MEDICAL REGISTRATION (AMENDMENT) BILL

MEDICAL REGISTRATION (AMENDMENT) BILL: Order for Second Reading read.

3.36 pm

The Minister for Health (Mr Khaw Boon Wan): Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time."

The Medical Registration Act (MRA) seeks to protect the health and safety of the public by creating mechanisms to ensure that medical practitioners are competent and fit to practise medicine. In this way, we uphold the standards of medical practice in Singapore, and so doing, maintain public confidence in the medical profession.

The MRA was last amended in 2003. Since then, new issues in professional conduct and standards have arisen due to changing demands and expectations of patients and the public. This Bill seeks Members' support for several amendments to the MRA. The amendments will address four key objectives:

(a) To strengthen and streamline the Singapore Medical Council (SMC)'s existing disciplinary processes to cope with the

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increase in the number and complexity of complaints and disciplinary proceedings;

(b) To provide a wider range of orders and penalties which the SMC can impose, commensurate with the extent of a medical practitioner's wrongdoing and circumstances of the case;

(c) To adopt a more nuanced approach to medical registration for both local and foreign-trained doctors; and

(d) To set up a Register of Family Physicians.

Let me elaborate on each of these objectives and explain how the proposed amendments would achieve them.

SMC's disciplinary processes

First, we see a need to strengthen and streamline the SMC's disciplinary processes, to cope with the rising number and complexity of complaints against doctors. Singaporeans enjoy high standard of medical care and largely have high confidence in our doctors. Nevertheless, the number of complaints has gone up from 66 in 2003 to 96 in 2009. This is partly because the number of doctors has also increased substantially, from 6,292 in 2003 to more than 9,000 in 2009. This works out to about 11 complaints per 1,000 doctor per year, which is not alarming. However, SMC's capacity to cope with the rising number of complaints has remained the same during this period. The result is a growing delay by the SMC in processing the cases, especially if they are complex. Last year, as an example, a simple complaint took about three months to conclude, and one complex case actually took more than five years. As a result of long delay, there have been instances where the complainant who was dissatisfied with the outcome of the disciplinary process, was unable to initiate civil proceedings against the doctor. The complainant also has no recourse for

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appeal against the Disciplinary Committee's decision under the current Act. This is unsatisfactory.

Clause 26 repeals and re-enacts Part VII of the Act relating to inquiry and disciplinary proceedings. The changes in Part VII seek to achieve more expeditious and equitable management of complaints. SMC's Complaints and Disciplinary Committee members are all volunteers. With the increasing number of complaints, the existing members have been heavily burdened with disciplinary inquiries which could last up to 10 days, and requiring at least six hours each day. The frequent and heavy commitment required makes it difficult at times to constitute the committees, thus delaying the proceedings. To improve the situation,

(a) the new section 38 will raise the cap on the number of lay persons and registered doctors in the Complaints Panel from the current 80 to 150, almost doubled. Together with clause 4 which increases the number of Council members from the present 19 to 25 members, these changes will effectively increase the number of chairmen and committees that can be constituted to handle the larger number of complaints.

(b) Further, the new section 40 will reduce the number of members of the Complaints Committees from the present four to three members, and all three members of the committee need to be present to constitute a quorum. With a smaller committee, this will make it easier and faster to coordinate members' schedules for meetings.

(c) In addition, the new section 50 renames the Disciplinary Committees as Disciplinary Tribunals, a more appropriate term and changes the way they are constituted. With the amendments, the Disciplinary Tribunals will no longer

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specifically require the chair and one member to be Council member as is the case today. The Disciplinary Tribunal's Chairman and members will be constituted from a panel of Chairmen appointed by the Minister, and the Complaints Panel respectively. It will also allow the SMC the option of appointing members with experience in legal matters, such as a senior legal officer, senior lawyer, former Supreme Court Judge or Judicial Commissioner, to be a member or the chair of a Disciplinary Tribunal. I will speak more on this amendment later, but briefly these changes expand the Council's capacity and capability to deal with the increasing number and complexity of disciplinary cases by widening the pool of members that can be appointed to the Disciplinary Tribunals.

The new section 42 and clause 28 will allow SMC's Complaints Committee to appoint and empower officers to investigate complaints against doctors. Currently, where information is received regarding a doctor's practice, such as errant prescribing of addictive drugs, there are no provisions for SMC to conduct a thorough investigation. A Complaints Committee can only rely on exculpatory statements and medical records submitted by the doctor and expert opinions. These may not fully reflect the facts or severity of the case. These amendments will empower the appointed investigators to seize evidence without notice to the doctor, and conduct a thorough investigation. In this way, the Complaints Committees will be better able to make informed and impartial decisions, resulting in complaints being processed more quickly and with fairer outcomes.

The new section 55 sets out the framework for the SMC or an aggrieved complainant to appeal to the High Court against the Disciplinary Tribunal's decisions. Currently, only the defendant doctor is allowed to appeal to the High Court on the decision of the Disciplinary

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Committee. This is not necessarily fair to the public or the complainant. This section allows the SMC to appeal when the Council is not in agreement with its independent Tribunal's orders. The framework also allows the complainant an avenue to initiate an appeal through a review committee appointed by the Minister.

_Expanding the range of orders
_

Second, we propose to expand the range of orders for SMC, its Complaints Committees, Disciplinary Tribunals and Health Committees so as to grant them more powers to be able to deal more effectively and appropriately with errant doctors.

The new section 37A provides for a doctor, who is aware of his performance difficulties to voluntarily request the SMC to remove his name from the register, suspend him, or impose conditions or restrictions to his practice. This enables SMC to resolve certain less serious health or performance issues with the mutual consent of the doctor instead of going through tedious, and formal disciplinary proceedings. However, this section will not apply if a complaint had been received against the doctor.

Currently, the Complaints Committees are only empowered to issue letters of advice or warnings where no further inquiry is necessary, or order an inquiry to be held by a disciplinary committee or a health committee. We propose to widen the range of orders available to the Complaints Committees so that less serious complaints can be concluded expeditiously without the heavy legal involvement and time required for Disciplinary Tribunals. When the Complaints Committee deems that no formal inquiry is necessary, the new section 49 will allow the Committee to:

(a) order that the registered medical practitioner seek and undergo medical or

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psychiatric treatment, or report on the status of his fitness to practise periodically to SMC;

(b) order that the registered medical practitioner undergo further training, or seek and take advice in relation to the management of his practice;

(c) refer complaints for external mediation to facilitate resolution amongst the parties concerned, for example, where miscommunication or compensation between the parties had been the key issue in the complaint; and

(d) by agreement of the doctor, remove the name of a doctor from the register, suspend his practice for not more than three years, cancel or suspend his practising certificate, or impose restrictions and conditions on his practice.

These changes also allow the SMC to deal with correctable behaviours more constructively.

Under the current Medical Registration Act, the Disciplinary Committee can impose a financial penalty not exceeding $10,000 on a medical practitioner who is convicted. The next level of penalty is a suspension of between three months and three years. There is, therefore, a significant gap in the range of penalties in the current Act.

The new section 53 will allow the Tribunal to impose a fine of up to $100,000, thereby enabling the Tribunal to mete out a penalty that is appropriate to the severity of the case. This section will also allow the Disciplinary Tribunal to impose other orders, for example, changing his medical registration from one that is fully registered and unsupervised to one that is conditionally registered and supervised. The SMC, by so doing, can thus impose appropriate conditions or restrictions on the practitioner. The Disciplinary Tribunals will also be able to mete out the new range of orders

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available to the Complaints Committee. All this enhances the powers of the Tribunal by expanding the array of possible orders.

Similarly, the new section 58 will enable the Health Committee to restrict a doctor's practice for a period exceeding the current three years where necessary. These changes, in conjunction with the expansion of orders available to the Complaints Committees, and Disciplinary Tribunals will allow appropriate rehabilitative or punitive actions to be taken that commensurate with the severity and circumstances of the cases.

_A more nuanced medical registration
_

Third, we seek to enhance medical registration for both local and foreign-trained doctors. Mr Speaker, Sir, to cope with the rising demand for doctors in Singapore, we have increased the medical school intake at NUS, and started the NUS-Duke Graduate Medical School (GMS). However, this is still not enough to meet the rising healthcare needs of our larger population base, a significant segment of which is rapidly aging. We are actively recruiting competent foreign trained doctors and the enhanced registration framework will enable the SMC to cater to new issues that have arisen in view of these developments. Let me explain.

The new GMS with its different model of education will require a different mechanism for assessing its graduates for registration as opposed to the graduates from the NUS Yong Loo Lin School of Medicine. This is generally not provided for under the current MRA. Clause 10 enables the Medical Council to prescribe different requirements for the different degrees in medicine and surgery specified in the First Schedule. This will allow the

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SMC to adopt requirements similar to the US system in assessing the NUS-Duke GMS graduates.

Over the years, we have also increased the number of overseas medical schools recognised in Singapore from 24 to 160, to facilitate the entry of foreign-trained doctors from good medical schools. There is a sizeable influx of foreign-trained doctors, both foreigners and Singaporeans who studied overseas, into our medical workforce. Last year, two out of three new medical registrations were foreign-trained. In other words, for every local graduate, there were two graduates from foreign medical schools. Aside from medical qualifications, we also need to monitor the performance of these doctors, making sure that they are up to our standards and adapt well to the local environment. The following changes will better enable the Medical Council to scrutinise and, if necessary, limit the practice and conduct of new doctors entering the healthcare system and to act to maintain standards:

(a) The current Act only allows the SMC to consider reports from the supervisor in monitoring and assessing the conditional registrant. This is not always adequate for assessing competencies in areas such as communication and teamwork. Clause 11 improves the current supervisory framework by enabling the SMC to seek feedback and reports from other healthcare professionals other than the supervisor to provide a fuller assessment of the doctor's competence and ability to work in our local environment.

(b) Clause 14 allows the SMC to cancel the provisional registration of a medical practitioner if he was found to be underperforming. Under the current Act, the SMC does not have such powers and is not able to stop a house officer from practising even when there are serious issues with his performance.

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(c) Currently, the SMC can refuse to register an applicant only if he was not qualified to be registered; was not of good reputation and character; or had his name removed from a register of medical practitioners in another country. For fresh foreign-trained medical graduates, neither of these reasons would apply. However, they may have health conditions, such as Hepatitis B, HIV or psychiatric disorders, which may render them to be unsuitable for practice in some areas. Clause 16 allows the Council to refuse to register persons who are found incompetent or is unfit to practise medicine due to a physical or mental condition, or fails to submit to a medical examination, or comply with any condition or restriction of any previous registration. This will enable the SMC to assess the applicants more thoroughly prior to registration and proactively deal with the registrant's condition.

(d) Clause 22 allows the Specialists Accreditation Board to certify as specialists, persons who have the experience and meet the conditions for specialist registration even if they did not have recognised qualifications, and to define areas of sub-specialty. Clause 12 clarifies that conditions and restrictions can be imposed on a person's Specialist Registration. This will allow the SMC to register a foreign specialist, and limit the scope of his practice to only his field of specialisation or area of expertise where necessary. For example, hepatology is not defined as a specialty in Singapore. However, with the amendments, we can certify a hepatologist as a specialist in gastroenterology, which is a specialty here, but restrict his practice to hepatology. Hepatology is a sub-specialty of gastroenterology. I think it deals with liver diseases. This will help safeguard public interest and safety.

Registering family physicians

Fourth, we propose to set up a register of Family Physicians. With an

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ageing population and the rising prevalence of complex chronic illnesses, there is a need to have more well-trained family physicians to serve the healthcare needs of Singaporeans in the community. Every Singaporean should have a trusted Family Physician. If you do not have one, better look for one now. The Family Physician will be a valued physician who will coordinate care for the patient and his family competently and cost effectively. Clause 23 of the Bill will establish the Family Physicians Accreditation Board to accredit such practitioners and clause 13 provides for the Registration of Family Physicians with the SMC. This Register will list the names of Family Physicians who have undergone a recognised formal training programme in family medicine. The new Board and Register will further enhance the level of healthcare in the community and raise the standard of family medicine practice in Singapore. If Singaporeans receive good and affordable healthcare in the community, they can avoid unnecessary visits to acute hospitals and therefore save money.

Miscellaneous amendments

Finally, we are taking the opportunity to introduce a number of miscellaneous amendments to enable the SMC to operate more effectively and efficiently. They include:

(a) clause 5 which allows the SMC to provide administrative services to other bodies (whether corporate or unincorporate) responsible for the regulation of healthcare professionals;

(b) clause 18 which removes the requirement for the SMC to publish a list of doctors in the Gazette , as such information is now already and regularly updated on the Council's Internet website; and

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(c) clause 31 which allows the SMC to compound offences in lieu of prosecution.

Consequential amendments will also be made to the following Acts:

(a) section 12 of the Private Hospitals and Medical Clinics Act (PHMCA) to widen its powers of investigation, and section 13 to allow authorised officers to disclose information obtained under the Act, if such disclosure is under or for the purpose of administering and enforcing the Medicines Act or the Health Products Act; and

(b) section 14C of the Dental Registration Act and section 18 of the Pharmacists Registration Act to empower the Singapore Dental Council and Singapore Pharmacy Council to impose conditions and restrictions on specialist registration for dentists and pharmacists respectively.

_Public consultations
_

Mr Speaker, Sir, the Second Reading of this Bill today follows months of consultation that involved the general public, doctors and key professional groups. MOH had engaged the SMC and key leaders of various professional bodies, including the College of Family Physicians, Singapore Medical Association and the Academy of Medicine. I would like to thank all who have contributed their views to help shape the Bill.

One proposed amendment has been the subject of much debate from a segment of the medical fraternity. It is the provision to allow the SMC to appoint legal professionals either as chairman or as a member of a Disciplinary Tribunal. Let me explain why such a change is not only necessary but will also add value to the current system.

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Disciplinary inquiries increasingly involve complex issues that are legally and procedurally challenging. In almost every inquiry, both the Council and the defendant are represented by legal teams. Thus, Disciplinary Committees always require the presence of a Legal Assessor to assist in the proceedings. For high profile cases, doctors have been known to engage top lawyers, including Senior Counsels. Disciplinary Committees are increasingly saddled with legal arguments, technicalities or materials that unnecessarily lengthen proceedings. Consequently, the legal costs of conducting inquiries have risen considerably.

Senior lawyers appointed by the Medical Council as Legal Assessors are, by law, limited in their ability to direct the course of proceedings at the inquiry, to assess the weight of evidence, or to participate in the final decision of the Disciplinary Committee. The quality and pace of proceedings can be significantly improved by appointing appropriate chairpersons or members who will be legally empowered to control the proceedings and rein in prosecution and defence counsels.

Sir, let me emphasise that the presence of legally-trained persons in the Tribunal is not intended to replace the medical profession's self-regulation. The reality is that the SMC can no longer hold any disciplinary inquiry without significant legal assistance and no inquiry can be conducted without legal inputs and extensive legal preparation and costs. No Disciplinary Committee wishes to risk submitting legal errors or judgements that can be subjected to challenges in a court of law. Even in the course of such extensive legal consultations, there have been cases in the past where the High Court had taken prosecuting lawyers or Disciplinary Committees to task for errors arising from failure to appreciate and comply with legal principles. Such situations may be reduced or avoided by

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allowing senior legal professionals to sit in the Tribunals where it is deemed expedient by the SMC.

From the public consultations and discussions in the media and with the professional community, we believe that the changes will help to augment the processes and improve public confidence. As the provision was of great interest to the medical community, my Director of Medical Services (DMS) wrote to all the 8,000 registered doctors in Singapore, to explain fully the purpose of the provision and to seek their individual views. We assure our doctors that the decision to appoint a legal professional as chairman or a member of the Disciplinary Tribunal remains in the hands of the SMC – which is a body entirely made up of senior doctors. In any verdict passed, the influence of a legal professional will only come into being when the doctors on the Tribunal have different votes. Furthermore, only very senior and eminent legal professionals such as a former Supreme Court Judge or Judicial Commissioner, senior lawyers, or senior legal officers can be appointed to chair the Disciplinary Tribunal. After his explanation, the vast majority of the medical community have no objection to the provision.

Mr Speaker, Sir, the standard of clinical and ethical practice of our doctors in Singapore is high. I believe Singaporeans are proud of our healthcare services. In addition, a large number of international patients come here annually to seek treatment, which is further evidence of their trust in our medical services. Our job is to maintain the high standard that our patients expect and make sure that professional medical regulation keeps up with continuing changes in the environment.

I seek the Members' support for this Bill as we forge ahead in providing medical regulation that protects the interest of the general public and also the

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reputation of our good medical professionals.

Sir, I beg to move.

Question proposed.

Mr Speaker: Order. I propose to take the break now. I suspend the Sitting and will take the Chair again at 4.25 pm.

_Sitting accordingly suspended at
4.05 pm until 4.25 pm.
_

Sitting resumed at 4.25 pm

[Mr Deputy Speaker (Mr Matthias Yao Chih) in the Chair]: Column: 1908

MEDICAL REGISTRATION (AMENDMENT) BILL: Debate resumed.

Dr Lam Pin Min (Ang Mo Kio): Mr Deputy Speaker, Sir, thank you for giving me this opportunity to speak on the Medical Registration (Amendment) Bill. First and foremost, I would like to declare my interest as a practising medical professional.

The Medical Registration Act (MRA) governs the registration of medical practitioners and regulates the conduct and ethics of doctors. It was last amended in 2003. It is therefore apt to amend the MRA to keep abreast the rapid changes in the medical profession.

There is a rising trend in the number of complaints and claims against medical practitioners. This rising trend is a reflection of two major contributing factors.

Firstly, the practice of medicine is becoming increasingly more sophisticated and complex. The advent of new medical technologies, surgical techniques, pharmaceuticals and emerging diseases has

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resulted in more treatment options for many medical illnesses. Many diseases that may have been deemed untreatable in the past can now be treated, albeit with more new modalities that can carry with it potential adverse effects and inherent risks. In addition, with more doctors and more procedures being performed, many of which are technically more difficult, the number of complications will inevitably increase.

A good analogy that could be drawn is the rising number of road traffic accidents in recent years compared to 20 to 30 years ago where the number of road users and vehicles was much fewer. More cars, higher performance vehicles and higher speed limits on our highways all contribute to the rising trend. However, this does not mean that the drivers today are worse off in terms of their driving skills compared to those of yesteryears. Similarly, one should not conclude that doctors today are more reckless or less capable compared to the past.

Secondly, patients are also more educated and better informed these days. Many would have read all about their medical illnesses and treatment options through the Internet even before stepping into the consultation room. As a result, patients demand and expect more from their doctors and any deviation from the expected ideal can be perceived as unacceptable or worse – negligence. Gone are the days when doctors' words were taken as the "gospel truth" and their medical advice as "orders". Patients nowadays will demand the treatment they want to receive and would have no qualms questioning the doctors' treatment plans.

I believe, and I hope I am right, that we have not deteriorated to the extent of being highly litigious, whereby doctors

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practise defensive medicine to protect their own interest rather than the interest of patients. Undoubtedly the cost of healthcare will escalate if we do go the way of the western countries. The practice of good medicine is a combination of both science and art. Doctors must exercise proper clinical acumen and professional judgment when treating patients as each patient is unique. There is no "one size fits all" in medicine. The doctor-patient relationship is also critical and proper communication and trusts are keys to minimising misunderstanding and unhappiness which can lead to potential legal actions.

Unfortunately and coincidentally, there have been a few high profile cases of medical negligence reported in the media of late. It has also been highlighted by the Minister that as a result of the limited capacity of SMC in processing complaint cases, certain complex cases actually took more than five years to conclude. As a consequence of this delay, complainants could be deprived of the option to initiate civil proceedings against the doctor. I am glad to know that one of the provisions of the amendment to the MRA is to address this shortcoming.

Sir, I would like to touch on three key areas in the Amendment Bill, namely, the Singapore Medical Council's disciplinary processes, the financial penalty and the new Family Physician register.

Under the current system, complaints of professional misconduct against any medical practitioners are handled by the Singapore Medical Council (SMC) which comprises entirely of medical doctors. When a complaint is lodged, the Chairman of the Complaints Panel will appoint a Complaints Committee comprising three doctors and a lay person, who will then be tasked to investigate the complaint and debate if a formal inquiry is necessary.

The Disciplinary Committee (which this Amendment Bill proposes to rename

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"Tribunal"), comprises of three doctors (two of whom must be Council members), and a non-voting fourth lay person. The Disciplinary Committee must be chaired by a member of the Medical Council.

Clause 26 repeals and re-enacts Part VII of the Act, with the changes to facilitate a more expeditious management of complaints by the SMC. These changes include the new section 38 and section 40 which enlarges the pool of the Complaints Panel and decreases the number of members in the Complaints Committee respectively. However, one of my concerns would be the availability of training to ensure that the appointed members of the Complaints Panel will be equipped with the appropriate knowledge to act effectively in their various roles. I would therefore like to ask the Minister what sort of training do the Disciplinary Committee chairpersons and members receive currently and if this training would be refined further in light of the latest amendments.

Under the proposed amendments in the new section 50, the new Disciplinary Tribunal could be chaired by a senior doctor, or the Medical Council could exercise its discretion to appoint a senior lawyer, legal officer or retired judge for certain cases, in which case the Disciplinary Tribunal (DT) need not have lay person. This proposed change has led to a significant amount of unease and apprehension in the medical fraternity as the provision to allow the appointment of a lawyer to chair a medical Disciplinary Tribunal may send the wrong signal to the public that the medical profession lacks the integrity and ability to self-regulate.

As highlighted by the Singapore Medical Association President in the Straits Times Forum page on 24th June 2009, one of the main concerns of having a lawyer to chair the DT is that "it may bring about the legal-ethics convergence,

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leading to a more legalistic SMC and a deterioration of ethics." The Minister has also mentioned in his speech that disciplinary inquiries increasingly involve complex issues that are legally and procedurally challenging and that in high profile cases, doctors have been known to engage top lawyers. However, the definition of "complex" is subjective and can be ambiguous.

There are possibly three sources of complexity in any disciplinary case – it can be scientifically complex, in which a doctor is better than a lawyer to chair the DT; or if it is ethically complex, then a doctor will be no worse than a lawyer or could even be more appropriate. In fact, a senior medical chairperson who has trodden the marathon of doctoring would have a deeper understanding of the nuances of a complex medical case in question. But if it is legally complex, then maybe such cases should be referred by SMC to the Courts, where it can be dealt with more fittingly.

Whilst appointing a lawyer in the DT can be argued to increase the transparency of the disciplinary processes, it may be perceived as SMC lacking the moral courage and legitimacy to discipline high profile complex cases. As it is, the Disciplinary Committees already have lawyers as legal assessors, and also lay people sitting in ensuring transparency, the SMC can have the option of appointing more than one lawyer to observe the proceedings. Getting a lawyer to chair the Disciplinary Tribunal can be counterproductive as it may give the negative impression that SMC is arrogating responsibility.

In a landmark case in which Singapore's ex-Chief Justice stated in his judgment:

"We often enough tell doctors not to play god; it seems only fair that, similarly, judges and lawyers should not play at being doctors. A judge, unschooled and unskilled in the art of

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medicine, has no business adjudicating matters over which medical experts themselves cannot come to agreement."

I understand the intent of the new proposal is to ensure fair outcomes for the public, the complainant and the doctor, and engenders greater general public trust in the profession. The inclusion of non-medical practitioners such as senior lawyers as chairmen in such tribunals is not unusual. It is practised in New Zealand and Victoria in Australia, Canada and Britain. However, before we undertake to go in that direction, it is also important to understand the background and rationale for the inclusion in these countries.

In addition, the Law Society has decided to do away with appointing layman in their Disciplinary Tribunal (DT). If the Law Society is going in the opposite direction, how is it that the medical profession is regressing and arrogating responsibility?

The new section 55 dealing with Appeals against orders by the DT allows SMC or an aggrieved complainant to appeal to the High Court against the decisions of the DT. The current system only allows doctors unhappy with the disciplinary decision against them to appeal. This is reasonable as the complainant must be extended the same privilege that is accorded to the doctor who is being complained against. However, section 55(2) states that this appeal to the High Court will be conducted by the SMC on behalf of the complainant. If the DT was appointed by the SMC in the first instance, would not this be seen as a "double whammy" where the doctor is being persecuted twice by the SMC? Will it also lead to a situation where almost every dissatisfied complainant will, by default, file an appeal

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without giving due consideration. I hope the Minister can elaborate on this.

Mr Deputy Speaker, Sir, most professions rightly cherish the concept and privilege of self-regulation. This ideal is upheld if those who err are made accountable in the requisite measure and the quickest time. The proposed amendment to the MRA might suggest to some that it is not possible to find respectable, impartial, effective and legally well-advised senior medical doctors to chair a SMC DT.

Sir, this debate is not about doctors protecting doctors. Neither is it about doctors refusing to countenance judicially controlled disciplining of the profession. It is about the principle and the spirit of self-regulation. The entire rationale of the existence of the SMC is to have a self-regulatory body, and that having non-doctors as the Chairman of the DT completely defeats this purpose. Hence, I hope that the Minister can clarify the impetus and rationale for this change.

The new section 53 allows the Disciplinary Tribunal to impose a fine of up to $100,000, which is a ten-fold increase from the previous amount of $10,000. Many medical practitioners have expressed that this steep increase is alarming. I hope the Minister can also elaborate on the reasons for the need to raise it by so much.

The proposal to set up a register of family physicians is indeed welcome as it serves to raise the overall standard of family medicine practice. Family physicians play an important role in the provision of healthcare to the general public. Family physicians deliver over 80% of the primary healthcare in Singapore and will play a pivotal function in the delivery of quality primary healthcare in the face of the changing landscape of a greying population.

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The newly established Family Physicians Accreditation Board will determine the qualifications, experience and other conditions for registration as a family physician under this Act. However, will existing family physicians be automatically included in this register? Or do they have to go through an arduous accreditation process, over and above the experience they have accumulated over the years of practice? I hope the Minister can clarify this.

Mr Deputy Speaker, Sir, in moving the Amendment to the Medical Registration Act, it is important that the Ministry gives an unequivocal signal to the greater public that there is really nothing seriously wrong with the medical profession here in Singapore. This amendment comes amidst many adverse media reports of medical glitches and, instinctively, Singaporeans may have the wrong perception that the state of medical malpractice may have reached an epidemic level, warranting harsher measures to be introduced. In the practice of medicine, the patient's confidence and ultimate trust in the doctor is vital. Hence, if the integrity of the medical profession is placed in doubt, good medical services can never be delivered as doctors may put up a self-protective shield by practising defensive medicine.

On that note, I support the Bill.

4.39 pm

Mr Christopher de Souza: Mr Deputy Speaker, Sir, thank you for allowing me to join in this debate. Singapore's health system was ranked sixth best in the world by the World Health Organization in 2000. This is a remarkable testimony to our medical professionals. However, no health system is perfect, and we must constantly look for ways to improve. The Medical Registration (Amendment) Bill seeks to further strengthen our healthcare system, particularly in relation to medical practitioners.

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One amendment has been hotly debated. This is the new section 50 that allows the SMC to appoint legal professionals either as chairman or member (with voting rights) of a Disciplinary Tribunal (DT). I understand that, initially, 96% of 800 doctors polled by the Singapore Medical Association (SMA) voiced their objections. In contrast, a smaller public survey conducted by the Health Ministry found that 59 out of 78 people are in favour of the change. A concern among doctors relates to the possibility that, as Chairman, the legal professional will have more influence over the conduct of the proceedings.

However, I understand that this concern has been dealt with in the Bill, under the new section 50. Where the Chairman is a medical practitioner, he will have a casting vote. Where the Chairman is not a medical practitioner, the issue will be decided by a majority of votes from the tribunal members who are medical practitioners. So it seems that that concern has been addressed. There is a perception among some members of the public that doctors side with fellow practitioners in disciplinary matters. Allowing a non-medical professional to chair certain disciplinary proceedings will help dispel this notion. The public would have greater trust in the medical profession if disciplinary proceedings are perceived to be fair and impartial.

Nonetheless, will the Minister be able to assure us that there will be measures in place to ensure that allowing lawyers on Disciplinary Tribunals will not result in the proceedings becoming overly legalistic, which may inadvertently shift the focus from what is medically professional or ethical to what is strictly legal. Therefore, will the Minister assure us that high medical professionalism will continue to be the guiding beacon for the Disciplinary Tribunals?

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I understand that doctors may also object to a legal professional being appointed as a member or chairman of a DT on the grounds that the industry should be self-regulating. However, I believe that there is also a strong argument that the good of the patient and the public should also be a primary consideration. In cases where a legal professional can make valuable contribution as chair or member of a tribunal, he or she should be brought in. I would like to touch on a point that my hon. fellow Member raised. Dr Lam said that the Law Society had moved on by not including a lay person in the panel and why does the Singapore Medical Council regress by having a lawyer on board, which is in contrast to what the Law Society is doing? I would like to point out that lawyers often call on doctors as expert witnesses in court and they see that there is an importance for the synergy between legal understanding and jurisprudence and what goes on in an operation theatre or how a patient is treated. The lawyers themselves have realised the importance of that synergy and I think that can also be transposed into disciplinary proceedings tribunals.

Finally, I would like to state my support for the new approach to registration of doctors under clause 22. This would allow persons who have the experience and meet the conditions to be registered as specialists. This will help expand our pool of medical talent and benefit the community.

So, I join Dr Lam in supporting this Bill.

4.44 pm

Mdm Halimah Yacob: Mr Deputy Speaker, Sir, I rise in support of the Medical Registration (Amendment) Bill. Under the amendments, the law is now very clear. Its aim is to protect the health

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and safety of the public through mechanisms that ensure that doctors are competent, uphold the highest standards and maintain public confidence. As the practice of medicine becomes more complex, not only with the evolution of new diseases but also because of the rapid advancements in technology and the practice of medicine, the public needs a more effective protection regime. Although all doctors have vowed to uphold the Hippocratic Oath, the fact remains that increasingly medical services are also treated as commodities and, with some doctors, commercial decisions may override other considerations.

There is no doubt, Sir, that many in the medical profession uphold the highest standards of professionalism and have the patients’ interests at heart. Such doctors have nothing to fear with the changes as they are not likely to have the Act invoked against them. The changes are meant to check the small number of errant doctors who because of incompetence, neglect or crass commercialism, compromise their patients' interests. The changes will help to instil greater confidence and comfort among the public and is beneficial to the profession as a whole. We must never forget, Sir, that the doctor-patient relationship is very different from other transactions simply because patients rely very heavily on their doctors’ advice, judgment and expertise, more so than in any other profession and the damage is also greater as any neglect or misconduct results not just in financial loss but, more importantly, harm to the health and lives of patients.

Sir, some doctors are concerned that the amendments would go against the principle of self-regulation, since non-doctors will be allowed to sit in the Disciplinary Tribunals and also to chair the Disciplinary Tribunals. In my view, Sir, self-regulation cannot exist as an ideal in isolation of the basic purpose for which it was allowed in the first place, which is, to

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protect and promote public interest. In other words, we cannot preserve self-regulation at all cost for the sake of self-regulation alone. If some tweaking is needed in the public interest, then it should be done.

Indeed, Sir, if self-regulation had worked so well, we may not need any law at all. But we all know that the reality is otherwise. In any event, the amendments had taken into account doctors’ concerns, as the appointment of any legally qualified person, whether as Chairman or a committee member, is at the discretion of the SMC. This, to me, Sir, is a major concession. We have to bear in mind that the appointment of non-doctors to head disciplinary committees is not new and is already found in other countries such as Britain, Australia and the US.

Sir, I agree with the Minister that the current situation is indeed unsatisfactory as there are long delays and this does not serve public interest when their claims cannot be pursued in the civil court because they have exceeded the limitation period. Hence, the various provisions aimed at expediting the disciplinary process are greatly welcomed. In cases where due to incompetence or neglect, a death or other serious mishap had occurred, the patient or aggrieved family members had already suffered a great deal and the interest of justice is certainly not served by delays which add to their anxiety, strain and loss.

Sir, whilst I applaud the Ministry for the progressive amendments designed to better protect public interest, I feel that there are several areas which were not addressed which could have helped us develop a more robust disciplinary regime.

One area that can be improved is the need for greater transparency in the SMC’s proceedings. As the disciplinary proceedings conducted by the SMC is behind closed doors, the public is not aware of the reasons or basis for the

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SMC’s decisions. This is particularly important if their complaint is rejected and they are not told the reasons. It is in the interest of both the doctor and the patient to share the reasons so that there is no doubt or ambiguity that full consideration has been given to the complaint and all the pertinent factors. If a complaint is dismissed, for example, and reasons are given, then it would not lead to the kind of damaging speculation that we sometimes hear on whether the SMC is trying to protect its own kind.

Sir, making public the reasons for the disciplinary actions against professionals is not new. There are already precedents. Singapore’s Legal Profession Act requires a copy of the entire record of the proceedings of the Disciplinary Tribunal, including its findings and outcome, to be made public. This means that the reasons for disciplinary actions against lawyers are open to public scrutiny. In Britain, their Fitness to Practices Panel, the disciplinary arm of their General Medical Council, publishes its findings against doctors. If patient confidentiality is the concern, surely the SMC can find ways to address this, such as by keeping out sensitive patient information details.

The current SMC practice of publishing investigation outcomes only through press statements is very limited and does not give a clear picture of the reasons for the decisions taken. This is one area that I hope the Minister can review as justice must not only be done but must also be seen to be done.

Sir, the second concern that has widely surfaced is over the penalties imposed by the SMC. In the most recent case, a General Practitioner (GP) who pretended to be a plastic surgeon, not once but twice, was merely censured and fined $10,000. For his first offence, he was suspended for six months. In another case, a doctor who failed to conduct a Hepatitis B test on a patient before

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starting him on cancer treatment, which is a routine test, thus causing the patient’s death, was merely suspended for three months. Coupled with the fact that detailed explanations are not given, the public is left with the impression that the penalties are not commensurate with the gravity of the offence. This concern could be addressed if there is a transparent set of guidelines on penalties and this will certainly instil greater public confidence. I urge the Minister to seriously consider providing a penalty guide for the various offences. The current practice of imposing penalties based on precedents can be arbitrary and is unsatisfactory. If it is not MOH issuing the guidelines, at least it is SMC that should consider issuing the guidelines.

The third area that we need to focus on is greater patient empowerment so that they could make more informed decisions when choosing doctors to treat them. Currently, other than medical qualifications and areas of specialties, patients may not know much about the doctor that they want to consult or are consulting. For instance, is there a list that a member of the public can refer to on doctors who have been subject to disciplinary action so that they can make informed decisions on whether or not to seek their services? Take the recent case of the GP who pretended to be a plastic surgeon – could this have been avoided if his patients were able to check on a list which indicates that he was disciplined before for the same offence? Also, now that the range of orders which the SMC can make has been expanded under sections 37A and 49, to include a doctor voluntarily removing his name or agreeing to the imposition of conditions or restrictions on his practice because of performance difficulties, how would the public know and is it not important for the public to know this? Or if a doctor has been subject to periodically report on the

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status of his fitness to practise, should the public also not know about this?

Finally, as I understand it, most of the cases brought before the SMC are referred to it by the authorities, particularly the Ministry of Health, and not by private individuals or patients. Could the Minister confirm whether this is indeed true and what are the reasons for this? Could one reason be because the public is not aware of the complaint procedure or is the complaint procedure too difficult or has the public become frustrated because of the long delays in hearing their cases? Who in Singapore is responsible for educating patients on their rights to seek redress? How user-friendly is the current system? What about patients who are not well educated or cannot understand English well, what measures are in place to assist them as the process of filing a complaint can be quite daunting? Are we satisfied that the mere 96 complaints filed with the SMC in 2009 is an accurate reflection of the state of satisfaction with our doctors, considering that the number of doctors and patients have increased substantially? While we may not be thinking of a Charter of Rights for patients that exists in some countries and we may not even be ready for it, I think that there is a greater scope to educate patients on their rights, particularly their right to seek redress for the pain, suffering and loss caused to them due to incompetence, neglect or abuse. This is also another area which I hope the Ministry as well as the SMC can play a bigger role.

Sir, two other amendments which I strongly support are the establishment of the register of family physicians and the monitoring and supervision of foreign doctors practising here. There have been concerns expressed whether the Ministry has been too liberal in admitting foreign doctors and so these new amendments are helpful. But apart from the professional competence, there is also a need

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to ensure the foreign doctors also understand the diversity in languages and cultures that are prevalent in Singapore and that they are able to communicate effectively with patients, particularly in the public hospitals, as this is important in ensuring effective treatments. I hope that the Ministry would also look at such softer skills in the training of our foreign doctors.

Finally, in conclusion, Sir, the amendments are indeed very progressive and will help to enhance public safety and confidence in our medical profession, and I think it would also help the doctors themselves.

I support the amendments, Sir.

Ms Ellen Lee: Mr Deputy Speaker, I rise in support of the Medical Registration (Amendment) Bill and I thank the Minister for his elaborate explanation of the purpose of this Bill.

I feel that this Bill is timely. As I had shared previously, mental illness and impairment affect anyone regardless of race, profession or status and appear to be on the increase. Therefore, it is good to see this Bill introducing new changes to ensure that registered medical practitioners are competent and fit to practise medicine and also to uphold the high standards of practice and reinforce public confidence in the medical profession, not only locally but also internationally.

I am particularly drawn by the new section 37A which proposes to allow a practitioner who realises that his performance may be impaired for whatever reason so as to make him unfit to continue in practice to voluntarily apply to the SMC to remove his name from the register, or to suspend him or to impose conditions or restrictions to his practice. As this is a voluntary action, it does require the medical practitioner concerned to be honest and honourable and to

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possess an extremely high level of moral courage and self-discipline to ensure that he puts the well-being of his patients in priority to his, that he will not jeopardise his patients’ life and well-being especially if he finds himself unable to treat his patients effectively due to his own physical or mental health or other hindrances. I sincerely believe that this provision seeks to provide the hallmark of a truly honourable physician. The courage to admit his inability to cure for whatever reason is heroic and commendable. In the interest of patients who have placed much trust in their doctors and physicians to save their lives, I hope to see this provision being widely practised for the benefit of not only the patients but also of the profession.

As a follow through of this, I would like to urge the Minister to consider allowing greater transparency to evolve and contemporaneously update the public in the MOH’s website the names of doctors censured or subject to disciplinary proceedings as well as those who are deemed unfit or have applied to limit their practice ambit due to physical or mental unfitness.

On a separate note, I would like to request the Minister to clarify my concerns on a recent article that I came across sometime in July last year. It was mentioned in the local newspapers that a survey was conducted in the wake of the conviction two years ago of a trainee doctor from the Tan Tock Seng Hospital who had tried to film a female colleague in the shower. Among the questions asked in the survey was whether he should be allowed to practise as a doctor. Fewer than half of the NUS-trained doctors said he should not be allowed to practise, compared to 71% of their foreign-trained counterparts. Furthermore, seven of the doctors trained locally found his actions pardonable. From the survey, it appeared that the Singapore-trained doctors were more unwilling to have their

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colleagues disciplined or struck off the register even if they have a criminal record. Nor are they likely to tell on the colleagues who are tardy or abrasive. In short, they are said to be more lenient on colleagues who fall short on ethics compared to those who are trained in medical schools abroad.

In comparison, the survey pointed out that doctors trained in Australia, Canada, Malaysia, New Zealand and Britain were well taught, and I quote, "well taught and fully understood what constitutes 'medical professionalism'." It is sad to read that Singapore-trained doctors were thus said to lack professionalism and at times labelled as being tardy or abrasive when treating patients.

I would like to ask the Minister what are the current measures used in assessing the professional standards, ethics and service quality amongst our locally trained doctors. What have been done to place greater emphasis on training doctors on professionalism and communication? Moving forward, what is the system in place where newly trained doctors can receive ample learning opportunities especially in exemplifying professionalism, service and care?

Sir, with that, I support the Bill.

Assoc. Prof. Paulin Tay Straughan: Thank you, Mr Deputy Speaker, for this opportunity to share my views on this important Bill.

This is a comprehensive Bill that covers a wide range of issues central to the professional management of medical services. Of key significance is the aim to foster greater public trust in the disciplinary process within the medical profession.

The main bulk of this very long Bill focuses specifically on this aspect. Details

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on Disciplinary Proceedings, Health Committee Inquiries and Performance Assessments are spelt out in clause 26,

which spans from pages 16-52 and revamps the entire Part VII of the original Act. I applaud the Ministry of Health and the Medical Fraternity for amendments set out in this Bill.

In a climate where litigation is increasingly the first option for the aggrieved and where the increased incidence of medical malpractice lawsuits will result in escalating healthcare costs, a move to uphold high standards of professional conduct through enhanced self-regulation by the Medical Fraternity reflects social responsibility on the part of our physicians. As I stand in support of this Bill, I would like to seek the Minister’s elaboration of the some of the details involved. There are four aspects which I have queries on.

The first deals with transparency of the disciplinary review process and my concerns resonate with that expressed by Mdm Halimah. In his letter to the Medical Fraternity published in the SMA News (dated 13th July 2009), Director of Medical Services, Prof. K Satku wrote, and I quote:

"Self-regulation in a profession is intended primarily for the benefit of the public. In assessing whether the proposed amendment is appropriate, it is therefore pertinent to seriously consider if the proposed change ensures fair outcomes for the public, the complainant and the doctor, and engenders greater public trust in the profession."

For the lay community to appreciate and accept the internal review outcomes of the Complaints Committee and the Disciplinary Tribunal, we must first be able to follow the processes involved and observe the procedural steps which lead to the final outcomes. Sections 47 and 48

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uphold the confidentiality of information obtained during the investigation. Sections 49 and 53 lay out the procedures to be taken at the completion of the investigation of the Complaints Committee and Disciplinary Tribunal, and detailed actions involving the medical practitioner in question. As the focus of the Bill is on self-policing, there is little attention paid to how information should be disseminated to the lay complainant.

While I applaud the inclusion of sections 49(11) and 55(2) which facilitate an appeals process for the complainant, I also note the feedback on this Bill from the Law Society of Singapore where Mr Kenneth Goh, Director of Representation and Law Reform, commented on the difficulties a complainant would face in filing an appeal. For the complainant to make an informed decision on whether or not he should exercise this option of appeal, he must first have access to the evidence on which the Disciplinary Tribunal’s decision was based. For the general public following the proceedings, it is equally important that there is sufficient information made available to allow for a fair assessment of how the judgment was influenced. Only when the processes invoked are understood and appreciated by the public, will self-regulation result in the promotion of trust in the medical profession.

May I ask the Minister to share with us the details on how information gathered during the investigation and the rationale for the outcomes arrived at, by the Complaints Committee and the Disciplinary Tribunal, will be shared with the complainant as well as the general public following the proceedings? Additionally, will there be mechanisms which will allow for queries or feedback on the proceedings by the lay community? I strongly believe that an informed lay community will be more likely to partner the medical profession in a constructive

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manner that will promote a more efficient and effective healthcare delivery system.

My second query is on the nature of complaints which should be referred to the Medical Council for possible action by the Complaints Committee and Disciplinary Tribunal. Section 39(1)(a) to (d) outlines the complaints that can be considered. But the descriptives invoked are broad and vague. For example, section 39(1)(c) notes an eligible grouse as a "complaint that the professional services provided by a registered medical practitioner are not of the quality which is reasonable to expect of him".

Can the Minister elaborate on what "professional services" would cover? In many instances, expectations from patients may vary from the standard medical practice that is accepted by the medical profession. Whose expectations will be taken into consideration? With this broader definition of what is acceptable cause for raising concerns, does the Minister expect that the number of complaints should rise? And if so, will the Singapore Medical Council (SMC) be able to manage the increased caseload and revert on each case within a reasonable timeline? Relating to this is the statute of limitation for personal injuries, which currently stands at three years. As we expect most aggrieved complainants who are seeking redress to first lodge their complaints with the Medical Council, will the Singapore Medical Council (SMC) be able to complete its investigations within the three-year period, so that complainants who may wish to pursue a civil lawsuit can rely on the outcome of the Disciplinary Tribunal's decision to make an informed decision on what they should proceed with?

My third concern relates to the investigators that can be appointed by the Complaints Committee. On page 52 of the Bill, section 60A details how the investigator will be empowered to carry out his duties. The investigator, if you

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read that section carefully, is a very powerful agent and he has fairly extensive authority. Can the Minister please comment on the qualifications investigators are expected to hold, given their significant role in the self-regulation process?

My fourth and final concern is on interim orders. Section 59B outlines the process which allows the immediate suspension of a physician if the Interim Orders Committee feels that it will benefit public interest. This is while investigations are still ongoing. While this may be reassuring to the public when it concerns a rogue doctor, may I ask the Minister what processes are in place to protect the innocent doctor?

My fellow Members had commented on the merits of publishing a list of errant doctors – I am not sure if I agree with this because in the spirit of encouraging self-discipline within the profession, I think that for a compassionate society, we should give doctors who have made serious errors or mistakes a chance to redeem themselves. So, therefore, publishing this list would pretty much limit their chances of redeeming that professional etiquette.

With these comments, I stand in support of the Bill.

5.08 pm

Ms Audrey Wong Wai Yen (Nominated Member): Mr Deputy Speaker, Sir, thank you for allowing me to join this debate.

I understand that it has been some years since the Medical Registration Act was last amended and since then, there have certainly been new developments in the medical profession and practice. I am in support of the Bill’s broad aims which take into account new needs and

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developments in the sector, while maintaining the necessity of self-regulation by the medical profession and the importance of upholding the very highest standards of treatment, care and, last but not least, ethics.

The proposed amendments certainly appear to be aimed at developing more rigour in the Medical Council’s self-regulatory mechanisms and are also broadening aspects of the Council’s powers and scope to take into account the more complex issues in medical practice today. It also takes into account the increasing number of complaints and a better-read public with more access to information about medicine.

Among the changes, I welcome the formation of a Register of Family Physicians. This field of medicine which provides comprehensive health care for the person and the family covering the biological, clinical, and behavioural aspects of medicine for all ages, from children to the elderly, is likely to be more important for our society which is aging rapidly and where people are more susceptible to stress-related, mental as well as physical ailments at different stages of their lives. We have a College of Family Physicians founded in 1971 and a Register of Family Physicians recognises this branch of medicine and will encourage a high standard of practice.

When the proposed amendments to the Medical Registration Act were put out for public consultation in early 2009, there was understandably much interest and concern. Healthcare and housing issues probably draw the most emotional responses from Singaporeans as they affect all of us at some point in our lives. It is emotionally draining and heartbreaking to fall severely ill, or to care for a loved one who is sick, or to watch someone you love suffering. Added to this emotional aspect of the issue of regulating medical practice is the rising number of

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complaints handled by the Singapore Medical Council (SMC) in the last three years. According to a New Paper report in 2009, there were 81 cases in 2006, 115 in 2007 and 138 in 2008. There has also been an increase in the number of claims for compensation being filed by patients against doctors. According to a Straits Times report, also last year, the claims rate is going up by about 10% a year.

Singaporeans are definitely becoming more demanding patients; they do not only desire the best clinical care, they also demand good service and customer care from doctors and hospitals. And this has put more pressure on the modern-day doctor. With many diseases and their treatments being complicated, there is always a risk of patients and doctors ending up in situations of misunderstanding.

There is also the growing practice of aesthetic medicine, where patient satisfaction is not based solely on the doctor prescribing the right treatment for a clinical condition. The recent tightening of rules for aesthetic medical practice is certainly welcome; however, people will always be enticed by promises of procedures that will enhance their physical appearance and, hence, the chances of things going wrong or the patient being unhappy with the results would be higher as more people go for such treatments. And the trend of more Singaporeans, especially younger Singaporeans going for aesthetic treatments, perhaps is worrying, but that is a debate for another time.

We cannot completely eradicate mistakes as no one is infallible. But we do not want to end up with a scenario where doctors are constantly on the defensive for fear of lawsuits. High-profile cases featured in the media where patients have successfully brought a complaint against doctors, may have dented the image of the medical profession somewhat. But

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despite these cases, as a society, we must commit to the value of self-regulation in the medical profession, and empower the Medical Council with the means to uphold the highest standards of practice and ethics. In such a specialised field as medicine, it is impossible to expect the layman to make the right judgment call when it comes to questions of diagnosis and treatment. There is a history of practice and experience in the medical profession which doctors call on, not only in treating patients but also in hearing complaints brought against fellow members.

A highly-ethical, socially responsible, self-regulatory body is crucial for the future of the medical profession and the quality of healthcare for all. To put the responsibility of monitoring and, if necessary, trial and punishment, at the hands of doctors while the public could sometimes question the transparency of the processes – it actually demands that doctors practise medicine with a commitment to proper treatment of patients, justice and concern for the community. Self-regulation asks that doctors demand the same kind of commitment from their peers and colleagues. And this commitment can only benefit society. For instance, let us not forget that doctors often waive or lower fees for patients who simply cannot afford proper medical treatment; on the other hand, a wrong diagnosis or mistake has an impact on the community as it undermines public confidence in the profession and system. But having said that, I am sure that no doctor is wilfully negligent.

In the spirit of encouraging the highest standards of self-regulation and evaluation by the profession, I applaud the provision for voluntary suspension or removal from the Register of Medical Practitioners, where a registered medical practitioner who feels he is unfit to practise by reason of a physical or mental condition, or due

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to his inability to deliver medical services at the required standard, can actually apply for voluntary suspension, removal or other measures. I have two queries with respect to the provisions in the Bill on disciplinary proceedings. But before I ask for the clarification, I would like to also bring up some concerns with regard to the disciplinary hearings.

One of the public’s concerns is about doctors hearing complaints against their peers and the concerns about the transparency of these processes. The public is understandably concerned that doctors might want to protect and defend their own, and that therefore their complaints may not be given a fair hearing and that is an easy conclusion to jump to, given that the professional community is quite small and doctors are often acquainted with one another. However, we have to balance this concern against the need to have knowledgeable and experienced adjudicators who know how to examine and assess medical and scientific evidence.

One way to have a balance is to demand transparency and rigour in all inquiries, and I believe that even the existing Bill has provision for this: for instance, the requirement that non-medical practitioners are also appointed to the Disciplinary Tribunal and Complaint Committees. In the new Bill, the provision for aggrieved parties, whether the complaint or the person who is complained against, to appeal to the High Court is another safeguard, even though that might take another complicated legal route. The other concern from the medical fraternity as well as the public is the backlog of complaints. I understand that one of the reasons for the changes in disciplinary proceedings is to speed up the complaints process and facilitate them more efficiently. But I would like to ask for clarifications on a couple of points.

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One of the changes is in section 39(3) where the Medical Council will no longer have to send to the Complaints Panel matters that are related to a complaint about professional services provided by a medical practitioner or to issues on the physical or mental fitness of a medical practitioner to practise. Instead, the Council can simply notify the medical practitioner involved and proceed to take action such as removing his name from the register or suspending him. This might be a response to the number of complaints that are related to such things like advertising by doctors, but this change might also backfire I feel, as the public may perceive it to be a less transparent way of dealing with complaints – even if the inquiry process is rigorous. Also in this section, the use of the term "professional services" is vague, and I wonder if it might be more fruitful to have a clearer definition and why the Ministry of Health has opted to use this term.

The proposed change that has drawn the most fire from the medical profession itself has already been mentioned by fellow Members, which is the provision for the appointment of a senior member of the legal profession to chair a Disciplinary Tribunal. I note that the proposed amendment, as it stands today in the new section 50, has been changed from the draft Bill initially presented for public consultation. In the Bill before us today, it is stated that a chairman who is not from the medical profession will not be allowed a casting vote; ultimately, it will still be medical practitioners making the ultimate judgment call. The concerns of the medical profession are valid and I believe it should not be dismissed out of hand. They have clearly stated their points of concern during the process of consultation and I do not need to rehash the same arguments. But just a couple of quick points. Most importantly, the medical profession is arguing a point of principle. They pointed out that having a

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non-medical practitioner as Chair of a Disciplinary Tribunal defeats the purpose of the Singapore Medical Council being a self-regulatory body. They also noted that this is contrary to what is practised by other similar regulatory bodies in other professions such as the Law Society. And while acknowledging that some medical complaint cases involve some legal matters, and that doctors and complainants appear at disciplinary hearings with their own legal teams, the Singapore Medical Council also pointed out that a non-medically-trained person would not have the level of expertise to assess complex medical cases, especially those where even medical experts are divided in opinion.

Furthermore, the SMC already has legal counsel who I believe is present at the hearings and can advise on legal matters. In fact, with the legal ammunition that both doctors and complainants can bring to a tribunal hearing today, having a legal professional as Chair may not speed up the hearing and settlement process; it might be more drawn-out and more costly for all parties concerned. I hope that the Minister will address this concern.

Finally, I believe that despite new regulations, we are likely to see an increase in the number of complaints against doctors rather than a decrease. Singaporeans are more health conscious and seek more treatments today. We are also more aware of our rights as customers and, unfortunately, we can sometimes be a little too trigger-happy in hitting the complaint button. Having said that, patients are also entitled to be made aware of their options, should they wish to lodge a complaint. In the end, our public policy and legislation have to aim to maintain the medical profession’s high level of competence and strong ethical practices for it is that which sustains public confidence in the profession; and as I have already said, this is of

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paramount importance in an ageing society where healthcare concerns will always be in the public spotlight. I welcome the Bill's expansion of the scope of the disciplinary measures and resolutions in cases of complaints, which allows the SMC to adopt a more calibrated approach that will enhance the rigour of its work. But, ultimately, legislation cannot be the only guarantee of good, proper medical practice; the medical profession has to continue to commit itself to the most exacting standards and be led by a core leadership with a deep understanding of medical ethics. I close by quoting from Dr T. Thirumoorthy’s letter published in the Singapore Medical Association's newsletter in June 2009: "Strong public policy and medical leadership that is prepared to establish and develop medical professionalism based on competence, ethics and altruism are still the best assurance to protect the interests of patients and doctors."

With that, I support the Bill.

Ms Sylvia Lim: Sir, it is indeed important for the public to have confidence in the standards and disciplinary processes of the medical profession. I wish to seek clarification on two points from the Minister. First, concerning Part VII on disciplinary proceedings; and second, the implications of the decision to recognise Duke NUS Graduate Medical School requirements on doctor training. Sir, the new Part VII makes some drastic changes to the disciplinary regime concerning doctors. Besides the Complaints Committee and the Disciplinary Tribunal, it introduces a intermediary core and investigator. Under the proposed section 42, any Complaints Committee who believes that a complaint against the doctor should be investigated further, must appoint an investigator to do so. Under section 44, it is the investigator who will now write to the doctor enclosing the complaint, and asking him if he has any written explanation to give.

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Under section 48(2), the investigator must put up a final report to the Complaints Committee, which should include a recommendation on whether a formal enquiry by Disciplinary Tribunal should be convened. The investigator is thus earmarked for a very important and almost pivotal role in the disciplinary procedure at the complaint stage. He will be the one who interfaces with the doctor complained against, conducts the investigation and puts up the report on its findings to the Complaints Committee. He will also recommend to the Complaints Committee whether the doctor should face the second stage of appearing before the Disciplinary Tribunal, which decides whether the doctor should continue to practise. Given the importance of the task at hand, the investigator should be someone with suitable knowledge and experience to understand medical practice as well as patient interest. The proposed section 60(A) defines the investigator as being "a Member or employee of the Medical Council, any public officer or any person appointed by the Medical Council". Since the definition is very wide, it will be good for the Minister to elaborate on the likely persons to be called upon to fulfil this role. Will public officers from other Ministries, for example, become investigators? Will law enforcement investigators be called upon? Will the choice of investigator vary, depending on the nature of the complaint?

Second, Sir, the Bill proposes to recognise the degree conferred by Duke NUS Graduate Medical School as a Singapore degree. By doing so, I understand that Singapore would also be accepting the post qualification training requirements of Duke. While I note that Duke is well-known, there is local concern about its post qualifications training requirements, specifically the removal of the year of general housemanship and allowing graduates to choose their

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specialisation immediately upon obtaining their medical degree. The one year of housemanship, with rotations among different fields of medicine, has been compulsory for medical graduates in Singapore for many years. Even for doctors who aspire to be specialists, housemanship was required to get an overview of the breadth of medical practice and knowledge of the realities of practising in the various fields. Patients here have had the assurance that their specialists generally have some clinical experience in other fields of medicine, which is useful in diagnosing health concerns which are often multifaceted. Will doing away with housemanship compromise on patient care by our specialists? How will fresh medical graduates be able to make an informed choice of specialisation if they had not had the taste of what each field involves? Will this chance lead to a drop in standards and in patients being short-changed?

Mr Calvin Cheng (Nominated Member): Mr Deputy Speaker, Sir, thank you for allowing me to speak on this Bill. I rise in support of the amendments to this Bill.

I have three points to make regarding these amendments.

Firstly, the new section 38 – although the number of lay persons has been increased, the majority of the complaints panel will still be medical practitioners. Although I see the relevance of medical experience in assisting investigation and fact-finding in alleged offences by doctors, I question the need for doctors to retain a majority on the complaints panel. Although peer regulation remains an important tenet amongst professions, the credibility of the medical watchdog body may be increased if medical doctors do not form the majority of the complaints panel. I am not questioning the ability or integrity of medical practitioners to self-regulate; however I note that one of the

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aims of these amendments is to increase the public confidence in the medical profession. For better or for worse, public confidence is often based on perception and it is my opinion that the perception of the neutrality and objectivity of the complaints panel would be increased if the majority of the medical complaints panel are not doctors. Moreover, the skills needed for investigation, fact-finding, adjudication and disciplinary judgment are quite separate from medical skills; a substantial number of years of medical experience may help in giving investigators background information of the alleged offences or in giving expert opinion, but are not directly applicable to legal fact-finding, adjudication and judgment which calls on a totally different set of skills and experience. I therefore urge the Minister to consider allowing non-medical practitioners, especially those with vast experience in disciplinary investigation and procedures, to form the majority of the complaints panel.

My second point is related to the first. I note that in section 50 (12), in the event of an equality of votes in the Disciplinary Tribunal, where the Chairman is a registered medical practitioner, the Chairman shall have a casting vote; or where the Chairman is not a registered medical practitioner, the question shall be determined by a majority of votes of the members of the Disciplinary Tribunal who are registered medical practitioners. If there is no such majority of votes, the question shall be resolved in favour of the registered medical practitioner under inquiry. For the same reasons I stated above, I wonder why this requirement is needed especially since I feel this will increase the chance that the public may perceive that medical practitioners are protecting their own. I would like to reiterate that although this may well not be reality, perception is important in the maintenance of public confidence, and unless there are overriding legal and technical reasons for doctors to maintain

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their casting vote in the Disciplinary Tribunal, and I think there are not for the reasons I spelled out above, I urge the Minister to re-consider this subsection.

Finally, again in the interests of increasing public confidence, like my hon. colleague Mdm Halimah, I urge the Minister to consider making all proceedings and judgments fully transparent to the public. Closed-door adjudications may lead to less not more public confidence. Given the importance of the medical profession in society, it is my opinion that strengthening public confidence is of paramount importance. A complaints panel with a majority of non-medical practitioners, consisting of people with vast experience in procedural fact-finding, investigation and adjudication, as well as a process transparent to the public, will go a long way to ensure that members of the public will have full faith in all our doctors.

With that, Mr Deputy Speaker, Sir, I support the amendments to the Bill.

Dr Lim Wee Kiak (Sembawang): Mr Deputy Speaker, Sir, thank you very much for the opportunity to voice my opinion on this particular Bill. While I support the Minister's points on the Bill, I would like to voice some concerns mainly in two areas.

One of them is the proposed Residency Programme and the other one is the proposed Disciplinary Tribunal (DT) which has been debated so far in this House.

First, let me make some clarifications. My learned and hon. fellow Member of Parliament Mr Christopher de Souza brought up the point that sometimes a medical doctor may be invited by the legal fraternity to assist in legal proceedings. But that is as a medical expert. I have not heard of any medical doctors being requested by the legal professionals to help them in a disciplinary case against a lawyer within their own fraternity yet.

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Second point I would like to highlight is that I disagree with our hon. Nominated Member of Parliament Mr Calvin Cheng who was pushing for the majority of the DT members to be non-doctors. That really goes against the spirit of self-regulation. At the end of the day, this is the Singapore Medical Council and I do fully support the concern that was brought up by the hon. Dr Lam Pin Min as well as some other Members that we have to protect self-regulation.

Let me just proceed with my speech on this particular debate. The training years of a doctor really constitute the most important part of their career. Essentially they lay the foundation for the grooming of an exemplary doctor so that he can be adequately equipped to go out and practise after having been exposed to good practices during this time. They are like your kindergarten and primary school years. In the UK-style residency programme or our training programme which has served Singapore very well in the past few decades, medical graduates rotate in different medical departments for a year in housemanship, after which they become medical officers for one to three years before deciding and being admitted into a three-year Basic Specialty Programme. We call it BST. And, subsequently, they have to go through another three years of Advanced Specialty Training before they are registered as a medical specialist by the Singapore Medical Council. This system gives our doctors a very good and wide exposure to different subspecialty as he gradually builds up a holistic knowledge and broad-based experience in medicine. And that is the reason why Singapore doctors are so well respected internationally. A doctor who seeks to become a specialist definitely must have holistic knowledge of various subspecialities as this will equip him as a specialist to be able to identify symptoms of ailments that may not be

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related to his area of practice later on so that he can refer a patient in a timely manner to see another specialist. The entire process is long but is necessary. It takes about seven to 10 years. Under the new proposed US-style residency programme, it takes only five years to complete the training, during which the medical graduates spend the first year involved in clinical work and further education, and the next four years training in the subspecialty of their choice. When the duration is shortened, what is the impact on training as well as the knowledge imparted for this particular doctor? My personal view is that something has to give. I wonder if the Ministry has done any study on the implications of the reduction in the training period? And will our future medical specialists be less knowledgeable and less skilled than the medical specialists that we produce today under the current system?

Besides, you need to give young medical graduates adequate exposure by spending sufficient time in different subspecialties so that he can make up his mind on which area of medicine he wants to pursue for specialisation, and this is a lifelong commitment. This particular period is critical so that he can understand the subject, appreciate the implication before making an informed decision. While the shortened duration may benefit those who are already certain of the subspecialty they are interested in from the onset of the training, it is not so for most of them who have not yet decided immediately after graduation.

More than a reduction in duration, the proposed new residency programme is actually a complete overhaul of the existing system. With such short notice for the graduating batch of medical students, they may be forced to make some very rushed and uninformed decisions. As one medical student actually lamented in a blog that the sudden

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announcement of this change has left him only one month to decide on the path he wished to take. Furthermore, as this is a new concept which affects an entire graduating batch of medical students, flaws in the new programme may result in trainees not performing up to standard. Will they then be expelled, or will they be given a second chance as the programme gets a review? More importantly, will mentors be able to cope with the changes and revise their training methods for this new programme adequately? These are really genuine concerns of doctors as well as medical students.

A doctor shoulders a very heavy responsibility. Will a shorter training duration now compromise the time needed for trainees to learn and excel in every area that is required in their career? How can they juggle between research, clinical practice as well as administration? We need to remember that doctors in Singapore actually see a much higher workload compared to those overseas. The US Society of Hospital Medicine at a recent meeting in Chicago in 2009 noted that the conventional wisdom holds that the optimal daily output for a doctor is 15 patients, but that varies from doctor to doctor. In Singapore, it is not uncommon for our doctors to see a much higher throughput, especially at Government clinics of up 80 to 100 patients a day. Hence all the more we need to ensure doctors are adequately exposed through the years of his training as the demand on them is much greater.

It also raised the question of the new batch of doctors be less rounded than their seniors who have additional years of rotation and hands-on experience before focusing on their eventual subspecialty. Given the complexity of medicine and the advent of new medical technology and advances in medical science, the longer the time a doctor spends in training, the better he is able to grasp and understand the practice of medicine. It is about life and death.

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There is little room for trial and error. Even under the current regime, under our rigorous regime, we read of lapses on the part of doctors with the patients having to bear the consequences of their oversights. Are we able to continue to uphold our medical excellence that we have proudly and painstakingly built up over the years with the new programme?

Next, I will touch on the Disciplinary Tribunal (DT). I have some reservations with the proposal that a legally trained person should be appointed as a chairperson for the Tribunal although it is not always the case. The roles of the DT and the Courts of Law are entirely different. The DT actually is a platform to hear out complaints involving ethical issues and professional misconduct or mispractice. The DT presides and penalises doctors who misconduct themselves professionally in specialised area of their practice. Hence, who is better to lead the DT than someone who is trained in the practice, to be able to understand the thought processes and the judgments or decisions made by a trained medical professional?

The presence of a lawyer may bring about a technical convergence of the law and medical practice but it does not promote higher standards of medical ethics. In fact, in my view, moral ethics may perhaps be better advocated and better served by one who commands a very high degree of respect and trust from the public and the members of the medical profession, such as a Justice of Peace. Indeed, if there is a problem in terms of public perception that doctors may not be judging harshly on their peers who have come before the DT, then I think the presence of an eminent member of our community as the Chairman of the Tribunal, namely a Justice of Peace, more than a lawyer would actually add more weight to the proceedings. For more complex cases with legal implications,

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there is already a provision for a legal assessor to be appointed to assist and advise the DT during such proceedings.

With that, I hope that the Minister would have time to elaborate on some of the points. I thank you for the opportunity to present my views on this Bill.

Mr Christopher de Souza: Mr Deputy Speaker, I would like to clarify one point. When Dr Lam said – I was out of the Chamber – but I was told that he had rebutted one of my points. I would like to clarify my position that I am not advocating that a medical doctor be now on a legal Disciplinary Tribunal although we hold medical doctors in very high regard, and I hope that there is a reciprocity between the two professions in that regard. What I was saying was that I think there is a great synergy between the legal fraternity calling doctors as medical experts in cases, and in fact the case that the hon. Dr Lam Pin Min cited was the case of Dr James Khoo against Gunapathy. That was a case in which medical experts were called by lawyers. So, it is really a point of synergy that section 50 of the new Medical Registration Act achieves between the legal profession as well as the medical profession which I think will only add to the disciplinary process and be a positive feature for doctors and patients.

Mr Deputy Speaker: Dr Lam, you were mentioned.

Dr Lam Pin Min: Thank you, Mr de Souza for that clarification. I would like to point out that in the current system there is already a provision for the legal assessor to be in the DT. But to allow a doctor to sit in a legal DT and to be the Chairman, I think it is a different story altogether. So, there is no comparison between the two although we understand

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that doctors and lawyers can collaborate and work closely together for the benefit of the complainant.

Mr Deputy Speaker: I think it is quite clear now. Mr Ang Mong Seng.

5.40 pm

Mr Ang Mong Seng (Hong Kah): ( In Mandarin ): [For vernacular speech, please refer to Appendix A.] Mr Deputy Speaker, Sir, in order to improve the regulatory mechanism for doctors and to raise the standard of medical services, the Ministry of Health is once again seeking to amend the Medical Registration Act to provide medical protection to the public.

Over the last few months, the Ministry of Health has conducted extensive public consultation on the Bill involving doctors, lawyers, professionals, members of the public, grassroots organisations and various relevant agencies, and Minister Khaw Boon Wan himself has made very incisive observations on the responses by the doctors and the key professional groups on this Bill. Members who spoke on this debate today are mainly doctors, professionals or lawyers. As far as this Act is concerned, let me raise some of my views on this Bill in my capacity as a lay person, for the Minister's consideration.

First, set a time-frame for the Complaints Committee to complete the processing of complaint cases. The new section 38 will raise the cap on the number of registered doctors and lay persons in the Complaints Panel from the current 80 to 150 and the number of Council Members will also be increased from the present 19 to 25. This is to shorten the time taken to process the complaint cases, because at the moment some cases may take as long as five years to complete the whole process.

I think increasing the number of members is a correct decision. With

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increased manpower, cases can be dealt with more rapidly. But this Amendment Bill does not specify a timetable for the dealing of these cases. I would like to suggest that complaints received by the Ministry of Health be separated into two categories: the "core" and the "non-core" complaints. If it is a non-core complaint, the Medical Council must set up a committee to start proceedings within a month, and the whole case should be completed within three months. If the complaint is medical in nature and more complicated, then the Singapore Medical Council should set up a committee within a month and allow another month's "cooling period" to allow the parties to cool off and deal with the matter in a more peaceful and calm mindset. Case hearing should start on the third month and be completed within a year. If the committee needs more time to deal with the more complicated matters, they can apply to the Ministry of Health for an extension of time. In this manner, all the complaint cases can be dealt with within the prescribed timeframe to satisfy the needs of the complainants and also to enhance the image of the medical profession.

Secondly, improve the transparency of the Disciplinary Tribunal's proceedings. Some members of the public complained that the Disciplinary Committee's proceedings lack transparency. They said with all the committee members being doctors, they tend to be more tolerant of their fellow doctors for their mistakes or negligence. So, in order to improve the transparency of the proceedings, I would suggest that the complainants or members of their family be allowed to attend the proceedings, but they will not be allowed to interfere with the proceedings and they also must sign an agreement not to disclose details of the proceedings to outsiders. If they have any views, they can instruct their counsel to make the point. I think in this way, the complainants and their family members

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would have a better understanding of what transpired at the tribunal. I hope that the Minister would consider this suggestion.

Thirdly, doctors with repeated offences. I would like to ask the Minister, over the last five years, how many doctors were complained against on the same issue, ie, the repeat offenders.

Fourthly, high-tech medical equipment. With modern advance technology readily available, I would like to ask the Minister whether there is any provision for technology to be deployed to prevent or detect any unintentional wrong-doings on the part of the surgeons. I remember there was a case where a surgeon left his scalpel inside the body of the patient after the operation. Could we consider using some sophisticated detector scanners, just like the metal detectors at the customs checkpoints, to scan the patient after each surgical operation? Should any substance that should not be left in the body of the patient be detected, it could be removed as soon as possible, thus improving the safety of the patient and reducing the chance of the doctor making a mistake.

I support this Medical Registration (Amendment) Bill.

*Cols. 1987-1990.

Mr Khaw Boon Wan: Mr Deputy Speaker, Sir, I thank Members who have spoken very passionately on this Bill – not always agreeing with one another – and generally in support of this Bill.

Let me address their comments and suggestions.

First, the proposal to allow senior lawyers to chair Disciplinary Tribunals. I am not surprised that this is one of the most heated issues this afternoon. Dr Lam noted that the practice was not unusual, having been done in Australia, Canada and elsewhere. However, he worried that

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it might be perceived as, "SMC lacking the moral courage and legitimacy to discipline high profile complex cases". In any case, he commented that "the definition of complex is subjective and can be ambiguous". In contrast, he and Ms Audrey Wong noted the Law Society going in the opposite direction, doing away with the appointment of laypersons in the Disciplinary Committees. Dr Lam asked whether the amendment would mean "the medical profession is regressing and arrogating responsibility".

I do not know fully the circumstances that led to the amendment to the Legal Profession Act. But I recall the debate in this House which noted that formalised legal processes, like the legal disciplinary proceedings, would benefit from lawyers' participation. And the amendment to remove the layperson was to help speed up the proceedings. SMC's disciplinary proceedings are similarly formalised legal processes but currently without the advantage of having legal professionals on its Disciplinary Tribunal. Although there is a legal assessor present to assist the SMC's Disciplinary Committee, as noted by a number of Members, to address issues of law, the extent to which legal assessors can guide the proceedings is limited. During the public consultation on this amendment, one senior lawyer who has served many years as legal assessor for the SMC wrote in to express his observations that frequently the SMC's Disciplinary Committee wasted a lot of time on irrelevant matters but he was unable to intervene. I have his letter to the Ministry of Health here. I have not sought his permission to quote him – so I will not name him – but I would read an extract of what he said, because this is a real, personal experience of one who has helped out as legal assessor for many years. This is what he said:

"As a legal assessor, my role in the disciplinary proceedings is limited to advising

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the Disciplinary Committee on questions of law arising in the course of the proceedings or informing the Disciplinary Committee of any irregularity in the conduct of the proceedings and advising the Disciplinary Committee when it appears to me that there is a possibility of a mistake of law being made. In that restricted role, I often felt inadequate and at times frustrated in being constrained from intervening when I noted counsel, either for the doctors concerned or for the SMC, spending a great deal of time in questioning witnesses on or dealing with irrelevant or peripheral matters arising. The doctors chairing the Disciplinary Committees were often too polite and indulgent to counsels and gave them a lot of leeway. Conducting hearings and dealing with contentious counsels, arguing with each other across the table and disputing on issues or points – sometimes serious and at other times frivolous – are not matters with which the doctors are familiar. It seems to me that if the proceedings were chaired by an experienced legally trained chairman, or if there were present such a person as a member, not as a legal assessor, the proceedings could and indeed would have progressed more expeditiously."

I spoke to the President and a couple of past presidents of the SMC, because when the reaction from a certain segment of the medical community emerged during the public consultation phase, I felt it necessary to get to the bottom of this, so I spent time with a few of these current and past presidents. All of them strongly recommended that we include this particular amendment. They have personal experience conducting the disciplinary proceedings and felt strongly that the presence of an experienced legal professional on the Disciplinary Tribunal will be a significant advantage. I note Mr de Souza's support for this amendment and also his very sound advice that SMC proceedings should not become overly legalistic, shifting the focus from what is medically professional and ethical to what is strictly legal. I agree with his call but the reality is that increasingly, senior

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lawyers are being engaged in high-profile cases saddling disciplinary committees with legal arguments and technicalities, the relevance of which does require legal training to discern. And that is why the SMC President and past presidents have made such a strong recommendation to allow them the option to appoint senior lawyers to chair some Disciplinary Tribunals, where circumstances may demand it. This is not an indictment of the medical professional, rather it is a progressive development where the medical practitioners collaborate "synergistically" to use Mr de Souza's words, with the legal professionals to do their best, to manage efficiently both questions or fact of medical practice and questions of law. This will help the Disciplinary Tribunal to make fair judgments in complex cases.

Let me reiterate again that the SMC is not arrogating its responsibility. As noted by Mdm Halimah, "the amendments have taken into account doctors' concerns as their appointment of any legally qualified person, whether chairman or committee member is at the discretion of the SMC." The SMC will have the prerogative to include a senior lawyer to Disciplinary Tribunal, only when it deems appropriate. The Bills specify that there should be at least three voting members in a Tribunal, of which at least two, shall be medical practitioners and does not set an upper limit to the number of voting medical practitioners. The Medical Council may have two or more practitioners in addition to the legal professionals to constitute such Tribunals, so that when it comes to questions of facts pertaining to medical practice, the medical professionals' views will prevail. This amendment is to mitigate potential legal errors which may arise when dealing with complex issues of law which medical professionals are often either not familiar with or is aware of. After the Director of Medical Services has explained the background of this

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amendment to the entire medical community, as I highlighted during my speech a couple of hours ago, the vast majority of the medical community had no further objections on this particular amendment.

And as noted by Mr de Souza and Ms Audrey Wong, we have made some amendments to the original draft Bill, which I put out for public consultation. The current Bill, which is in front of the House, contains amendments to the original because I take public consultations seriously. It is not just a show. When I consult, I am really keen to see what are the comments and if there are valid points, we will incorporate them. This is one example where, because of the strong views expressed by certain segments of the medical community, I decided to hold back the whole tabling of this Bill by two or three months to allow me to consult the various people and along the way, we amend the original draft Bill, which is the version that Members see today. I think and as noted by Mdm Halimah, we have made sufficient and relevant compromise to finding this trade-off between preserving the interest of the public as well as making sure that the self-regulation approach to medical professionalism that we have in the medical profession, is not compromised. And Members can notice that just on this point, in this House this afternoon, there are strong views, different views and I hope Members can accept that the compromise that I have struck, is a fair one.

Dr Lim Wee Kiak would like us to consider an alternative, which is to appoint a highly respected individual such as a Justice of the Peace, and not necessarily a legal professional to chair the Disciplinary Tribunal. Unfortunately, that cannot resolve the problem that we have identified, which is the legal complications which have been imposed on the Disciplinary Tribunal in dragging

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out unnecessarily the whole entire proceedings. Of course, what is complex, I agree, is hard to codify or define, and that is why this is the question best left to the SMC. The SMC will have to consider each case differently and they are the ones who decide if this case is sufficiently complex in nature such that having a senior lawyer to chair will bring advantages to the proceedings.

Mr Calvin Cheng suggested that we should allow laypersons to form the majority of the Tribunals. But unfortunately, this will defeat the whole purpose as pointed out by Dr Lim Wee Kiak. This will undermine the whole approach of self-regulation that we wanted the medical profession to follow.

Dr Lam Pin Min also asked if the new provisions for SMC to lodge an appeal to the High Courts on behalf of a patient under section 55(2), constitutes a "double whammy" as this amounted to a doctor being prosecuted twice. This is not an issue unique to Singapore. In fact, there was a similar issue that was raised in the UK, where they have a Council for Healthcare Regulatory Excellence, which has the power to refer matters to the High Court that it considers to be "unduly lenient". Like the SMC, this UK Council can in effect, appeal on behalf of patients even where the doctor has been acquitted by the general medical council in UK. And when the issue was raised in the English Court of Appeal, the English Court accepted that this power creates an element of "double jeopardy", as they put it. But overall, they thought that such concerns were to take second place when this is necessary to protect the public. And in this instance, we have taken a similar approach in Singapore.

Second, Dr Lam asked if Disciplinary Committee members receive any form of training. Yes, they do. The SMC conducts

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training sessions for all members of the Complaints Panel from which members of the Disciplinary Tribunals are drawn. The training sessions are conducted by SMC's lawyers and focus on legal issues, procedures and policies relating to the Medical Registration Act.

Third, Prof. Paulin Straughan noted that investigators appointed by the SMC are potentially powerful agents, as she put it, with fairly extensive authority. Ms Sylvia Lim also noted that the investigator holds an important and pivotal role in the disciplinary process. Both wanted to know the qualifications these investigators are expected to hold. Our plan is to recruit officers with at least 10 years of experience in the Police or related enforcement agencies. They will be very much like the officers in my Ministry's Enforcement Branch. We would like to assure this House that investigators will be provided with all the necessary training to equip them with the appropriate skills to carry out the duties of an SMC investigator.

Fourth, Prof. Paulin Straughan and Ms Audrey Wong commented on the time taken by the SMC to deal with each complaint. They are concerned about rising number of cases, resulting in delay and a backlog. I share similar concerns. In fact, one main objective of this Bill, as noted and welcomed by Mdm Halimah, is to help the SMC speed up the disciplinary processes.

Mr Ang Mong Seng offered some suggestions. He proposed that we categorise cases as core or non-core and set a time limit for each category. For instance, complicated cases should be concluded within a year and if more time is needed, a formal request for extension should be made. I agree that all complaints should be dealt with speedily. There are provisions to limit the time taken by the Complaints Committee and the Disciplinary Tribunals. The authority

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to vary the time for the Complaints Committee and the Disciplinary Tribunal to complete the cases resides with the SMC. Prof. Straughan asked whether all complaints could be dealt with within the three-year limitation period so that complainants who may wish to pursue a civil lawsuit can rely on the outcome of the Disciplinary Tribunal to make an informed decision. SMC will make every effort to conclude the investigations of every complaint within a reasonable time. However, civil suits are best legally advised and considered independently from the Disciplinary Inquiry. Complainants who wish to commence civil proceedings should not wait for the outcome of SMC's investigation. If they intend to, they should instead file a civil suit within the limitation period to ensure that their right to sue is preserved. That said, SMC has assured me that most cases can be concluded within three years and, with the various amendments that I hope the House would pass this afternoon, we will now have greater ability to form Complaints Committee and Disciplinary Tribunals and get the proceedings off speedily.

Fifth, Mdm Halimah, Prof. Straughan, Mr Ang and Mr Calvin Cheng commented on the need for more transparency in disciplinary inquiries. As noted by Mdm Halimah, this is a trend that we already see in the UK, US and Australia. Current proceedings are not completely opaque, neither are they fully transparent. What makes this subject complicated? It is the need to protect patient confidentiality. However, given rising level of interest in the issue of transparency, we will study this issue further. I have noted the various suggestions and we will discuss with the medical community and the general public on whether the proceedings should continue to be held in private or with limited attendance and whether the proceedings should be published in full or in an abridged version while maintaining confidentiality of patients. So this is

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bound to be another subject of public consultation which I will undertake. We will have to find a balance which will serve the public interest best.

I have also noted Mdm Halimah's suggestion about some schedule of penalties in order to improve transparency, and we will take a look at that as well. Related to this issue of transparency, Ms Ellen Lee and Mdm Halimah suggested that we publish and regularly update a list of errant doctors. I thank Prof. Paulin Straughan for expressing her views why she thinks this is not a good idea. It is a debatable idea – whether we should maintain an active public listing of the guilty – and we can argue about it. Would that not unduly stigmatise doctors whose offences may not be so serious and, if so, then what constitutes serious offence? Then, what about those who have genuinely turned over a new leaf? I am a champion of the Yellow Ribbon Movement. People make mistakes – they should be given a second chance. The key point is: do you realise your mistake and do you sincerely want to change? And if you do, I think society must support that. If you stigmatise them, you are forcing them down a different route, which I do not think is productive for the society. Ms Audrey Wong referred to the provision of the Bill which allows the SMC to deal directly with the medical practitioner without referring to the Chairman of the Complaints Panel. She felt that this may be seen by the public as less transparent. Let me clarify that this provision only pertains to situations where a formal complaint has never been received from the public. However, if the information received by the SMC pertains to a serious offence of professional misconduct, SMC will proceed to forward the information to the Chairman of the Complaints Panel and formal investigations will be initiated even though no formal complaint has yet been lodged.

Sixth, Dr Lam asked why there is a need to raise the maximum financial

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penalty from $10,000 to $100,000. At the same time, I heard Mdm Halimah complaining about the $10,000 penalty on a recent case as just too low. The current quantum was set in 1997 when the financial penalty was first introduced. Prior to that, there was no financial penalty as part of the disciplinary orders available to SMC. Many years have passed since and we thought that the $100,000 penalty for medical misconduct is not excessive. Mr Ang asked about the number of doctors who have repeated similar offences in the past five years. There were 17 such doctors.

Mdm Halimah asked whether most of the cases brought before the SMC were referred by MOH. This was not so. Three in four of the complaints received by the SMC during the last three years came from members of the public.

Seventh, many Members have spoken in support of the establishment of a Family Physician Register. Dr Lam asked if existing family physicians would automatically be included in this register. There must be minimum requirements for registration as a family physician. The criteria and qualifying conditions were extensively discussed previously when I undertook another public consultation several years ago but, generally, we will take an inclusive approach.

Finally, there were a number of comments which do not pertain to the proposed amendments in the current Bill. So let me address them briefly. Ms Ellen Lee noted a recent media report which suggested that Singapore-trained doctors as compared to foreign-trained doctors were more lenient to colleagues who misbehave. The media report was based on a survey done on a small sample of house offices. We had then discussed this subject in this House. We must certainly take issues on medical ethics and

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professionalism seriously. The teaching and learning start early in the medical school and extend to postgraduate medical education and throughout the medical career. Professionalism and communication skills are core competencies which our training authorities will strengthen through structured training processes and exposure to clinician mentors. We have started on this journey to reaffirm the importance of professionalism and ethics in medicine, and we will press on.

Ms Sylvia Lim asked whether the postgraduate training at Duke NUS without the one year of requisite housemanship would be compromised. Under the Medical Registration Regulations, first year post-graduation is required to have broad-based training exposure. This applies to graduates from both medical schools. Dr Lim Wee Kiak referred to the enhanced postgraduate training programme and wondered if the reduced duration would compromise quality. For almost all specialties, there will be no reduction in the training duration. The intent of the enhancement is to ensure a more structured approach to training. Trainees will be assessed each step of the way so that we can raise training effectiveness and reduce attritions.

We are injecting more resources, assigning dedicated clinical teaching and establishing a sustainable structure to improve the learning experience of our trainees. In other words, it is a modular approach and whether you progress to the next stage of training depends on what you have achieved and you must demonstrate that. So it is not purely based on: Have you done three years, five years or six years? Rather, we would progressively test, examine, assess and be confident that, yes, this trainee has imbibed what has been taught to him or her so that he can progress on to the next stage. The idea is to improve effectiveness and reduce attritions. Dr Lim is

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familiar with our current system which has been around for many years. It is a good system but in some specialties, it has led to huge attritions. The Americans look at such issues from a different point of view. To them, doctors are specially selected, so they ought to be capable of being trained properly. When there are huge attritions, they would blame the trainer: "What kind of training are you providing that, at the end, most of your students fail?" Therefore, what they believe more in is structured training so that at each step of the way I know what I am supposed to learn and what I should be capable of doing at the end of that stage, and if I do, then I progress on. It means objective assessment of outcomes so that both trainer and trainee are familiar with what to expect and along the way, they are able to reduce attritions. This is the approach that we hope we can incorporate into Singapore. What we intend to do is certainly to enhance training so that our specialists will be competent and properly trained. This is something that we have always been proud of and we will not lose that.

Prof. Straughan touched on the Interim Orders Committee (IOC) and the issue of justice to the doctor. The need for the IOC and the safeguards were debated in this House when the previous amendment was introduced. I do not want to repeat the arguments. The facts, I hope, will be comforting to Prof. Straughan. In the last five years, there has only been one case when an IOC was convened. This was in a case of a recalcitrant doctor who had a prior conviction for the indiscriminate dispensing of addictive drugs. The IOC decided to curtail his practice.

Mr Ang asked if there is a monitoring system in place to prevent drug addicts hopping from clinic to clinic, collecting drugs such as sleeping pills. Such a system exists for one highly addictive drug, methadone. Whether we should

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extend this system for sleeping pills will need to be carefully studied. Mr Ang also asked whether our hospitals are adequately equipped to detect medical errors. This is a big topic – as medical errors can come from many causes and no hospital has been able to eradicate medical errors as we are dealing with human beings and human errors do occur. Proper staff training and supervision are important. Systems must also be in place to monitor adverse events so that lessons are learnt and staff reminded. Where systemic inadequacy leads to the error, then systemic solutions have to be found and implemented.

Mr Deputy Speaker, Sir, I believe I have addressed all the concerns raised. Singaporeans enjoy a high standard of healthcare services and our doctors are largely ethical, professional and competent. As Dr Lam put it, "There is really nothing seriously wrong with the medical profession here in Singapore". And we should not give Singaporeans the wrong impression that, "The state of medical malpractice may have reached an epidemic level warranting harsher measures". But like all professions, there are some black sheep and we need efficient, transparent and fair processes in place to ensure that misconduct is dealt with speedily so as to strengthen the good reputation that our medical profession enjoys. As Mdm Halimah put it, with the proposed amendments, "The law is now very clear. Its aim is to protect the health and safety of the public through mechanisms to ensure that doctors are competent, uphold the highest standards and maintain public confidence."

On this note, I thank Members again for their support of this Bill.

Question put, and agreed to.

Bill accordingly read a Second time and committed to a Committee of the whole House.

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The House immediately resolved itself into a Committee on the Bill. – [Mr Khaw Boon Wan].

Bill considered in Committee.

Mr Khaw Boon Wan:

The Chairman: The citation year "2009" will be changed to "2010", as indicated in the Order Paper Supplement.

Clauses 1 to 41 inclusive ordered to stand part of the Bill.

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Bill reported without amendment; read a Third time and passed.