Last summer I explored the latest book by Vijay Govindarajan, which proposes a number of ways in which healthcare in India can boost healthcare in the developed world.

The book outlines five key principles by which the authors believe the west can learn from healthcare pioneers in India.  One of these is the so called hub-and-spoke configuration, which basically advocates allocating only the toughest cases to the highest skilled employees.

So the hub would be retained for the most challenging cases, with each rung outwards attempting to intervene at a much earlier stage where the skills required of staff are lower.  The authors suggest this has a number of benefits:

1. It concentrates the use of expensive equipment – the argument is that there is a lot of duplication and wastage throughout modern health systems, with expensive equipment laying un-used for large periods of time.  The aim is to ‘sweat’ the expensive stuff as much as possible.
2. It centralizes scarce expertise – few countries have an abundance of medical expertise, so it makes sense to make the best use of what you do have.  This means freeing expensive experts from mundane tasks that they don’t need to do, whether that’s administration or routine tasks that can be performed by other staff.
3. It turns each hub and spoke into focused factories – rather than facilities trying to be all things to all people, a hub-and-spoke model encourages them to focus and specialize instead.  The Aravind Eye Hospital is a well known example of such specialization, and they churn out top-notch eye surgeries at a rate and expense that is the envy of the world.
4. It accelerates learning and development – this specialization and volume of work then supports the development of skills in those facilities.  They truly become masters of their domain.
5. It facilitates system-wide protocols – a central tenet of lean systems is that they have strict ways of working that are optimized for peak performance.  This sounds a bit like a recipe for intransigence, but the authors argue that it also allows for procedures to be performed by lower-skilled personnel.

Put into action

An example of how this could be put into practice is provided by a recently published study from a team at the University of Rochester.  The study explored data from 50 states to explore whether nurse practitioners (NP) are taking on a growing range of primary care roles, and in what circumstances they do so.

The data revealed that the role of NPs has grown most in areas where there is a low supply of physicians, which thus provides much needed primary care capacity in underserved communities.

The number of nurse practitioners has risen incredibly in recent years, to 123,316 in 2016 from just 59,442 in 2010.  The research suggests they can play a hugely valuable role in supporting rural and other underserved communities.

“The demand for care is not exactly the same across areas. Some areas have high demand, and some have low demand,” the authors say. “Low-income and rural areas have higher demand and greater health disparities. Increasing the number of primary care clinicians in those areas would help to increase access and help reduce health disparities. That’s the ultimate goal: To have sufficient clinicians to provide care in those areas.”

Much needed care

The considerable growth in primary care NPs, especially in low-income areas means that those communities that would previously have been underserved, now have access to good quality care.  Patients in those community report that the care provided is comparable with that offered by a physician, and the authors believe that their findings highlight the potential for these kind of services to be rolled out much more, especially when trying to deliver preventative care.

“This paper is really sending a message from a policy perspective about how to more effectively use NPs in primary care delivery,” they conclude. “It may be most beneficial in looking at how to further structure the entire primary care workforce and how to mobilize all primary care clinicians in order to maximize timely access to care for populations in need.”