Much has been said and written over the past few years about the work of Dr Devi Shetty and the Narayana Health system. With 17 hospitals covering a full range of specialities and employing 1300 doctors, it’s one of India's largest – and the world's most economical – healthcare providers with a reputation for its ability to reconcile quality, affordability and scale. Interestingly, NH manages to both attract the affluent as a provider of the world's best healthcare and meet the needs of the poor, through innovative insurance schemes and philanthropy. They pride themselves on the fact that no-one is refused treatment due to a lack of funds. Starting from a 300-bed hospital in 2001, Narayana Health has grown to a 6000-bed healthcare conglomerate in 2013. As part of an IPIHD study tour looking for examples of 'reverse innovation' – an innovation seen first in the developing world before spreading to the industrialised world – I had a chance to see NH first hand. I wasn't disappointed. We know that context can be everything in healthcare and there’s no doubt that the context NH operates in is different from the UK. Lower labour costs dramatically reduce price. Less regulation allows for greater flexibility in how the workforce is used. Current health status and access to healthcare means that they have a much greater relative advantage, so 'anything is better than nothing'. However, this isn't a case of healthcare that is 'good enough' for India, this is healthcare that is world-class in terms of clinical outcomes. So what are the take home messages for the NHS? Four things stood out for me… First, the leadership has made delivering high quality care at the lowest possible cost a noble aim. This mission brings the workforce together and creates a culture where people are constantly asking 'how can we do this for less?' The NHS was founded in 1948 on the noble aim of universal coverage but, as we face severe economic challenges perhaps we could do well to adopt the same goal of NH? Every pound spent inefficiently is a pound taken away from someone who could have benefited – we simply can't afford for this to continue. Second, the leaders at NH are a mix of clinicians, including Dr Shetty and the equally inspirational CEO Dr. Raghuvanshi, and managers. Yet talking to them, you also realise that they are very commercially savvy. In the NHS people often baulk at talk of healthcare as an 'industry' but, like it or not, it is and unless we can develop the same commercial awareness in the NHS and embrace new possibilities for healthcare delivery, our current approaches will become as obsolete as the typewriter in the age of the iPad. Third, there is a relentless focus on standardisation, standard supply chains and standard clinical processes. And yet, this doesn't seem to constrain innovation. Protocols are seen as guidelines – anyone can deviate from them if they can show they can get a better outcome. Deviations are fed back and reviewed so that where an advantage is shown the standard protocol can be changed. This is a learning system that the NHS needs to create. Finally, NH have seen the importance of harnessing every asset, and for me the most inspirational thing is how they are engaging families in patients' care. Rather than having family members sit in waiting areas during hospital stays, NH have developed a training programme to equip relatives with the skills needed to support their loved ones at home. Relatives receive training in managing and monitoring vital signs and supporting rehabilitation – they even sit an exam! They have a chance to practice these skills on the ward during the inpatient stay, building confidence to care effectively in the home setting. Of course there were aspects of the care that would not sit comfortably with our expectations. But we are at a crossroads. We don't want to go back to the 'something is better than nothing' philosophy. But, if we want affordable, universal access to high quality healthcare, we need to accept that our current 'anything less than everything is unacceptable' standpoint is no longer sustainable. We need to start to making some hard choices about what is at the heart of high quality healthcare. Source: Jo Bibby (http://www.health.org.uk)