Opening Speech For Second Reading Of The Civil Law (Amendment) Bill And Medical Registration (Amendment Bill) By Mr Edwin Tong, Second Minister For Law, On 6 October 2020

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

2.     This Bill is linked to the next Bill on our Order Paper, the Medical Registration (Amendment) Bill (“MRA Bill”).

3.     Sir, with your permission, may I propose that the substantive debate on both these Bills takes place now.

a.     Members would be welcome to raise questions or express their views on both Bills during this debate.

b.     We will still have the formal second reading of the MRA Bill to ensure that procedural requirements are dealt with.

c.     However, this proposal to allow for the substantive debate for both Bills to take place at the same time, to allow for concerns on the related subject matter to be captured cogently in a single debate.

I.     Introduction and Rationale for the Bills 

4.      Mr Speaker, the practice of medicine revolves around the patient-doctor relationship.  

a.     It is not exactly an equal relationship because the doctor has far more information and expertise than the patient.

b.     We call this information asymmetry in favour of the doctor.

c.     That is why this patient-doctor relationship must be under-girded, supported and have its foundation in trust – trust between the patient and the doctor.

5.      The patient has to be able to trust that his doctor is doing his best for him; and to the doctor, the interests of the patient must be paramount, at all times. 

6.      Unfortunately, there will be instances where a doctor might fall short of what is expected of him and the doctor’s conduct has to be looked at and if necessary, sanctions will be imposed on the doctor. 

7.      In such a situation, a doctor has to be able to trust the system that regulates the medical profession. He has to be certain as to the standards by which he is to be judged, able to put faith in a system that will be fair, transparent, and also produce consistent outcomes.

8.      On this point, I would like to reiterate that we are in full agreement with the High Court Judges on several occasions, who have pronounced the three main aims of the disciplinary system that regulates the ethical and professional behaviour of the medical profession and they are:

• To uphold public interest;

• To preserve and protect public confidence in the health system and medical profession; and

• To achieve general deterrence in disciplinary outcomes such that other doctors are deterred from adopting unethical practices

9.      The importance of trust in both contexts cannot be overstated.

a.     For patients, the quality of the doctor-patient relationship has a direct impact on the quality of care and of course, the outcome of care.

b.     Where the relationship is strong, the patients are more willing, more open to confide in the doctors, and that itself enhances the quality of the diagnosis and the quality of the outcomes.

c.     This in turns also allows the doctor freely, to focus on his patient’s needs, communicate information about the disease or condition and options for treatment honestly, openly, and without the spectre of having to look over his shoulders each time a patient walks into his clinic.

d.     This, in my view, enhances decision-making and outcomes for the patient.

10.      For doctors, where the disciplinary system does not effectively and also consistently enforce the profession’s standards, then they face uncertainty and unnecessary stress.

a.     To cope with this, doctors may feel pressured to adopt defensive practices that they think will best protect themselves, not enhance the patient’s outcome but protect themselves.

b.     And even in doing so, they might end up being less effective in serving the needs of their patients.

c.     We have seen and I will show later on in my speech, some examples both here in Singapore as well as elsewhere in the world of such practices proceeding and then undermining the quality of care, given to patients.

11.     Over time, these practices erode the trust of the patient and undermine the doctor-patient relationship.

12.     To be clear, our medical profession is, and has been, built on and is in fact steeped in the finest tradition of looking after a patient first, doing what is best for the patients and putting their interests as paramount.

a.     That has not changed, and high ethical standards that are found within the medical profession must be maintained and the patient must know that he receives the best possible treatment, each time and every time.

13.     In recent years, however, the relationships of trust that underpin our healthcare ecosystem have been called into question following several well publicised medico-legal cases from the Singapore Medical Council (“SMC”) disciplinary tribunals (“DT”).

14.     To give one example – members will recall the case of Dr Lim Lian Arn, where the SMC DT had found Dr Lim guilty of failing to obtain informed consent from his patient.

a.     This was on the basis that he had failed to advise the patient on the risks of possible complications of a steroid injection, some of which subsequently manifested in the patient at hand.

b.     Dr Lim pleaded guilty to the charge and was fined the maximum of $100,000 by the DT.

15.     Many doctors took the view that the sentence and conviction by the DT were unwarranted.

a.     It set an unreasonable standard as to how much information should be given to a patient in order to meet the standard and what the standard might as well be, and many doctors felt that even if there was a lapse in standard in this case, whether it was of sufficient gravamen so as to amount to professional misconduct.

b.     Dr Lim’s conviction was subsequently overturned on appeal to the Court of Three Judges, primarily on the basis that the disciplinary threshold of professional misconduct was not satisfied in that case. And in my view, rightly so.

c.     Questions arose as to whether this case ought even have gone to the DT in the first place, let alone result in a conviction with a sentence that attracted the highest possible fine under our legislation.

d.     The Court observed that in Dr Lim’s case, it was a “one-off failing committed in the course of a routine procedure”, labelling the conviction in fairly strong words a “miscarriage of justice”. That is a very serious indictment on the system.

e.     The Chief Justice’s observations in Dr Lim’s case were correct and timely, and served to restore some faith in the outcomes, and in the system.

f.     But members will also recall that shortly after Dr Lim’s case, another decision by the SMC DT – this time with Dr Soo Shuenn Chiang’s case – gave rise to some further disquiet amongst the medical profession. This case also had to be subsequently overturned by the Court of Three Judges.

16.     In the wake of these cases, there was a significant disquiet within the medical fraternity. Many doctors grew uncertain as to what might be required of them when they saw a patient, advised a patient, took informed consent as well as have serious concerns as to whether the rigour of the SMC system was sufficient to see through the case to get a clear, consistent, and certain outcome.

17.     Whenever disciplinary outcomes diverge from well-established practices by doctors on patient care within the medical community, uncertainty follows.

a.     Doctors start to question their own judgment as to how to much information is going to be enough to care for the patient, and there is the constant worry of whether this patient will make a complaint and what will happen to the adjudication of the complaint.

b.     This has damaged the doctor-patient relationship and I should add that the fact that cases, particularly in those two that I have mentioned, and others, have taken an extraordinary long period of time to be dealt with from the time the complaints were first made to when the DT resolved the case, has also been an added source of frustration not just for doctors, but also for complainants. This issue has arisen several times and on several occasions over the last, I believe, at least a decade, before the Courts, resulting in many cases where the Courts have felt that they had to intervene to reduce the sentence on otherwise recalcitrant doctors, and that is also an indictment on the system.

18.     We are already seeing the negative effects of this uncertainty and worry in the medical profession.

a.     Let me cite a peer-reviewed study commissioned by the Singapore Medical Association and the College of Family Physicians. This was done in the period just after the DT’s decision in Dr Lim Lian Arn’s case. During a survey on the number of doctors who gave the same steroid injection, it showed that the number of doctors who were prepared to and continued to give the same H&L steroid injection, came down, while the median costs of these same injections increased.

b.     So – fewer doctors were prepared to offer the treatment, and when they did, it became more expensive for the patient. That is something done in Singapore, on a procedure which most doctors would tell you is fairly routine.

c.     This study has demonstrated how the uncertainty engendered by these uncertainties, the medico-legal cases and outcomes has affected practice behaviour to the detriment of patients.

19.     In addition, there are also accounts from the ground, from doctors themselves, doctors whom we met.

a.     We have heard, for example, anecdotal accounts of doctors, seeking to give patients voluminous amounts of information about all forms of possible risks from the textbooks and alternatives for a procedure, resulting in what the Courts regard as an “information dump” on the patient, a lot more information but really, with a lot less understanding.

b.     The Workgroup that was appointed by MOH to review the taking of informed consent and study the SMC disciplinary procedure discussed the issue at the many townhalls, and there were many opened townhalls that took place both in the public hospitals and private hospitals. There was a clear, palpable sense that doctors grew uncertain about standards expected of them, and many of them turned inwards.

c.     They were spending less time on patient-focussed information, and instead –providing information in a manner which they themselves judged would best absolve the doctor of liability, should the patient complain, so the focus became very different.

d.     The Court has, and the lawyers amongst us would know, the Court has on numerous occasions said that the doctor does not discharge its obligation to the patient by simply giving information without trying to solicit understanding.

e.     That is not the way to take informed consent but yet, we have seen numerous accounts of this take place.

20.     Beyond our shores, the experiences of other jurisdictions also serve as a warning to what might come, if we do not take steps to address these issues.

a.     A 2017 study published in the British Medical Journal (Open) found that protracted disciplinary proceedings were associated with an increase in defensive medicine in the form of avoidance behaviour, the kind of behaviour one might have seen after Lim Lian Arn’s case, when less doctors were prepared to offer that treatment.

b.     And this journal was published, taking sensing and survey statistics from the same jurisdiction where the Montgomery test on informed consent was framed.

c.     Sir, I should add also that these are not novel issues. In 2001, Minister Shanmugam, at the time where he was a practicing lawyer, gave the SMA Lecture that year entitled “Testing the Bolam Test”. It was given at a time when there was a discussion after a landmark decision in the High Court about what the relevant standard of care ought to be, when taking informed consent. That was in 2001. At that time, like now, the issue arose from a judicial decision on how informed consent ought to be assessed.

d.     In that lecture, it was assessed that an increase in the practice of defensive medicine leads to far poorer outcomes: with some of the negative effects being

i.     One, a rise in medical procedures which are not in the best interests of the patient, more investigation, more checks, just to ensure that there could not be a suggestion that perhaps some other test could have been done for this patient.

ii.     Second, rising insurance and hence medical costs, overall increase in cost to the detriment of patients and society.

iii.     Third, stress for doctors, which we have heard, articulated to the Workgroup on several occasions and,

iv.     Finally, critically, an erosion of trust in the doctor-patient relationship. 

21.     These are also the issues identified by the Workgroup, today.

22.     It is clear that there is an urgent need to now address these issues, swiftly and also decisively.

23.     Minister Gan Kim Yong made a Ministerial Statement in April last year, outlining the steps that MOH would be taking to address these issues and one of them was the appointment of the Workgroup – we gave them a clean canvas, told them toleave no stone unturned, start from a blank canvas, go out and consult with as many as you can, take the time to study it, understand the concerns and make the recommendations.

24.     The Workgroup was appointed in March 2019.

a.     It comprised doctors from various disciplines and also looking at having a composition come from across a spectrum of different seniorities of doctors, and it also includes the heads of the major medical professional bodies.

b.     It also comprised lawyers with significant medico-legal experience as well as laypersons with expertise in various fields. It was co-chaired by the Medical Director of a National Specialty Centre as well as a Senior Counsel.

25.     In formulating its recommendations, the Workgroup consulted extensively with relevant stakeholders. They held more than 40 townhalls and engagement sessions.

a.     These engagements sought to understand the breadth and depth of concerns and issues with the taking of informed consent and the SMC disciplinary procedure.

b.     They consulted more than 1,000 doctors of varying seniority from a range of diverse practices across public and private healthcare settings. They went to see the SMC itself, past and present members of the Complaints Committee and the Disciplinary Tribunal, the medical professional bodies of which there are three and they represent the vast majority of the doctors in Singapore, patient advocacy groups to ensure that in scoping the test one does not also ignore the interest of the patient which is paramount, insurers who have a relevant role to play in rising healthcare costs and ensuring that we continue to maintain a cap on where these costs are going and of course also the lawyers both on the prosecution and on the defense side in medico-legal cases. So it’s a very broad, extensive range of sessions that they had.

26.     The sessions were a very effective platform for the Workgroup to listen to a wide range of views.

a.     What was obvious was that there was a consistent theme in a call for change, not just in relation to the prevailing legal and ethical requirements,

b.     but nearly also in the manner in which the disciplinary process was being conducted.

c.     It was quite clear that there was an urgent need to restore trust in the system.

d.     I would say to members that the broad range, and depth, of the consultations itself by the Workgroup lends weight to the observations and recommendations which they have made.

27.     Starting from a clean canvas, the Workgroup formulated preliminary recommendations from the early feedback they received.

a.     These were then presented back to doctors, the medical professional bodies and other groups, stakeholders for further reviews, fine-tuning, testing, , and before they finalised those recommendations.

b.     On 28 November 2019, the Workgroup released its 100-page report setting out its final recommendations and the background thinking to these recommendations and what it was proposing to do. The Government subsequently accepted the recommendations and the contents of the Workgroup’s report ought to be considered by members when debating these two Bills before us.

28.     Sir, before we move on from this topic, I’d like to thank the Workgroup members, the many organisers of the engagement sessions, all who have provided views and suggestions voluntarily. They really kept coming – at townhalls, meetings, through emails, and even on social media.And if you talk to the Workgroup members, they will tell you that they lived and breathed the topic for a good nine months before they produced the report.

29.     Since accepting the Workgroup’s recommendations in December 2019:

a.     Before coming to Parliament with these Bills, we have already implemented some of the changes, and let me quickly outline a few of them.

b.     Those that do not require legislative change, for example, enhanced training to ensure that there is quality of personnel across the spectrum of tribunals, have started.

c.     Internally, the SMC has devoted separate and additional resources to clear the existing backlog because members would know that when this Bill is passed, this process and procedure will apply to new cases, but not to existing ones, which are to be resolved under the old regime.

d.     In other aspects, such as the enhanced use of mediation, that has also been promoted to the extent possible, even within the current framework and rubric.

e.     For other changes, we needed to come to Parliament for legislative changes to provide for the establishment of the required structures, and to reform processes and procedures.

30.     And Sir, these changes are not reflected by way of amendments to the Civil Law Act and Medical Registration Act.

a.     We also, apart from what the Workgroup has recommended propose to include some additional amendments, some related and some fresher ones to enhance the workflow and to streamline and strengthen the disciplinary process.

b.     Some of these amendments arise from an earlier review of the SMC process that the SMC had itself commissioned, independent of the commencement of work by the Workgroup.

31.     Sir, the amendments to the Civil Law Act and Medical Registration Act aim to achieve two broad objectives:

a.     First, is to set a clear standard for healthcare professionals’ duty in giving medical advice to their patients; and on this, members would note what I’ve said earlier on about there being a lack of clarity and if the doctors themselves have that uncertainty that lends itself to an outcome that is uncertain and in the longer term leading into defensive practices.

b.     Two, to strengthen the medical disciplinary system through more effective enforcement of professional standards, more expeditious resolution of complaints, and an increased transparency overall in the disciplinary process.

c.     Clarity, certainty and consistency will be the driving principles behind these amendments.

32.     Sir, I will now highlight the key features of the Bill, starting with the Civil Law (Amendment) Bill.

II. Main features of the Bill

33.     The Bill seeks to legislate the standard of care that healthcare professionals have to meet in giving medical advice to their patients.

34.     For brevity, I will in this speech refer to this as the “duty to advise”.

35.     To understand the background and context to these amendments, it would be useful to quickly set out the current legal standard.

36.     Prior to 2017, whether a doctor had met the requisite standard of care in the duty to advise or not was assessed by reference to the practices and opinions of a responsible body of his peers. 

a.     This is called the “responsible body of medical opinion”, some might know it as the Bolam-Bolitho Test. 

37.     In 2017, the Court of Appeal pronounced the current legal standard for the doctor’s duty to advise, in the case of Hii Chii Kok v Ooi Peng Jin London Lucien.

38.     I will refer to this 2017 decision as the “Hii Chii Kok test”.

39.     Under the Hii Chii Kok test, a doctor’s duty to advise requires that he disclose to a patient information that is relevant and material when giving the patient medical advice. The Court assesses what is relevant and material information from the perspective of the particular patient.

40.     The Hii Chii Kok Test was borne out of the observation that the Bolam-Bolitho Test did not sufficiently give effect to the principle of patient autonomy and that the previous Test was regarded as too “doctor-centric”.

41.     Whilst undoubtedly well-intentioned, this test in Hii Chii Kok has led to some uncertainty amongst doctors.

42.     The Workgroup in particular found that many doctors perceived the Hii Chii Kok test as bringing in an element of variability and hence uncertainty as to what each patient might want to know, since what is relevant and material is said to be assessed from the patient’s perspective. Sir, I hasten to add that this is not necessarily an accurate meaning of the test in Hii Chii Kok. The test in Hii Chii Kok seeks to strike the balance that the way in which it is articulated has given rise to these uncertainties and at paragraph 13 of its Report, the Workgroup stated:

“While some doctors understand how the test is to be applied, many have expressed confusion and anxiety about what exactly they are now required to do.  Some doctors have even candidly admitted that they now practice defensively just to be sure.”

43.     The Workgroup found that doctors became unsure of how to advise patients in a manner that meets the standard of care,

a.     especially so given the realities of practice, where doctors see a large number of patients across a wide spectrum on a given day.

b.     I would add that much of this is likely to be a perceived uncertainty, as the Workgroup have also found, but perceived or otherwise, this leads to a course of conduct to guard against the perception.

44.     In the face of this perceived uncertainty, some doctors have started to adopt defensive practices.

a.     I mentioned some of these engagements earlier. In one such engagement, a senior consultant specialist in private practice shared that this doctor took as long as 30 minutes to explain procedures to patients, not necessarily with the end outcome of ensuring that the patient will come away with it, with more information, or more understanding, but really out of an abundance of caution.

b.     And this doctor presented his view in a townhall that had close to 250 doctors present. It was quite a startling admission.

c.     As the Workgroup put it, in their Report, “Patients are not necessarily better informed. On the contrary, we have received feedback that they are now increasingly inundated with information and are none the wiser.”

45.     Some doctors have become reluctant to guide their patients’ decision-making, worrying that they may be accused of paternalism in doing so.

a.     Others, such as general practitioners, and we have heard one example earlier in the statistics, have decided not to offer the treatments altogether.

b.     They opt to refer their patients to specialists instead, for fear of complaints being made against them.

c.     All of these as members appreciate, are worrying developments – they threaten patient safety, they undermine the doctor-patient relationship and they make it less cost-effective and overall, a weaker system for all.

Another subtle but perhaps understated state of affairs is that the current system is premised on a dichotomy that  one has to be either patient-centric or doctor-centric, rendering the patient and doctor constantly pitted against one another in a zero-sum game.

46.     It would be better to frame a legal test which coheres with a patient and his doctor jointly managing his or her medical outcome:

a.     One which acknowledges the reality that doctors and patients are in fact on the same side, working towards the same outcomes: the good health and the recovery of the patient and striving to create an environment where doctors feel safe to give advice to allow a patient to make the judgement himself, but at the same time, creating an environment where the patients knows that he is impelled to ask any questions he wants in the consultation and the doctor has to give due regard to it.

47.     After studying the Workgroup’s recommendations, the Government accepted the recommendation to recalibrate the test for medical advice, in the way which I have outlined earlier.

a.     On the one hand, the new test will strive to preserve the principle of patient autonomy as set up in Hii Chii Kok, by requiring healthcare professionals give their patients the information they require to make an informed decision.

b.     For example, information about a procedure that a patient specifically asks for, must be provided to the patient. And this is irrespective of whether some other patient might have wanted it, or some other patient might have regarded it as material or otherwise.

c.     This gives primacy to what might be of concern to the patient at hand, the patient in front of the doctor, recognising that no two patients and no two consultations are identical.

48.     At the same time, however, the test will uphold the principle of self-regulation in the medical profession, by providing that regard should be had to what peer healthcare professionals say as to the appropriate standard of care in giving a patient information.

49.     This is the peer review standard, which I mentioned earlier. The Courts will continue to have oversight, by ensuring that the views of peer healthcare professionals pass muster when it comes to logic and reasonableness.

50.     In concept, this is not a fundamental shift in direction – the underlying principles would be familiar to doctors and to lawyers alike and they are ones which are currently established in law.

51.     However, we agree with the Workgroup that the way in which this test is articulated best strikes the appropriate balance between the principles of self-regulation and patient autonomy.

52.     Before I go into the specific provisions, I would like to highlight that we are not alone in taking steps to codify the law in this area.

a.     In Australia, the law of negligence (including its application to professionals such as healthcare professionals) had already departed from the English common law in some significant ways in Rogers v Whitaker. It has been subsequently codified in various Australian states through legislation on civil liability, following a review of the law of negligence by an expert panel in 2002.

b.     For example, Queensland’s Civil Liability Act and Victoria’s Victorian Wrongs Act prescribe a general standard of care for professionals. Section 21 of the Queensland Statute in particular, sets out the scope of a doctor’s duty to warn a patient of risks.

53.      I will now take members through the main features of the new statutory test.

Standard of care for medical advice

54.      The test provides that a healthcare professional will meet the standard of care in giving medical advice to a patient where two conditions are satisfied. This is set out in Section 37(1). These two conditions are:

55.      Firstly, he acts in a manner which is accepted by the medical opinion of a respectable body of such healthcare professionals as reasonable professional practice in the circumstances. We call this the “peer professional opinion”.

56.      Second, this peer professional opinion has to be logical, in that it has compared and weighed the risks and benefits of the conduct in question and arrived at a defensible conclusion that is internally consistent and does not ignore known medical facts and formulation .

57.      These two conditions incorporate the same legal principles that were used to assess healthcare professionals’ conduct using the Bolam-Bolitho Test. 

58.      To be clear, this does not change the burden of proof for civil claims in medical negligence. As before, a claimant patient continues to have the legal burden of proving that the healthcare professional has not met the standard of care in providing the medical advice to him.  

59.      This statutory test also does not change the test for medical diagnosis and treatment, both of which continue to be governed by the existing legal test in the common law that is premised solely or largely on peer professional opinion, i.e. the Bolam-Bolitho test. This is since the principle of patient autonomy has a much smaller role to play in the arena of medical diagnosis and treatment, both of which remain largely within the domains of doctors.  

Standard of assessment by peer professional opinion

60.      The new test also prescribes the standard by which the peer professional opinion must assess the information given by healthcare professionals and to this, there are three limbs.

61.      In the First Limb, set up in Section 37(2)(a)(i), the healthcare professional must give his patient information that a patient in the same circumstances, i.e. a “typical” patient, would reasonably require to make an informed decision about whether to undergo treatment or follow a particular piece of medical advice.

62.      In the Second Limb, in Section 37(2)(a)(ii), the healthcare professional must give his patient information that he knows or reasonably to know is material to that “specific” patient for the purposes of making the same informed decision as in the First Limb.

63.      Section 37(2)(a)(i) provides for what you might do to a typical patient, that is judged by what the peers would regard. Limb Two, requires the professional to also think about what might be material to this patient, and let me explain that a little bit more. 

What is “material” information

64.      Material information falls into either of two categories, which are set out in the next subsection, Section 37(3):

a.     First, if it relates to specific concerns or queries that the patient expressly communicates in relation to undergoing the treatment or the medical advice, so an expressed question or query or some discussion raised by the patient and if the doctors are asked specific questions, that becomes something he has to explain.

b.     Second, in the second Limb, Section 37(3)(b), where it relates to specific concerns or queries which the patient does not expressly communicate, but which ought to be apparent from the medical records of the patient which the healthcare professional has reasonable access to, and also ought to reasonably review. Let me explain why it is covered in this way, and to ensure members of the house understand it.

65.      For the avoidance of doubt, any concerns expressly communicated by a patient has to be addressed and the Workgroup was quite unanimous in the view that if it has been brought up expressly to the doctor, the doctor has to address those queries .

a.     In short, in that scenario, the patient can be assured that when he walks into a clinic and sees the doctor, there really are no “stupid questions”. Every question that this patient raises with this doctor is a valid, relevant question that has to be addressed.

66.      In relation to

a.     information that ought to be apparent from medical records,

b.     this is not intended to impose an obligation on healthcare professionals to review and go back into reviewing substantial volumes of medical records, or voluminous medical history on the National Electronic Health Record in order to try and work out or ferret out what are the concerns or queries that the patient might have. That is not the intention and clearly that is not also provided for in the statute.

c.     It is also not practical or feasible in practice.

67.      The litmus test is that of reasonableness – both in terms of what the healthcare professional has reasonable access to, and also whether in the circumstance of the case, the discussion with the patient, the context in which the patient is seeing the doctor that creates a scenario where the doctor ought reasonably to review these past records. What is reasonable is a matter to be assessed in the context of each case, and it is not possible to define upfront at the start all the categories in a closed fashion of information that will be regarded as reasonable or not reasonable.

68.      For instance, a factor that would go into the assessment of what is reasonable might well be the age of the medical records in question.

a.     So, it would not ordinarily appear to be reasonable for someone to have to trawl through old microfilms and medical records going back 10 years, barring some exceptional circumstance.

b.     Therefore, the older the medical records are, the less likely it would be, that it would be reasonable to expect the healthcare professional to review them.

c.     But if for example, there is an old medical record or an old investigation that is labelled and you put a bright sticky tape on it, and taped to the front of the file in an obvious way and it makes some notes about this person’s history from some years ago, perhaps, an unusual investigation that has taken place, or perhaps an allergy that would not be easy to discern from trawling through the files, then it would make it harder for that healthcare professional to say that that is not something that he ought not to looked at in context of this treatment.

69.      Other relevant factors to the assessment would include what transpired during the discussion that the patient has had with the doctor, and how the query or concern was characterised in the previous medical records.

a.     If something is mentioned only in passing, and does not feature prominently across the spectrum of the medical records, then it is less likely that it is something that ought to be apparent to the doctor.

70.      To enhance the understanding of how the provision operates, the Bill also provides an illustration at Section 37(3)(b) on when information that is not expressly communicated to the attending doctor will be considered material.

a.     This illustration of a patient undergoing a total knee reconstruction is by no means intended to define or circumscribe what is “reasonable” in every case–

b.     it is just intended to give an example of what could or would satisfy the requirements of reasonableness.

Reasonable justification for not providing information

71.      Let me now move on to the Third Limb.

72.      The Third Limb, by contrast, addresses the other side of the equation; it asks whether there is reasonable justification on the part of the healthcare professional in situations where information was not given. This is found in Section 37(2)(b).

a.     The Bill contains several illustrations as well in this regard.

b.     For example, there may be reasonable justification for not providing information in a situation of emergency.

c.     or where a patient has waived his right to information, by telling the healthcare professional that he does not want to be given information. That can be established.

d.     Whether there is a waiver is a matter of fact, sometimes of mixed fact and law, and the peer professional opinion can assist in the forensic analysis and weighing up of whether it is such a waiver by the Judge or tribunal.

73.      On the other hand, we are also making clear that a healthcare professional cannot simply refuse to provide information to his patient, merely because he thinks that providing a particular piece of medical advice or undergoing a treatment is in the best interests of his patient. In other words, you cannot make up your mind for the patient and then decide based on that, an outcome, what you will and will not tell the patient.

74.      That would not be reasonable justification.

An opinion that differs from other professional opinions can be relied on

75.      If there are different peer or professional opinions held by other respected healthcare professionals, then each of these opinions can still be used, provided it satisfies the test of logic. If members can look at Section 37(4).

a.     This recognises that there may be a diversity of views amongst healthcare professionals, all of which are in principle equally valid for consideration. But of course, for each of them to be logical, they have to cohere with the standards and pass the test of logic and reasonableness, in a manner which I have discussed earlier.

Scope of the test

76.      Finally, let me outline the scope of the new test.

77.      Section 37(6) of the Bill provides that the test applies not only in respect of medical advice given to patients, but also medical advice given to a person who is responsible for making a decision about undergoing a treatment or following a particular piece of medical advice on behalf of someone else, that someone else being a patient who is legally disabled.

78.      A legally disabled person is someone who does not have the mental competence to make a decision for himself or herself. For example, a parent would be responsible for making a decision on behalf of his infant child.

79.      Second, the test applies to healthcare professionals.

a.     This is defined in Section 37(7) of the Bill to mean an individual practicing a profession that provides medical advice.

b.     This includes doctors, dentists and oral health therapists, and it is not an exhaustive list.

c.     The scope is broad enough to include any individual who practices a profession that provides medical advice, or for which it can be shown that there exists peer professional opinion.

80.     We appreciate that, beyond the language and contours of the legislation itself, healthcare professionals will require detailed guidance on what is required from them under the new test in practice.

a.     We fully agree and we intend to provide such guidance, working with professional bodies, also the SMC and the CMEP to do so.

b.     For a start, we will be revising the Ethical Code and Ethical Guidelines of both the Singapore Medical Council and Singapore Dental Council in respect of the issue of the taking of informed consent. That in fact was something the Workgroup itself had proposed as a draft in its report, and we will use that as a basis to start the revision of the ECEG. There was in fact strong recommendation by the Workgroup to do so, to reduce the ECEG into basic core irreducible principles of professional conduct and use that to gauge and guide doctors in terms of where that bright white line ought to be when it comes to the thresholds.

c.     Steps will be taken to review and revise the SMC Ethical Code and Ethical Guidelines. It is in-step with these latest proposed amendments both to the Civil Law Act as well as to the Medical Registration Act.

III.  Conclusion

81.     This new test for medical advice seeks to recalibrate but not completely overhaul the standard of care for medical advice. We believe it endows it with more clarity and certainty. Healthcare professionals will have the assurance that they will be evaluated on the basis of a peer who can assess and also contextualise the standard required to that of a clinical setting, which is important as no two patients and no two consultations are identical.

82.     At the same time, it maintains the high degree of patient autonomy that was present in the Hii Chii Kok test.

83.     And we strive to move away from a test that is described as patient or doctor-centric but instead one where we say is undergirded by patient empowerment.

a.     Patient autonomy and certainty in the medico-legal climate for doctors cannot be mutually exclusive ideals; they can exist in a virtuous cycle, and in the process, build more trust into the patient-doctor relationship.

b.     That ultimately is the overriding objective of designing this test and adopting it in a way in which I’ve just outlined.

MEDICAL REGISTRATION (AMENDMENT) BILL

84.     Sir, I will now highlight the key features of the second Bill, the Medical Registration (Amendment) Bill, which amends the Medical Registration Act.

a.     Broadly, these amendments seek to strengthen the system, make it more robust and deal with as many of the problems that have been identified in the cases that I have outlined, and also beyond that.

85.     This is the second slate of legislative amendments that we are proposing, arising out of the Workgroup’s recommendations.

86.     It is of utmost importance that the medical disciplinary system operates functions efficiently, effectively and fairly.

a.     Both doctors and the public alike must trust in this outcome, know that it will be independent and transparent, and also be able to enforce standards that are fair and consistent.

b.     If the system falls short, it undermines confidence, which in turn affects doctors’ practices, and erode trust in the way I have outlined.

IV. Objectives of the Bill

87.     The amendments in this Bill are quite substantial, and I do not propose to cover every clause.But I will add that it is not a silver bullet. You cannot look at the provisions in and of itself and we would like members to look at these amendments as a collective whole because you can’t just change the process, or you can’t just impose a time discipline, or you can’t just say training. They have to be all taken into account together. The amendments that we seek to introduce broadly strive towards four objectives, which I will organise my speech around and highlight the salient clauses in relation to these objectives. The four objectives are: a.     Firstly, to improve the quality and consistency of processes and outcomes in the system;

b.     Second, to reduce delays and facilitate the more expeditious resolution of complaints;

c.     Third, to protect patients more effectively; and

d.     Fourth, to encourage as far as possible the amicable resolution of complaints and facilitate a less adversarial disciplinary process in the appropriate between patients and doctors.

Improving the quality and consistency of processes and outcomes in the system

88.     I will address first the changes that we seek to make to improve the quality of the processes and outcomes.

89.     When the disciplinary system does not effectively and consistently enforce the profession’s standards, doctors are faced with uncertainty and unnecessary stress.

90.     In these cases, the patient-doctor relationship is sometimes supplanted by the plaintiff-doctor relationship.

91.     So we seek to propose a number of changes to enhance the structure and to give more robustness to the disciplinary framework.

(1) Disciplinary Commission

92.     First, to further improve the quality of processes and outcomes, the new Section 57 provides for the appointment by the Minister of an independent body to be known as the Disciplinary Commission (“DC”).

a.     This will be a body that is separate from the SMC, headed by a senior doctor as President, and it is envisaged that the President will be a full time appointment.

b.     The DC will have a dedicated secretariat that will exclusively support its functions, and it will have two key mandates. First, it will be responsible for constituting the DTs. In each of the cases, it will set up the DTs and ensure the personnel is appropriate for the DTs. This is in place of the current SMC, which through its secretariat assists in setting up the DT.

93.     This addresses concerns about the independence of the DTs from the SMC. Currently, the DT is independent of the SMC, which also acts on behalf of the complainant as the prosecutor.

a.     However, there is a continued perception of the lack of independence, simply because the SMC appoints the DT, and also has its prosecution arm looking after the complaints of the complainant, and fielding the charges against the doctor.

b.     This is ostensibly because they appoint the DT, but the reality is that it suggested that the DT is influenced in any way by the SMC. But nonetheless, this perception is a troubling one, with the potential to undermine confidence. We want the impartiality to be not just real, but to be seen to be obviously separate

94.     We are not starting from a clean slate as it were in this case, as we looked at the practices in other countries and other jurisdictions, and the one that is fairly close to what we are proposing is found in the United Kingdom.

a.     In the U.K., the General Medical Council (which is the equivalent of the SMC) established their Medical Practitioners Tribunal Service in 2012.

b.     The purpose of this was, amongst other things, to provide a clear separation between the General Medical Council’s investigation functions and the adjudication of hearings, which is similar to what we are proposing here. With the DC, it is responsible for the setting up of the DTs to hear the cases, as tribunals, and the SMC will continue with their function providing the charges and prosecuting the charges on behalf of the complainant.
95.     The DC’s second key mandate is to oversee the training of members of the Complaints Panel and Health Committees, and ensure that they are appropriately trained to carry out their roles in the various committees.

96.     This addresses various feedback both from members of CCs and DTs, and also from doctors in the townhalls, that we need to increase and uphold the standards of the doctors who sit on these tribunals. Many of them are experienced doctors, but sometimes, marrying their experience as doctors with a process that has a fairly strong legal slant to it, may not always make for a good match.

a.     Other than providing for this training – regular and systematic training will help them to carry out their duties better.

b.     That is something that the DC will oversee, to ensure that the various disciplinary committees are staffed by well-trained, up-to-date and competent members.

(2) DTs to have legal professionals

97.     As a first step to ensure consistency in processes and outcomes, we are proposing that a legal professional is required to sit on each DT.

98.     The new Section 58(1) provides that individual DTs will now comprise two doctors and one legal professional.

a.     Previously, DTs were constituted in various permutations, and it was not obligatory to have a legal professional sit in one of these tribunals.

b.     Our view is that having an experienced legal professional on the DT, will bring greater legal and forensic expertise to the DT’s deliberations and determinations.

c.     In addition, the quasi-judicial nature of DT hearings means that they also invariably require the consideration and application of legal concepts and forensic analysis, such as the application of the standard of proof and assessing the weight and relevance of evidence.

99.     In some of the more difficult cases, the key issues may also be more legal rather than medical in nature.

100.   In addition, having a legally-trained member sit on the DT will assist the DTs in preparing its decisions, ensuring they are legally sound and structured, and also ensure that there is a consistent body of decisions to guide future DTs in their decision-making. In some cases where the DC President might regard as being more complex, or novel, or perhaps raise novel issues in law, they may be more appropriately directed to a serving Judge or a Judicial Commissioner of the Supreme Court.

101.   The new Section 59 provides a mechanism for the President of the DC in those cases, to apply to the Chief Justice for permission for a Judge or a Judicial Commissioner of the Supreme Court to chair the DT in those cases. There is an option in Section 59 for the President of the DC to decide on the case being more complex, and inviting the Chief Justice to nominate a Judge or a Judicial Commissioner to sit as the chairman of that particular DT.

102.   I should make clear that, with this proposal, we continue to maintain the principle of self-regulation by the medical profession.

a.     The legal professional will not necessarily be the chairman of the DT.

b.     Further, a serving Judge or Judicial Commissioner will only chair cases where the President of the DC feels is appropriate to do so.

c.     Decisions of the DT will still be determined by majority vote. Even in the case where a Judge or Judicial Commissioner sits as a chairman, that person cannot on his or her own, override that of the two doctors if they both agree with each other.

103.   On this note, I should also highlight that the SMC appointed a Sentencing Guidelines Committee in January 2019 to look at and to draw up sentencing guidelines for DTs, to ensure, uniformity, consistency, and to ensure that the DTs pay sufficient regard to the relevant practice, when deciding on an appropriate sentence.

a.     The committee has completed its work, and the SMC published these guidelines in July 2020.

b.     These will complement the current amendments to facilitate fair and consistent decision-making by DTs.

(3) Legal Advisory and Prosecution Unit

104.   The next change we are proposing is to introduce greater legal support throughout the system. This is to strive to improve the quality of decision-making at every level of the process.

105.   For this purpose, the SMC will be establishing a Legal Advisory and Prosecution Unit.

a.     The advisory arm of this unit will advise the disciplinary committees in their disciplinary framework, and ensure that they have access to the legal support they require to perform their functions.

b.     This in turn facilitates clarity on the applicable standards, how the charges might be preferred, what kind of legal standards will apply, and so on.

c.     The prosecution arm of the new unit will undertake prosecutions for the SMC, a topic that I will return to later.

106.   While the creation of the Legal Advisory and Prosecution Unit does not in itself require legislative amendment and will be effected by the SMC administratively, I thought to highlight this to Members as they reflect an important part of the structural changes being made. Later on, when I deal with the IC and the RC, Members should also recall that the legal unit does sit and is present with the IC at the outset. The moment the case is referred to the IC, the IC gets legal support to assess the case – to assess whether it is vexatious, or scandalous, and whether or not it meets the required threshold for professional misconduct.

(4) Giving SMC the discretion to determine if matters should be referred to the DT, and setting a clear standard for the threshold for referral to the DT

107.   Next, the amendments will provide that it is the SMC, rather than the CC, which will determine whether a matter is to referred to a DT or not.

108.   Currently, the MRA requires the SMC to appoint a DT if the CC determines that a formal inquiry by the DT is necessary. A typical CC will be appointed, it will be a three-member CC, and if the CC after deciding that it needs to be sent to the DT, currently the SMC has got no role to play in that process, and the matter goes to the DT. That is the case even if the SMC might otherwise disagree with the view of the CC.

109.   During the Workgroup’s consultations, both the SMC as well as the medical community felt that the SMC should play a more proactive role in ensuring that it is aware of the outcomes of complaints, and that there is also a more consistent and uniform filter that the SMC can play before it goes to the DT.

110.   The medical community feels that the SMC as a whole has to take ownership and oversight of handling of complaints, and not just delegate this to a CC.

111.   To this end, the SMC will be responsible for the ultimate decision as to whether a matter should be referred to the DT or not.

112.   We believe that the collective wisdom of the SMC in reviewing the CC’s decisions will also act as a check to ensure that the threshold for professional misconduct is met, or at least met in a prima facie way, before a case the matter is referred to the DT.

113.   The new Section 46(6) will provide that the CC will now make recommendations to the SMC as to whether or not there should be a formal inquiry by a DT.

114.   If a CC recommends a formal inquiry by the DT, it will also have to formulate the charges and to give its reasons for recommending the referral of the complaint to a DT.

115.   This provides for a more seamless transition. At present, the moment the CC recommends that the matter should be heard by the DT, it finishes its functions, it passes the matter on, and a new team takes over. Here, once the CC has decided, it states its reasons, and it will also formulate the charges, if not fully, at least in draft, so that the DT or the prosecution at that stage, will know the thinking of the CC, and know what were the considerations previously by the CC in referring the matter to the DT.

 116.  On the other hand, if the SMC determines after the recommendation by the CC, that the case should not proceed to a formal inquiry, then under Section 46(7):

a.     it must inform the parties of its determination and the reasons for this, the fact that it has decided not to take up the CCs recommendations, and also its reasons for not doing so.

b.     it may also take a range of alternative actions, such as issuing letters of advice or warning, or perhaps directing the doctor to seek and undergo medical or psychiatric treatment or counselling in the appropriate cases.

117.  The decision of the SMC as to whether to refer a case to the DT will be final.

a.     This is also in line with what is currently the system with the Law Society, a similar system where the Council of the Law Society makes the final decision on whether to recommend a complainant to further action after it receives the recommendation(s) from the Inquiry Committee, which is the Law Society’s equivalent of the CC.

118.  In this regard, we are also making clear the standard for referral of a case to the DT, which is not currently provided for in the MRA. Section 46(2) provides that it must be a case where there is cause of sufficient gravity for a formal inquiry. We wanted to do this to ensure that there is at least a gate or a threshold before the matter is referred to the DT, and that the relevant members of both the CC and the SMC apply their minds to the standards that have to be established.

119.  In assessing whether the threshold is satisfied, the CC and SMC should engage in the three-stage inquiry that the Court of Three Judges set out in Lim Lian Arn. Those will be the criteria and we would require the SMC members to have regard to that pronouncement in making the assessment.

120.  The amendments to provide for the SMC to determine if a DT should be appointed, as well as the prescribing of the standards for referral, overall, we believe will allow for greater consistency of cases, and also an overall uniformity of standards to be applied, so that as far as possible, whilst I have said no two cases are alike, but the gravamen between the cases should result in a similar outcome in terms of the disciplinary process.

Reducing delays and facilitating the more expeditious resolution of complaints121.  I move on next to the amendments to facilitate the more expeditious resolution of complaints. I think Members know that that has been one of the chief complaints about the system, that it is taking too long, that between the time the complaint is launched until it is resolved can be five, six, seven years in some cases.

122.  In the case where doctors are ultimately found not liable or not guilty, it is a real strain and stress on the doctor. In the case where a patient is successful and the doctor is found liable for professional misconduct, then the question will be, why is it that the last six, seven years, the doctor has been practicing and what has been done to protect patients’ interests.

123.  All of these issues do arise, and what we have done is to look at some very specific measures to ensure that it is more expeditious. Overall, Members will know from the Bill that there is an overarching timeline that applies to the conduct of the cases. At each stage, there is a timeline. There is some provision for extensions, and beyond a certain number of extensions, the relevant committees will have to go to High Court to make the case for an extension. We believe that this is the best way of driving this forward in a fair way.

124.  On our estimate, an average case will take something like a year and a half – about 18 to 22 months – for a case to be resolved, and we believe that is sufficiently reasonable time for the cases to be adequately disposed of. Of course, in the cases which are more complex and require more time and more investigations, parties can apply to court and justify that.

125.  I will quickly outline the measures that we have set up in the Bill to address the delays:

a.     First, an early notification to a doctor that there has been a complaint that has been filed. Currently part of the problem is that doctors do not really know immediately, and it takes months, sometimes years, before a doctor is aware that a complaint has been made.

b.     Second, we strive to increase the pool of Complaints Panel members. The Complaints Panel is the bottleneck, and if the Complaints Panel is more well-resourced and better staffed, then these cases can proceed more expeditiously and enable disciplinary committees to be constituted more quickly.

c.     Third, introducing a time limitation period for complaints. This is also similar to what is done in the Law Society to ensure that very stale complaints, do not get refreshed, to ensure that there is fairness in terms of having the doctors maintain his or her notes, and the quality of evidence does not diminish if the complaint is an old one. There are provisions for exceptions to be made, in cases where patients are unable to, or did not know they can still seek leave, justify that, and complaints can still be brought despite the timeline.

d.     Fourth, we have created levers to control both individual stages of the proceedings as well as the overall length of time that a complaint takes to be resolved.

126.  There are two areas that are relatively new, and I will spend a bit more time to explain this to Members.

(5) Inquiry Committee

127.  The first is the Inquiry Committee. We have proposed a new filter mechanism upfront to sieve out unmeritorious complaints at an early stage. Since 2010, over the past decade or so, the SMC has received an average of 165 complaints every year.

a.     Quite a significant percentage of these complaints are eventually found to be of no merit, either because they did not pass muster in terms of the standards or the facts were found to be of a different sort than what was advanced by the patients, or it was otherwise vexatious in the sense that it was a repeat complaint or a complaint that has been dredged up when it has already been resolved, and so on.

b.     Each such complaint takes up considerable resources to manage, which would be better utilised for more deserving cases where the complaint actually has a good basis. On our rough numbers, about 10% of these complaints make it to the DT every year, so about 16 to 18 complaints make it to the DT. There are a fair number of cases that do not end up in the DT, and the thinking behind having the IC is to have more resources upfront, to evaluate these cases better, early, and direct more attention to them and dispose of them if possible, upfront.

c.     As one can imagine, if you have the full 165 cases travel through the cases, it will create a lot more strain on the resources, and will take a lot more time for each of the cases to be resolved. Having more specialised and dedicated resources upfront, will play, in our view, a significant role in filtering out the cases appropriate even for early resolution, or perhaps channelling it to mediation, and only allow those that require investigation, or have merit in the substance of the complaint, to proceed.

128.  Some complainants may not necessarily have all information at the time they make the complaint. This rule is not designed to shut them out, but because we know that, on the one hand that making a complaint is a serious matter, and complainants are expected to substantiate their allegations. At the same time, complaints will not be dismissed out of hand, simply because they do not have the requisite level of information or the level of detail that is needed. In the appropriate cases, the IC will also direct that this will be either investigated further, or for the Complaints Committee to take it up.

129.  In any event, if the complaint is dismissed, the IC will be required to give reasons for the decision, this is under the new Section 43(3)(a).

a.     It is the SMC’s practice currently to inform complainants of the outcome of their complaints. This will continue to be the case, even after the amendments come into force.

b.     The complainants will be informed if an IC dismisses their complaint, along with the reasons for dismissal.

130.  The new Sections 43(3)(b)(ii) and 43(3)(c) give the IC the power to direct that investigations commence upon referral to the CC, without having to wait for the CC to be appointed. This is just to close the gap between the two committees, so that at the time that one is handed over, straightaway the investigation unit is empowered to commence investigations, take statements, take documents, and be in a position to be ready once the CC steps in and is constituted.

a.     Once the CC is appointed, it then takes over and assumes oversight of the investigations.

131.  Similar to the Review Committee under the Legal Profession Act, there is no right of appeal from the IC’s decision to another committee in the disciplinary process, or to a Court. However, this does not preclude judicial review, which is present, and that is governed by the general law.

132.  There was some feedback during the Workgroup’s consultations as to whether or not this additional layer was necessary. Some might think that the CC could play this function and do this filter role. For the reasons I have set out earlier as to why allowing these cases to be resolved earlier, rather than have them channel through a system and take up committee time, investigation and resources. It is for that reason that we have a filter upfront, staffed better, more resourced, and also in tandem with the legal advice unit.

133.  The creation of the IC also parallels the Legal Profession Act, which has a similar filtering committee which is called a Review Committee.

(6) Creation of Review Committees to review the decisions of CCs

134.  Next, let me talk about the Review Committee (RC). The Review Committee reviews the decisions of the CC except decisions to refer the complaint for a formal inquiry. This will replace the current appeals process, whereby appeals against such decisions are made to the Minister for Health.

135.  There is some feedback that the existing process for appeal was either not transparent or slow, and sometimes unclear as to what the considerations were. Sometimes new evidence were let in, in those cases, which then led to the process being delayed.

136.  The new Sections 54, 55 and 56 provide for the appointment of a RC to consider requests made by the complainant, doctor, or the SMC against the CC.

137.  The RC is not intended to be a second CC, and so the scope will be limited to two specific instances:

a.     First, whether or not there has been due process. It looks at the CC and evaluates it from the position of whether due process has been complied with.

b.     Second, to assess whether any new evidence has been submitted to an RC, and if so, why, and will consider whether the new evidence is material to the complaint or to the outcome (as the case may be).

138.  The RC proceeds by majority, and can make the orders such as:

a.     requiring the CC to comply with procedural requirement that it failed to comply with,

b.     or it may direct the original CC to conduct further investigations or inquiry.

Protecting patients more effectively

139.  I will move to the third broad basket of changes, that is to protect the patients more effectively. I will briefly set out some of the provisions.

140.  First, we seek to empower the IC and CC to obtain relevant documents and information for the purposes of their inquiries. The relevant investigative arms of this process must be betrothed with the power to obtain documents and take information as quickly as possible. The new Sections 43(2) and 45(5) will provide for that.

141.  Second, we seek that the investigator can look into wrongdoings not covered by the complaint. It is something that we have considered for some time because there are two schools of thought. One, if it is not contained in the four corners of the complaint, then why should the investigation start to look into this. On the other hand, it will be a related matter, one which will be a matter of interest and in the current rules you will have to restart the process just to look into that.

142.  In the end we have decided that to the extent that it is in respect to the same doctor, the mechanism that is set out in Sections 50(6) and (7), and the SMC may on the basis of the report made by the investigator who has looked into these matters and file a new complaint against the doctor. So, you can investigate it at the same time, file a new complaint and we believe this is an improvement on the current process.

(9) Allowing Interim Orders to be issued more expediently in appropriate cases

143.  Next, allowing for Interim Orders to be issued more expediently in appropriate cases. This is also a new provision, and it seeks to introduce a framework for the Interim Orders Committees (called “IOCs”). It provides for the IOCs to be constituted more expediently and act more quickly in circumstances where there is an imminent threat to the health or safety of a doctor’s patients.

144.  Let me very quickly outline the main changes.

145.  Under the current MRA, the referrals to the IOC are made by the Chairman of the Complaints Panel.

a.     The SMC does not have the power to refer complaints to the IOC of its own accord.

b.     The effect of this is that where SMC learns of matters which would warrant referral to an IOC, it is reliant on the Chairman of the Complaints Panel to do so

c.     And we regard this as less than ideal.

146.  The new Section 59J(4) will give the SMC the power to order to do so on its own motion.

147.  Under the current MRA, the doctor must be heard at an IOC hearing in all cases before the order is made. With the best of intentions, sometimes these hearings can take place weeks, if not months, after the referral is first made, for a number of reasons not because of an intention to delay.

148.  The new Section 59K provides that an IOC can make an interim order immediately, without first giving the doctor the right to be heard, in certain exceptional situations.

149.  These situations are limited to two types:

a.     First, when a court of law in Singapore has found that the doctor has engaged in the conduct alleged in the complaint or information, and the conduct poses an imminent danger to the health or safety of any of the doctor’s patients. A finding of this has been made by a Court in Singapore, and the SMC is of the view that this doctor’s continued practice will pose an imminent danger to his patients.

b.     Second, where the SMC is of the opinion that such conduct poses an imminent danger to the health or safety of any of the doctor’s patients. The thresholds are high, but we regard this as being in the interest of patient safety and public interest.

150.  In the situation where such an interim order is made, the IOC must then convene a hearing within 1 month, where the doctor will then be heard on his position and the interim order can then either be set aside, or it can be varied as the case may be. If the hearing is not able to be convened within the month, then the immediate interim order will lapse. This seeks to preserve the balance between the SMC and the doctor’s livelihood.

Greater representation within the SMC(11) Changes to the composition of the SMC

151.  Let me know move on to some other related revision, and wrap up this afternoon’s speech. We are also making changes to the composition of the SMC. This is to ensure greater diversity of representation and views.

152.  The SMC is the paramount body that regulates and represents the medical community, and it is important that its composition reflects the range of views amongst the different groups, as well as the different range of seniorities in the medical profession.

153.  The amended Section 4 makes 2 key changes to the composition of the SMC. First, the major medical professional bodies will now be represented on the SMC.

a.     These are the Academy of Medicine Singapore, College of Family Physicians and the Singapore Medical Association.

b.     They will be represented by their respective Master or Presidents, as the case may be, or by a member of their respective Councils as nominated by the President or the Master.

c.     Second, there will now be one, instead of two, representatives from each Medical School in Singapore. This could be the Dean, or his representative.

154.  As the leaders of the major medical professional bodies are elected into their roles, the elected membership in the SMC will in effect be increased from 12 to up to 15 members, whilst the appointed membership will be changed from 15 members to 12 members.

155.  In the same vein, the amended Section 8 reduces the minimum years of standing required for doctors to serve on the SMC from 10 years, to 8 years.

a.     A similar amendment has been made to the years of standing to allow a doctor to serve as a member on the Complaints Panel.

b.     We hope that this will encourage younger, and also more doctors to also step forward and serve on the SMC, and on the Complaints Panel.

Encouraging the amicable resolution of complaints and facilitating a less adversarial disciplinary process

156.  Finally, I mentioned the increased and enhanced use of mediation from the outset. We have set up some provisions which allow for this.

(12) Facilitate the referral of cases to mediation at an early stage

157.  In the interest of time, I will not go into that, but to ask Members to look at Section 47, which empowers the IC to refer the complaint for mediation during its inquiry.

a.     This section similarly empowers the CC to do so.

b.     If the parties are participating in mediation, in the middle of the mediation you do not want to have a disciplinary inquiry. So the IC and CC may, having regard to the progress of the mediation, suspend the inquiry.

158.  We will work with institutions like the Singapore Mediation Centre to provide the relevant expertise and also the infrastructural settings to achieve better outcomes through the use of well-trained, highly qualified mediators.

a.    There will be a reporting obligation for mediators, who report to the IC or CC to ensure that one keeps an even keel on the progress of the mediation and is not used to as an excuse to dislodge or disrupt the timetable for the conduct of the disciplinary proceedings.

(14) Legal Advisory and Prosecution Unit

159.  Before I conclude, I would like to go back to the point I had made earlier on the Legal Advisory and Prosecution Unit. To recap:

a.    It is the advisory arm of the new unit that will advise the various committees.

b.    There will also be the prosecution arm of the new unit and this will conduct prosecutions on behalf of the SMC.

160.  When the Workgroup canvassed views, particularly from doctors, there were some who expressed concern that the use of private law firms for prosecution of DT cases may sometimes result in a “I must get a conviction at all costs” kind of approach. That is not the case, and it is also not healthy that there is that impression.

161.  On the other hand, a dedicated in-house prosecution team residing within the SMC under the new Unit will help the SMC to strengthen its own capabilities. It will aggregate the cases, it will build up experience, to be able to handle prosecutions, and to have, residing within the SMC, institutional knowledge and the collective wisdom of what it will take to prosecute these cases. This lend itself will lend to consistency across the spectrum, as to how a charge is framed and the factors that would be taken into account in mitigation or aggravation as the case may be.

V.   Conclusion

162.  Sir, I have covered most of the key recommendations. As I have mentioned to members, these all have to be taken together. You have to look at it in its totality. I have not gone through every clause in detail.

163.  I just want to end by saying that these reforms are significant. They reflect a very strong ground sentiment, both by doctors and patients, and the extensive work of the Workgroup in consulting over so many months. The number ofdoctors they have seen, and the number of patient advocacy groups they have seen. They have also touched on stakeholders – insurers, lawyers and practitioners. They represent a very strong sense of what the industry – the medical fraternity – wants to see, and many of these amendments that we have made reflect that sentiment.

164.  It remains only for me to thank the Workgroup members. I also want to record my appreciation to the members of the three professional bodies. They have been very supportive of our efforts and they also have people sitting on our workgroup, and they have also recorded their agreement and support for the changes effected in this Bill.

165.  Sir, with that, I beg to move.