Tuesday, 18 August 2015

Ancient Art of Dying

The ancient Art of Dying

Fear of Death

The time of our death is almost never in our control (except perhaps where suicide was achieved). The manner in which we die is also almost never within our control. The only fact is that death is inevitable. Thus the concept of the art of dying may not be relevant for an overwhelming majority of human beings. Having said that, every day we live takes us closer to the day we die, hence it is possible in a broad sense to ‘prepare’ for death. The art of dying is to psychologically prepare for death, the main component is to remove the fear of death.

Fear of death is common; humans often fear the unknown. The difference between most other unknowns and death is that a human will not have any perception of the unknown called death simply due to the fact that we will be dead after that and hence not be able to perceive the unknown as we normally do. So the first point is not to fear death from the perspective of our own body and our own mind.

The only other reason for fearing death is the issue of our duties and responsibilities towards our family and communities. This is a difficult one, we do have such commitments and though no one is really indispensable broadly speaking families can severely feel the negative impact of the death of a person who had ongoing responsibilities, typically persons with young children or very old parents. There may really be no resolution to this issue. The philosophical logic by which we may attempt to remove the fear of death in these circumstances are as already stated, we do not control the time or manner of death, death happens to anyone – fearing something that we have no control over and is inevitable is perhaps not rational. However human psychology is unlikely to accept this rationality and that is why the issue is difficult to resolve.

Fear of illness

It is possible, in fact likely, that most of us when we think we fear death, we may actually be fearing any precursors, pathways, process that lead to death, specifically we probably link that to acute or chronic ill health and their related effects, especially painful effects – no wonder it induces fear. To explain this in simplistic terms we are actually fearing illness but we include death into that spectrum and fear death as well. In some terminal illness situations where illness causes severe pain, death may actually provide relief.

Fear of illness in some contexts could be a motivator for some people to embark on action to attempt to improve their own health with the hope of preventing illness; that is possible in some types of illnesses and generally is a long term issue. While the trigger to act might be a good thing, if the fear persists it becomes very uncomfortable existence psychologically even in the presence of good health.

Good Death

The fear of death and fear of illness makes most of us wish that we have a ‘good death’. Many of us imagine that a good death is when ‘the time comes’ we will die in our sleep and that is what we wish for ourselves. That does happen sometimes. That does not happen sometimes.

Are there other descriptions of ‘good death’?

Quality of Death

Many healthcare professionals are aware of this concept of quality of death, which is when cure is no longer possible and death becomes a probably outcome within a short time span, healthcare professionals would aim for that short time span to be spent or lived in comfort where possible or at least with a lack of distress. Many aspects of terminal care is geared towards the quality of death.


Most of us would have heard the term Euthanasia – literally translates into good death (Eu meaning good or normal; Thanos meaning a wish to die). Currently, it has meandered about a bit and refers to one person helping another to die. In many or most parts of the world it is illegal for someone to help another to die. Where euthanasia is legal it is reserved for terminal illness situations where an individual explicitly desires to end his/her own life and seeks help from another to fulfill that desire. This could be counted as 'good death' in the limited circumstances. There are debates to be resolved in terms of the 'active' nature of this effort, the issue of a second person playing that active role and other related arguments.


Is a very large topic. Suicide is defined as the act of taking one’s own life. It is thus intentional and active. The drivers for suicide are complex and are significantly related to mental health issues and drug issues. Whether suicide counts as good death or comes within the ambit of the discussion of ancient art of dying is questionable and in my view probably not counted as ‘good death’.

In Euthanasia and in Suicide there is an act of commission, seen as possible violence against the soul, this could be the basis of potential arguments against them. 

The Ancient Art of Dying

The ancient art of death is separate and well away from the above concepts. The origins are from ancient Vedic or Hindu practices.

There are a number of terminologies including Mahaprasthna (great journey), Samadhi-marana, Sanyasamarana, Samadhi, prayopavesha and others. The Jain religion has terms such as Sallekana (properly thinning out), Santharan,et al. Veer Savarkar pushed the concept by talking about aatma arpan (surrendering the soul) while the general agreement seems to be that he actually practised prayopavesa.

The modes are primarily two fold, one is literally setting out on a great journey during which death happens without the actual details being ever known (Mahaprasthna). The other more commonly known is by gradual withdrawal from food, by voluntary fasting (Prayopavesa or Sallekana). There are other modes but those are rare, unusual and no longer found in practice (e.g. jal-samadhi - where one simply walks calmly into deep waters).

There seem to be reasonable and clear conditions when one can embark on prayopavesa (or sallekana). The main condition seems to be that there is no purposeful use of the body and mind – i.e. the purpose of life is completed. It is voluntary (meaning that there is competence of the individual’s mind to contemplate and make such a decision). It also a slow process and often a gradual process. It must be announced. The end of natural life should be close e.g. terminal illness. It is overseen by the community (there seems to be no question of sanction or approval by any person or group).

The ancient Vedic based art of dying is thus very different and bears neither resemblance nor comparison to euthanasia, suicide or terminal care; the philosophy and ethical frameworks are almost poles apart; the relevance is also directed differently; we will not debate these right now. There are no external agents, there is only the self and if at all there is an act of omission (rather than an act of commission); it is even questionable whether there is an act of omission due to the gradually adjusted constantly decremental nature of the process.

The art of dying is the culmination of life long practice of renunciation leading on to some individuals deciding to renounce life itself. It happens to be the pinnacle of discipline after numerous varied long term practices based on discipline. Very few are actually able to achieve it, they achieve it by making a deliberate active decision to take up a slow voluntary process to end their physical living. They possibly see it as the ultimate union of the soul to the eternal by a directed effort.

The art of living is relatively easy by comparison to the art of dying. It seems that it is by learning the art of living we can even begin to comprehend the ancient art of dying.

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PS: The concept of the art of dying as written here is not applicable to many of us within the current contexts as it stands. I am hoping it will inform the important debate around death, dying, quality of death, pain before death, etc and we will in time be able to apply the concepts of the art of dying to the contemporary lives of a larger number of people.

Friday, 7 August 2015

Surgical Swab - tail it, tag it, secure - then let us see how many are lost

Retained Swab after surgical procedures

Surgical Swabs – tail it, tag it, secure it – and then let us see how many are retained.

Swabs retained in patients’ bodies after surgical procedures are thought to happen from 1 in 500 to 1 in 5000 patients. However, NHSLA data would suggest that it happens much less often (possibly rarer than 1 in 10000 during caesareans). The point is not about the numbers or frequency or other statistics. Firstly, a retained swab is a completely avoidable complication. More importantly, the impact on patients’ lives can be extremely profound when a swab is left behind with infections, difficulty in diagnosis of the complication, re-operation, all sorts of other complications and death.

The impact on the doctor is also serious though not as much as for the patient. It seems that an average surgeon could have a 1 in 3 or 1 in 4 chance of a retained swab happening by his/her hands.

The primary responsibility for all instruments, needles, swabs and in general, anything that happens during a surgical procedure belongs to the operating surgeon. The primary method now used to ensure that a swab is not left in a patient is operator memory, as we all know memory is a fallible method to ensure patient safety. The adjunct to memory is the intra-operative swab notes/notices where the surgeon tells the scrub nurse a swab is placed within a patient, the scrub nurse tells the runner nurse who writes on the theatre white board and at the surgeon tells the scrub nurse when the swab is removed, the scrub nurse tells the runner nurse who removes the note from the board. This six or eight step communication is prone for failure once again because the initiation point is the surgeon’s memory (remembering to mention) and then simply by the number of steps involved in the communication.  

The current next step currently taken is the end of procedure swab count – this happens at the end of the procedure when swabs are counted and confirmed as matching the number of swabs that were opened for use during the procedure. This is actually not a prevention method, this is technically a detection method to confirm that a swab has not been missed, at the best a secondary method of ‘prevention’. 

When a swab count shows a missing swab x-ray is used to detect if a swab is retained within a patient. Surgical swabs these days have a radio-opaque line so that a retained swab can be detected by an on-table x-ray when the swab count detects a missing swab; this is a tertiary or third order issue for detection of a missed or retained swab and does not prevent the swab going missing in the first place. The x-ray method has a known but rare rate of failure in detecting a retained swab.

We know that the current methods are failure prone. The primary prevention methods are memory based – hence fallible under stressful complex conditions.

The swab count, is post-hoc (post procedure), after the event, hence a swab count does not act as prevention, it only acts as a detection method in an area where primary prevention method is highly fallible.

It is known that mechanical methods are better than memory alone. It is best to agree on a single mechanical primary prevention method so as to either enhance the effectiveness of the secondary prevention or to make it a luxurious yet essential redundant detection mechanism.


In the context of retained swabs, surgical swabs during intra-operative use are of two kinds:

Held swab: one that does not leave the surgeons’ (or the assistant’s hand). The swab can be held in two ways a) directly held (surgeons’ hands) b) indirectly held (swab on a stick)

Free swab: is one that is placed within the patient by the surgeon and does not have contact with the surgeons’ hands for any period of time.

A directly held swab has no risk of being left in the patient – by definition a directly held swab does not end up being a retained swab.

An indirectly held swab has a small risk of ending up retained in the patient if the swab slips unnoticed (this is especially possible in the case of pledgets).

A free swab has the highest risk of being retained in the patient. Hence a primary mechanical prevention method is essential for a free swab, irrespective of the swab’s size or the anatomical site of use. Let us look at a method that could prevent a swab from being retained in the first place.


Tail-Tag-Secure is a must for Free Swabs

TAIL: Free swab must always have a tail (taped swabs) which extends outside the wound/incision. This tail could be part of the swab which is extending out of the wound or a formal tail from the swab.

TAG: At the end of the tail which is outside the wound the tail must always have a tag (clip/artery forceps or other instrument holding on it) so that it does not migrate inadvertently into the wound. 

SECURE (the tag): The purist is welcome to secure this tag (clip/artery forceps or other instrument) to the drape as a third level safety procedure, using another instrument. 

TAIL-TAG-SECURE means there is a constant visual reminder about the swab inside the abdomen and a mechanical hindrance to closing the wound acting as a second level safety mechanism. 

The recommendation is that all Free Swabs (any swab that is within a patient and does not have contact with the surgeons’ hand at any point of time), irrespective of the size of the swab or the anatomical site of its use must have a tail (tape), must be tagged (with a clip, artery forceps or other instrument) and most often be secured (to the drape using another instrument or an adhesive sticker). 

This makes the swab count a needed redundancy in the system which is what a detection method should be rather than the surgeons’ memory or a multi-point communication system both of which are potentially highly unreliable as a prevention methods.

A number of surgeons are already using this method. Obviously when these methods are insisted upon, there will be resistance and arguments that may sound valid; however, we know the current method does not work, we know that a retained swab is completely avoidable, we know that a retained swab is designated as a never event. It is time to look for and implement a different and a better solution – the tail-tag-secure is hence essential.

Electronic chip embedded swabs and routine scanning of patients before closure of the wound would be a technology intensive (and possibly costlier) solution. We may be far away, if at all, from completely absorbable swabs. We don’t know if these would have their own problems.

Current Method of primary prevention
Suggested Method of primary prevention
Memory based (fallible): Surgeon’s memory
Visual and Mechanical methods (more reliable)  
Tail (tape) – Tag – Secure the swab

Multi-person Communication based (fallible): Notes on the theatre board

Detection methods (swab counts, x-ray) remain essential
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Sunday, 12 July 2015

Business language in a public service NHS is wrong

One of the first things to get right in the NHS is the language. Perhaps the use of wrong language is the expression of some fundamental misunderstanding of the way the NHS works.

First thing to understand is that the NHS is not a business. It is a publicly funded and mostly publicly delivered service. So the NHS has to stop using the terms and language of business.

Let us look at the terms profit and loss. Why would the NHS use those terms? The terms to use are surplus and deficit. NHS uses things like trading account, when it actually does not trade in anything. NHS staff including clinical staff in their ‘management’ courses are taught how to write a business plan. Why? Why should people in an organisation that is actually not doing business know or write a business plan? They should be writing a service development or service improvement plan which is totally different from a business plan. The aim of a business plan is to generate a profit. The aim of a service development or service improvement plan is self-explanatory. A primary aim of business is to be profitable – get a return on investment. A secondary aim of a public service healthcare organisation is to stay within budget.

A private company’s money is from its sales, the NHS does not sell anything, NHS money is derived from a budget. Technically when sales generate more money than how much the product or service costs then the private company makes a profit and in theory the profits are unlimited. The NHS money is from an allocated budget, if less money than the allocated budget is spent then a surplus is generated – by definition the surplus is limited, very limited.

When a private company sells less or at a price less than what it takes them to make the product or deliver the service then the company makes a loss. By definition this loss is limited to the capital of the company (for limited companies). When the NHS spends more money than its allocated budget then a deficit (not a loss) happens, this money is spent for keeping the health of the population and hence in theory it is unlimited (as a public funded service the government can print money) though in practice a line will be drawn somewhere when the service is delivered differently, perhaps inadequately.

For a private company the theoretical profits are unlimited and for a public service like the NHS the theoretical surplus is limited. For a private company the losses are limited and for a public service like the NHS the deficit in theory can be unlimited. Some NHS managers many not know or understand this, many do – yet the language of profit and loss are used. Wrong language leads to wrong attitudes and wrong expressions.

Sales for a private company can be very variable from day to day, week to week, month to month, yet to year. Budgets vary too but not that much. In fact budgets are assured though the amount can vary. Every NHS clinical organisation can be assured that they will get some budgeted amount next year, simply because their catchment population’s need remain, irrespective of what the organisation is called, how it is structured or who runs it.

The fundamentals are different between a business and government organisation. The reasons, attitudes are different, the methods are different, the language should be different. Yet the business language is used in the NHS. When a business language is used, business attitudes kick in. When a public service is run like a business yet the funding/accounting principles are different people do not know where to stop. People think by making a surplus they are getting bigger and better, they often do not. People by not calling it a deficit and not call it a loss when they make a loss and yet they do not really go out of ‘business’ or ‘existence’ they do not realise when to stop. The ability to recognise a good or a bad idea gets distorted at the best or lost. That is exactly what has happened to NHS managers – wrong language leading to wrong thinking leading to an inability to recognise good, bad, right, wrong. It is like a hypoxic pilot in free fall.

Let us get the language right. The language influences understanding which impacts on attitudes. Get the language wrong and the path towards disaster is established with the inability to recognise it till it is too late.

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Monday, 6 July 2015

Is there an ethics deficit in the delivery of healthcare?

Ethics of quality in Healthcare Delivery

Is there is an ethics deficit in the delivery of healthcare?

Ethics are paramount in clinical research. Currently there is emerging requirement for ethical values and oversight of quality improvement projects. However, it seems unclear if strong ethical principles underpin the delivery of routine healthcare. By routine delivery of healthcare I mean activities such as scheduling/rescheduling appointments, communication methods when non-clinical staff are dealing with patients, staffing levels (numbers, skill mix, acuity matching,etc) and similar. I also mean most of strategy, planning and operations at the provider level.

It is well recognised that it is the huge variation in processes of care delivery results in large disparities in healthcare outcomes. I subscribe to the view that it is not the science or the individual that causes bad results; it is the vagaries of the processes of care delivery that causes poor outcomes.

Policy making is subject to ethical ideas that are broadly utilitarian. Individuals are also subject to ethical principles. Ethics for healthcare professionals especially doctors are specifically person centric irrespective of whether they are individual professionals or patients. Between policy and individuals lies the system, group or team, whose operations are not in reality tested against ethical principles. There seems no clear group based ethics on which care can be delivered though there are innumerable rule based arrangements that seem not to satisfy the cause of quality in healthcare delivery.

In other words, individuals are held to account for quality deficits using ethical principles- groups and systems are not. A group of individuals who practise sound ethical principles do not constitute a ‘group ethic’. The lack of group ethics seems to be preventing known good outcomes from being achieved.

How can this quality gap due to the variation of processes and outcomes be assigned with relevant ethical principles or frameworks with a view to resolving them?

My main argument would be that it is unethical not to aim to achieve or not to achieve a desired result:
-          in the absence of any material restricting factors and
-          when the knowledge and methods have been described and publicly available

However, since medical ethics is effectively applicable to individuals and other ethical theories are applicable to policy making, there seems either a lack of ethical theory/reasoning or a lack of application of ethical theories to understand the ethicality of group operations in healthcare delivery.

My assumption is when the issue of ethics for operational groups who are implementing care delivery are defined, available and clarified a contextual framework could become available to bridge the quality delivery gap where healthcare delivery outcome deficits can be seen as ethical deficits; thus ethics becoming a powerful lever in ensuring highest known optimum outcomes.

The utilitarian policy making at one end, with medical ethics (a mixed application of various basic principles) at the other end, seems not be served very well by the current version of possibly deontological 'operations'. Is that the case? If that was the case, how do we resolve it?


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Friday, 5 June 2015

MSc in Healthcare Improvement Leadership

Applications are now open for the second cohort of the MSc in Healthcare Improvement Leadership starting in October 2015.  This is a bespoke programme that has been developed jointly between University of Hull (Faculty of Health Sciences) Hull University Business School and Hull and East Yorkshire Hospitals and is open to all Healthcare Professionals.  

The first cohort (a mixture of clinical and non-clinical staff) have reported that the programme is “interesting, enjoyable and thought-provoking” as well as “blowing my mind with different perspectives of quality”

If you are interested in being a part of the second cohort and for further information please contact:-
Tracey Heath – Director of Enterprise
University of Hull 01482464519

Further information:

MSc in Healthcare Improvement Leadership

A unique opportunity has arisen to undertake a Masters in Healthcare Improvement
Leadership at Hull University. This MSc programme is developed jointly between Hull
University, Hull Business School and Hull and East Yorkshire NHS Trust. This programme is
open to all healthcare professionals from primary, secondary and other health care sectors.
- To provide the participants with theoretical and practical understanding of the
concepts of quality improvement in healthcare delivery
- To equip the participants with practical tools to enable quality improvement
- To equip the participants with the attitude and ability to be a leader of healthcare
quality improvement
- To explore the links between evidence, experts, experience, policy and practice.
- To understand the relationship between quality and cost
- To understand the concepts of shared baselines, local clinical protocols and the
improvement method
- To understand the modelling of the process of quality improvement
- To review tools available for healthcare delivery improvement
- To understand the relevance of measurement in improvement and to learn about
the tools to do so
- To understand the various kinds of leadership that brings about the preferred
response from colleagues using a selection of human factors and communication
methods thus defining the human face of quality improvement leadership
- To appreciate the importance of learning from immediate peers and colleagues.
Attendance Requirement
There will be 10 contact classes in the first year which participants are required to attend.
Other aspects of the course will be delivered by a combination of e-learning and support as
Modular progression
At the successful completion of first year there will be the option to take the qualification of
Certificate in Healthcare Improvement Leadership and to progress to a Diploma and Masters


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Declaration of interest: I teach some parts of the course. No current financial interest.

Monday, 25 May 2015

Colonoscopy Pain Score - How I do it

Colonoscopy is often a painful procedure – the duration of the pain or the intensity of it varies from patient to patient and for the same patient for procedure done at different times. The pain also depends on operator experience. What goes on in the patient’s life external to their physical/mental health also plays a part in the patient’s behavioural interaction during endoscopy. Hence, there are patient factors, endoscopist factors and environmental factors at play.

Assessing the pain during the procedure is the responsibility of the endoscopists and the endoscopy nurses. Endoscopy nurses are thought to be a ‘third party’ in terms of assessing patient comfort. The patient comfort assessment takes the form of the Gloucester score. 

The Gloucester Scale takes into account the frequency and duration of discomfort and any distress it might cause the patient; it is often reported as
Comfortable – talking / comfortable throughout
Minimal – 1 or 2 episodes of mild discomfort without distress
Mild – more than 2 episodes of discomfort without distress
Moderate – significant discomfort experienced several times with some distress
Severe – frequent discomfort with significant distress
Numerical rating of 0 to 4 are assigned for the above.

The difficulty for colonoscopists and endoscopy nurses is that the Gloucester scoring scale is subjective and acts as a post-event record rather than an intra-procedure guide. In other words how to decide on how to score and while the patient is having a particular score during the procedure what to do about it? The scoring system, I feel, is currently is static and slightly retrospective. A scoring system, in my view, should be current and a guide to action.

At a human emotional level the idea that a medical procedure could cause or causes distress (defined as extreme anxiety, sorrow or pain) in a patient is something that is very difficult to cope for most clinical practitioners in healthcare. It would be better for any assessment or score of such distress to be defined (parametered) and linked to action so as to help the practitioner. This is probably the intention of the Gloucester score anyway but it is not explicit from the scoring system chart or table.

As an endoscopist I reflect on how and why I have been scoring patients the way I do and this is what I find myself doing.

0 – No pain Comfortable – no visible evidence, if conversational no change in tone or speed of conversation

1 – Minimal pain – facial changes such as crease lines, licking the lips, pursing the lips, in white patient’s skin turning pink or red. If conversational, tone of voice changes or conversation transiently stops. There may be changes in the breathing but difficult to detect. Patient does not complain explicitly.

2 – Mild pain – facial and audible changes (grimace, moan, groan, sigh)  Conversation stops for a longer period. Vocally mentions (not complains) about discomfort Slight holding of breath Conversation restarts with reassurance

3 – Moderate pain – Patient asks you to stop temporarily due to pain. Patient explicitly states that they have pain. There is a needed top up of IV medication. If Entonox is used, then having to wait for pain to pass and the patient to give permission before continuing procedure again. Needing to change position to resolve or reduce pain. Patient withdraws consent due to a combination of predominantly anxiety and less predominantly pain (pre-existing anxiety must be present preferably with evidence such as tachycardia on admission or pre-procedure or patient explicitly expressed anxiety, or on regular medication for anxiety).

4 – Severe pain – Pain after iv top up medication, attempts to unloop, changes of patient position or (especially if Entonox) several patient guided stop-starts.  Patient withdraws consent due to pain and the procedure is abandoned. Simple reason, if the patient is in severe pain we have no business to continue.

In practice, there is no difference between 0 and 1 i.e. no pain and minimal pain; once a scope is inserted and insufflation begins there is some degree of discomfort and pain is bound to happen and at the level of 0 or 1 it simply means that the patient is not concerned about it. No reassurance is needed for the purpose of pain.

In practice if reassurance is needed, offered and sufficient to continue the procedure after a patient mention or staff recognition of pain then it is mild pain.

If the patient shows features of what is assessed as moderate pain then top up intravenous medication is given or if Entonox wait till patient gives permission to proceed. For the purpose of scoring if top up intravenous medication was given or in the case of Entonox if there was a need to wait for the patient to permit explicitly to proceed then it is scored as moderate pain. If the patient withdraws consent due to mostly anxiety (on the assumption that however anxious the patient having started the procedure pain would be a trigger to withdraw consent and probably not just anxiety alone) then the scoring would still be ‘moderate’ pain.

If the patient is in severe pain the procedure is abandoned (and for the purposes off scoring, if procedure had to be stopped due to pain then it is severe pain)

This is the way I use a broadly subjective retrospective pain score into a mostly objective intra-procedure guide by a hopefully logical three way dynamic link of defined parameters, action taken and score.

Parameter (Observed)
Parameter (expressed)
No pain

Complete procedure
Facial creasing, pursing lips, change in tone of voice, transient stop in conversation. No verbal complaint.

Complete Procedure
Grimace, moan, groan, sigh. Breath holding. Verbally mentions pain (but not as ‘complaint’)

Complete procedure with reassurance
All of the above and need to change position
All of above and patient explicitly complains of pain with a need to stop procedure temporarily.

Complete procedure with additional medication

Anxiety explicitly stated on admission
Taking medication for anxiety
Physical features of anxiety eg. tachycardia
Patient withdraws consent due to a predominance of anxiety made worse by pain
Abandon procedure (after additional medication was tried)
Pain not relieved by top-up iv medication
Pain not relieved by change of positions and attempted unlooping. If Entonox, then Pain not relieved by waiting for patient to guide us to proceed.
Patient withdraws consent
Abandon procedure

By having a link between observable defined parameters and scoring I feel I am reducing my potential bias in the manner I might score. By linking score parameters to action I feel I further reduce the bias, I also feel this is able to offer better decision making for myself. A pre-defined parameter-outcome link makes operational sense and ensures ease of process.

These are all based on self-reflection and observation of my own practice, I did not set out to practice this way, I observed that I am practicing in this manner.

Then there is an issue of ensuring a better patient memory of the procedure irrespective of how uncomfortable the procedure actually was. This is achieved by slow withdrawal, in addition I have already written about the explicit use of humour if possible and appropriate, this is important for all the scores.

Perhaps all endoscopists are already doing this, may be not explicitly, in which case this was my excuse to write a blog.


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Sunday, 29 March 2015

Narayana Health - A company to watch

In its website Narayana Health (NH) states it is ‘Amongst top 50 local dynamos of the world’ (

NH’s growth is phenomenal from 225 beds in 2000 in Bangalore to 7500 beds in 2014 in 29 hospitals across 17 cities. NH wants to grow to 30000 beds by 2018. NH has a project stated to be worth $2billion over 15 years in the Cayman Islands in association with an American non-profit partner for the purposes of medical tourism style of healthcare services.  (Cayman Island has a population of approximately 57000 with the financial services industry seemingly as its main economic activity and the world’s second most significant tax haven as per Wikipedia)

In percentage terms for the number of beds is 3333% growth in 14 years which is 238% growth each year.

With that kind of growth no wonder JP Morgan and Pinebridge invested $100million for a 25% stake in the company (  ). There are news reports that they are now looking to exit.

Narayana Hrudayalaya Private Limited (NHPL) is a company with a subscribed capital of Rs 3,000,000,000.00 ($48million) and a paid up capital of Rs 3,457,530.00 ($55000) according to their last balance sheet of 31/03/2014 filed with the Indian government. NHPL has ‘charge amount secured’ as charges registered in the MCA government of India website Rs 2,005,500,000.00 ($31million) to Indian financial companies. In other words it seems like NHPL has Rs 200crores of secured loans for Rs 34 lakhs worth of paid up capital. This company has many of its stakeholders’ representatives as directors.

There is also another private limited company called Narayana Hrudayalaya Surgical Hospital Private Limited (NHSHPL) with authorised capital 50,000,000.00; paid up capital of Rs 27,027,040.00; charge amount secured Rs 541,238,215.00 In other words Rs 54crores of secured loans for a paid up capital of Rs2.7crores.

Narayana Hrudayala’s quoted profit is about 8% which is decent but not probably good enough for some.  At a capex of Rs 17.5lakhs per bed their 7500 beds would result in assets of Rs 13,125,000,000 (about $211million). However, they have already stated they are trying an asset light model, where the asset belongs to someone else and Narayana Health provides operations.

The $100million private equity investment for the 25% stake of the company would put NHPL’s value at $400million. Perhaps there are other constructs/structures/vehicles that relates to these numbers quoted in the press.  However, the subscribed capital of the company is $48million. Narayana Health website in its disclaimer, terms and conditions and copyright all refers to Narayana Hrudayalaya Private Limited, so for the purposes of this write up I am assuming that they are indeed referring to NHPL. NHPL has a variety of stakeholders including private equity representatives on its board; NHSHPL has only Dr Shetty and a couple of others on the board. As an industry watcher, I am not interested in the nitty gritty of their financial architecture. I am interested in how successful they will be in the medium and longer term.

NH and Dr Devi Shetty are known for their low cost model of private healthcare, their large scale operations and mega ambition. They have not accessed the public with a share offering yet. Their models have also been criticised ( ) There is definitely something exciting happening with NH, time will tell us whether that excitement is positive. Time will tell us whether their debt will negatively affect them, or if their assets will sustain them, or a share offering will boost them. Time will also tell if their model of innovation would be successful.

Irrespective of whether one is interested in finance, healthcare, innovation, politics, off-shore investments, medical tourism or any combination of these, Narayana Health is a company to watch.


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PS: Narayana Health and its growth fascinates me and reminds me of Apollo Hospitals in its rapid growth phase. The above information is gleaned and presented from internet searches. I will be happy to correct, amend or post additional information if that was necessary.