Edwin Tong Chun Fai
Singapore
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“NAC is working with arts educators to convert their student-facing programmes, such as the NAC Arts Education Programme, into digital or blended forms in the same way as we do for so many other programmes so that they become more accessible and we can reach a wider audience. NAC has also paired up with NIE to develop an e-learning primer and an e-pedagogy course for the arts, which will be launched in December 2020 and made available to arts educators at no cost. Let me assure Mr David that we are committed to ensuring that arts and culture remain an integral part of the curriculum, as students continue to develop awareness of our cultural heritage. Today, I am sure Mr David knows, museum-based learning forms a key component of the Primary Arts syllabus, with a recommended learning journey for Primary 4 students to the National Gallery in Singapore or to the Singapore Art Museum. On top of that, all Primary 6 and Secondary 2 cohorts will also visit the Asian Civilisations Museum and the National Museum of Singapore respectively, to enhance their learning and also to complement what they are taught in school, out of the classroom, as far as possible. Sir, I would like to next speak on the role which freelancers play in our sectors and address the challenges they face, besides what I mentioned earlier, in the programmes. There is a certain messiness in the way in which the sports and arts practitioners are organised. That is not only inevitable, but perhaps also useful to keep the sector fresh, and maintain some of that carefree entrepreneurial spirit.”
“We will also set aside an additional $4 million for sports businesses and freelancers to enhance the quality of their own digital productions to become even more interactive and more engaging and attract a greater following on their platforms. In addition, we will work with MOE and other partners to ensure that our students continue to have access to high quality arts experiences as part of their holistic education. Let me speak a little bit about this. The intent, Sir, is to continue to nurture and develop an appreciation, and hopefully, eventually ignite a passion for the arts in our young. The young will make up our audiences, our supporters and our patrons, and of course, the practitioners, in years to come. I have noted Mr Darryl David’s suggestion to engage our arts practitioners as auxiliary educators in schools. In fact, to ensure that students can benefit from the knowledge and experience of our arts practitioners, which I agree with Mr David it is a critical resource, NAC has worked with NIE International since 2012 to develop a course on the Essentials of Teaching and Learning for arts practitioners, precisely to become arts educators. NAC has also worked with other partners such as the Social Service Institute and SEED Institute to develop relevant pedagogical skills to complement what they are already do and are able to practice so that they can then seamlessly work with children with special needs and pre-schoolers. One needs to merge or blend what you have in your own experience as an arts practitioner with the relevant pedagogical skills so that pre-schoolers and those with special needs can also benefit from such education.”
“With this in mind, the Sports Resilience Package (SRP) will provide eligible businesses with an operating grant to cover up to 25% of their total operating expenses, capped at $15,000 a month. And this will last for six months, beginning from October 2020 right through to March 2021. We hope to be able to support up to 150 sports businesses with this operating grant, helping operators who do not currently receive Government funding. This grant will also ensure that our critical sports businesses which contribute richly, as I have said, to our athlete pipeline development and training, do not close down due to the pandemic, do not marginalise the programmes that are available for athletes, allowing our athletes to benefit from the best training programmes. Sir, let me now touch on some of the mid-term measures to partner our arts and sports community to innovate and adapt to the new environment. The last few months have shown that going digital is paramount, in fact, completely necessary. It allows our businesses and freelancers to reach out to existing audiences, to newer and also wider audiences, allowing higher quality content to be developed and also a degree of interactivity, despite the fact that you are communicating across two screens. Under the SRP, we will provide $5 million to help expand the existing Blended initiative to include eligible private academies and clubs as well. We recognise the work that they do and we have extended this programme to them, aiming to support 100 projects, which will, in turn, see the participation of about 450,000 Singaporeans in sports programmes over the next six months.”
“Since 1996, the APSC has channeled swimming talents spotted from the APS Swim School into specialised competitive swimming training, diving and also synchronised swimming. They have also provided competition opportunities across a range of different levels and through its many myriad of events. We understand the impact that COVID-19 has had on these private academies, such as APS and others, the leagues and facility operators and we understand the challenges they go through. Many of them need some measure of support, if nothing else, to tide over the period. Recently, the Cage and other such similar sport facility operators also reached out to me to share their concerns. They spoke about the inevitable loss of revenue because of the safe management measures. They had to close. They were not allowed to open. And they had difficulties affording rent and continuing to sustain the salaries of their staff. And we can well understand how these restrictions have impacted their ability to operate. SportSG has worked with many such businesses to allow them to resume some programmes and activities safely, coming out of the Circuit Breaker. But I am sure Members in this House will agree that we do not want these operators to be a casualty of the pandemic. Our sporting landscape, with its broad spectrum of different players and options, will be the poorer if that happens. While the resumption of sports activities since June has alleviated some immediate operational concerns, we recognise that there is still the longer term sustainability and survivability. And I think that is a major area of stress for many of these operators.”
“Pay it forward, like what Objectifs and JASS have done. This grant is expected to benefit over 300 organisations and more information will be made available by NAC in end-October and we will also reach out directly to eligible organisations to tell them about this and to assist them in their application. With this grant, we expect to fully utilise the $55 million set aside for the ACRP by the end of FY2020. Sir, for the sports sector, we will add a further $25 million for new and expanded measures. Added to the earlier announced $25 million package, this makes for a total of $50 million available to the sports sector. Let me say a little more about how this will be administered. First, some background to our sports eco-system. It is made up of a diverse range of different institutions, from the National Sport Associations (NSAs), to the private academies and clubs. They are private leagues that run the sports facility as well. They are run privately. And, of course, the whole mass of coaches and freelance instructors, they all make up a very rich and vibrant sports eco-system. They all play an important role in our collective efforts to build a strong pipeline of athletes to mould and shape them and to support them on their quest for competitive success on both the domestic and international front. Many private academies and clubs, in particular, complement the efforts of our NSAs. They enrich training and talent development, and they also offer a range of different competition opportunities. Take the Aquatic Performance Swim Club or APSC, or the APS Swim School, for example. It is a private swimming academy which has, over the years, contributed significantly to the identification and talent of Singaporean swimmers.”
“Through the Circle, she has discovered new ways to reach out to both existing and also to new students, with reasonable fees, to make these classes and these interactive sessions a lot more accessible. SportSG has also introduced Blended, an initiative to encourage sport event companies and organisers to transition to events that blend virtual and physical participation which Singaporeans can look forward to more of in the coming months. This format will certainly be with us for some time and we will continue to study how we can support them better so that instructors, coaches and other freelancers alike can continue to reach out to an audience and, as far as possible, even in these times, to continue with as much as they would have done in normal circumstances as possible. Sir, let me now touch on what else we will be doing to support these sectors in the immediate term. MCCY will provide immediate assistance to critical segments with special talents. We know that if we lose these talents, inadvertently or otherwise, in this pandemic, it could take years to recover. It would set us back in our efforts to promote arts, culture and sports in Singapore. So, for the arts and culture sector, we will be providing an Operating Grant under the ACRP to support arts and culture organisations and also those in closely-related sectors. They hold key talent capabilities in our eco-system and we must not lose them. Eligible arts and culture organisations will receive a one-off ACRP Operating Grant of either $75,000 or $50,000 which they can use to defray their operating costs, and the amount depends on the size of their organisation. We hope organisations that receive this grant will provide work opportunities for the many employees in this sector, including the freelancers.”
“To better support freelancers or smaller set-ups, the Arts Resource Hub (ARH), set up under the National Arts Council (NAC), provides targeted support for all of them, including co-working spaces, talks, clinics on financial planning, probono legal support, digital tools and copyright – a broad spectrum of what is needed, giving them a platform and tools for these artists to pursue their craft and also build on their dream, much like what JASS and Objectifs have done. In the immediate short-term, the ARH has also provided freelancers with aggregated information and assistance to help them tap on the broader Government programmes like the Self-Employed Persons Income Relief Scheme (SIRS), COVID-19 Support Grant and the SEP Training Support Scheme. At the same time, MCCY has also worked with people within the community spaces to develop platforms to bring digital experiences and also blended programmes, which are often hybrid in nature, to blend or both in-person and virtual and finding platforms to bring more of these to Singaporeans. For example, #SGCultureAnywhere by NAC is an integrated campaign that profiles the best of Singapore arts. Our cultural institutions and major arts companies have also made their content available on new digital platforms, such as SISTIC Live. Those of you who have not gone on SISTIC Live, I encourage you to give it a try. In sports, we developed ActiveSG Circle as a virtual sports centre to encourage and inspire Singaporeans to get active, as well as to provide a marketplace for sports and fitness instructors and their potential students and trainees to get in touch with each other. Jasmine Wong, a certified KpopX fitness instructor, has conducted 85 virtual classes on the Circle since April.”
“I attended many of their presentations – high quality, innovative, entertaining but I think, most of all, comforting, to the many Singaporeans and, especially, in these times. On top of that, in the true spirit of giving back, JASS has also started their own Crisis Fund to assist local jazz musicians affected by the crisis with short-term financial aid. So, JASS receives a grant from the Government but they also pay it forward. Bhaskar's Arts Academy was also awarded the DPG for DashaTanMatra (10 Subtle Elements), a series of 10 mini digital presentations of new dance, music works, webinars on Bharatanatyam, and re-adaptation of past repertoires. We will continue to support the industry as they seek to go digital. Another practitioner I met recently was Ms Emmeline Yong. She was an investment banker in New York. She gave it all up, returned to Singapore to pursue her passion in visual arts and she set up Objectifs in 2003. Objectifs is an example of an arts organisation that MCCY is committed to supporting. It has a strong sense of mission to nurture and also provide a platform for other practitioners and freelancers to hone, practise and exhibit their craft. With the support of the ACRP, Objectifs put up free photography and videography courses for arts practitioners and other freelancers to help them create strong social media content to outreach, a campaign to pitch their offerings.”
“Many have been so very generous in sharing their views and vision with me, giving me a good grasp of the industry and good ideas for the longer term development of these sectors. But they also spoke candidly about their here and now, their immediate challenges, and I think all of us in this House understand those difficulties. Over the past few months, MCCY has rolled out dedicated support measures for our sectors to supplement the assistance they already receive from the broad-based Government measures. We understand what many are going through and we know that we must, where we can, help them further. Let me outline a few of these initiatives. To help them manage overheads, we have provided rental waivers to tenants in SportSG facilities and arts venues, as well as venue hire subsidies for users of our cultural institutions. We have also supported practitioners to hone their digital skills and expertise in areas, such as business literacy. And many of them, in turn, support the industry as a whole. The Arts and Culture Resilience (ACR) package has generated over 10,000 work and training opportunities, of which almost 4,000 alone were for freelancers. It has also supported close to 1,200 digitalisation projects and programmes by local artists and organisations. For example, the Jazz Association of Singapore – Mr Jeremy Monteiro is their Music Director, someone that Mr David mentioned earlier – they were one of the first recipients of the Digital Presentation Grant. They went online overnight and launched multiple digital programmes, including JASS@Home, a digital concert in celebration of UNESCO's International Jazz Day 2020. This featured performances by many local musicians.”
“The events and programmes of our arts community reach ever wider and growing audiences. They fill us with pride. They also teach and they inspire us in a way which almost nothing else can. All of this is possible because we have, over time, nurtured the best talents, helped them along in their journey, developed them, given them a boost in their chosen craft, built a platform from which they can showcase their talents. So, we owe a lot also to our community of trainers, coaches, instructors and freelancers, all of whom contribute richly to this landscape. As Mr Darryl David says, we must do what we can to rally behind them during this difficult time. Sir, Deputy Prime Minister has spoken about the unevenness of COVID-19's impact on the different sectors. Whilst some sectors have seen a measure of recovery, the past few months have really not been easy for those in the arts, culture and sports sectors. Fundamentally, these sectors thrive on large group gatherings. Theatre, performances and competitive sport – they all play to an audience. Yet, this is precisely what we cannot now do, as we continue to fight against COVID-19, to keep Singaporeans safe and to keep the virus at bay. We have had to suspend large-scale events and limit group sizes to five. These measures are necessary but we must not forget that they have severely impacted the viability of businesses and the livelihoods, particularly of freelancers in these sectors. In the almost three months that I have been at MCCY, I have met a broad range of people across the various sectors. I have met with many leaders of our National Sports Associations, talked to athletes, coaches and freelance instructors. I have also heard from artists, musicians and arts educators.”
“Sir, I have previously spoken in this House about how the Singapore society is like a tapestry, woven out of diversity, bound by community, forged from a shared sense of destiny. Every part of Singapore, coming together, for a beautiful, tightly knitted, cohesive fabric. These diverse strands of our social fabric include our arts, culture and sports sectors. Mr Darryl David has spoken passionately about these three sectors and I will address his queries. These sectors make the Singapore tapestry even more beautiful, vibrant, and meaningful. These strands coe together, to represent the heart of Singapore. In recent times, like the many threads which make up the fabric of our society, these strands have come under strain. The COVID-19 pandemic has fundamentally affected the way in which we interact and socialise with one another and has threatened to unravel some of these threads. But we know that even as we battle the pandemic, it is critical for us to ensure that each of these threads – our arts, culture and sports sectors – remain vibrant, cohesive and remain very much a part of the Singapore Tapestry. We must continue to sustain and develop them. And they, in turn, must continue to be an avenue through which Singaporeans fulfil their aspirations, dreams and desires. These threads must also continue to connect Singaporeans from all walks of life and be able to inspire and imbue a sense of pride in being Singaporean. Sir, Members will agree that, in one way or another, our lives have been touched by the many contributions and achievements of our artists and our athletes alike. Our sportsmen and sportswomen, past and present, have been a source of inspiration to many Singaporeans. We share the joys of their success and we feel the pain of their defeat.”
“Mr Speaker, Sir, I hope I can bring a fresh perspective on an entirely different topic.”
“Mr Speaker, Sir, on behalf of the Minister for Health, I beg to move, "That the Bill be now read a Second time." The contents of this Bill have been debated in Parliament earlier in conjunction with the Civil Law (Amendment) Act amendments. I beg to move, "That the Bill be now read a Second time." [(proc text) Question put, and agreed to. (proc text)] [(proc text) Bill accordingly read a Second time and committed to a Committee of the whole House. (proc text)] [(proc text) The House immediately resolved itself into a Committee on the Bill. – [Mr Edwin Tong Chun Fai]. (proc text)] [(proc text) Bill considered in Committee; reported without amendment; read a Third time and passed. (proc text)]”
“On the SMC composition, I mentioned this at the outset, as it stands today, the number of persons nominated by the Minister has come down, and if you take into account the fact that the representation on the professional bodies, which are themselves elected by members of the medical profession – either the Academy of Medicine, College of Family Physicians Singapore or the SMA – then I think you will find that actually, after today's amendments, the cross representation and the spectrum of representation on the SMC of the medical fraternity is far broader and the numbers elected would outnumber the numbers appointed by the Minister. Sir, I think I have covered, as far as I can, all the critical points. I know that I would have omitted some and I beg the Members' indulgence. We are prepared, after this Bill is passed, to take any of the further suggestions offline with the Members directly because the suggestions are good suggestions. And to borrow a phrase from my colleague, "No one has a monopoly over good suggestions". So, we welcome suggestions even after the Bill might be passed. Sir, with that, I beg to move.”
“But there has also been specific training not just for the members of the CC and the DT because they require more specialist training, but also encouraging doctors, as a whole, even if you are not involved in the CC or the DT, to have at least some basic knowledge of medico-legal principles. And I think that overall, with time, would help the appreciation of the standard of care, would help in appreciation of how doctors are to interact with their patients. Mr Perera talked about whether we could recognise the support and remunerate persons who sit in in these Tribunals. Mr Perera may wish to know that, as of now, we already give an honorarium of $800 per day to a member of the DT. For members of the CC, there is also some amount but it is smaller, having regard to the fact that they play a lesser role in a sense that their time commitment is not as severe. But it is also very difficult, as I think Mr Perera also noted, to quantify the amount of remuneration to give. When you are designing a system that is meant to be a self-regulating system, then people within that system must step forward. I heard Dr Lim Wee Kiak say that we must encourage more members to come forward. And indeed, that is true. This system is really only sustainable if the best, the most experienced, those who can afford the time and even those who cannot afford the time, should step forward and serve in some capacity in the CCs, in the DTs, in the RCs. And it is not just because of the honorarium or the financial compensation.”
“Mr Leon Perera supported the Bill and said that it is in the right directions, which I appreciate, and also raised several suggestions for us to consider. I think he had about 10 or 12 suggestions. I cannot cover them all here in today's response. But I will respond to a few. In terms of the time bar and the limitation period, why was there a difference? The reason is because when we have a complaint, as I have mentioned just now, about a doctor's conduct, this is an issue of public interest in itself because we are talking about upholding standards and confidence in the way in which doctors give treatment to patients. So, compared to a civil or commercial time bar where you are locked out from making a monetary claim, for example, or a claim for land, you are locked out after six years or such other period as the time limitation might prescribe. Those come on a very different footing from trying to look at complaints or entertain complaints outside of the time bar when you are talking about upholding public interest. Second, in terms of the certified training, I think I have covered part of it in my response to Mr Singh's suggestion of Recommendation 3. But certainly, that will be taken up. We do want to enhance training. It is a very significant plank of what we have proposed here, as you have heard me saying. But that should also be taken in conjunction with the sentencing guidelines that have now been issued. We also want to remind Members that we have a legal unit that will support each of the committees across the spectrum of when they review the cases. Mr Perera is right that there are already training programmes that are on-going now today. I am told that they have been fairly well attended until there was a break during the last few months because of COVID-19.”
“I am happy to say that MOH has said that they will not pass on these costs to the patients and, as far as possible, not to the doctors. The reason for this is because the grants have been given to SMC to look at setting up these structures to look at redeploying what we have currently used, by way of resources, to deal with the cases which have taken four, five years or so to deal with but applying them upfront. So, we feel we can manage with the current resources. If not, we can top it up with some more, and I think Minister Gan will have to approach the Deputy Prime Minister for that. But the idea is to be cost-neutral as far as possible because we believe that this is in a public interest. It is a system meant to safeguard patient welfare, public interest and public confidence in the system. That is why, like Dr Lim Wee Kiak had suggested, we also do not want to put a financial bar in front of every complainant before you can make a complaint to the SMC. That was something that was actually canvassed quite robustly at many of the town halls to put a fee upfront before a complainant can make a complaint. But we studied it and we decided, as did the work group, that we did not want, and it was against public interest, to put a financial bar to patients to file a complaint. Instead, we decided that we will empower the CCs and the DTs to grant costs in the appropriate cases. My colleagues, who are lawyers in this House, will know that that is used very sparingly. The power does exist in the Legal Profession Act. It is used very sparingly and, really, as a measure of last resort to ensure that these frivolous vexatious claims do not continue.”
“We are trying to put everything into a system where, on the average, between 18 and 20-22 months, we are able to complete the entire process. In terms of cases and backlog, the SMC has been working very hard to come up with a lot more resources and they have also used standing committees for the Complaints Committee and close to 90% of the stock of outstanding complaints as at September 2019 – that means all the complaints up to September 2019 – have been concluded by early September 2020. So, we have the remainder of the last quarter of 2019 cases standing, and then we are into 2020 cases. Over the last two years or so, the SMC had worked very hard and managed to resolve many of these cases. As I have explained to members, this new regime will not be able to apply to existing cases. So, the existing cases still have to follow the current track and the current timelines. Cases filed once this Bill is in force will enjoy the new track. Dr Tan Wu Meng, Mr Ang Wei Neng and Dr Lim Wee Kiak are all obviously very concerned about what Minister Gan might have to do to ask Deputy Prime Minister Heng, seated next to him now, for additional resources. I wanted to say that these are changes that we have made which we believe will enhance the system. You either spend on the system having a case travel through like I have explained in Dr Lim's case and incur a lot of resources and, at the same time, you do not really get any good outcomes as far as the doctor or the patient is concerned. Rather, we think resources are better spent putting upfront legal resources, mediation resources and a good filtering system. And, yes, that requires manpower and also resources. Some Members are concerned whether we will have sufficient resources to support the new structure.”
“The reason for the IC is that it needs to act as a stronger filter. Today, yes, we have 6% to 7% of cases that are filtered away from that. But let me cite the Lim Lian Arn example to Members. In Lim Lian Arn, the Court of Three Judges felt that there was a miscarriage of justice and one of the factors they looked at was to analyse the complaint and they formed the view that even if the complaint was taken in its extreme, that means, you accept every fact set out by the complainant as correct and true, that still does not amount to professional misconduct. And there was a very detailed analysis by the Chief Justice in that case. And those are precisely the type of cases that we want to be able to filter at the IC. The IC, together with legal resources, we feel will be better equipped to look at these cases, apply the law to these cases early and upfront, rather than, as in the case of Dr Lim's case, have the case travel through the system for a good four or five years, using up resources in that period of time, only to be thrown out at the hearing of final reckoning, at the last stage. So, that is what we want to do – to move the decision-making, move the resourcing upfront, and have that dealt with as early as we can. Mr Yip Hon Weng and Mr Louis Ng asked for some timelines and also about some resourcing. How long does it take for the investigation to be concluded at present? It varies. But over the last five years, based on data, the average time that it takes to conclude cases at the CC is about 18 months. Some are a little bit longer. In fact, some take more time than this. And then cases referred to the DT take an additional 23 months. So, two more years on top of this.”
“So, these were the two recent cases, by way of examples, to assure Members that this is not going to be used at a very low threshold. Dr Lim Wee Kiak and Mr Louis Ng asked about the composition of non-SMC members currently at the Complaints Panel, and the resourcing issues that we will have to address post-passing of this Bill. Let me just inform Members that, currently, there are 89 doctors who are not SMC members and there are 50 non-doctors on the Complaints Panel. The 50 non-doctors comprised 18 legal professionals and another 32 lay persons. That, in part, also answers Mr Leon Perera's point about the way in which we will engage patient advocacy groups. Looking at these numbers, the representation by lay persons, or rather non-doctors, is not small and not insignificant. And the role they play directly in the process in the Complaints Committee, in fact, in several other committees that are set up in the SMC, that takes into account the non-medical, non-doctor input as well. Moving forward, once the amendments are in force, the SMC intends to have minimally 120 doctors and 60 lay persons and legal professionals on the Complaints Panel. Obviously, we look at the volume of cases to determine whether or not that will be sufficient. But looking at the statistics, the numbers and what we forecast, these are the numbers that we intend to start with once the Bill is operationalised and then we can decide whether we want to move up thereafter. Mr Louis Ng also asked about the IC. The IC will share the reasons, as I have outlined in my opening speech, for its decision, so that members of the public who have complained and the complaint is being dismissed by the IC will be aware not only of the decision but also of the reasons for the IC reaching that view. Why the IC?”
“That is actually quite a baseline consideration, given that medical technology innovation is changing, evolving, and we do want to ensure that our system that looks after discipline has the public interest of the patients at heart, is constantly updated and kept updated with technological progress. Mr Louis Ng asked several questions, one of which was in relation to the cases that can go directly to a DT. He asked why the SMC was allowed to retain some discretion in doing that. The answer to that is that it depends on the nature of the case and it gives the SMC some degree of latitude in terms of assessing the case. The SMC themselves will then play a more proactive role in reviewing and determining whether these cases ought to be directed to the DT straightaway. Mr Louis Ng also asked about the interim orders and the fact that the interim orders committees have a wide remit to determine what is necessary for the protection of members of the public or otherwise in the public interest. That is put in that form so that it can allow the IOC to take into account a broad spectrum of matters, including how it affects public interest, when it might affect public interest and the kind of occasions or risk factors that a doctor is exposed to in any given scenario and, therefore, tailor the way in which the IOC orders are sought accordingly. So, we do need to give some degree of assessment on the ground. But to illustrate the point that these orders are not made lightly, Members may be aware that it has been used twice in recent times – one against Dr Wee when there was a Court decision in relation to his conduct, and there was also a case involving Dr Ler Teck Siang who was involved in the leak of data from a HIV registry.”
“But I will just briefly mention that an idiosyncratic reason is just a reason that is peculiar to that patient. It may not be relevant or material to many other patients or most other patients or, in fact, maybe even any other patient. But if to that patient it is, and he has asked the question about it, then the doctor is required to address those concerns. Mr Pritam Singh also asked what do we do with a multi-disciplinary team setting. I would just like to say that, actually, in today's context, most care is given in that setting. If you go to a polyclinic, there is a team that looks after you. If you go to a PHI, a public hospital, there is also a team that looks after you. And the law actually takes that into account. The law does not require that only one doctor, the leading doctor, takes the consent. The law does accept that any member of the team can take the consent. But, obviously, the requirements of the consent-taking has to be fulfilled. You have got to give the right information, you got to ensure that the patient understands and so on. There have been several cases, the most recent of which is the case involving Dr Yeo Tseng Tsai, a decision decided last year where the Courts commented and I would just quote from a small portion of it at paragraph 50 of the Judgment where the Court says that "...in a public hospital that practises team-based care, it is reasonable for other members of the operating surgeon's team to explain the risks of the proposed treatment and to obtain the patient's consent on the surgeon's behalf." And that is a point that is quite consistent across several other decisions in the High Court in Singapore. To Mr Pritam Singh's point that we must look at this more frequently and regularly, we agree.”
“Anything that has got to do with putting on more workload and the workload then perhaps undermining the quality of care is something that MOH would be concerned about. And I would like to assure Members about that. But I would also like to say that we need to frame a test now which best promotes the doctor-patient relationship, gives that relationship the best chance of having a good interactive discourse that promotes the best outcomes. That has to be the starting point. Yes, there might be an increase in workload – although I do have something to say about that in a moment – but that ought not to be the starting point. That should not drive the way we define or formulate this test. We may have to find ways to work around it, to put better resources in public hospitals or polyclinics. But, as in designing the Civil Law Act test, I think we must first focus, and perhaps only focus, on what is good for the patient and doctor in that relationship. Anecdotally, I also do not see this formulation adding more to the current status quo. It might add more to what might have been the old Bolam test. But on the current modified Montgomery test, I do not think this formulation would add more by way of the time that you take to consult. I have also had a quick look at the polyclinic caseload over the years and I believe the numbers have been relatively steady in the past three to five years in terms of the caseload, roughly per consultant per day. In fact, if anything, you take that back 10 to 15 years, the numbers actually have come down. But that said, I appreciate the point made by both Mr Pritam Singh as well as Dr Tan Wu Meng about looking after the systemic issues. We will do so. Mr Louis Ng asked what might be an idiosyncratic reason. I think I have addressed this.”
“Because it is very situational, very fact-specific, fact-dependent. I hesitate even to say but probably the longer, further back a medical record is, the scan is – 10, 12, 15 years ago – the less likely it is to be relevant. I would not rule it out but the less likely it is. It probably would have been superseded by something else. It is really designed with the illustrations to give some degree of fluidity and some flexibility to look at the particular situation. With this framework, and I think Mr Vikram Nair also said, actually this is something that is very familiar territory. Not every detail needs to be given and within this framework, I think most doctors, if not, at least the lawyers would know, what is the peer opinion? Who are the peers? Who would qualify as a good, decent peer? What is an opinion that is logical, defensible, internally consistent? I think lawyers all know this. Then, you graft onto it – what did the patient ask or if the patient did not ask, what is reasonable to derive from the information before you? That is how we see the test operating. In some ways, to answer Dr Tan's point, we had to put out legislation to deal with this partly because we saw this was how it was going. We looked at the numbers that have been cited by myself and Members. We looked at observations of the work group. We understand where this is going and we understand that it might be a perception and it might well even be wrong. But that is the way in which the industry is reacting to it and I think it behooves us to do something about it. That is why these amendments have been offered. Sir, let me now move to a point that was raised by Mr Pritam Singh about the implication of a test like this for a busy polyclinic setting. That is a fair concern and the point is taken.”
“To Mr Pritam Singh's point about Recommendation 3 in the work group's report – yes, that is something that we will continue to look at, put in place and with due course, to have sufficient level of guidance for the medical fraternity. Going back to this test, we therefore start with, "What would my peers do in a typical consultation like this?" But we graft onto it what we regard as giving primacy to the patient's inquiries. If you go in and you do not say anything, we have some rules that set out what a doctor has to reasonably ascertain. I will come back to that in a moment. But if a patient asks a question directly, expresses a view or a concern, then even if that view of concern might not be regarded by the peer professional test as being material in every consultation, that still has to be answered by the doctor. That still has to be addressed by the doctor to their satisfaction. So, if I am a doctor and you ask me about a concern that is otherwise not within the radar of the peer professional opinion, I still have to address it, I still have to get my information to you correctly on what is the risk for this particular type of very small injury, which may not be material to many other people but to this patient, it is. This is my patient, I have to address it. That is how we strike that balance between certain starting points for doctors, but also taking into account patient autonomy. On this second question about what might be reasonably looked at and what is material. To Dr Lim's point, we do not need to look at all the medical records, all the microfiches, all the scans. That is not reasonable. If you ask me today, standing here, can we come up with a formula for what is reasonable, I think that is not possible. I think Members know why.”
“We therefore want philosophically to start with giving the doctors the assurance that when you walk into a room with a typical patient, average patient, this is what the practice of peer professionals would do. As long as you conform with that as a starting point, that is your baseline. As I mentioned earlier in my speech, it is the baseline standard. How do we assist this? Well, we also want to work with the professional bodies like Academy of Medicine of Singapore or AMS. AMS has got several chapters. We want to work with them to ensure that as far as they are concerned, for some of these more standard procedures, there is a benchmark that can be used to educate and inform doctors. Earlier on, a Member said: let us not wait until these cases are decided by the Court, because by that time, it is too late – at least for that case. We agree. We want to proactively look at what we can do, working with the fraternity to help the fraternity understand this better. We also want to amend the ECEG as I said earlier on to give better guidance to doctors on how these guidelines are to be applied. We want to do training. Many of the Members have mentioned and we have made a commitment to training in perhaps the boldest possible way by setting up a separate body, the Disciplinary Commission (DC), to look specifically at training, to make sure that the members who sit on the Complaints Committees (CCs), on the Disciplinary Tribunals (DTs), on the Review Committees (RCs), on the many "Cs" that someone has spoken about, are all of sufficient standard and not just at one point in time but are continually refreshed.”
“We therefore look at the test as trying to give doctors that degree of assurance when they first walk into a consultation room. The test starts with, as a matter of philosophy, what would my peers do in that situation? A peer might be a peer like Dr Koh's peers, who would decide that in such a situation, there is something to be gained by exercising therapeutic privilege. It is not something that patients easily understand if you look at it from the patient's perspective. I want to make one other observation, which is that in every single case where the patient's perspective is called into question and you have to assess what is the patient's perspective – whether it is a quasi-criminal case when it is before the Disciplinary Tribunal or DT, or whether it is a civil liability case – at that juncture, when you are assessing and talking about the patient's perspective, there is already an adverse issue between the patient and the doctor. The claim has already been made or the complaint has already been made. That is why you are looking at the patient's perspective. The patient's perspective is going to be very different. So, if you are a doctor, you think about walking into a room. You think about the therapeutic privilege that perhaps Dr Koh might think about, and then worry about whether or not at some stage downstream – not in the light of this fairly amicable discussion in the consultation room today – but you think about what might happen if you start the inquiry as, "What would that patient in that particular perspective want to know?" Then, I think the outcome might well be very different or at least perceived to be very different. There is going to be a tangible impact on the way you conduct yourself as a doctor.”
“Yes, it was discussed in the context of the previous decisions. That is the terminology that has been used. The work group has also used that terminology, but we have chosen to make sure that we stay away from it – as far as we can, to advance it as a common denominator of benefiting the patient and the doctor together. Sir, Mr Pillai asked – why change the test? What do we see as the value of making this change? Sir, I just want to make reference to one statistic. Earlier on, Mr Xie, Dr Lim Wee Kiak had talked about what the position was in the UK post-Montgomery, and I think there is a lesson to be learned there as well – the number of cases not just post-Montgomery but in respect of informed consent post-Montgomery. But look at the position in Singapore based on cases filed with the SMC. On informed consent complaints, there was an average of one per year from the years 2010 to 2016. It became five per year in 2017 and 2018 – roughly around the period of time that Hii Chii Kok was decided. In 2019 alone last year, there were 17 cases – 17 cases filed in respect of alleged informed consent breaches and drop in standard. That was in the year around the period of time when the Lim Lian Arn DT or Disciplinary Tribunal was decided. To Mr Pillai's point – and I get your point that perhaps if it is just a perception, why not we just deal with the perception. But the point I am making is that the perception actually results in there being tangible impact in the way the complaints are brought, in the way that damages have gone up over the years. And so, in Singapore, between 2017 and 2019, it is a threefold increase. That is a sign that we do need to do something about it.”
“Thank you, Mr Speaker, and thank you to all the hon Members who have spoken on this Bill and in support of this Bill. Let me just go straight into the heart of the Civil Law Act issues raised by Dr Tan Wu Meng, Mr Murali Pillai, Mr Vikram Nair, Dr Lim Wee Kiak, amongst others. Let me start by picking up on what Dr Koh Poh Koon said. I think he has given a very vivid explanation of why doctors need to feel that they are able to take some risk with the patient, able to advance the patient's interests in the best way that they know how to do. Knowing the information that they have, making the judgement that they do. And in some ways, trying to make the best decision and guide the patient towards that best decision sometimes does require the doctor to take a position – to exercise some degree of therapeutic privilege and to assess the kind of information that ought to be appropriate for not just this kind of injury and this kind of outcome but for this kind of patient and their family and overall, not losing sight of the end outcome. I would dare say that the majority of doctors want to be in that position where they do not have to look over their shoulder, they do not have to worry about what the patient might say and worry first about whether or not they have given everything to the patient based on the textbook. I think that is really an illustration of why the practice of medicine is truly an art and is not a science. It is an inexact art to begin with. It is a judgement call in every sense of the word. It is in that context that we start with the proposition that we do not want to place labels on the test. It should not be pro-doctor or pro-patient. That is why Mr Pillai is right that in this Bill, we have deliberately stayed away from putting that label on.”
“Yes, Sir. [Laughter.] But 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 work group in consulting over so many months – the number of doctors they have seen, the number of patients the advocacy groups have seen. They have also touched on stakeholders – insurers, lawyers, practitioners. They represent a very strong sense of what the industry – the legal, medical fraternity – wants to see. And many of these amendments that we have made here reflect that sentiment. It remains only for me to thank the work group members. I also want to record my appreciation to the members of the three professional bodies. They have been very supportive of our efforts. They also have people sitting on the work group and they have also recorded their agreement and support for the changes reflected in this Bill. Sir, with that, I beg to move. [Applause.] [(proc text) Question proposed. (proc text)] 3.24 pm”
“This, itself, will lend consistency across the spectrum as to how a charge might be framed and the factors to be taken into account in mitigation or aggravation as the case may be. Sir, I believe I have covered most of the key recommendations. As I have mentioned to Members, these have all to be taken together. You have to look at it in its totality and I have not gone through every clause in detail.”
“So, the IC or the CC may, having regard to the progress of the mediation, suspend the inquiry. We will work with institutions, like the Singapore Mediation Centre, to provide the relevant expertise and also infrastructural settings to achieve better outcomes through the use of well-trained, highly qualified mediators. There will be a reporting obligation for mediators who will report to the IC and CC to ensure that one keeps an even keel on the progress of the mediation and it is not used as an excuse to dislodge or disrupt the timetable for the conduct of the disciplinary proceedings. Sir, before I conclude, I just want to go back to a point I made earlier about the Legal Advisory and Prosecution Unit. I talked about it earlier. To recap, it is the advisory arm of the new unit that will advise the various committees. But there will also be a prosecution arm of that new unit and this will conduct prosecutions on behalf of the SMC. When that work group canvassed views, particularly from doctors, there were some who expressed the concern that the use of private law firms for prosecution may sometimes result in a "I must get a conviction at all costs" kind of approach and that is not the case. But it is also not healthy that there is that impression. On the other hand, a dedicated in-house prosecution team, residing within the SMC under the new unit, will help SMC to strengthen its own capabilities. It will aggregate the cases, 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 would take to prosecute these cases.”
“So, the amended section 4 makes two key changes to the composition of the SMC. First, the major medical professional bodies will now be represented on the SMC. So, these are the Academy of Medicine Singapore, the College of Family Physicians Singapore and the Singapore Medical Association. 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. Second, there will now be one instead of two representatives from each medical school in Singapore. This could be the Dean or his representative. 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 up to 15 members whilst the appointed membership will be changed from 15 to 12 members. In the same vein, the amended section 8 reduces the minimum years of standing required for a doctor to serve on the SMC from 10 years to eight years and a similar amendment has been made to the years of standing to allow a doctor to serve as a member on the Complaints Panel. We hope that this will encourage younger and also more doctors to step forward and serve on the SMC and on the Complaints Panel. Finally, I have mentioned the increased and enhanced use of mediation at the outset. We have set out some provisions which allow for this and, 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 a complaint to mediation during its inquiry; this section similarly empowers the CC also to do so. If the parties are participating in the mediation, obviously, if you are in the middle of a mediation, you do not want to have also a disciplinary inquiry.”
“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. And these situations are limited to two types. First, where a Court of law in Singapore has found that a doctor has engaged in 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. So, 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 would pose an imminent danger to his patients. 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. So, the thresholds are high, but we regard this as being in the interest of patient safety and public interest. In situations where such an interim order is made, the IOC must then convene the hearing within one month where the doctor will then be heard on his position and the interim order can then either be revoked or it can be replaced, as the case may be. If the hearing is not able to be convened within the month, then the immediate interim order will lapse. So, this also seeks to preserve the balance between the SMC and the doctor's livelihood. Sir, let me now move on to some other related revisions and then wrap up this afternoon's speech. Sir, we are also making changes to the composition of the SMC. This is to ensure a greater diversity of representation and views. The SMC is the paramount body that regulates and also represents the medical community, and it is important that its composition reflects the range of views amongst the different groups and also the different range of seniorities in the medical profession.”
“So, in the end, it was decided that, to the extent that it is in respect of the same doctor or another doctor, the mechanism that is set out is in section 50, subsection 6 and 7 will apply, and the SMC may, on the basis of the report made by the investigator who has looked into these matters, file a new complaint against the doctor. So, you can investigate it at the same time, file a new complaint and I believe this is an improvement over the current process. Next, allowing for interim orders to be issued more expediently in appropriate cases. This is also a new provision. It seeks to introduce a framework for the Interim Orders Committee (IOC). We provided for the IOC to be constituted more expediently and to act more quickly in circumstances where there is an imminent threat to the health or safety of doctors' patients. Let me very quickly outline the main changes. Under the current MRA, the referrals to the IOC are made by the Chairman of the Complaints Panel. The SMC does not have power to refer complaints to the IOC on its own accord and the effect of this is that where the SMC learns of matters which might warrant a referral to the IOC, it is reliant on the Chairman of the Complaints Panel to do so, and we regard this as less than ideal. The new section 59J(4) will, therefore, give the SMC power to do so on its own motion. Under the current MRA, the doctor must be heard at an IOC hearing in all cases before the order is made. So, with the best of intentions, sometimes, these hearings will take place weeks, if not months, after the referral is first made, for a number of reasons, not necessarily because of an intention to delay.”
“I hasten to add that this RC is not intended to be a second CC and so the scope will be limited to two specific instances: First, whether or not there has been due process. So, it looks at the CC and evaluates it from the position of whether due process has been complied with. Second, to assess whether any new evidence has been submitted to an RC and if so, why and it will consider whether the new evidence is material to the complaint or to the outcome, as the case may be. The RC proceeds by majority and can make the orders such as stating that the CC has compiled with the procedural requirements, or it may direct the CC to conduct further investigations or inquiry. Sir, I move very quickly to the third broad basket of changes, that is to protect the patients more effectively and just very briefly set out some of the provisions in the interest of time for Members. First, we seek to empower the IC and the CC to obtain relevant documents and information for the purposes of their inquiries. I think it can brook no dissent that the relevant investigative arms of this process must be clothed with the power to obtain documents, take information as quickly as possible. So, the new sections 43(2) and 45(5) provide for that. Second, we seek to also provide that the investigator can look into wrongdoings not covered by the complaint. It is something that we 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 may be a related matter, one which would be a matter of interest and in the current rules, you would have to restart the process just to look into that.”
“However, this does not preclude judicial review which is present and that is governed by general law. Sir, there was some feedback during the work groups 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 to have them channel through the system, take up committee time, investigation resources, it is for that reason that we propose to have a filter up front and staffed better, more resource and also in tandem with the legal advisory unit that I mentioned earlier. I just want to also mention to Members that the creation of the IC also parallels the Legal Profession Act which has a similar filtering committee and I think it is called the Review Committee. Next, let me talk about the Review Committee or RC. It is a new creation; that is why I will spend some time on this. The Review Committee reviews the decisions of the CC except decisions to refer the complaint for a formal inquiry. This replaces the current appeals process whereby appeals against such decisions of CCs are made to the Minister for Health. There is some feedback that the existing process for appeals was either not transparent or was slow; and sometimes unclear as to what the considerations were; and sometimes new evidence was let in, in those cases which then led to the process being derailed. The new sections 54, 55 and 56 provide for the appointment of the RC to consider requests made by the complainant doctor or the SMC against the CC.”
“This rule is not designed to shut them out because we do know, on one hand, that making a complaint is a serious matter and complainants are expected to substantiate the allegations. At the same time, complaints will not be dismissed out of head 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. In any event, if the complaint is dismissed, the IC will be required to give its reasons for the decision. This is under the new section 43(3)(a). It is the SMC's practice currently to inform complainants of the outcome of the complaints. This will continue to be the case even after the amendments come into force and the complainants will of course be informed if an IC dismisses their complaint along with the reasons for that dismissal. Sir, there are new powers in section 43(3)(b)(ii) and 43(3)(c), which give the IC the power to direct the investigations commence upon referral to the CC without having to wait for the CC to be appointed. Sir, this is really just to close the gap between the two committees, so that at the time when one is handed over, straightaway, the investigation unit is empowered to commence investigations, take statements, take documents and really be in a position to be ready, once the CC steps in and is constituted. Once the CC is appointed, it then takes over and assumes oversight of those investigations. Similar to the Review Committee of the Legal Profession Act or LPA, which some Members might be familiar with, there is no right of appeal from the IC's decision to another committee in the disciplinary process or to a Court.”
“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 patient; or it was otherwise vexatious in a sense that it was a repeat complaint; or a complaint that has been dredged up when it has already been resolved and so on. Each such complaint takes up considerable resources to manage, which will be better utilised for more deserving cases where the complaint actually has a good basis. And on our rough numbers, roughly about 10% of these complaints make it to the DT every year. So, roughly about 16 to 18 cases make it to the DT. There is a fair number of cases that do not end up in the DT. 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 where possible upfront. Because as one can imagine, if you have the full 165 cases travel through the system, it will create a lot more strain on the resources and it will take a lot more time for each of the cases to be resolved. So, having more specialised and dedicated resources upfront, will play in our view, a significant role in filtering out the cases appropriate either for resolution, early resolution, or perhaps channelling into mediation and then only allowing those that require investigation or have merit in the substance of the complaint to proceed. Sir, some complainants may not necessarily have all the information at hand at the time they make the complaint.”
“Currently, part of the problem is the doctors do not always know immediately and sometimes it takes months, if not a year, before the doctor is aware that a complaint has been made. Second, we strive to increase the pool of Complaints Panel members because the Complaints Panel really is the bottleneck. If the Complaints Panel is more well resourced, better staffed, then these cases can proceed more expeditiously and they enable disciplinary committees to be constituted more quickly. Third, introducing a time limit – time limitation period for complaints. This is also similar to what is done in the Law Society to ensure that very stale complains do not get refreshed, really to ensure that there is also fairness in terms of having the doctors maintain his or her notes and the evidence and the quality of the 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 time bar. Fourth, we have created, as I mentioned just now, levers to control both individual stages of the proceedings as well as the overall length of time that the complaint takes to be resolved. There are just two areas which are relatively new and I just want to spend a bit more time on them, to explain this to Members. The first is the Inquiry Committee. We have proposed a new filter mechanism up front, to help to sieve out unmeritorious complaints at an early stage. To give Members some idea of the thinking behind this, I will just give you some of the numbers that we have. Since 2010, in other words, for the past decade or so, the SMC has received an average of about 165 complaints every year.”
“Sir, I think Members know that that has been one of the chief complaints about the system that has taken too long; that between the time a complaint is lodged until it is resolved, can be five, six, seven years in some cases; in the case where a doctor is found ultimately not liable, not guilty, it is a real strain on the doctor and a real stress on the doctor; in a case where the patient is successful and the doctor is found liable for professional misconduct, then the question will be – why is it that for the last six, seven years, this doctor has been practising and what has been done to protect the patient's interest. 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 case. I am not going to go into the specific timelines, but at each stage there is a timeline, there is some provision for extensions beyond certain number of extensions, the relevant committees will have to go to the High Court to make a case for that extension. And we believe that that is the really the best way of driving this forward in a fair way. On our estimate, on an average case, it would take something like a year and a half, 18 to about 20, 22 months for a case to be resolved and we believe that that is sufficiently reasonable time for the cases to be adequately disposed of. But of course, in the cases, which are more complex, require more time and more investigations, parties can apply to Court and justify that. I will just quickly outline the measures that we have set up in the Bill to address the delays. They are first, an early notification to a doctor that a complaint has been filed.”
“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 take further action in relation to a complaint after it receives the recommendations from the Inquiry Committee or IC in this case, which is the Law Society's equivalent of the CC. Sir, 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 a cause of sufficient gravity for 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 the relevant members of both the CC and the SMC apply their minds to the standards that have to be established. Sir, 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. I do not need to repeat that here, but those will be the criteria and we would require the SMC members to have regard to that pronouncement in making the assessment. The amendments to provide for the SMC to determine if a DT to be appointed as well as prescribing the standards for referral, overall, we believe would 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. Sir, I move on next to look at the amendments to facilitate a more expeditious resolution of complaints.”
“And we believe that the collective wisdom of the SMC in reviewing the CC's decision 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 the matter is referred to the DT. The new section 46(6) provides that the CC will now make recommendations to the SMC as to whether there should be a formal inquiry by a DT. If a CC recommends a formal inquiry by the DT, it will also have to formulate the charges and give its reasons for recommending the referral of the complaint to a DT. 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 then a new team, almost, takes over. Here, once the CC has decided, it states its reasons and it will also at least formulate the charges, if not fully, as 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 by the CC in referring the matter to the DT. 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), it must inform the parties of its determination and the reasons for this. So, the fact that it has decided not to take up the CC's recommendation and also its reasons for not doing so. 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. The decision of the SMC as to whether to refer a case to the DT will be final.”
“While the creation of the new 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. So later on, when I deal with the IC and the RC, Members should also recall that the legal unit does sit and is present to assist the IC at the outset. The moment a case is referred to the IC, the IC gets legal support to assess the case, to assess whether it is vexatious or frivolous and whether or not it meets the required threshold for professional misconduct. Next Sir, the amendment will also provide that it is the SMC rather than the CC which will determine whether a matter is referred to the DT or not. Currently, the MRA requires the SMC to appoint a DT if the CC determines that a formal inquiry by the DT is necessary. So, 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. And that is the case even if the SMC might otherwise disagree with the view of the CC. During the work group'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. 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. To this end, the SMC will be responsible for the ultimate decision as to whether a matter will be referred to the DT or not.”
“The legal professional will not necessarily be the chairman of the DT and further, a serving Judge or JC will only chair cases where the President of the DC feels that it is appropriate to do so, and the decisions of the DT will still be determined by majority vote. Even in a case where a Judge or JC sits as a Chairman, that person cannot on his or her own override the opinion of two doctors if both doctors agree with each other. Sir, 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 factors when deciding on an appropriate sentence. The committee has completed its work and the SMC published these guidelines in July 2020. These will complement the current amendments to facilitate fair, consistent decision making by the DT. 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. For this purpose, the SMC will be establishing a legal advisory and prosecution unit. The advisory arm of this unit will advise the disciplinary committees in their disciplinary framework and ensure that they have access to legal support that they require to perform the functions, and this in turns facilitates clarity on the applicable standards, how the charges might be preferred, what kind of legal standards will apply and so on. The prosecution arm of the new unit will undertake prosecutions for the SMC; a topic that I will return to later.”
“Previously, DTs were constituted in various permutations, and it was not obligatory to have a legal professional sit in one of these tribunals, but our view is that having an experienced legal professional on the DT will bring greater legal and forensic expertise to the DTs' deliberations and determinations. 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. In some of the more difficult cases, the key issues may also be more legal rather than medical in nature. In addition, having a legally trained member sit on the DT will assist the DT in preparing his decisions, ensuring that 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 of law, they may be more appropriately directed to a serving Judge or Judicial Commissioner of the Supreme Court. 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. So, there is an opening or option in section 59 for the President of the DC to decide on a case being more complex and inviting the Chief Justice to nominate a Judge or a JC to sit as a Chairman of that particular DT. Sir, I should make it clear that with this proposal, we still continue to maintain the principle of self-regulation by the medical profession.”
“In the UK, the General Medical Council, which is the equivalent of the SMC, established their Medical Practitioners Tribunal Service in 2012, and the purpose of this was, amongst other things, to provide a clear separation between a GMC's investigation functions and the adjudication of hearings, which is similar to what we are proposing here. With the DC, it will be responsible for the setting up of the DTs to hear the cases as tribunal and the SMC will continue with the function of preferring the charges and prosecuting the charges on behalf of the complainants. The DC’s second key mandate is to oversee the training of members of the Complaints Panel and the Health Committee, and ensure that they are appropriately trained to carry out their roles in the various committees. This addresses various feedback both from members of the CCs and DTs and also from doctors in the town halls that we need to increase and uphold the standards of doctors who sit in these tribunals. Many of them are experienced doctors, but sometimes marrying the experience as doctors to a process that has a fairly strong legal slant to it may not always make for a good match. Other than providing for this, training, regular and systemic training will also help them to carry out their duties better. And 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. As a step to ensuring consistency in processes and outcomes, we are proposing that a legal professional is required to sit on each DT. The new section 58(1) provides that individual DTs will now comprise two doctors and one legal professional.”
“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 or DC. This will be a body that is separate from the SMC, headed by a senior doctor as President. It is envisaged that the President will be a full-time appointment. The DC will have a dedicated secretariat that will exclusively support its functions and it will have two key mandates. 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. 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. However, there is a continuing perception of the lack of independence simply because the SMC appoints the DT and also has a prosecution arm looking after the complaints of the complainant and framing the charges against the doctor. This is ostensibly because as I said, they appoint the DT, but the reality is that it is not 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. We are not starting from a clean slate as it were in this case as we looked at their practices in other countries, other jurisdictions, and the one that is fairly close to what we are proposing is found in the United Kingdom.”
“If this system falls short, it undermines confidence and in turn, will affect doctors’ practices and erode trust, in the way I have outlined. The amendments in this Bill are quite substantial and I do not propose to cover every clause, probably to your relief, Sir. But I would add, Sir, that it is not a silver bullet. You cannot look at the provisions in and of itself, and so, we would like Members to look at these amendments as a collective whole. Because you cannot just change the process or you cannot just impose a time discipline or you cannot just say enhance training. They have got 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 then highlight the salient clauses in relation to each of these objectives to Members. The four objectives are: firstly, to improve the quality and consistency of processes and outcomes in the system; second, to reduce delays and facilitate a more expeditious resolution of complaints; third, to protect patients more effectively; and fourth, to encourage as far as possible, the amicable resolution of complaints and facilitate a less adversarial disciplinary process in the appropriate cases between patients and doctors. Sir, I will first address the change that we seek to make to improve the quality of the process and outcomes. When the disciplinary system does not effectively enforce the profession's standards, doctors are faced with uncertainty and unnecessary stress. In these cases, the patient-doctor relationship is sometimes supplanted by the plaintiff-doctor relationship. We seek to introduce a number of changes to enhance the structure and to give more robustness to the disciplinary framework.”
“Healthcare professionals will also 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 because as I have said, no two patients and no two consultations are identical. At the same time, it maintains the high degree of patient autonomy that was present in the Hii Chii Kok test. And we strive to move away from a test that is described as patient-centric or a doctor-centric, but instead to one where we can say that it is really undergirded by patient empowerment. 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. And that ultimately, is the overriding objective of designing this test and adopting it in a way in which I have just outlined. Sir, I will now move on to key features of the second Bill – the Medical Registration (Amendment) Bill, which amends the Medical Registration Act. 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. This is the second slate of amendments that we are proposing, arising out also of the work group's recommendations. Sir, I think it cannot be gain said that it is really of utmost importance that the medical disciplinary system functions efficiently, effectively and fairly. 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.”