“It is unjust to scrap the very structure of MCI”

Dr Vinay Agarwal, former President, Indian Medical Association (IMA), New Delhi and Founder Chairman, Max Super speciality Hospital, Vaishali (Ghaziabad) expresses serious concern over the proposed National Medical Commission (NMC) Bill, 2016. According to him, all the functions enumerated therein are already being carried out by Medical Council of India (MCI) presently under the provisions of the present IMC Act which the proposed bill seeks to repeal. As a member of IMA and IMC’s ethics committee, he does not agreewith the new NMC Bill that he describes as nothing else but “old wine in new bottle”.
According to Dr Agarwal, if the new bill is implemented, non MBBS doctors can get registered in NMR and start practicing modern medicine. So, NMC Bill 2016 must be abandoned totally. Changes can be brought about in the MCI by retaining and strengthening its self-regulatory role and functional autonomy, and that can be achieved by making relevant amendments to the IMC Act 1956 itself. Excerpts from Dr Vinay Agarwal’s interview with Amresh Kumar Tiwary of Double Helical…

What are your views on the recently drafted National Medical Commission (NMC) Bill, 2016?
The National Medical Commission Bill,2016 is totally flawed and will create more problems to all aspects of modern medical practice in India than any solutions. We, therefore, suggest total abandonment of the NMC Bill,2016.
The Parliamentary Report of the Committee on the reforms of the Indian Medical Council Act 1956, appended to the draft NMC Bill, has stated that the current electoral process of appointing regulators is inherently saddled with compromises and attracts professionals who may not be best suited for the task at hand. It creates an ab-initio conflict of interest and therefore this system must be discarded in favour of one based on search and selection.

Do you find anything wrong in this premise? Why shouldn’t regulators of highest standards of professional integrity and excellence be appointed through an independent and transparent selection process by a broad-based search cum selection committee?
We object to this premise as being baseless and uncalled for. The report does not provide any proof for the statement that it “is now widely regarded as a flawed principle”. In India, the following institutions are set up under law for self-regulation of professions: Bar Council of India(BCI) formed under the Advocates Act,1961,Medical Council of India(MCI) formed under the Indian Medical Council Act,1956, the Institute of Chartered Accountants of India(ICAI) formed under the Chartered Accountants Act,1949, Institute of Cost and Works Accountants(ICWAI) formed under the Cost and Works Accountants Act,1959, Institute of Company Secretaries of India(ICSI) formed under The Company Secretaries Act 1980 and the Council of Architecture (COA) formed under the Architects Act, 1972.

Similar laws of self-regulation of such professions exit in the United Kingdom, other countries of the Commonwealth, the United States and many other European countries as well. The professions that are allowed by law to be self-regulated, including the medical profession, are the ones that require high levels of knowledge, skill and commitment, with high levels of complexities. For such professions, self-regulation enables setting of high standards of skills and ethics, so as to preserve and improve the quality standards. Therefore, the prevalent laws of the country, such as the Indian Medical Council Act of 1956, which are in tune with the international laws, should not be trampled.
We also object to another contention in the report. If self-regulation of medical professionals creates ab-initio conflict of interest, the same must be true of all other professions, and also legislatures that make laws and procedures for themselves. By this standard, Bar Council cannot be allowed to regulate advocates, ICAI cannot regulate chartered accountants, parliamentarians and legislators should not make laws regulating themselves, and their perks and so forth.
It is indeed very perplexing to note that the report which questions the standards of self-regulation by elected members of the MCI, goes on to self-certify the standards of the proposed Search cum Selection Committee! It is indeed baffling as to how the NITI Aayog, whose CEO has been listed as a member of the proposed Search cum Selection Committee, can certify the very same committee as independent and transparent and capable of appointing regulators of highest standards of professional integrity and excellence, disregarding the very principle of conflict of interest that it espouses to decry the MCI! NITI Aayog should be placed above this body to become eligible to critically evaluate the search cum selection committee rather than be a part of the committee.
Further, all the discussions, media reports and the like that have been quoted in the report appear to be one sided and do not necessarily offer an objective reasoning for scrapping the Medical Council of India. It is not an unknown fact that the Medical Council of India has been interfered with time and again, and many politicians across the divide and many businessmen of various trades have succeeded in starting medical colleges of their own in the past three decades. Now to blame it all on the Medical Council of India and use that alibi to scrap the very structure of the MCI is unjust and will certainly do more harm than good.

Then, what would you propose for the draft of NMC Bill 2016?
We strongly propose that the Preamble of the Draft NMC Bill must be discarded. Instead, the following amendment should be inserted into the Indian Medical Council Act, 1956: The words AN ACT TO PROVIDE FOR THE RECONSTITUTION OF THE MEDICAL COUNCIL OF INDIA AND THE MAINTENANCE OF A MEDICAL REGISTER FOR INDIA AND FOR MATTERS CONNECTED THEREWITH must be replaced with the words AN ACT TO PROVIDE FOR THE CONSTITUTION OF THE MEDICAL COUNCIL ON INDIA AND ITS SUB COMMITTEES,PROVIDING FOR THE MAINTENANCE OF A MEDICAL REGISTER FOR INDIA AND FOR ENFORCING HIGH ETHICAL STANDARDS IN ALL ASPECTS OF MEDICAL SERVICES, FOR REGULATING THE CURRICULUM AND STANDARDS OF MEDICAL EDUCATION, FOR OBJECTIVE PERIODIC ASSESSMENT OF MEDICAL COLLEGES, AND TO ENCOURAGE MEDICAL PROFESSIONALS TO INCORPORATE THE LATEST MEDICAL RESEARCH IN THEIR WORK AND TO CONTRIBUTE TO SUCH RESEARCH AND FOR OTHER MATIERS CONNECTED THEREWITH.
CHAPTER 1 and Chapter 2 of the Draft NMC Bill should be discarded.Instead, the IMC Act 1956 must be amended as below:
Section 3 (1) The Central Government shall cause to be constituted a council consisting of the following member, namely should be amended as Section 3 (1) The Central Government shall cause to be constituted a council called the Medical Council of India, and its subcommittees to be called as Sub Committee for Undergraduate Medical Education, Sub Committee for Postgraduate Medical Education, Sub Committee for Assessment and Accreditation of Medical Colleges and Sub Committee for Registration and Monitoring of Medical Professionals.
Chapters 3-8 of the Draft NMC Bill must be discarded. Instead, the IMC Act 19563(1) (a) One member from each state other than a Union Territory to be nominated by the Central Government in consultations with the State Government concerned should be amended as:
(a) One member from each state and Union Territory, having registered with the medical council for a period of not less than 15 years, and not a teaching faculty in any medical college, to be elected by the registered medical practitioners having a qualification equal to a postgraduate diploma or a postgraduate degree or above.
(b)One member from each University to be elected from amongst the members of the medical faculty of the University by members of Senate of the University or in case the University has no Senate, by members of the Court should be amended as (b) One member from each state and Union Territory, having registered with the medical council for a period of not less than 15 years, to be elected by the registered medical practitioners with post graduate degree or above, and working as faculty in the medical colleges within the state.
(c) One member from each state in which a State Medical Register is maintained, to be elected from amongst themselves by persons enrolled on such register who possess the medical qualifications included in the First or the Second Schedule or in Part 2 of the Third Schedule should be amended as (c)One member from each State and Union Territory, having registered with the medical council for a period of not less than 15 years, to be elected from amongst themselves by persons enrolled on such register who possess the medical qualifications in the First or the Second Schedule or the third Schedule that is not above level of graduation.

Apart from these, are there major drawbacks in the proposed NMC Bill? The representative character of MCI and the fine balance between elected and nominated members has been completely given a go bye in the process. In fact in the proposed bill, there is total exclusion of the elected members,thereby, making a mockery of democratic process. There are other professional councils under Health and Family Welfare department like Dental Council of India, Nursing Council of India, and Pharmacy Council of India or under other departments like the Bar Council of India. However,the proposed bill is brought by abolishing MCI only. There is no proposal in respect of other Councils or even a whisper about such a move. There is no legitimate reason for giving such step-motherly treatment to MCI.

Evaluating the NMC Bill, 2016

The government has proposed to appoint members of National Medical Commission (NMC) following the recommendation of a high-level search and selection committee. Similarly, the four autonomous Boards for undergraduate education (UGMEB), post-graduate education (PGMEB), assessment and rating (MARB) and medical registration (BMR), and the effective convergence in the form of NMC are well-designed and well-integrated.
The new Bill recommends that the NMC should not engage in fee regulation of private colleges. As the Committee pointed out, once a merit-based, transparent admission system is in place, there is no need to regulate fee structure. The Bill also calls for a nation-wide entrance test (NEET) for under-graduate admission, and a National Licentiate Exam for granting doctors license to practice medicine and enrolment into the Medical Register, and also for admission into postgraduate courses to ensure transparency & fairness, eliminate corruption and promote competence.
The Bill addresses challenges of rampant corruption, failure to establish and maintain standards of medical education and ineffective regulation of medical profession. It provides for second appeal on orders of Medical Accreditation and Rating Board (MARB) and later the NMC to the government with respect to the UG and PG education. As Section 27: Permission for establishment of a New Medical College Subsection 3(para 3) reads, “Provided further that the person/college shall be free to make a second appeal to the Government in case no decision is received within one year from the date of his submission or the scheme is disapproved.”
This provision of second appeal to the Government is redundant and counterproductive as the members of both the MARB & NMC are appointed by the Government itself through Searchcum-Selection Committee on the basis of qualifications as per the provisions of the law.
It is proposed that up to 40% seats in private colleges should have regulated fee as per NMC norms, and the institutions should be given full freedom to charge the fees that they deem appropriate for the balance seats. All these are excellent recommendations based on past experience and future needs. However, these recommendations do not find place in the Bill. Given the ubiquitous corruption and lack of transparency in respect of admissions to private medical colleges and fees charged for unregulated seats, NitiAyog believes that relevant provisions should be incorporated in the NMC law.
The Bill seeks to give greater authority and autonomy to four vertical Boards- UGMEB, PGMEB, MARB& BMR. They have far reaching powers and functions. All these Boards are appointed by the Union Government based on recommendations of a high power search and selection committee. However, three of these Boards – UGMEB, PGMEB and MARB have a full time President, assisted by staff from the NMC secretariat. In effect, each is a single-member Board.
The 40% seats with regulated fee should be filled by NEET examination for UG admission, and by the Common Licentiate Examination for PG admission. Only those candidates willing to pay the higher fee should be considered for admission to seats with unregulated fee, but admission should be merit-based among the eligible candidates. Common Licentiate Exam is a very good intervention that would ensure the minimum standards for a medical graduate. In addition, this will serve as the national entrance test for the post-graduate courses. However, greater attention needs to be paid to the under-graduate examination system.
According to new Bill, a fact-based assessment is a crude tool considering that medical expertise is mostly skills based rather than possessing the factual knowledge. Most of the developing countries moved towards the Objective Structured Clinical Examinations (OSCE) in addition to the MCQ based tests. These are very important tools in improving the clinical and communication skills of the doctors. These can be easily implemented in India in centralized manner –for example at state or a particular region level by a large group of examiners.
Medical specialty organizations and associations in India have evolved significantly in the recent years and have been providing excellent continuing medical education to the medical specialists. One must avail the expertise of these professional associations constructively in improving the standards of post-graduate training in the respective specialties. Involving the stakeholders with expertise directly in devising and updating the training standards of rapidly evolving medical specialties is very essential. This also serves as a mutually reinforcing mechanism strengthening the specialty associations and raising the training standards.
An important role to be played by NBE in shaping the functions of the PGMEB, and proposed that they could continue to conduct voluntary examinations with institutions / candidates willing to take part in such a process. However the transitory provisions in Section 42 of the draft Bill provide for immediate merger of The National Board of Examinations (NBE) with Post-Graduate Medical Education Board (PGMEB).
In all major nations, almost all medical graduates have the opportunity to specialize, get trained and obtain post-graduate diplomas and degrees. In India, typically around 25,577 (49%) medical graduates have that opportunity given the limited postgraduate training facilities and seats. Among the PG seats, only 50-60% are in clinical medicine, and therefore only about 12-15% of medical graduates are able to specialize in clinical care.
As a result, there are serious deficiencies in competence and expertise in medical care. NBE has been created to meet the legitimate needs of the society and to ensure quality training of post-graduates in a flexible and effective manner. Most objective observers and experts agree that NBE has been doing a very creditable job with honesty and efficacy. MCI historically had no flexibility or institutional ethos to expand PG education. There are many institutions of excellence and credible, high-quality private hospitals which do not want to start medical colleges but are nevertheless excellent institutions for PG education.
The government should review the situation after, say five years, and then take a policy decision on merger of NBE with the new NMC.
The proposed Bill rightly provides for an appeal to the Board of Medical Registration whose decision shall be binding on the State Medical Council in section 29 Clause 1 Sub clause iii: “Where the name of any person has been removed from a State Register on a ground other than non-possession of the requisite medical qualifications, he may appeal in the prescribed manner to the BMR, whose decision shall be binding on the State Council subject to the provisions of Section 29” However, the draft Bill is silent on the composition of the State Medical Council (SMC).
Given the enormous importance of NMC’s role in regulating standards of medical education, professional ethics and medical care in India, a regular framework for reporting and accountability should be institutionalized in the law itself. Therefore, we suggest that the NMC Act should provide for a mandatory annual reports to the Parliament, so that there can be effective accountability through Parliamentary debate and Committee hearings.