Medical Registration (Amendment) Bill - Closing Speech by Mr Khaw Boon Wan, Minister for Health

11 Jan 2010

By Mr Khaw Boon Wan

Venue: In Parliment

Mr Speaker, Sir, I thank the Members who have spoken on this Bill and for their support. Let me address their comments and suggestions.

(I) SMC’s Disciplinary Processes

(a) Chair of Disciplinary Tribunals (DTs)

2 First, the proposal to allow senior lawyers to chair Disciplinary Tribunals.  Dr Lam noted that the practice was “not unusual”, having been done in Australia, Canada and elsewhere.  However, he worried that it might be perceived as the “SMC lacking the moral courage and legitimacy to discipline high profile complex cases”.  In any case, he commented that “the definition of complex is subjective and can be ambiguous”.  In contrast, he and Ms Audrey Wong noted the Law Society “going in the opposite direction”, doing away with the appointment of laypersons in their Disciplinary Committees.  Dr Lam asked whether the amendment would mean “the medical profession is regressing and arrogating responsibility”. 

3 I do not know fully the circumstances that led to the amendment to the Legal Profession Act.  But I recall the debate in this House which noted that formalised legal processes, like the legal disciplinary proceeding would require lawyers and their amendment to remove the layperson was to help speed up their proceedings. SMC’s disciplinary proceedings are similarly formalised legal processes but currently without the advantage of having legal professionals on its disciplinary tribunal. Although there is a Legal Assessor present to assist the SMC’s Disciplinary Committee to address issues of law, the extent to which Legal Assessors can guide the proceedings is limited. During the public consultation on this amendment, one senior lawyer who has served many years as a Legal Assessor for the SMC wrote in to express his observations that frequently, the SMC Disciplinary Committee wasted a lot of time on irrelevant matters but he was unable to intervene. I spoke to the present and past Presidents of the SMC.  They felt strongly about the need for this particular amendment. They have personal experience conducting disciplinary proceedings and felt strongly that the presence of an experienced legal professional on the Disciplinary Tribunal will be a significant advantage. I am sure these feedback will assure Mr Christopher de Souza that allowing senior experienced lawyers on Disciplinary Tribunals will trim down irrelevant legalistic matters. This amendment is also not an indictment of the medical profession.  Rather it should be seen as a progressive development where the medical practitioners collaborate with the legal professionals to do their best to manage efficiently both questions of fact of medical practice and questions of law. This will help the Disciplinary Tribunal to make fair judgements in complex cases. 

4 Let me stress that the SMC is not arrogating its responsibility.  As noted by Mdm Halimah, “the amendments had taken into account doctors’ concerns, as the appointment of any legally qualified person, whether as chairman or a committee member, is at the discretion of the SMC”. The SMC will have the prerogative to include a senior lawyer in the Disciplinary Tribunal only when it deems appropriate. The Bill specifies that there should be at least 3 voting members in the tribunal, of which at least 2 shall be medical practitioners and does not set an upper limit to the number of voting medical practitioners. The Medical Council may have 2 or more medical practitioners in addition to the legal professional to constitute such tribunals so that when it comes to questions of facts pertaining to medical practice the medical profession’s views will prevail. This amendment is to mitigate potential legal errors which may arise when dealing with complex issues of law which medical professionals are often either not familiar with or not aware of. After the Director of Medical Services has explained the background of this amendment to the entire medical community, the vast majority of the medical community had no further objection to it.

5 Dr Lim Wee Kiak would like us to go further and suggested that any highly respected individual, such as a Justice of the Peace, and not necessarily a legal professional, can chair a Disciplinary Tribunal. But I think his suggestion would not be able to meet our requirement as the SMC is looking for someone who can competently address questions of law in some complex cases.

6 What is a complex case is hard to codify.  This is a question best left to the SMC when confronted with a particular case.  They can then make the decision on whether to appoint a senior lawyer to chair a particular case. 

6A Mr Cheng mentioned about laypersons being the majority in the Complaints Committee. This is not in the spirit of self-regulation.

(b)    Training for Members of Disciplinary Tribunals

7 Second, Dr Lam asked if disciplinary committee members receive any form of training. Yes, they do.  The SMC conducts training sessions for all members of the Complaints Panel from which members of the Disciplinary Tribunals are drawn. The training sessions are conducted by SMC's lawyers and focuses on legal issues, procedures and policies relating to the Medical Registration Act (MRA). 

(ba)  Appeal to High Court by SMC on behalf of patient (section 55(2))

7A Mr Lam Pin Min opined that the new procedure for SMC to lodge an appeal to the High Court on behalf of a patient under section 55(2) constitutes a “double whammy” as this amounted to a doctor being prosecuted twice. This is an issue that has been raised in the UK, where the Council for Healthcare Regulatory Excellence (CHRE) has a power to refer matters to the High Court that it considers to be “unduly lenient”. Like the SMC, the CHRE can in effect appeal on behalf of patients, even where the doctor has been acquitted by the General Medical Council in UK. The English Court of Appeal in CHRE v GMC and Ruscillo (“the Ruscillo case”) accepted that this power creates an element of “double jeopardy”, but thought that such concerns were to take second place when this is necessary to protect the public.

(c)   Investigators

8 Third, Professor Pauline Straughan noted that investigators appointed by the SMC are potentially “powerful agents” with fairly extensive authority.  Ms Sylvia Lim also noted that the investigator holds an important and pivotal role in the disciplinary process. Both wanted to know the qualifications these investigators are expected to hold.

9 The plan is to recruit officers with at least 10 years of experience in the police or related enforcement agencies.  They will be very much like the officers in my Ministry’s Enforcement Branch.  

(d)  Delay and Backlog

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

11 Mr Ang Mong Seng offered some suggestions, including the concept of a “cooling period”. He proposed that we categorise cases as simple or complex complaints and set a time limit for each category. For instance, complicated cases should be concluded within a year and if more time is needed, a formal request for extension should be made.  I agree that all complaints should be dealt with speedily.  There are provisions to limit the time taken by the Complaints Committee and the Disciplinary Tribunals. The authority to vary the time for the Complaints Committee and the Disciplinary Tribunal to complete its cases resides with the SMC.

12 Prof Straughan asked whether all complaints could be dealt with within the 3-year limitation period so that complainants who may wish to pursue a civil lawsuit can rely on the outcome of the Disciplinary Tribunal to make an informed decision. SMC will certainly make every effort to conclude the investigations of every complaint within a reasonable time.  However, civil suits are best legally advised and considered independently from the disciplinary inquiry. Complainants who wish to commence civil proceedings should not wait for the outcome of SMC's investigation. If they intend to, they should instead file a civil suit within the limitation period to ensure that their right to sue is preserved. That said, SMC has assured me that most cases can be concluded within 3 years.  

(e)  Greater Transparency 

13 Fifth, Mdm Halimah, Prof Straughan, and Mr Ang commented on the need for more transparency in disciplinary inquiries. As noted by Mdm Halimah, this is a trend that we see in UK, US and Australia. 

14 Current proceedings are not completely opaque; neither are they fully transparent.  What makes this subject complicated is the need to protect patient confidentiality.  However, given rising level of interest in the issue of transparency, we will study this issue further.  I have noted the various suggestions and we will discuss with the medical community and the general public on whether the proceedings should be held in private, or with limited attendance and whether the proceedings should be published in full or in an abridged version while maintaining confidentiality of patients. With regards to guidelines on penalties, we will take a look at it as well in the public consultation. We will have to find a balance which will serve the public interest best.

15 Related to this issue of transparency, Ms Ellen Lee and Mdm Halimah suggested that we publish and regularly update a list of errant doctors. I thank Prof Straughan for expressing her view. Today, every case where a doctor is found guilty of disciplinary charges is published. Whether we should go further and maintain an active public listing of the guilty is however debatable.  Should we stigmatise doctors whose offences may not be so serious?  What constitute a serious offence?  What about those who have turned over a new leaf? We should give a second change to those who have realised their mistakes. I am a staunch supporter of the Yellow Ribbon Project.

16 Ms Audrey Wong referred to the provision in the Bill which allows the SMC to deal directly with the medical practitioner, without referring to the Chairman of the Complaints Panel. She felt that this may be seen by the public as a less transparent way of dealing with complaints. Let me clarify that this provision only pertains to situations where a formal complaint has never been received from the public. However, if the information received by the SMC pertains to a serious offence of professional misconduct, SMC will proceed to forward the information to the Chairman of the Complaints Panel and formal investigations will be initiated, even though no formal complaint has yet been lodged.

(II) Expanding the range of disciplinary orders

17 Sixth, Dr Lam asked why there is a need to raise the maximum financial penalty from $10,000 to $100,000.  The current quantum was set in 1997 when it was first introduced.  Prior to that financial penalty there was not a disciplinary order available to the SMC.  Many years have passed since and a $100,000 penalty for medical misconduct is not excessive.

18 Mr Ang asked about the number of doctors who have repeated similar offences in the past 5 years.  There were 17 such doctors.

19 Mdm Halimah asked if most of the cases brought before SMC were referred by the authorities such as MOH. This was not so.  Three out of four complaints received the SMC during the last 3 years, were from members of the public.

(III)  Family Physicians Register

20 Seventh, many members have spoken in support of the establishment of the Family Physician Register. Dr Lam asked if existing family physicians would automatically be included in this register.  There must be minimum requirements for registration as a Family Physician. The criteria and qualifying conditions were extensively discussed previously.  But generally, we will take an inclusive approach.

(III) Non-Bill Issues

21 Finally, there were a number of comments which do not pertain to the proposed amendments in the current Bill.  But let me address them.

22 Ms Ellen Lee noted a recent media report which suggested that Singapore trained doctors, as compared to foreign trained doctors, were more lenient on colleagues who misbehaved. The media report was based on a survey done on a small sample of house officers.  We had then discussed this subject in this House.  We must certainly take issues of medical ethics and professionalism seriously. The teaching and learning start early in the medical school and extend into post-graduate medical education and throughout the medical career. Professionalism and communication skills are core competencies which our training authorities will strengthen through a structured training process and exposure to clinician mentors. We have started on this journey to reaffirm the importance of professionalism and ethics in Medicine and we will press on.

22A Ms Sylvia Lim asked whether the post-graduate training Duke-NUS, without the one-year of requisite housemanship, will be compromised. Under the MR regulations, first year post graduation is required to have broad-based training exposure. This applies to graduates from both medical schools.

23 Dr Lim Wee Kiak referred to the enhanced post-graduate training programme and wondered if the reduced duration would compromise quality. Almost all specialties have no reduction in training duration.  The enhancements aim to ensure a more structured approach to training and trainees will be assessed each step of the way, so that we can raise training effectiveness and reduce attritions.  We are injecting more resources, assigning dedicated clinical teaching and establishing a sustainable structure to improve the learning experience of our trainees. The tools for assessment of competency that we have now will be retained. We expect our specialists to be properly trained and competent. The new system of training will enhance it, not weaken it.

24 Prof Straughan touched on the Interim Orders Committee and the issue of justice to the doctor.  The need for the IOC and the safeguards were debated in this House when the previous amendment was introduced.  I would not repeat the arguments.  The facts, I hope, will be comforting to Prof Straughan. In the past 5 years, there has only been one case where an IOC was convened. This was in the case of a recalcitrant doctor who had a prior conviction for the indiscriminate dispensing of addictive drugs. The IOC decided to curtail his practice.

25 Mr Ang asked if there is a monitoring system in place to prevent drug addicts hopping from clinic to clinic to accumulate drugs such as sleeping pills. Such a system exists but it is currently used for only one drug. Whether we should extend this system for other drugs such as sleeping pills will need to be carefully studied. 

26 Mr Ang also asked whether our hospitals are adequately equipped to detect medical errors. This is a big topic as medical errors can come from many causes and no hospital has been able to eradicate medical errors.  Proper training and supervision are important.  Systems must also be in place to monitor adverse events so that lessons are learnt, and staff reminded. Where systemic inadequacy leads to the error, then systemic solutions has to be found and implemented.

Conclusion

27 Mr Speaker, Sir, I believe I have addressed all the concerns raised.  Singaporeans enjoy a high standard of healthcare services and our doctors are largely ethical, professional and competent.  As Dr Lam put it: “there is really nothing seriously wrong with the medical profession here in Singapore”; and we should not give Singaporeans the wrong perception that “the state of medical malpractice may have reached an epidemic level, warranting harsher measures”.  But like all professions, there are some black sheep and we need efficient, transparent and fair processes in place to ensure that misconduct is dealt with speedily, in a way which will strengthen the good reputation that our medical profession enjoys, with justification.  And as Mdm Halimah put it, with the proposed amendments, “the law is now very clear. Its aim is to protect the health and safety of the public through mechanisms that ensure that doctors are competent, uphold the highest standards and maintain public confidence”.  On this note, I once again thank Members for their support of this Bill. 

28 Mr Speaker Sir, I beg to move.