the wealthy. His hospital would concern itself mainly with the removal of cataracts. Central to Aravind’s success has been ruthless cost-cutting. Each cataract operation in the UK costs the National Health Service (NHS) £932. The cost to Aravind of removing a cataract in its ‘free’ section is just £10.

How can such a dramatic reduction be achieved? Partly this is a reflection of the system’s efficiency; surgeon, nurse and operating room time is used to full capacity. It is also because salaries are lower in India and surgeons save time (at least in the free section of Aravind) by removing cataracts via the ‘Small Incision Cataract Surgery’ method (similar to traditional extracapsular surgery) rather than the more sophisticated minimally invasive method of phacoemulsification. However, much of the cost reduction lies in the low cost of their intraocular lenses (IOLs) and surgical equipment.

Aurolab manufacturing facility

Recognising the high cost of such equipment sold by multinational American and European companies, Aravind set up its own manufacturing plant in 1992 – the Aurolab. Through the same principles of efficiency and a diligent work ethic that is central to their hospitals, this facility has developed into an international business over the last 20 years. It now sells world-class IOLs and other surgical equipment to many countries around the globe, including to Europe and America. Due to this success it has recently moved to a large newlybuilt facility and as it is growing so quickly it has deliberately left the third and fourth floors empty for further expansion.

In addition to cost, Dr Venkataswamy realised that another major barrier to his goal was the lack of ophthalmologists in India. In the UK, we have nearly 100 ophthalmologists per million population. In India, this number is between four and 25 per million. Therefore, key to the success of his healthcare system was to maximise the use of his most scarce resource, the ophthalmologists’ time. In order to achieve this, there had to be a considerable amount of careful time management to ensure that the ophthalmologists never had to wait for a patient, a set of notes, their instruments etc.

Today, Aravind has expanded to five self-sustaining eye hospitals in Southern India and 33 primary eye care centres seeing 1.4 million outpatients and performing 200,000 sight-restoring operations each year, two-thirds of which are free to the patient. As such, it is the largest eye care provider in the world. Although Dr Venkataswamy died in 2006, his founding principles are still strongly evident throughout Aravind.

Another world

I was fortunate to visit Aravind for an internship in the summer of 2011. It was like entering another world. Everything was noticeably more orderly. Even the way the clinics are set up is designed to maximize efficiency. Patients formed neat queues whilst they waited in silence to go through a well-designed series of stations progressing from registration to sight tests to eye examinations and finally counselling if an operation was required. Whilst waiting to be seen, patients are asked to stand immediately outside the consultation booths to ensure a quick transition as soon as the previous patient has finished so that the doctors’ time at work is never wasted.

[caption id='attachment_5203' align='aligncenter' width='600'] Operating theatre: two surgeons are operating, with two tables each. There is one microscope per surgeon situated between the two beds[/caption]

Doctors may see as many as 100 patients in a day. They work solidly from 7.30am to 6pm with just two 15-minute coffee breaks and a half hour lunch break during the day. The managers have even removed the chairs from the coffee room to encourage doctors to return quickly back to work rather than sitting down and socialising.

The same principles of efficiency extend to the operating theatres. Instead of having just one table per operating theatre, they have two. This allows the nursing staff to prepare the next patient whilst the previous is still being operated. Each time the surgeon finishes a case, he simply moves his microscope across and immediately starts on the next. In the UK surgeons may frequently wait half an hour or more between operations before the next patient is ready for them; at Aravind they have managed to reduce this time to less than one minute and are frequently able to complete 15 cases per hour.

Could the West learn from Aravind’s example? Concerns about patient safety are often raised when new measures to increase efficiency are discussed. However, it is important to remember that improving efficiency need not jeopardise patient safety.

In fact, increasing efficiency can often go together with improved patient safety. For example, at Aravind they use dedicated operating rooms for each type of surgery; all cataract operations are done in Room 1, all cornea surgery in Room 2 etc. This streamlines the process and in addition decreases the chance of clinical incidents such as the wrong operation being performed or the wrong sets being prepared for surgery.

So why does the NHS cataract service continue to be inefficient? Perhaps the pressure of the mounting cataract burden in the UK is not yet high enough to make streamlining of the service a priority. However, I wonder if the answer could also lie in the unique position occupied by the NHS in the UK healthcare market. Unlike private providers, which make a greater profit if they carry out more procedures, the NHS makes a greater loss the more procedures they fund. Mounting waiting lists result in more people turning to the private sector, which is a short-sighted way for the government to save money in the immediate future.