SPEECH BY MR EDWIN TONG, SENIOR MINISTER OF STATE, MINISTRY OF LAW AND MINISTRY OF HEALTH, AT THE FAMILY MEDICINE CONVOCATION CEREMONY AND DINNER 2019, 23 NOVEMBER 2019

Adjunct Assistant Professor Tan Tze Lee, President, College of Family Physicians Singapore,

Distinguished guests,

Ladies and gentlemen,

1. This evening, we celebrate the Family Medicine Convocation Ceremony and Dinner We will soon see more than 200 graduates start their career in Family Medicine, a significant milestone in your career, one where we hope that you have acquired sufficient skills to start. Never forget that these skills do not last you a lifetime. Skills have to be continually upgraded and updated, and remain relevant. So we hope that as you graduate and you reach another milestone in your career, that you do not look back at this as the end of the journey.

Evolving Healthcare Needs

2. Let me set a bit of the landscape of what you are going into, much of which I think you would already know but let me just emphasise a few points from the report on the Burden of Disease in Singapore 1990-2017. One, Singaporeans are living longer, and as a matter of record, the women live a little bit longer than the men, with life expectancy for men at 84, and for women at 85. Second, despite the increased life expectancies, we also spend more time in ill health. If you look at the overall period of time, we have done very well – among the best in the world for life expectancies but the period of time spent in ill health is not an insignificant number. Third, today we have about 420,000 Singaporeans aged 65 and above. In a little over 10 years, about 11 years from now in 2030, that number will become 900,000. So it is not just a growing number but one that grows very quickly in the next decade or so. By 2030, the number of Singaporeans aged 65 and above will make up to 25 per cent of the total population.

a. Overall, when we have this landscape, it becomes immediately apparent that the disease burden will be a growing one. It is a significant part of what we will face in the coming years.

b. As a result, I believe that primary care will play an increasingly greater role in anchoring the care of our patients, whether young or elderly, across all life stages. Over the next few years, Family Physicians will be increasingly involved in care across various domains and domains that perhaps were non-traditional, from disease prevention, rehabilitation, home care, and increasingly, patient empowerment – how much we can provide patients with information and knowledge so that they can also be responsible for their own health.

c. Postgraduate training in Family Medicine for broad-based professional skills to be relevant, to continue updating them, will be a key enabler for us to achieve this objective of being able to bring a lot more of the care into the community.

Enhancing Family Physician Development

3. On this, I would like to commend the College of Family Physicians Singapore (CFPS). The College has been very proactive and active in enhancing Family Medicine care. They take the lead on all scores.

a. Over the years, CFPS has nominated representatives to sit with the Ministry of Health’s (MOH) committees. One example is the National General Practitioner Advisory Panel. These are committees that are relevant and give us a sense of feedback from the College and they have been very useful.

b. Last year, the College enhanced their Graduate Diploma in Family Medicine and launched the new Certificate in Community Hospital Practice programme.

c. This year, they worked with the Family Medicine Training Advisory Committee to flesh out the Entrustable Professional Activities (EPAs) to guide Family Medicine training across all levels. It is essential to remain up-to-date and relevant.

d. Moving forward, I am sure that the College will continue to strengthen training in medical ethics as part of its training programmes, with the emphasis and content specific to Family Medicine practice.

e. Next year, CFPS will also be jointly organising the Primary Care Conference 2020 with the three polyclinic clusters. This kind of collaboration would become very useful and I think the connection with the three polyclinic clusters would be invaluable.

f. Finally, I would also like to take this opportunity to congratulate the College on winning the bid to organise the WONCA in 2023 in Singapore and I look forward to work with the College on that.

4. MOH has been working with various Family Medicine training committees to map out what we believe are the envisaged roles of the primary and community doctors of various qualifications. We think that the paradigm of the Family Physician needs to evolve. The way which we look at the patient; the way in which patient dynamics and the treatment, and the role that the Family Physician plays in the community remains unchanged but the way which we track the patient will evolve. So what has happened is that we have looked at the refining of the Family Physician accreditation framework in the longer term, to look at how we can strengthen it, to make the KPIs and criteria a lot more relevant to the practice today.

a. This is undertaken with the view to enhance professional competencies by raising training standards, and certainly ensuring and equipping Family Physicians with deeper knowledge and skillsets in their Family Medicine training.

5. Family Physicians really are the first port of call for most patients in the community. Not only that, you are in the unique position to develop a long term relationship, one that goes through the test of time. I think that will be the experience for many Family Physicians, that you grow old together with your patients. They learn to lean on you, rely on you. They see you when they are ill. They see you when they are at their most difficult time in their lives when they are not well, and you go through that journey. I believe that that relationship between the Family Physician and patient is particularly important, and the trust that is built up in that relationship is particularly important.

Trust and the Doctor-Patient Relationship

6. That is why over the last few months, we have been very proactive in making sure that we look at how various facets of that trust which have gone on shaky ground can be re-established.

7. I am talking about the Workgroup that Tze Lee is part of, entrusted with looking at the Singapore Medical Council’s (SMC) process, entrusted with looking at how some of these cases in recent times might have gone wrong and which have since been corrected, and also looking at the way in which one looks at how informed consent needs to be taken.

8. Every one of you will when you see patients, embark on that process. You will make a judgment call with that patient. How much information? What does this patient need? What are the risk factors? What are the differential diagnoses that I have to disclose? What really is in the best interest of this patient? It is a dynamic process and so we want to make sure that at the backend, when one analyses whether there has been a breach of standards, whether someone has fallen short, that we do not do it in a way which is very formulaic, based on a formula where we draw boxes and we tick the boxes. I think we have to make sure that the law and the SMC’s disciplinary process will adopt a process that takes into account the circumstances, and the context in which the doctor has seen the patient.

9. That is why we are keen to make sure that the Workgroup has gone around in some detail, meeting with doctors, doing town halls with doctors in the private practice, doing town halls with doctors in the public sector, the older ones, the specialists, the Family Physicians, the general practitioners, and so on, to have a broad spectrum of views so that the recommendations can cover the broad spectrum of medical practice.

10. Why did we do this? Over time, if we do not start to address the trust issues with doctors and their patients, then doctors will tend to practise defensively. They will tend to over-prescribe. They will tend to over-order investigations and they generally tend to give advice on the course of action that is of the least resistance and least risk. Over time, if you allow that to happen, it is the patient who will suffer, because patient safety will be compromised, the cost of healthcare will go up, and certainly the cost of medical insurance will go up. So overall, we do all of these so that we can arrest these problems early, deal with the problems and address the question of trust upfront. Let me give you a couple of examples as to what we are looking at.

a. I mentioned just now what the appropriate legal test should be for informed consent. A couple of other points we looked at would be to ensure that the process, should a doctor be asked to account for his actions, must be quick, fair, transparent, and I think most of all, to must have consistently reliable and reasonable decisions. That is the objective we want to get to. How do we get there? We will have to improve the process. We will have to ensure that training is done properly but actually most of all, it has to also rely on doctors to come forward. The doctors’ system is unique in that it is self-regulation. To continue to be self-regulated, doctors must step forward and I work very much with the Workgroup to emphasise this point to doctors.

b. Second, because trust is the cornerstone and the foundation of that relationship, we want to see how much we can use mediation as an option. Some cases should not be put into mediation because as the SMC, they have a responsibility and obligation to the public to make sure that patient safety comes first. So should there be egregious cases, cases where the integrity of the doctor is an issue, and other such cases, that is not possible. But in the broad middle of a number of cases, mediation is an option. Mediation, meaning we bring the parties together, discuss what has gone wrong, and find some common ground. With this option available, it puts back into the patient and doctor relationship an opportunity for them to resolve the issue first. Very often, many of the problems arise because of a miscommunication. Sometimes, someone takes an opinion wrongly. Sometimes, it is misinterpreted and a sense of mistrust develops from there. So we can arrest these cases and curb them with mediation, which is also completely based on consent. If the parties do not want to mediate or do not want to come up with a settlement, that is their prerogative. But we feel that more can be done to encourage that option. So it will be built into the disciplinary process.

11. These and other processes, other improvements to the framework, will be part of the recommendations. The Workgroup has been working very hard. I want to thank Tze Lee and the many other workgroup members. As I was walking in here, I recognised some of you. I know you have attended town halls and I want to thank the College and the doctors through the College for giving us that feedback. We thought we could do it in two or three months but eventually, this process stretched out because we thought it was very useful to collect views. I want to thank all of you who have contributed to the views because you made the Workgroup’s work more challenging, but certainly more complete and more sustainable for the long term.

12. Those are some of the steps that are being looked at. My key message really is that Family Physicians ultimately occupy a very special place. That is partly why I brought up the issue of trust but more than that, I think you are a confidant, more than a general practitioner and certainly a family friend. So I hope you continue to hold dear those objectives, play that role in the community, because as we age in Singapore, a lot more will depend on the primary care efforts, such as each and every one of you.

Closing

13. On that note, let me thank all of you for inviting me here this evening and congratulations to all the 200 or more graduates this evening. I look forward to celebrating the occasion with you. Thank you very much.