OPTOMETRISTS AND OPTICIANS BILL

OPTOMETRISTS AND OPTICIANS BILL: Order for Second Reading read.

3.15 pm

The Minister of State for Health (Mr Heng Chee How): Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time."

Background

Like other countries, eye care in Singapore is provided by ophthalmologists, with auxiliary support from optometrists and opticians. Our ophthalmologists are highly trained and enjoy a good international reputation.

In our situation, unlike many other countries, we have left the practice of optometry and opticianry unregulated. This has been historical. But several years ago, the Health Ministry decided that we should bring the practice of optometry and opticianry under regulation and started to prepare the industry for it.

In 1994, we took the first major step when the Singapore Polytechnic launched a diploma course in optometry and certificate courses in ophthalmic dispensing. This was to provide the industry with well-trained optometrists and opticians to help raise the standard of eye care by these allied health professionals. Over the years, the Singapore Polytechnic has graduated about 600 optometrists and provided training for about 300 opticians. We now have an active market in such eye care practices with competitive prices.

In 1995, we took the second major step when the Contact Lens Practitioners

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Act was introduced to regulate contact lens practice. This was a priority to ensure public safety by allowing only properly trained practitioners to fit and dispense contact lenses.

We are now ready to take the third major step by bringing legislation to bear on the remaining practices of optometry and opticianry, which fall outside of the Contact Lens Practitioners Act. This is an important piece of legislation particularly because myopia is rather common in Singapore. Our prevalence rate for myopia is high at 40% among Chinese adult Singaporeans over 40 years old, as compared to, say, 15% among Australians and 27% among Americans in the same age group. The problem will grow as our population ages.

There are several reasons why we need to regulate the practice of optometry and opticianry. First, the public will then be better assured of high standards of primary eye care, refraction and optical aid dispensing. Second, practitioners will be required to maintain high standards in their professional practice through mandatory continuing professional education. Third, errant practitioners may be disciplined for, amongst other things, professional misconduct or negligence, or any improper act or conduct which brings disrepute to the profession, arising from a complaint brought by an aggrieved patient or client.

Our approach to regulation

The regulation of optometrists and opticians is, however, not straight-forward. In most other countries, there is a clear division of labour between optometrists and opticians, depending on their training. Optometrists are trained to perform refraction and basic eye examination procedures, such as examining eyeball pressure, visual field and retina.

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On the other hand, opticians are trained to prepare, adjust and fit optical aids and perform other retail duties. However, in Singapore, there is much overlap between the practices of these two groups of eye care professionals, with opticians doing refraction and optometrists dispensing optical aids. As a result, our public has become accustomed to having both refraction and dispensing provided by the same optical service provider rather than being served by separate providers, as is the case in many other countries.

In developing our regulatory framework, our principal objective is to ensure that optometry and opticianry services are safe for our public. While we want to regulate the optometrists and opticians as two distinct professions, we want also to take into account market realities and to avoid unnecessary disruption to the way that the public uses the services of these professionals. Our legislation will therefore enable opticians to continue to perform refraction provided that they are properly trained. But we propose to exclude children under 8 from the persons whom an optician may refract. Young children are more difficult to refract and may have eye anomalies that opticians are not trained to detect. With our legislation, refraction services for such young children will require the higher skills of an optometrist. In addition, optometrists will be formally recognised for their ability to perform basic eye examination procedures and diagnose certain eye problems.

We are mindful that regulation may cause some disruption to the practices of some existing optometrists and opticians, and we seek to minimise this as far as possible. Some opticians currently only perform dispensing and have no intention to learn refraction. We will register such opticians to perform only dispensing so as to allow them to continue their practice. Nonetheless, there is a competing need to ensure that opticians attain a reasonable level of competence. To achieve this

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balance, existing opticians will be registered under the Act according to their experience, qualifications and competence. Those who do not satisfy certain minimum requirements will be required to undergo upgrading courses in order to qualify for registration.

Based on this approach, we have drafted the Optometrists and Opticians Bill which is now before this House.

Main features of Bill

Let me now go through the main features of this Bill. First, we have defined the acts constituting optometry and opticianry in the Schedule. Only persons who are registered as optometrists or opticians are allowed to perform the respective activities listed in the Schedule. However, exemptions will be made in subsidiary legislation to allow health professionals, such as medical practitioners and orthoptists, to continue performing eye examination procedures which are part of their scopes of practice.

Part II of the Bill establishes the Optometrists and Opticians Board. The Board will be represented by members from the optometry, opticianry and ophthalmology professions, public officers from the Ministry of Health and the Ministry of Education as well as some lay-persons. The main functions of the Board are to approve or reject applications for registration, accredit courses in optometry and opticianry, and determine guidelines for the professional conduct and practice of optometrists and opticians.

Part III sets out the role of the Registrar in maintaining the registers of optometrists and opticians, and the powers of the Board to take disciplinary action against registered optometrists or opticians, including the cancellation or suspension of the registration of such

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persons, and the imposition of monetary penalties. It also provides for a right for any person aggrieved by the decision of the Board to appeal to the High Court. Part III also requires optometrists and opticians to apply for practising certificates, which will be made renewable, subject to mandatory continuing professional education to be specified in subsidiary legislation. This is to ensure that the practitioners continue to maintain a high level of competence so as to provide quality and safe primary eye care to the public.

Part IV provides for offences in regard to the unlawful engagement in optometry and opticianry and fraudulent registration. A person who practises optometry or opticianry without registration or a valid practising certificate will be liable on conviction to a fine not exceeding $25,000 and/or imprisonment for a term not exceeding six months for a first offence, and a fine not exceeding $50,000 and/or imprisonment for a term not exceeding 12 months for subsequent offences. Under clause 29, the Board may also compound any offence prescribed as a compoundable offence under the Act.

Part V, clause 31, allows for the appointment of Inspectors to investigate into offences under the Act, and complaints against registered optometrists and opticians.

Finally, under Part VI, clause 39, the Contact Lens Practitioners Act will be repealed.

Implementation

Let me now touch on implementation. To minimise the impact of regulation on contact lens practitioners licensed under the current Contact Lens Practitioners Act, licensed practitioners will be automatically registered as opticians and

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granted practising certificates in respect of opticianry when the Act comes into operation. Furthermore, contact lens practitioners with the appropriate qualifications and experience may also apply to be registered as optometrists.

For optometrists, those with recognised qualifications and at least one year of optometry experience will be fully registered. Optometrists with less than one year of experience will be provisionally registered, and will have to work under supervision for one year before they become fully registered.

For opticians, those with work experience of at least five years will be fully registered as opticians if they pass a competency test. Those with between two and five years of experience will need to undergo a part-time modular upgrading course. There may be some opticians who do not intend to do any refraction but wish to do only dispensing; they will need to undergo a competency test or failing which, an upgrading programme but without the refraction component. In this way, we will ensure that they can uphold safe standards in dispensing.

Opticians with less than two years' experience and all new entrants to the profession will need to attend a certificate course in opticianry in order to qualify for registration. Singapore Polytechnic has organised a course to cater to these opticians. The course can be completed between nine and 24 months, depending on the frequency of attending the modules.

Further details of the registration of optometrists and opticians will be spelt out in subsidiary legislation to be enacted at a later date. My Ministry will be reaching out to existing optometrists and opticians through the media, seminars and other efforts to inform the practitioners on

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the procedure for registration, including details on the competency tests and upgrading courses that are necessary for registration.

In preparing this Bill, the Ministry has consulted persons who will be affected by this new legislation and, in particular, the key representative groups of the professions, such as the Singapore Optometric Association, the Singapore Opticianry Practitioners and the Singapore Polytechnic Optometry Centre. These stakeholders have been supportive of the Bill. We will continue to consult them as we develop the subsidiary legislation.

In conclusion, we are ready now to regulate the practice of optometry and opticianry. The existing Contact Lens Practitioners Act has laid the ground for us to take this step, and years of training optometrists and opticians have created a sufficiently competitive market to support this move. I seek the House's support for this Bill to ensure that the public continues to enjoy high standards of eye care, in relation to the practice in optometry and opticianry in Singapore.

Sir, I beg to move.

Question proposed.

3.28 pm

Mdm Halimah Yacob: Mr Speaker, Sir, I rise in support of this Bill.

This Bill to regulate the practice of optometry and opticianry in Singapore is necessary and is long overdue. Singapore has one of the highest incidences of myopia in the world. A local study shows that by age seven, about 28% of children are myopic. And as the Minister of State has pointed out, 40% of Chinese adults above the age of 40 years suffer from myopia, which is a high prevalence rate for our adult population. Yet, the practice of optometry and opticianry has long

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remained unregulated, leaving the public to make important decisions about their eyesight without any legal control.

The situation is vastly different in many developed countries, such as the US, Canada, UK and Australia, which have long regulated the practice of optometry and opticianry in order to protect the public. But it is better late than never and I strongly welcome this Bill, which I hope will bring about the kind of improvement in standards that we have seen in the developed countries.

Under the Bill, optometrists and opticians will now have to be registered, and they will also have to continuously upgrade their skills and capabilities to keep pace with new developments, thus ensuring that they maintain high standards of professionalism. In this way, the public can expect to have better standards of eye care, and optometrists and opticians will in turn be better recognised as healthcare professionals.

In Singapore, there is not enough recognition of optometry and opticianry as a profession, let alone as part of healthcare profession. Often, optometrists and opticians are regarded as merely retailers of eye care products. Hopefully, this Bill

will help to enhance the image of our optometrists and opticians and generate a better understanding of their role in helping Singaporeans to improve their eye health.

The importance of this Bill and the need for standards to improve cannot be overemphasised. Years ago, when I needed a new pair of glasses, I picked up one from an optician. Unfortunately for me, the optician was poorly trained and ill-equipped to do a proper eye examination before prescribing the glasses. As a result, I had to endure a few months of terrible headaches which I did not realise was due to the poorly-fitted prescribed glasses until I went for a

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proper eye check and was prescribed the correct glasses. I learned a painful lesson, but I am glad that there was no lasting damage. But we can never tell how many more people could have experienced the same problem and what is the extent of the damage to their health.

Sir, I would like to raise three issues with regard to this Bill.

First, in many developed countries, as the Minister of State had correctly pointed out, a distinction is maintained between the role of optometrists and opticians. In a nutshell, these countries do not allow opticians to do refraction, that is, basic eye examination procedures such as examining eyeball pressure, visual field and retina. The Minister of State has also explained that the reason why there is no such distinction under the current Bill and opticians can continue to perform refraction, which they are currently doing, is because of the considerable overlap in the practice of optometry and opticianry in Singapore. And the Ministry does not want to disrupt the way the public uses the services of these professionals. I am not sure that this is a sufficient ground for continuing with the status quo. The primary consideration should be what is in the interest of the public and whether it is in their interest to continue to allow opticians to do refraction. A lot also depends on the kind of training that opticians undergo which we heard from the Minister of State will now be enhanced. But the question remains whether this is sufficient and extensive enough for them to do refraction, considering that some countries, like Australia and the US, even require a degree before someone can practise optometry.

A trained optometrist doing a comprehensive eye examination will not only be able to evaluate a person's vision for spectacles and contact lens, but the optometrist can also check the person's eye health through screening for eye

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diseases such as glaucoma, cataracts, lid disorders, conjunctivitis and retinal disorders. As we have one of the highest rates of myopia in the world, which has just been confirmed by the Minister of State, a rapidly ageing population and an estimated one million people suffering from chronic illnesses, such as diabetes, hypertension, strokes and other chronic illnesses, obviously proper checks on eye health are important to prevent blindness and other debilitating eye disorders that will cost more to the Government and the individual to correct later on. For example, one optometrist shared with me about a 50-year-old man who wanted to get a pair of spectacles. The man claimed that he was in good health and not on any medication. However, when the optometrist did an internal eye examination, he noticed that there was bleeding in his retina. The optometrist referred him to an ophthalmologist who subsequently diagnosed diabetic retinopathy. The patient was an undiagnosed diabetic. His vision and life were saved because of a proper eye examination.

I am aware that opticians are already doing refraction and perhaps the Ministry's concern could be that we do not have enough optometrists today to separate the two functions. There may also be the concern about how this would impact on the livelihood of existing opticians. These are valid and practical concerns. One way to address these concerns is to allow existing opticians to continue to perform refraction and impose restrictions only on the new entrants to opticianry. This is also the suggestion, I believe, that has been made by the Singapore Optometrist Association which, I understand, has also voiced some concerns on this issue. I hope that the Ministry of Health could give us a better insight on why it decides to maintain the status quo and not take this opportunity, particularly considering the critical posi-

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tion that we are in - myopia, ageing and the number of chronic illness are very high - to upgrade and impose higher standards by ensuring that gradually, over time, refraction is only done by trained and competent optometrists.

My second point, Sir, is to ask how this Bill is going to be enforced once it becomes law. The Bill provides for the appointment of inspectors to ensure that the law is complied with and only registered optometrists and opticians can do eye examinations and prescribe glasses. Once registered, the Optometrists and Opticians Board could ensure that they go for continuing education before they will continue to be issued with the licence to practise, an important point to ensure that our optometrists and opticians continue to maintain high standards. And I want to really applaud the Ministry of Health as I think this is a very important and positive development. However, Sir, the real challenge lies in the implementation.

I note that since 1996, we have had the Contact Lens Practitioners Act to regulate the contact lens practice, and to ensure that only properly trained practitioners are allowed to fit and dispense contact lens. Of course, this Act will now be subsumed under this Optometrists and Opticians Act. But, today, we can still find instances of contact lens being dispensed by untrained people in optical shops. I would, therefore, like to ask the Ministry of Health how it intends to enforce this Act, as there are now about 800 optical retail outlets in Singapore, a large number that would require a large enforcement machinery for this Bill to be properly enforced once it becomes law. A much wider issue, of course, is the sense of responsibility of businesses involved in this trade that they are not just selling a product, but a health accessory which, if badly fitted, can have a tremendous impact on the health of the user. But if this sense of responsibility is not yet

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deeply ingrained, then we do need an effective enforcement mechanism to ensure compliance and to improve standards of eye care in Singapore.

My third point is on the need to educate the public. There is generally a low level of awareness in Singapore about the importance of eye health and ensuring regular and proper eye checks. With more Singaporeans suffering from chronic diseases and with a rapidly ageing population, compounded by the onslaught of new technology such as the Internet and computer games, it is important for people, particularly those who are at risk, to have regular eye checks and to understand the importance of maintaining proper eye care. In this regard, I note that the Singapore Eye Research Institute, together with the NUS, has undertaken a study to examine the cause of the high myopia rates among infants and youngsters in Singapore. This is, indeed, an important move which, hopefully, could shed more light on why we have become a country with one of the highest number of myopics in the world and what other measures we can put in place to prevent a further deterioration of public health in this area. I certainly hope that more researches of this nature could be done.

I would like to suggest, Sir, that we devote more resources and efforts to educate the public on the importance of regular eye checks and proper eye care, particularly among the young, in order to prevent myopia or to arrest the problem more effectively. There could be more concerted programmes in schools targeted at children and programmes in the HDB heartlands targeted at adults, particularly the elderly and those at risk. The elderly is, of course, a creeping problem now and I think the need for eye care health should also be addressed. A more pervasive programme on the proper use of computers at work would also be beneficial, particularly for workers who have to spend a lot of time doing

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computer work. I do urge the Ministry to look into this and work with our schools, grassroots bodies, employers, workers and other relevant organisations to have a more effective public health outreach programme.

On this note, Sir, I think this is a very important and good Bill, and I fully support it.

3.39 pm

Dr Lam Pin Min (Ang Mo Kio): Mr Speaker, I rise in support of the Optometrists and Opticians Bill.

Vision is arguably one of the most important and valued of our human faculties. It is important for learning, working, moving about and enjoying human endeavours. In Singapore, many patients turn to optometrists and opticians whenever they experience visual problems. Optometrists and opticians can therefore play an important role as primary eyecare providers.

Myopia is one of the most common eye conditions in Singapore and is also one of the most common causes of poor vision. Poor vision from myopia affects about 30% of our primary one students and about 65% of our primary six students. Interestingly, Singapore has the dubious honour of having one of the highest myopia incidences in the world. In fact, we are also known as the myopia capital of the world. The problem of myopia is also affecting Singaporeans at a much younger age. This "myopia epidemic" has caused much concern and attention nationally as sub-optimally managed myopia and severe myopia can result in amblyopia or lazy eyes and potentially blinding complications respectively.

With the decreasing total fertility rate and the rapidly ageing population in Singapore, one in five Singaporeans will be aged 65 and above by the year 2030.

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The prevalence of chronic systemic diseases, such as diabetes mellitus and hypertension and eye conditions such as glaucoma, aged-related macular degeneration and cataracts, will see a significant rise with the increasing ageing population. It is envisaged that the role of primary eye care providers is even more important as early detection and management of these eye conditions will result in better visual prognosis.

Unlike most developed countries, Singapore currently does not regulate its optometrists and opticians, other than those involved in the practice of contact lens fitting and dispensing. In most developed countries, like Australia, Canada, Hong Kong, United Kingdom and the United States, the practice of optometry and opticianry is tightly regulated. In these countries, only those with the appropriate qualifications can register and practise as optometrists and opticians. In general, optometrists function as primary eyecare providers, performing refraction, eye screening and basic eyecare while opticians dispense optical aids. Errant practitioners can be disciplined by the respective regulatory agencies. However, this is not so in Singapore currently.

Traditionally, practitioners learn their role through apprenticeships and only a small number was trained overseas. The situation has started to change in the 1990s when Singapore Polytechnic started conducting courses in optometry. It is prudent to maintain high standards in the optometry and opticianry profession as many people turn to them whenever they have visual problems, commonly blurring of vision. Improper optometry and opticianry practices can pose a health risk to the public. Hence, although the intent and purpose of this Bill has been mooted for sometime now, it is timely and necessary.

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Up until now, the optometry and opticianry industry is a low entry barrier industry. It requires little or no formal training for one to set up a practice in the private sector. Few or almost nobody demand to see the qualification of the optometrists and opticians that they visit.

The Bill provides for the setting of a proper footing for the primary eyecare industry. It will definitely raise the standard of primary eyecare providers through the requirement of formal training for the optometrists and opticians. This is an important step in the right direction. The registration of optometrists and opticians would bring the industry practice in line with other healthcare professionals. Mandating continued professional education as a prerequisite for subsequent renewal of the practising certificates is important as such a requirement will ensure that these primary eyecare providers keep up to date with new developments in their fields and also to maintain a high level of competency so as to provide quality and safe primary eyecare to the public.

Sir, I strongly support Part II of the Bill which calls for the establishment of the Optometrists and Opticians Board. With the setting up of the Optometrists and Opticians Board, under the new statutory regulatory framework, professional guidelines, including the training requirements for admission to the register, accreditation of courses and disciplinary actions against errant practitioners will be set. This would go towards raising the optometrists and opticians' professional standards and also instill a higher level of patients' confidence. In addition, in order to protect the interest of Singaporeans, I would like to suggest the imposition of provisional registration for foreigners or locals with overseas training should they want to practise in Singapore. This would allow the Board to assess the competency level of these practitioners before they receive

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their full registration. This practice is similar to those of other professional healthcare providers, like doctors and dentists.

The Schedule sets out the acts or activities contributing to the practices of opticianry and optometry. However, there is ambiguity in Part II of the Schedule on whether

the use of pharmaceutical eyedrops is permitted in the practice of optometry. Proper refraction of very young children requires the use of cycloplegic eyedrops such as mydriacyl, cyclopentolate and atropine. Such pharmaceutical eyedrops can give rise to local as well as systemic side effects or adverse reactions, and therefore must only be used with proper medical supervision and guidance.

Sir, while the Bill has many positive elements and is worth supporting, it is indeed like a duck floating in a pond. While we see the duck floating gracefully, we need to also be conscious of the duck's struggle below the water. The introduction of the Bill to regulate the industry would also cause disruption to the existing primary eyecare practitioners. The Ministry should strive to be as fair and as reasonable as possible in managing the current group of primary eyecare practitioners. It is estimated that, amongst these existing practitioners, about 40% are without any formal training. Requiring them to go for formal training, passing the test and then be registered with the new Board seems to be the right and logical thing to do. However, there are quite a sizeable number of them with decent on-the-job training and many years of experience, but may lack the linguistic capability to pass the necessary qualifying examinations for registration. They may therefore unwittingly be forced out of the industry altogether and lose their only livelihood. This would be unfair and very unfortunate.

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Lastly, one of the perennial concerns of regulating any industry is the added cost as a result of compliance. I urge the Ministry to closely monitor the situation with the implementation of this Bill and to reassure the public that the Bill would not lead to spiralling of costs in the primary eyecare.

Sir, on that note, I support the Bill.

Mr Speaker: Order. I propose to take the break now. I suspend the Sitting and will take the Chair again at 4.05 pm.

Sitting accordingly suspended

at 3.42 pm until 4.05 pm .

Sitting resumed at 4.05 pm

[Mdm Deputy Speaker (Ms Indranee Rajah) in the Chair]:

OPTOMETRISTS AND OPTICIANS BILL: Debate resumed.

Dr Fatimah Lateef (Marine Parade): Mdm Deputy Speaker, the eyecare industry is undergoing rapid development and changes. With our open and global market economy, the industry will see more partnerships, joint ventures, international patrons and also cross border collaboration and interaction. One very recent example of this would be NeuroVision, a Singapore-based eyecare specialist partnership with Essilor International, a world leader in optical products. With more such opportunities, we have to be prepared and adapt as well as evolve. Our standards have to be on par with the rest of the First World.

On 11th October 1953, a group of dispensing opticians met in Kentucky, USA, and the elected office bearers formed the society of dispensing opticians with a membership fee of only US$10 each. They formed it because, and I

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quote, "to promote increased efficiency and higher qualifications of dispensing opticians by state law providing licences only to properly qualified persons." That was in 1953. We are now in 2007. It is more than half a century, and it is indeed time for regulation.

Economic theory suggests that in the absence of regulation, certain health personnel may provide lower quality service at higher quality prices to uninformed consumers. Thus, regulation will help to improve services and protect consumers and Singaporeans are indeed high consumers of eye services and products. What with four out of five young adults being myopic before the age of 21 years, where one-fifth of our young myopics have a high degree of myopia being of greater than 600 degrees and where the current trend shows a higher rate of myopia starting at the pre-school levels. Regulation will certainly set the minimum standards of education, qualification and experience. It would also help to specify permissible boundaries of practice as there is frequent overlap in the job description of the optometrists and the opticians.

Regulation will help enhance professionalism as well. Professional ethics must be adhered to strictly. And with this, there must be a formalised programme of continuing professional development to help continuous enhancement of technical and practical proficiencies. This would require an appointed Secretariat working with the proposed Board to set minimum standards and required hours of attendances. For those in the profession, who are specialised or sub-specialised, there may have to be a separate requirement for that as well. And I note the details given by the MOS on this in his earlier speech.

An example for us to consider would be, in Hong Kong, the register of

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optometrists is divided into two different parts. Part I is where the optometrist who is registered under this Part can practise without any restriction. And for Part II, certain stipulated restrictions are there but Part II registered optometrist can be registered as Part I, if he fulfils certain training and experiential requirements. Documentation and checking system, preferably electronic, would also be required for ourselves.

There was a study in 1986 in the district of Columbia and it found that increasing the restrictiveness of optometrist's licensing examination had a positive and statistically significant impact on the price of eye examination and eye glasses but need not have a significant impact on the quality of eye examination measured by the thoroughness of the examination. We hope that the prices will certainly not be too much affected by the regulation that we are setting upon.

The setting up of the Optometrists and Opticians Board is essential and indeed very timely. However, I would suggest dialogues and sessions to meet up and reach out to those affected, to gather feedback and hear their inputs before formalisation. Perhaps, a team can be set up to randomly visit some of these existing optical and eyecare shops to assist with relevant explanation, get feedback and checks through engagement of these personnel.

And, as we have heard, there are over 800 retail shops dealing with eyecare products and only about 40% have qualified personnel. That is a very low number indeed.

I note with delight that there will at least be one person on the proposed Board who will not be a doctor, optician or optometrist, and this will usually be from the consumer. This is a positive step for the consumer to give feedback and also sit on the Board.

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I am also glad to hear that there will be allowance for the Board to set up an appropriate committee, when necessary, for special duties and projects. This is relevant, as those with valuable skills and inputs must be invited to come forward and contribute. Examples would be physicians, legal representatives and also consumers when necessary. The Board may also want to consider mandating display of certification. This is because with the current status, there are eyecare product shops a dime a dozen in most malls and also in heartland areas. Thus, for the public to know that the premises are registered and recognised, there must be some form of identification which the public can identify. As we know, there are many so-called opticians and optical shops that are available widely in Singapore, and some of them are actually very old shops that have been passed down from generation to generation where many of the people who run these shops are performing refraction and also optical procedures are not highly qualified and do not have formal education. So we may have to give them a bit of time to adjust to this new regulation as well.

The Board will also have to decide on the duration of validity for the certification of practice. Usually, for most other professions, this is stipulated at about two to three years, and there is a reason for that. This is because, beyond that, usually you would need to be upgraded and updated in terms of information. So, that is something for us to consider as well.

Currently, the line between an optometrist and ophthalmologist with respect to detecting and treating eye diseases is also blurring. In places without therapeutic pharmaceutical agent law for optometrist, such as in Singapore, they must still refer patients to ophthalmologists for treatment where eye diseases are being detected or are present. With respect to contact lens

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dispensing, too, there is a need to define the job scope further for clarity.

One more area for the Board to consider will be that of the recruitment of foreign-trained optometrists and opticians. As we see more foreigners in our midst, we must have an allowance for their recruitment as well. What will be the policy in terms of recognition of foreign certification or their entry criteria for a job in Singapore? Let me share with you an example from country X, where the professional and ethical standards for practice states:

"Foreign reciprocity: No foreigner shall be admitted to the Optometric Board Examinations unless he proves in a manner prescribed by the rules of court the country of which he is a citizen, subject or national either admits our citizens to the practice of optometry without restriction or allows them to practise after an examination on terms of absolute or strict equality with citizens, subjects and nationals of the said country."

We may not be taking a course along these lines but it is certainly something for us to consider.

On the issue of complaints, I hope there can be some design to facilitate the resolution of complaints at the lowest and most appropriate level possible and also to avoid duplication of complaint resolution processes. There must, however, be some flexibility in handling the complaints system. Options may include taking no action at all, a decision that an action is unnecessary or inappropriate, referral to an advocate or a provider for resolution, or calling a mediation conference without a need for formal investigations. Investigations will be reserved for more serious cases, certainly.

Finally, of course, the stiffer penalties that are stipulated in these current guidelines are something which hopefully will serve as a deterrent.

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Mdm Deputy Speaker, I support the Bill.

4.20 pm

Dr Lim Wee Kiak (Sembawang): Mdm Deputy Speaker, first, I would like to declare my interest as an eyecare professional, an ophthalmologist.

Singapore has one of the highest myopia rates in the world and an ageing population, which has been alluded to by my parliamentary colleagues earlier. This has resulted in an ever-increasing demand for quality vision correction, especially for myopia and presbyopia. The optometrists, opticians and ophthalmologists are the main eyecare providers to cater for vision correction and eye health provision for the entire population and the foreigners who are staying here. The optometrists and opticians form the primary eyecare layer, while the ophthalmologists provide the secondary and tertiary eyecare which is mainly interventional, be it medical or surgical. In this respect, the three eyecare providers work together to form a seamless eyecare continuum to provide the best eyecare possible.

The introduction of the Optometrists and Opticians Bill will provide the legal framework to recognise our optician and optometrist colleagues as professionals, an equal partner in doing their job. In doing so, the public will benefit with the assurance of a standard of professional care by the opticians and optometrists.

I have three concerns regarding this particular Bill, two of which have been mentioned by earlier speakers as well.

(1) Will the older members of the trade be given ample time and opportunities to get the necessary certification? As the Ministry has dealt with the traditional Chinese medicine registration, I am

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confident that that experience will be well used in this case as well. Some of the older opticians learned their trade through apprenticeship over many years. Although they are experienced, they lack the necessary qualifications. I hope the new Board formed will take this into consideration and provide them with ample time, opportunities and training to allow them to register so they can continue their practice but without compromise on the standard of care.

(2) Will the registration and recertification process result in an increase in the cost of eyecare to consumers? I think the likely answer is, yes. With this Bill, the optometrists and opticians will be licensed and they will need regular recertification to ensure currency of their knowledge and skills. While all these will ensure quality eyecare, they also mean an increase in cost. I hope the new Board will keep registration, training and recertification costs to a minimum, so that the increase in eyecare cost for consumers will be minimised.

(3) This is my chief concern - will this Bill result in an unhealthy competition and a division in the eyecare sector similar to what is seen in some states in the USA? I would like to highlight the dangers that this Bill may be divisive to the eyecare industry. I was in America about two years ago for the American Association of Ophthalmologists' (AAO) meeting. This is a very big annual meeting attended by about 20,000 ophthalmologists and, at that particular meeting, there is a standard clause there. They deny the attendance of all their instruction courses as well as lectures by any optician and optometrist. This is because some of the opticians and optometrists have overstepped their clinical competence and performed ophthalmic intervention procedures, including surgical procedures, on their clients. The optometrists have lobbied through their individual state legislature to allow them

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to perform ophthalmic surgery, such as Lasik, using the training certificate issued by AAO as proof of proper training. Such practice, as we know, is unethical and is detrimental to the standard of eyecare for the public. I hope the new Optometrists and Opticians Board will ensure and maintain the highest standard of optometry and opticianry care for the public. There is definitely a need for close continuous consultation between the new Board and the Chapter of Ophthalmologists in the Singapore Academy of Medicine to ensure close collaboration between all eyecare providers.

I am glad to note that at least, on the Board, one of them is an ophthalmologist. In order to ensure that there is close collaboration and consultation, may I suggest that this particular ophthalmologist appointed to the new Optometrists and Opticians Board could perhaps be a board member of the Chapter of Ophthalmologists in the Singapore Academy of Medicine. With that arrangement, I hope the new Optometrists and Opticians Board will work very closely with the Chapter of Ophthalmologists to provide the best eyecare to the public. I hope that in this way they will really work together and see eye-to-eye and not work against one another, an eye-for-an-eye.

In terms of providing eyecare, I do agree to some point with Mdm Halimah Yacob in the sense that opticians should be provided some leeway, but I do not agree that they should not be allowed to do refraction. I think it is a matter of training. With proper training, I think the optician should be allowed to do refraction. The key thing is for the new Board to decide and to make sure that their training is adequate to ensure that the opticians are able to meet the mark of standards to provide the best eyecare possible.

The second portion that I wanted to bring up is what Dr Lam brought up

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regarding the use of eyedrops. I think it is a great concern. To some of our ophthalmologist colleagues, they may see the use of eyedrops becoming an intervention. However, in performing their duties in eye examination, sometimes these eyedrops may be necessary. There are certainly dangers to the use of these eyedrops because there are side effects. I think, with proper training and certification, the optometrists may be allowed to use, but that I would leave it to the Board to decide, as well as in close consultation with the Chapter of Ophthalmologists.

With this Bill, optometry and opticianry in Singapore will no longer be just an optical trade, but a profession - a profession that has a role in looking after the vision health of the entire population and beyond. I sincerely look forward to an exciting new era in eyecare in Singapore with optimism and enthusiasm.

Mdm Deputy Speaker, I support the Bill.

4.26 pm

Mr Zainudin Nordin: Mdm Deputy Speaker, thank you for this opportunity to speak on the Optometrists and Opticians Bill. Please allow me to start with these facts as a layman.

Myopia is the most common eye problem among children in Singapore. One in four seven-year-olds in Singapore is myopic, compared to about one in a hundred in Australia. Every other 12-year-old Singaporean suffers from myopia. Over 80% of our 18-year-olds are shortsighted. These figures rank the country as having one of the highest rates of myopia in the world. If poorly treated, this medical condition can lead to irrecoverable loss in vision or, worse still, sometimes blindness.

With such an alarming rate of myopia in the country, it is worrying to know that

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apart from the Contact Lens Practitioners Act of 1985, the eyecare industry is currently self-regulated. While we have first-class research and education expertise at the Singapore National Centre, a comprehensive cost-effective primary care structure is lacking. For instance, optometry, as a profession, is not really recognised. Practically, anyone can set up an optical shop, do a so-called eye test and issue prescription spectacles. In these cases, without the proper qualification and training, myopia and common eye diseases in children and adults will go undetected, poorly treated and, eventually, could lead to irrecoverable loss in vision.

Mdm Deputy Speaker, we must realise that people who visit the optical shops are not merely "customers" seeking cool shades. They are actually patients seeking a diagnosis and treatment of visual deficiencies and eye health from someone whom they perceive as an "eyecare professional". Unfortunately, under the current circumstances, this might not necessarily be the case. Sometimes, our vision is blurred by the appearances, especially when we enter a shop and are greeted by people in a crisp white coat and a shiny nametag. While there are opticians or optometrists who are truly qualified out there, there are also some who are merely "optical illusionists".

In order to enhance our capacity for competent and cost-effective eyecare, the Ministry of Health has rightly introduced a statutory regulatory framework to regulate the practice of optometry and opticianry in Singapore.

In essence, the general public has a lot to benefit from the proposed changes. I am confident, Madam, that the new regulation will raise the overall standard of eyecare by ensuring a certain level of competence, standards of practice and

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accountability by a certified eyecare professional.

When a patient goes to see an optician or optometrist, he can be assured that the person he meets is a properly qualified, trained and recognised optometrist or optician. The patient will also know that the skills and knowledge of these practitioners are continually kept up-to-date with the latest developments in their field through a systematic professional education programme.

The effectiveness of regulating the eyecare industry can be seen in many developed countries, such as the US, UK and Australia, who already have similar legislation in place. In most cases, statutory regulation has proven to improve the quality of eyecare for the patients and also develop experts and professionals in the practice of optometry. This also leads to an expanded scope of practice and career development.

Mdm Deputy Speaker, qualified optometrists and opticians have an important role to play in patient education. Optometrists who are academically qualified are commonly regarded as the general practitioners of eyecare. For example, in the United States, Canada and the Philippines, very often, the practising optometrists are highly qualified and he carries the title of "Dr of Optometry" as he provides professional primary eyecare. And, at times, the combined assessment by an eyecare professional together with the relevant medical specialists can lead to early detection of systemic manifestations such as anemia, diabetes, hypertension, neurological problems such as tumours and minor strokes, not to mention many primary eye conditions. For maximum effectiveness, the Government needs to embark on a continuous public education programme to help patients better understand the field of optometry. Singaporeans need to see the differences

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between opticians and optometrists and the capabilities of each professional. Only then can members of the public help to weed out the errant practitioners. Before seeking treatment, patients should approach their practitioners eyeball-to-eyeball and demand that they provide their qualifications and relevant certifications.

I mentioned earlier that myopia is the most common eye problem amongst children in Singapore. I believe that we are all very concerned with this trend. I am also encouraged to see that in the 2007 Budget, $86 million has been set aside for health education and promotion initiatives including the National Myopia Prevention Programme. I have been following the National Myopia Prevention Programme organised by the Health Promotion Board since it started in 2001 and would like to enquire on the public response and effectiveness of the programme. Are we doing enough to raise awareness on myopia amongst the students and parents? Can we include in the proposed legislation a programme with all the eyecare professionals to support the national programme, especially in patient education?

Besides the problem of myopia in our younger population, we also face the problem of blindness in the young. Could we also enlist the support from these eyecare professionals to screen for conditions such as glaucoma, cataracts, age-related macular degeneration and refractive errors which can affect the vision of the elderly? While patients with refractive errors can be treated by the optometrists, those found to have age-related macular degeneration, which is a leading cause of blindness in developed world, or glaucoma or cataracts, should be referred to the ophthalmologists for proper treatment. If left untreated, the patients may be unaware of its seriousness and treatment may no longer be effective.

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Mdm Deputy Speaker, the introduction of this Bill is both timely and necessary. I strongly believe that the proposed framework will benefit both patients and the profession. Patients can be assured of access to eyecare that is affordable and of high standards whilst practitioners will be accorded their deserved professional development, recognition and protection.

Mdm Deputy Speaker, I support the Bill.

4.33 pm

Mr Heng Chee How: Mdm Deputy Speaker, first, I thank the Members who have spoken - Mdm Halimah, Dr Fatimah Lateef, Dr Lam Pin Min, Dr Lim Wee Kiak as well as Mr Zainudin Nordin for their very constructive views and for their strong support for this Bill.

I am very happy that we all agree and see very clearly the key intentions of this Bill which are that eyecare is a very important part of well-being and, as a country, we must do our utmost to safeguard and promote it and that optometrists and opticians play an integral and important role in this entire care spectrum. So the regulation of these two professions, properly done, will enhance the national objectives. What are these objectives?

It would be that we want our population to have access to quality, high standard and safe eyecare at prices that are affordable, and doing so in a way that takes into account the market realities, without compromising safety and standards, to move forward with minimum disruptions.

I have grouped some of the comments by the Members into several parts and I will take them in turn now. Mdm Halimah was of the opinion that we adopt the situation in many other countries where

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you draw a clear line in the area of refraction - let the optometrists do the refraction and do not let the opticians do it, because it is something that is specialised. Some of the other Members have mentioned that we ought to take into account the fact that there are already opticians in Singapore who have been doing refraction adequately, and for years.

Dr Lim Wee Kiak has also pointed out to us that it is not a question of who gets to do it but whether or not the person who is doing it is competent to do it. And on this point, I agree with him, namely, it is a question of safety and standards. So, therefore, in this process of regulating, what we are going for is not to say that whoever is an optician and decides to do refraction, that he can just carry on and do it, but that there will be a competency test. And those who want to do refraction as opticians will have to pass this test. And if they pass, they will be certified that they meet the standards and then they can do so safely for their customers. And if they do not pass, then they go through an upgrading programme in order to make sure that they are competent before they are certified to practise. Then, for opticians who do not want to practise refraction - they just want to do dispensing - they will be certified to do dispensing. In that way, we separate between the groups of opticians and make sure that only those who are competent and certified to do refraction do refraction.

Mdm Halimah also asked how we intend to go about enforcing this Bill once it is passed. I think, as in all legislation, enforcement is key in order for it to be credible. Yes, there are many hundreds of optical shops out there and it will not be possible to station a checker or an inspector in every shop all the time to ensure that nothing goes wrong. But the

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same could be said of any other kind of business. In the end, it would be through a combination of opening up the channels for feedback, collecting information and intelligence of where sub-standard service, incompetent service or unlawful servicing might be going on as well as through regular and surprise inspections, and taking to task those who have been found to be in breach of the regulations. Through this combination of efforts, I think we can send a very strong signal to the industry that, on the one hand, we provide upgrading paths as we want to ensure standards and, on the other hand, that those who do not comply with the regulations would have to face the music. By doing so, we would make sure that nobody in this industry goes off with the wrong impression that they can continue in any way to remain unprofessional and get by with it and, in a way, cheat the customer.

I must also say that industry associations can play a very important role here. These associations have members who are opticians or optometrists and it is in their professional interest that they encourage their members to comply fully with those regulations as well as to take full advantage of all upgrading opportunities.

Dr Fatimah raised the point that even as we enforce and there may be complaints, the flipside of it is how we resolve these complaints without making the process too cumbersome. If they are the simple ones, can they not be resolved as simply as possible at the lowest possible level? I think that is a good suggestion. We have to see it in the context of the entire mechanism of dealing with these complaints and investigations, to grade the different types of complaints. Those that are suitable for resolution at the lowest level, the simplest possible level, should be so resolved. But, at the same time, I think it should also be very clear to people that if there is

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wrongdoing, it will be fully investigated and there are regulations to provide for that.

On the question of public education, including educating the public to go for regular eye screening and so on, we completely agree, and this is something that we have to step up and maintain our efforts simply because good vision is very important to our population.

On the point of whether regulation would drive up business cost, we will put it this way. Obviously, if you do not have to comply with anything compared to if you have to comply with something, a certain amount of attention has now to be paid. As far as the Optometrists and Opticians Board (OOB) is concerned, I am very sure that it will not be in its interest nor will it be its intention to drive this cost up unnecessarily. I would say that it will regulate only as necessary and not make that an issue that would hamper the practitioners and, ultimately, have the cost passed on to customers and undermine one of the fundamental objectives, which is affordability. So it is a question of balancing. But the intention must be to keep it to the minimum.

On the question of those practitioners, especially the opticians who have been doing so for many years but who may lack the language abilities or the formal education, under the implementation process, the idea is that for those with more than five years' experience, they will be put through a competency test. It is a practical test, so they are not placed at a disadvantage if, for example, they cannot speak English. And if they have experience and they know how to do it, that test will reveal their competency and they will be certified for it. Even for those who do not pass it the first time, there will be another attempt and there will be a course for those who have to go through upgrading. So I want to assure the House that every effort will be made to enable people with the competence to be so

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certified but they must demonstrate that competence.

On the question of the respective roles and the synergies that can come out of the three groups - the ophthalmologists, optometrists and opticians, which Dr Lim Wee Kiak brought up - if we do it properly, we can indeed derive those synergies that he talked about and that must indeed be our aim. I am very sure that the OOB, in its establishment, will make that a priority. It will be aided by the fact that its composition would have representatives from all three groups and more. And Dr Lim Wee Kiak's suggestion that a particular nominee comes from the Chapter of Ophthalmologists is something that the OOB can take into account.

There were inputs from Dr Fatimah as well as Dr Lam Pin Min on what we can do with regard to the conditional registration of foreign practitioners. Again, I thank them for their inputs and we will take this into consideration in drawing up the regulations.

On the specialist eyedrops, which is that line between the optometrist and the ophthalmologist, I think the general response will be the same as that for refraction, which is between the opticians and optometrists which is that, ultimately, it is the science of it, the competence of it, that safety is of primary concern, and we will make sure that in regulating this, we will not subject our population to risks that they ought not be exposed to.

There is a suggestion on the display of certificates so that a member of public, who does not know who is whom, can actually look at the certificate and feel confident that if he comes into the shop, he will get good standards and safe eyecare. This is a very good idea. I believe this will be taken up.

Mr Zainudin Nordin has also asked for an update on the Health Promotion

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Board's National Myopia Prevention Programme. This programme was started in 2001 and it was done in partnership with the Ministry of Education and MCYS. The aim of the programme was to delay the onset and reduce the progression of myopia in children. The prevention strategies include public education targeted at parents, teachers and children to inculcate good eyecare habits, such as adopting correct posture when reading, ensuring adequate lighting and having regular outdoor activities.

The HPB also introduced a vision screening programme in primary and secondary schools, and a Spectacles Fund to help children from needy families buy spectacles. On this, HPB works closely with kindergartens/childcare centres to extend the vision screening to pre-schoolers. The aim is to identify children with early myopia and the lazy eye problem. About one in seven pre-schoolers have defective vision and they are referred to refraction clinics in the polyclinics for further assessment and management. For children with the lazy eye condition, early treatment can prevent the development of functional blindness. These are serious ongoing efforts, but we also recognise that bringing down the myopia rate is an uphill task. We will continue to put in our efforts in this area to slow down the progression, even if we may not able to reverse the rate in the short term.

Mr Zainudin has also suggested that the HPB work more closely with the different eyecare professionals to enlist their help in this programme. The HPB will consider how best to do this.

Mdm Halimah Yacob: Madam, I just want to seek clarification from the Minister of State for Health. The first clarification I would like to ask the Minister of State is whether he agrees

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that by having two Registers - one for optometrists and the other for opticians - there is already a recognition that there are different levels of competencies residing in these two categories of professionals, and that even with the enhanced training, this dichotomy remains. If this is the case, should we not then, as we are trying to internationalise our medical hub and as we are trying to aspire for higher standards, also try to align our practice with international practice or the practice that exists in the developed countries? We may not aspire today but we can certainly aspire for the future, in the sense that existing opticians - I know there are over 1,500 of them - certainly, we do not want to break their rice bowls and affect their livelihood. But should we not consider better standards for the future? Because we are already recognising this by having two Registers with different competency levels. Should we not move higher in line with the developed countries?

My second clarification is: in MOH's view, how do we help the public so that they will not be confused when we now have opticians who can do refraction and opticians who cannot do refraction? They already have a big difficulty trying to assess whether those who are dispensing spectacles and contact lenses are competent or not, but now in addition to that, there are sub-set opticians and optometrists and there are opticians who can do refraction and those who cannot. Could the Minister of State clarify and enlighten how we do not further confuse the public? What are the blind sights of this particular strategy that you are having?

Mr Heng Chee How: Mdm Deputy Speaker, on the first question of having two Registers - one for optometrists and the other for opticians - that is correct, because we are not saying that they are the same. They are not the same. Yes, optometrists can definitely do refraction,

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but optometrists are not just opticians who can do refraction. They can do other things as well. So it is a spectrum. What we are saying here is that some opticians in Singapore over all these years are already doing refraction, and there are opticians who are just doing dispensing. Opticians who are doing refraction, subject to being tested and certified to demonstrate their competence, can carry on to do refraction. This does not make them optometrists.

For opticians who can do refraction and want to become optometrists, they must then take on other skills in order to qualify for registration as optometrists. That is why we have two Registers. Even if an optician can do refraction, he is not an optometrist. That is number one.

Her second question is whether we will further confuse the public when the Act comes into force, in the case of a person who walks into a shop and sees some opticians who can do refraction and some who cannot. The reality today is, with or without this Act, there are opticians in Singapore who are doing refraction and there are opticians who are not doing refraction. This is the current situation. What we are doing here is through a process of certification, and what Dr Fatimah Lateef has suggested, namely, the display of certificates, and through public education, ie, what types of eyecare professionals are there and what they do respectively. So it will take time, as the public gains more awareness of the different types of eyecare professionals and who they should see and for what. This is a process that will go on and, through time, people will be more aware of it. But the point is that when the Act comes into force, nobody walking into a shop of an optical service provider will be subjected to unsafe eyecare. That is the point.

Mdm Halimah Yacob: Mdm Deputy Speaker, I think the Minister of State

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missed the gist of the first point I made. My point is that we are trying to make ourselves into an international/regional medical hub. And, obviously, we therefore want to align ourselves with international standards, especially that of developed countries. In developed countries, refractions are done by optometrists, and not opticians, which means that they have moved to higher standards. Should we not also be thinking about that, not immediately? I recognise that there is a dearth or insufficient opticians to provide for the needs of the population at the present moment. There are over 1,500 opticians and it is not right to break their livelihood. But should we not be moving towards higher standards in the future? Should there not be some signal of that from the Ministry of Health, because I see the current Bill as maintaining the status quo ? What I am concerned about is: are we moving towards higher standards that we hope to achieve under this Bill? That is the point that the Minister of State missed.

Mr Heng Chee How: Mdm Deputy Speaker, I thank Mdm Halimah for that clarification.

What I wanted to say is that, internationally, optometrists are trained to do refraction, ours included. In our situation, which is unlike that in many other countries, we have some opticians in Singapore who do refraction. For a start, what we are saying is that provided they can demonstrate their competence, we will register them and allow them to continue to do this refraction component as opticians. Then we have the OOB set up under the Act. In a dynamic situation where the science is changing, the economics of practice amongst opticians, optometrists and ophthalmologists may also be shifting. So, in that situation, the Board, over time, would have to review and take into account all these factors and to see how best to balance between

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the needs of the three groups, and then balance that as against the needs of the population in terms of safety and standards. And, finally, how do we position that in favour of the development of the eyecare industry in Singapore? All that will take place and it is something that the OOB will certainly look at very carefully in its work.

Question put, and agreed to.

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

The House immediately resolved itself into a Committee on the Bill. - [Mr Heng Chee How].

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