MEDICAL REGISTRATION (AMENDMENT) BILL

11 Jan 2010

By Mr Khaw Boon Wan, Minister for Health

Venue: In Parliment

SECOND READING SPEECH BY MR KHAW BOON WAN

MINISTER FOR HEALTH

IN PARLIAMENT: 11 January 2010

Mr Speaker, Sir, I beg to move, “That the Bill be now read a Second time”.

2 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 in so doing, maintain public confidence in the medical profession.

3 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 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.

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

(a) SMC’s Disciplinary Processes

5 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 a 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 6292 in 2003 to 9033 in 2009. This works out to about 11 complaints per 1000 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, for example, a simple complaint took about three months to conclude, and a 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 appeal against the Disciplinary Committee’s decision under the current Act. This is unsatisfactory.

6 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 6 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. 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 (e.g. a chairman of Complaints Committee or Health Committee must be a Council member) 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 4 to 3 members, and all 3 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 specifically require the chair and one member to be Council members as is the case today. The Disciplinary Tribunal‘s chairman and members will be constituted from a panel of Chairmen appointed by 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.

7 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.

8 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 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.

(b) Expanding the range of orders

9 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.

10 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.

11 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 psychiatric treatment, or report on the status of his fitness to practice 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 3 years, cancel or suspend his practicing certificate, or impose restrictions and conditions on his practice.

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

12 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 to three years. There is, therefore, a significant gap in the range of penalties in the current Act.

13 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. The increase in fines is intended to be paid solely by the medical practitioner and will therefore not add to an increase in annual indemnity fees paid by our doctors. 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 available to the Complaints Committee. All this enhances the powers of the Tribunal by expanding the array of possible orders.

14 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.

(c) A more nuanced medical registration

15 Third, we seek to enhance medical registration for both local and foreigntrained doctors. Mr Speaker Sir, to cope with the increasing 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.

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

17 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 foreigntrained doctors from good medical schools. There is a sizeable influx of foreigntrained doctors, both foreigners and Singaporeans who studied overseas, into our medical workforce. Last year, 66% of new medical registrations were foreign-trained. 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 the 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.

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 SMC to register a foreign specialist, and limit the scope of his practice to only their 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. This will help safeguard public interest and safety.

(d) Registering Family Physicians

18 Fourth, we propose to set up a register of Family Physicians. With an aging 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. 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 save costs.

Miscellaneous Amendments

19 Finally, we are taking the opportunity to introduce a number of miscellaneous amendments to enable 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 SMC to publish a list of doctors in the Gazette, as such information is now regularly updated on the Council’s Internet website; and

c. Clause 31 which allows the SMC to compound offences in lieu of prosecution.

20 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

21 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.

22 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 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.

23 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.

24 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.

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

26 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, the Director of Medical Services (DMS) wrote to all the 8,000 registered doctors in Singapore, to explain 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 officer can be appointed to chair the Disciplinary Tribunal. The vast majority of the medical community have no objection to the provision, after the detailed explanation by the DMS.

Conclusion

27 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. 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.

28 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 reputation of our good medical professionals.

Sir, I beg to move.