Can National Patient Safety Implementation Framework save Indian Doctors?

It is one of the most polarising issues in India and also a litmus test for policymakers. Can legislation solve the problem of violence against doctors?

The bulk of the National Patient Safety Implementation Framework (2018-2025) was aimed at strengthening protections for patients. However, buried in the document is also an expansive patchwork of protections that apply to doctors.

Taken together, the framework-on everything from healthcare worker's safety requirements to better communication with patients- represents a significant shift in Indian healthcare policymaking. It says that the health worker's safety is as important as patient safety.

It also states that minimum healthcare worker's safety requirements have to be issued by the health ministry which needs to be incorporated in all licensing and accreditation programmes.

Further, it also calls for better communication with the patients for their safety and checking any violent incidents. "Patient safety concepts need to be incorporated into the work culture of healthcare providers and the way they communicate with each other while delivering the care. Apart from service providers, patients and the community at large also need to be sensitised on patient safety-related issues," the framework document states.  It suggests a comprehensive communication strategy for patient safety involving all stakeholders. The communication strategy will be developed, focusing on patients as well as care providers.

Also, according to news reports, the centre is planning for speedy implementation of the framework, on the heels of the nationwide doctors' protest that happened in June. It could also fuel momentum in states considering enacting laws protecting doctors at a time when 75 % of doctors are facing violence.

Apart from stringent central laws against hospital violence, the medical fraternity has also called for training doctors to tackle such cases during their studies. "We conduct yoga classes for doctors at the hospital. It is tough for a doctor at a government hospital to manage a huge number of patients. A doctor is willing to treat as many numbers of patients. However, what if 100 patients come and there are only forty beds in the hospitals?," asks Amarinder Singh Malhi, President of Resident Doctors Association at AIIMS, New Delhi. 

He also points out that security guards are often not able to ensure the safety of the patients.

How Doctors are Preparing for the New Challenges

Probably, that's the reason why Bihar doctors pooled money to pay for their private armies. According to a Times of India report, "While bigger hospitals have their security guards, smaller hospitals in Bihar have pooled funds to create Quick Reaction Team (QRT) that includes gunmen, bodybuilders and young men with lathis who are on call 24x7," states the report.

The IMA has tried to persuade the centre to enact a law to ensure the protection of doctors from violence. It submitted a draft Bill, "The Protection of Medical Service Persons and Medical Service Institutions (Prevention of Violence and Damage or Loss of Property) Act, 2015" for the centre's consideration.

But how did we get here?

Dr Harjit Singh believes that violence stifles the growth of India's healthcare system.

"In 2017 the world's best medical journal reported that Indian doctors are at the verge of breaking point, courtesy continuing attacks. Moreover, the attacks on doctors increased tremendously in recent years. These circumstances forced them to go for a nationwide strike. They are not demanding luxuries life or hike in pay they are demanding secure workplace, which is the fundamental right of every Indian citizen. Are we doctors are not Indian citizens then why the government is so reluctant to secure us with stringent central protection act," says the former President, RDA, AIIMS Delhi.

Among young doctors, legislation is the name spoken like a prayer. "It will create huge awareness among people that no one is allowed to hit the doctors; otherwise, they will have to face severe punishment. This awareness can only come with central legislation. Secondly, a uniform act for the whole nation will have more clear instructions for police and judiciary. It is lacking now and leads to the reluctance of police to lodge an FIR and judiciary also try to compromise and settle the case out of court that's why no prosecution of any assaulter ever," explains Singh.

The conflict was never between doctors and patients. The real battle is between a patient's requirements and available resources. Most of the government hospitals are not provided with adequate infrastructure, diagnostics and medicines which forces patients to go thousands of kilometres away from their native place to get treatment for even minor ailments. These hardships irk them, and when they come to the hospital, unfortunately, the doctor becomes the victim.

More investment and resources in public hospitals will completely stop these assaults.

Should hospitals be declared as safe zones?

According to the IMA, 19 states have already passed legislation to protect doctors. The states which have enacted laws to protect doctors include Andhra Pradesh, Assam, Bihar, Chhattisgarh, Delhi, Goa, Gujarat, Haryana, Karnataka, Madhya Pradesh, Maharashtra, Orissa, Puducherry, Punjab, Tamil Nadu, Tripura, Uttar Pradesh and West Bengal.

"The government has been fairly laissez-faire about the protection of doctors. It has left the decision to states to implement legislation. But it’s high time that structured safety measures including 3-layer security, CCTV and restriction of entry of visitors should be implemented in hospitals," said a doctor in Kerala, who didn't want to be named.

Does legislation protect the doctor?

Today's doctors face a problem that no one would have imagined fifty years ago in India: How do you protect doctors when patients are not scared of legislation? The West Bengal Medicare Service Persons and Medicare Service Institutions (Prevention of Violence and Damage to Property) Act, 2009 declares any violent act against doctors as a cognizable and non-bailable offence and imposes a punishment of imprisonment which may extend to three years and with a fine up to Rs 50,000 on those found guilty. However, that didn't prevent the crowd from attacking the junior doctor recently. It questions the effectiveness of legislation.

Drawing the line

In 2015, the IMA claimed that its survey of doctors – as revealed from 1,739 responses it received from all over India – led to shocking findings. About 45.4% of the doctors feared possible violence; 24.6% feared being sued, and 13.5% feared criminal prosecution. Only 16.6% of doctors, the IMA said, reported no stress of any kind in the performance of their duties.

Often what the doctors want is very different from what policymakers want and can deliver. Though the recent attack on the doctor is not something new in India, it has undoubtedly pressured the politicians to act fast on essential legislation. Hospitals like AIIMS stand both as an impregnable fortress as well as a symbol to several medical aspirants. "I could dream to be a doctor because of these premier institutes," said *Kiran, a Bangalore-based medical aspirant. "It's literally a dream."