Orthopaedic "Place": A tale of 3 cities!

I have worked as a Paediatric Orthopaedic Consultant in two countries now, in 3 different cities / town and in private & public healthcare setup, and the contrast could not be starker!

Starting off as a new Consultant in a brand-new state of the art tertiary care private hospital in Mumbai, India, every slick instrument, implant, equipment was available at my disposal with a state-of-the-art infrastructure, spacious well thought out wards and operations theatres and private rooms that could beat a 5-star hotel. But all of this comes at a cost. Although competitively priced for the location and facilities, private healthcare is a business and comes with a price tag that must be borne by self-paying patients or insurance companies.

A couple of years down the line I was fortunate enough to work as an honorary associate professor at a leading teaching government hospital in Mumbai. The word honorary would mean that there is no or nominal remuneration for the services provided. But it is one of the most rewarding experiences. I was fortunate enough to work there with one of the very experienced surgeons, who I had trained under several years prior. I would see some of the most complex cases here and I was privileged to treat these patients. In addition, teaching and training the residents was quite a rewarding experience.

But the infrastructure and resources available here were in complete contrast to the private healthcare set up. Lack of basic instruments, dull worn-out instruments, unaffordability of costly implants, theatre with lack of basic infrastructure like working air conditioner and at times questionable sterility. I would officially pray before every theatre that none of my patients should get any infection.

And then you learn to work around these systemic drawbacks by innovating working practices, making use of the best available implant choices, and discovering cost effective solutions, without compromising patient care. One great example is the use of 2 hole recon plate instead of 8 plate for guided growth.

The second town I would visit was a rural centre on a 2 monthly basis– a private hospital to provide a paediatric orthopaedic service about 500 odd km out of Mumbai. I was providing these services at no remuneration. And it was a different ball game altogether. While the infrastructure was decent for a private set up, there would be different sets of challenges here. Patients were from poor rural background and although there were no “surgeon fees” they would still have to pay for the hospital /operation theatre charges. The Orthopaedic surgeon at the hospital was my friend and hence I could trust him to provide the necessary post operative follow up care for these patients, else this would not have been a sustainable arrangement. I would not do any major surgeries there. Bringing the patients to Mumbai to do major surgeries was always a challenge.

India has a huge population and an ever-booming paediatric population. This would obviously place a huge demand on Paediatric Orthopaedic services. The divide between the poor and rich is wide and the demand for government hospital services is huge in stark contrast to demand for private healthcare. Access to specialist service in rural India is very poor. ?

Fast forward to 2020 and I start work at university teaching hospital at Southampton as a Paediatric Orthopaedic consultant. NHS is a huge organisation and one can write a book on huge drawbacks of this government backed healthcare provision and moan about huge NHS waiting lists, bed shortages, and spiralling costs,but one thing that is currently a huge asset to the people of UK is that the treatment is completely free at the point of care. You can have the most complex revision hip surgery with a brand-new implant or a robotic knee replacement or a magnetic lengthening nail and pay nothing out of your pocket. The service is bursting at its seams though, with staff burnout, infrastructure unable to cope with the demands, and chronic lack of funding. Only time will tell (and political will) if this is sustainable in the future.

Four different healthcare settings, three different cities (/town) and three different funding streams. Ultimately it all boils down to patient outcomes and “value for money"! No one system is without flaws and equity of healthcare is still a cherished dream even in developed nations.