PRIVATE HOSPITALS AND MEDICAL CLINICS (AMENDMENT) BILL

[Mr Speaker in the Chair]

Debate resumed.

Dr Lily Neo: Mr Speaker, Sir, I rise to speak in support of the Private Hospitals and Medical Clinics (Amendment) Bill. I would like to declare that I am a medical practitioner.

Sir, I must say that the introduction of this Amendment Bill is necessary and indeed timely. The extensive amendments are welcome as they suitably update the 1995 Edition of the Act to cater for the vast changes in the healthcare industry. It would appear to me that the main crux of this Amendment Bill seeks to rope in control of the so-called "healthcare establishments". I would suggest that the words "healthcare establishments" be inserted into the preamble of the original Act. Sir, this notwithstanding, I would like to seek clarification on several other matters in this Bill.

Would the Senior Minister of State for Health clarify on one of the main objectives of licensing the various private healthcare establishments, laboratories, clinics and hospitals in Singapore as provided in this Bill? Is the assurance for quality of such premises or the control of quantity of such premises the priority? Sir, my concern is that with the latter, we shall create, in the future, a tradable commodity for those licences of existing practices. This will pose difficulties for young doctors to set up new medical practices and other healthcare personnel and concerns to set up laboratories and hospitals. The problem may be further compounded if the controlled and restricted numbers of licences from existing holders invariably become scarce commodities. Mr Speaker, Sir, I would like to know if the licensing mechanism will enable better distribution of healthcare establishments in Singapore. Let us be reminded of a past incident where six clinics were opened in the same block of an estate. No doubt, the problem then was due to the "tender scheme" for HDB shops.

In the amendment of section 2 under clause 2(b), the definition of "healthcare establishment" as any premises or conveyance (not being a private hospital, medical clinic or clinical laboratory or part thereof, and not being an establishment or conveyance maintained by the Government or the National University of Singapore) that aims to provide the services stated would mean that a wide range of premises or conveyance will fall within the ambit of the Act. Sir, would the Senior Minister of State for Health confirm whether a wider definition like this is intended so that traditional Chinese medical clinics, acupuncture centres, health spas, and the like, can be included for licensing? That these establishments may provide or attempt to provide diagnosis, treatment, or care of persons suffering from any disease, injury, or disability is indisputable.

I applaud the provision for Quality Assurance Committees in new section 10 to enhance and ensure the quality standards at private hospitals and healthcare establishments. This amendment provides for transparency in quality control and reassurance to recipients of healthcare in Singapore. New subsection 10(3) is good, as this will give protection to quality assurance committee members and will facilitate their unrestrained and efficient contributions. My concern is on new subsection 10(4) in that the minutes of the meetings can be made available for any proceedings. Will these not erode the protection to the said members in any proceeding?

Related to the implementation of the Act, I would like to urge the Senior Minister of State for Health to cause her Ministry to be mindful of two issues:

(1) A surfeit of fees chargeable for various licences. For instance, in the case of a medical practitioner, besides the $600 fee for the clinic licence every two years, there are fees for the practising certificate, medical insurance, equipment like an ultrasound machine, and so on. All these add up to higher costs and run counter to our aspirations of containment of healthcare cost. Would the Minister consider waiving the fees or at least keeping them reasonably low?

(2) The new section 11 gives the Director or an authorised officer very wide powers to enter, search and inspect any premises and to ask a licensee to furnish information. Although we can understand that such powers are necessary to facilitate checking and compliance, I hope the licensees are not subject to excessive demands for inspections, data collection and submission or for surveys and audits. These can be counter productive insofar as they are fundamentally laborious, disruptive and expensive.

I hope this Amendment Bill will enable the Ministry to fulfil an effective "watchdog" role. Sir, I support the Bill.

Mdm Claire Chiang See Ngoh (Nominated Member): Mr Speaker, Sir, thank you for giving me the opportunity to speak. I agree, in principle, with the main thrust of the Bill which is to regulate the standards of medical care in the interest of the public. Although this Bill is intended to enforce good medical audit on healthcare institutions that are "western" in medical orientation and treatment, I urge the Minister to expand its scope to regulate non-western and experimental health practices.

In the past few years, we observe the growth of a grey spectrum of healthcare practices which some call "alternative medicine" and others call "complementary health systems". Some are more acceptable forms of alternative medicines like Chinese herbal treatment, homeopathy and acupuncture which apply different modalities towards health recovery. There are also the high-tech "clinical" centres offering services in colonic irrigation, live cell therapy, hair transplants and other forms of transformative cosmetic surgery. We have had cases of people dying because of botched up colonic irrigation or scarred by plastic surgery performed by inadequately trained beauticians. Hence, we have to be wary of these medical practices which are of questionable medical benefits.

This Bill is therefore timely, some may even argue that it is long overdue. It is an enabling instrument which will give the authorities the legal teeth to classify and regulate all healthcare practices and to vigorously intervene, when necessary, to safeguard the integrity of the medical profession and protect the public. But, Sir, I do have some qualms on certain elements in the Bill which, if not corrected, may not provide sufficient guidelines and checks on the authorities in the pursuit of their duty.

I would like the Minister to clarify four points. My first query is on the notion of "healthcare establishment". The advocates of alternative and complementary medicine will regard their healing modality as more holistic and less invasive than "western" institutional medical practices. Are these healing "clinics" in meditation, aromatherapy, acupuncture, foot reflexology and other holistic and wellness centres classified as "healthcare establishments"? Not only had these new approaches gained popularity among entrepreneurs who wished to develop them within medical institutions in the new millennium, users in the community have argued in favour of their "treatment" potency. A massage, for example, is regarded as having more healing power than the panadol. This marks a shift of medical preference in some pockets of Singaporeans away from western clinical methods of healing.

I would like the Minister to articulate at this juncture, other than the institutions earlier named by her, what would she define as "healthcare establishment". In line with my concern with the non-traditional medical institutions, are slimming centres, beauty parlours and hair transplant salons classified as "health establishments"? Do the practitioners like Chinese sinsehs and counsellors with non-credentialised qualifications in the new healing trades come under the scrutiny of this Bill? If they are not, I urge the Minister to consider broadening the scope of the Bill that enables the Ministry to regulate their growth, classify the plethora of healthcare practices, supervise and sanction their service and professional standards.

My second concern is on the notion of "prescribed standards" in relation to the issue or refusal to issue a licence by the Director. Alternative health healing practices are now carried out by individuals who are paid to make home visits to attend to the sickly, often without assistance of any nursing staff. Some are trained healers, having studied abroad, where alternative medicine has become institutionalised, many others are not accredited by any training body but have gained their healing experience through work. These same practitioners are invited sometimes by private clinics and hospitals to conduct limited healing programmes for the patients. If any mishap happens during the treatment and a patient suffers or dies, is the institution employing these holistic practitioners held responsible for the problem? Where do these freelance practitioners stand in relation to the Bill? I urge the Minister to develop some broad guidelines of "prescribed standards" in each field of "western", "traditional", alternative or complementary medicine to guide entrepreneurship in this area. I can understand that the Minister may not want to come down "heavy" on these practitioners by killing the industry with a narrow set of "do's" and "don'ts", but neither do we want to leave the matter so open that will lead to explosive contention upon the disagreement of definitions and standards between policy makers and practitioners.

That brings me to my third question on safeguards for practitioners. In the event that the Director revokes the licence of a medical establishment, what recourse is there for the licensee to have his case heard independently without prejudice? The Bill provides for appeal to be made to the Minister who will then set up an Advisory Committee to review the petition. Would the Minister consider setting up a recourse mechanism and procedures that allow an independent and professional judgement of alleged offences? In relation to this matter, does the Medical Council have a regulatory and disciplinary function in adjudicating the judgement process?

My fourth and last concern questions the total protection from any suit or other legal proceedings which the Director, any authorised officer or any member of an Advisory Committee enjoys. What is the rationale, Sir, for this protection? And how can we make sure that they will execute their duties in good faith, consistently and by maintaining a high level of sound judgment if they were not held responsible for wrongful decisions or malicious decisions? If directors in any business corporations come under the scrutiny of the laws, why not the Director in executing this Bill? Is it appropriate or necessary to endow so much power in one Director since the Attorney-General's Chambers are already entrusted with the jurisdiction to try any offence related to health malpractices? Could the Minister elaborate on some of the qualified privileges which the Director has to abide by before he proceeds to search and seize documents from private practices? I hope that the Minister would clarify these points in her response.

Dr Aline Wong: Mr Speaker, Sir, I will attempt to answer the points raised by Dr Lily Neo first. In general, she supports the Bill but she has raised a couple of issues. First, the issue of quality versus quantity. She asked whether the main objective of the Bill is to regulate quality, that is, the standard of the professional services or control the quantity, that is, the number of healthcare establishments that will be set up.

Let me reiterate that the main objective of the Bill is to give my Ministry more effective means to ensure that hospitals, clinics and nursing homes maintain a good quality of care and that there are provisions within the establishments for the QA activities. So the Act primarily seeks to enforce the parameters that the hospitals, nursing homes and clinics must work under in order that the health services given to the public are of a high standard. The new section 5(3) of the Bill defines the parameters for the Director to issue or refuse to issue a licence but none of these parameters refer to the distribution or the number of hospitals, clinics or nursing homes. In other words, the Bill does not control the number or distribution of such premises. She was correct in pointing out that one sometimes finds in HDB estates a concentration of five or six medical clinics. But this is the result of the tendering process where the doctors make a decision to locate their clinics in a certain locality. We have, in the past, left it to market forces and I think we should still leave it to market forces to decide on the number and distribution of healthcare establishments. The Bill is not intended at all to cover this aspect of her concern.

I would discuss her point about whether traditional Chinese medicine or acupuncture clinics can be considered as healthcare establishments under this Bill, and other kinds of healthcare establishments that we might want to regulate, later on.

She was concerned also about new sub-section 10(4) which states that "the minutes of meetings can be made available for any proceedings" and whether it would erode the protection of the said members in any proceedings. Under sub-section 10(3) of the Bill, a person who is a member of a QA committee is not compelled to disclose the proceedings of the committee. However, sub-section 10(4) would only apply if the Ministry has adequate reason to believe that this person has not acted in good faith and there is some deliberate cover-up of wrongdoings by the doctor under investigation. The Director can then require that the relevant information or minutes of meetings be made available for review. This is the same question that Mdm Claire Chiang has asked about qualified privilege. In other words, a member of a QC committee is protected by this Bill and is not compelled to divulge any proceedings, but if there is reason for the Ministry to suspect that there is some wrongdoing or that the QC member did not act in good faith, the minutes of evidence could still be called for. The Ministry can still look into this evidence and an aggrieved patient or doctor would still have recourse to the normal process of the law to sue, because if the QC member was found not to have acted in good faith, then what he said and his opinions in the QC committee would still be open to legal judgment.

As for the high fees that Dr Lily Neo talked about, I would like to clarify that the $600 clinic licence fee is actually for two years. It is not for one year. Also, this licence allows a clinic to have up to five doctors or dentists. The onus on a single or individual doctor or dentist is not that heavy in terms of financial burden. I take her point that doctors have to pay for their practising certificate, clinic licence fee and also some charges or fees for equipment such as ultrasound, laser, x-rays and so on. These are meant to cover only administrative expenses for enforcing the regulations under the various requirements. I have actually thought about this and I asked for some comparative figures on what lawyers have to pay to stay in the practice. They pay much more, in fact. For example, a practising certificate for lawyers can vary between $450 and $750 per year. All of them have also to pay for an indemnity policy, on an average of $4,000 for every million dollar revenue collected, as compared to the doctor's medical defence insurance which is just between $1,000 and $2,000. But this is for the good of lawyers and doctors. They should cover themselves with such funds. On top of that, if lawyers want to be a notary public or a Commissioner of Oaths, they have to pay an additional registration fee of $1,000. I should say that lawyers are comparable to doctors as professionals, but the fees they pay are higher than what doctors are paying under our present schedule.

I take her point that these fees should not be too onerous and her point that the requirement for licensees of healthcare establishments to furnish information on their practice, procedures, and so on, should not be too onerous. I would like to assure her that the visits would be coordinated by the various sections of the Ministry and my officers would make sure that the data collection and submission will not place an undue demand on healthcare establishments at the expense of their productivity.

Finally, she asked that the term "healthcare establishment" should be put in the preamble of the Act. I can look into that. I think there is no problem with putting back the term "healthcare establishment" into the preamble of the Act.

On Mdm Claire Chiang's concerns, I find her reference to the Director of Medical Services as being comparable to the director of a company rather puzzling. I think we are talking about two different things. The Director of Medical Services is charged with the responsibility to oversee the professional standards of the entire health sector. I find that it is not really a comparable issue.

As far as appeals are concerned and on safeguards, if the licensee commits a certain breach of the licensing requirement, this would be under the purview of our Ministry's regulations. The Act already provides for the composition of fines, instead of bringing the licensee to court. If it is a matter of medical ethics or a professional lapse, then the person would be brought before the Medical Council. So it is a matter of professional judgment and the Council is an independent body. I can assure her that various bodies are in place to regulate the healthcare establishments and to ensure that they perform to certain standards within the purview of this appeal process. If a licensee is aggrieved, he can appeal to the Minister and the Minister can appoint an Advisory Committee. This Advisory Committee would be a panel of experts, depending on the type of healthcare establishments you are talking about. Obviously, a dental clinic would be under a panel of dentists. A medical clinic would be referred to a panel of medical professionals who are in that specialty. We are talking about having panels of experts to assist the Minister in Advisory Committees. This appeal process is in place.

Why should they be protected in the same way for their opinions? As I explained, both the QA committee and members of the Advisory Committees are to give their opinions to the hospitals, the healthcare establishments or to the Minister in good faith. They can express their opinion very frankly in such committees and they give their opinion in good faith. But they are only given qualified privilege. If there is any reason to doubt that they are trying to cover up any mistakes done by the hospital or to protect another colleague, then there is a process whereby their evidence could still be discovered.

As for alternative medicine, I share her concern that there is a proliferation of so-called alternative medicine, complementary medicine or alternative healthcare practices springing up in Singapore. This is a world-wide trend and I think many countries in the world are still grappling with how to regulate and recognise them. I would not want to give my opinion on whether these alternative practices are more holistic than western medicine. I would not want to give an opinion on whether they are holistic or not. But definitely, they exist. Some have long traditions, like traditional Chinese medicine. Some have sprung up recently, like the revival of customary healing practices and so on.

At present, traditional medicine, whether it is of the Chinese, Malay or Indian tradition, is exempted from the Private Hospitals and Medical Clinics Act, just as these practitioners are exempted from the Medical Registration Act. But as I have informed the House in the Budget debate last year, we are already going into the area of registering acupuncture within the near future. With the registration of acupuncturists, we would go into the registration of acupuncture clinics and then maybe we would move on to other areas of traditional Chinese medicine.

As for other kinds of complementary medicine, I think we have to tread with great care. We have to be very cautious. The boundaries are vague and the claims are also very difficult for us to evaluate. We have to tread very slowly. But the Amendment Bill will precisely enable us to go into regulating them, if there is a need. At the moment, health or wellness centres and health spas do not carry out the kind of diagnosis, treatment and care of people with disease, injury or disabilities in the same way as medical practitioners do. So they are not under the purview of this Act. I think we have to be very careful about going into the area of regulating slimming centres, beauty salons and so on. We have already gone into regulation of cosmetics. The Amendment Bill will allow us the flexibility of regulating these other kinds of so-called healthcare establishments, if there is a need to.

On her point about colonic irrigation clinics, the case we know was an unlicensed clinic, and it is precisely because of this incident that we need to enhance our powers to go and search premises, and seize evidence because we had difficulty in getting evidence to prosecute this case. We had to seek the support of the Police because it was done in unlicensed premises. I think I have covered most of the points that she has raised, Sir.

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. - [Dr Aline Wong].

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