Tuesday, October 7, 2014

Clinical Establishment Act - Please respond

This is a post which I should have posted much before. I’m not sure about how many know about the Clinical Establishment Act 2010 which is being slowly implemented in the country. Couple of states like Assam and Orissa have already implemented it. There are many a hospital in both these states that have been closed down because of the regulations stipulated by the Act.

Recently, there was a notice from the the National Council forClinical Establishments under the Chairmanship of Director General of Health Services, Government of India inviting comments, suggestions, objections, including deletions /additions in the draft documents prepared by them from the public at large and concerned stakeholders.

I personally have much misgiving to the regulations of the Act in the present form.

1.      In a country like India which is very vast and the majority of the population (about 70%) lives in villages, it is going to be very difficult for anybody to set up hospitals in semi-urban and rural areas. The stipulations are going to be very hard to meet that setting up a hospital would hardly be a profitable venture. The other side is that even if hospitals are set up, the cost of care would be quite expensive. Almost all of us have mostly depended on small clinics or nursing homes which are run by a single doctor with the help of a nurse or by a doctor family. In fact, quite a lot of us may have knowingly or unknowingly gone to a unqualified practitioner or quack for our small medical problems. At present I live in a place where almost 95% of the population go to a quack first for treatment. They have bungled up cases where the patient ultimately died. However, nobody has been able to do anything. The only reason being that these guys are the only people who have some knowledge about medicine in remote settings. And they come very cheap. The regulations appear to be giving more importance for corporate multispecialty hospitals. This is quite protectionist in nature towards encouraging a corporate model which will ensure that healthcare is only available at a premium in the absence of an efficient public health care system.
2.      There is enough scientific evidence that family practice and nurse practioner based primary care is as efficient, and rather more people friendly than specialist doctors in full fledged hospital set ups.
3.      If you consider any of the complex clinical conditions one can think of, the primary level of care is much more important than high tech healthcare. We have examples of countries like Brazil and South Africa, where Family Medicine graduates have major role in healthcare. The present regulations would only increase costs. If you look at the regulations, the first level of treatment is going to be a Level 1 Hospital which needs to have a staffing of at least 6 for a place which do not have inpatient care.
4.      Most of our tertiary care centres are burdened with primary care. It is not uncommon for any faculty in our medical colleges who end up complaining that most of the patients that they see could have been easily managed at a Primary Health Centre or even by a Nurse Practioner. The ultimate result is that quite a many of our specialists are over-worked to the extent that they are not able to do justice to the specialised skills they’ve obtained.

If we can think of changes that can be proposed, I would propose the following –

1.      Legalising Nurse-Practioner Care: Nurses should be trained to treat simple illnesses allowed to prescribe medicines. A major need would be to allow a category of healthcentres which are entirely run by nurses who may or may not supervised by doctors. At least for populations who have poor access to healthcare, they would be a major boon. In fact, such nurse-led primary care centres have already been in existence in the country, mainly facilitated by various congregations of the Catholic Church.
2.      Provision for single doctor healthcare centres: We are all very familiar with such single doctor establishments. A 100 square feet room with a familiar friendly face to whom you ran when you had a toothache or a cold. You pay about 50 rupees and then you pay some more for the medicines and some basic investigations. The whole process took not more than half an hour. If the regulations in it's present form are accepted and finalised, the family doctor would be history.

May I encourage you to write back to the government, details of which can be found at http://clinicalestablishments.nic.in/WriteReadData/896.pdf.

1 comment:

  1. Dear Dr. Kuruvilla

    Thanks for such a detailed and informative write-up.

    I agree that Clinics/ Day Care centres should have a separate set of standards. The Standards mentioned under CEA 2010, are basically for hospitals.
    However, for hospitals, I am of the opinion that these standards need to be followed, if not in total then at least as a minimum set of standards required for providing good quality, safe medical care. The satffing of 6 is also required for a hospital to function, probably with the exception of Multipurpose Worker (MPW).
    I think the Act is a good beginning towards providing good standards of medical care in our country, and would go a long way in ensuring a good quality of care.