Speech by Mr. Louis Ng Kok Kwang, MP for Nee Soon GRC, at the Second Reading of the Medical Registration (Amendment) Bill (Bill No. 30/2020) and the Civil Law (Amendment) Bill (Bill No. 33/2020)
Introduction: Medical Registration (Amendment) Bill
Sir, in recent years, the Singapore Medical Council (SMC) has faced several questions about its disciplinary process.
Some cases brought to the SMC have taken a long time to resolve. It has created agony for some patients and doctors who wait up to seven years for justice to see its day.
For several doctors, they question whether justice is even on the table, as some cases brought by SMC were misguided and ended up being overturned by the High Court.
The Medical Registration (Amendment) Bill is a step in the right direction. It helps the process produce fairer, quicker and more consistent outcomes.
I support the Bill and I would also like to thank MOH for convening the Workgroup to Review the Taking of Informed Consent and SMC Disciplinary Process in March 2019.
The Workgroup engaged doctors, doctors’ associations, patient advocacy groups, lawyers and members of the public, producing a rich report whose imprint is clear in this Bill.
That said, I have some points of clarifications concerning this Bill.
Shortage of manpower
My first point relates to manpower as many have addressed before me.
This Bill adds several layers to the SMC disciplinary process. To reach its conclusion, a given case may now pass through as many as six committees: the Inquiry Committee, Complaints Committee, Review Committee, Health Committee, Interim Orders Committee, and Disciplinary Tribunal.
By my count, a case may require as many as 17 different committee members, not including experts or lawyers.
Some new measures will help with staffing, such as lifting the limit on the number of non-SMC members who can join the Complaints Panel.
But I worry that this is not enough. After all, we’re talking about a status quo where lack of manpower has delayed the process by years.
As such, I have two questions:
One, of the non-SMC members appointed to the Complaints Panel in 2019, how many were doctors and non-doctors? I ask this because we are lifting the limits on these numbers, but the change will not help if each number is currently nowhere near its limit.
Two, how many Complaints Panel members does the Ministry aim for the Complaints Panel to have in 2021? What steps will the Ministry take to achieve this target?
Is there a need for an Inquiry Committee
My second point of clarification is on the purpose of the Inquiry Committee.
This Bill introduces the idea of the Inquiry Committee. Any time a case reaches SMC, two doctors form the Inquiry Committee will decide whether the case is frivolous. If yes, they throw it out. If no, they pass it to the Complaints Committee to investigate.
But do we actually need it? According to the Workgroup, only 7% of SMC complaints have been dismissed as frivolous or vexatious. For the other 93% of the cases, this new proposal will add five weeks and two doctors without actually changing the outcome.
This does not help SMC’s manpower problems. Instead, it makes them worse. I have to agree with a group of doctors interviewed by the Workgroup, who said that a new committee is not the solution.
The most elegant solution, in my view, is to skip the creation of Inquiry Committees. We let the Complaints Committee determine whether a case is frivolous, but set a deadline of three weeks for them to do so.
If the case is not frivolous, they seamlessly continue their investigation. This way, we keep the committee sensitive to time and focused on tasks, while avoiding the work of forming new committees and the friction of transferring investigations between them.
If we do decide to keep the Inquiry Committee, I have two questions for the Ministry.
One, how many cases does the Ministry forecast will reach the Inquiry Committee but not the Complaints Committee?
Two, there is an existing problem of some Complaint Committee members avoiding risky decisions and passing the buck to Disciplinary Tribunal to make a decision, according to the Workgroup.
What will be done to ensure Inquiry Committees avoid this same exact practice?
Dismissal of inquiries
My third point of clarification relates to the dismissal of frivolous, vexatious, misconceived, or unsubstantive complaints by the Inquiry Committee.
Minister has earlier addressed this point substantively but I just wanted to confirm that the Inquiry Committee will share the decisions and reasons to the complainant when it dismisses the complain.
My next point was also addressed by Minister about the legal advisory unit and I will move on to my fifth point.
Escalation to Disciplinary Commission
My fifth point of clarification is about the avenues now available to the Medical Council in serious cases. It can do two things.
One, escalate a complaint to the President of the Disciplinary Commission. It can do this when the doctor has a criminal conviction, caused the death of a patient, is the subject of an adverse finding by a coroner, or is assessed to pose some other serious threat to patient health.
Two, seek interim orders that can suspend a doctor or impose conditions on a doctor’s work. It can do this when it determines that the orders would protect members of the public or otherwise serve the public interest.
I have three questions.
One, when is it appropriate for the Medical Council to choose not to escalate matters to the Disciplinary Commission?
The existence of discretion suggests that it is sometimes acceptable for the Medical Council to avoid escalating the matter even when a doctor has caused the death of a patient or been convicted of a serious criminal offense.
What factors mitigate against the severity of such incidents?
Two, what are the envisaged cases where an interim order is required and it is deemed “necessary for the protection of members of the public or otherwise in the public interest”?
What factors or principles should guide the consideration of the Interim Orders Committee?
Three, when should the Medical Council escalate matters to the Disciplinary Commission as opposed to seeking interim orders?
If a patient’s health is being threatened, these two avenues are available to the Medical Council.
Can the Ministry provide examples where it would be more appropriate to pursue an escalation to the Disciplinary Commission as opposed to seeking interim orders?
Sir, I believe that this Bill will lead to better outcomes for both patients and doctors and I stand in support of it.
Introduction: Civil Law (Amendment) Bill
Next, I also thank the Ministry for the direction taken in the Civil Law (Amendment) Bill towards a more patient-centered approach. This is consistent with the growing international consensus on the need for greater patient autonomy and informed consent.
Manpower and time constraints faced by doctors
My only concern on this Bill is on manpower and time constraints doctors face.
I understand that doctors have significant concerns on how to meet the proposed patient-care standards given the manpower and time constraints doctors face.
The current doctor patient ratio in Singapore is 1 doctor for every 444 patients or 2.3 doctors for every 1,000 patients.
In comparison, there are 2.8 doctors for every 1,000 patients in the UK.
The EU average ratio is 3.8 doctors for every 1,000 patients.
The OECD average ratio of 3.5 doctors for every 1,000 patients.
At the same time, I understand that doctors have very limited consultation time with their patients due to their workload.
Within a short amount of time, doctors are expected to assess needs, comb through a vast amount of medical history information that may be available on the National Electronic Healthcare System, explain the situation and assist patients to make important clinical decisions.
Due to consult time constraints and possible differences in language and levels of understanding, patients may not be able to convey their concerns well enough to their doctors.
Doctors similarly may not be able to extract enough information to understand every aspect of the patient’s concerns.
Time is also required to build understanding and to build confidence in the patient to undergo a recommended treatment.
The stress of having to meet hospital KPIs measured in terms of consult times and manpower may also be overwhelming.
I understand some doctors fear that what is ‘reasonable’ to the court may in fact, be humanly impossible to achieve.
They also fear that such expectations can lead to further burnout amongst doctors.
If the calibration is not done well, this may tilt the balance towards doctors practicing defensive medicine while simultaneously managing consultation times.
Can Minister share what additional support will be given to our doctors to allow them to meet these enhanced standards of advice that is required to be given to our patients?
For example, will doctor-patient ratios and consultation times be increased in public hospitals?
Can Minister also provide assurance that practical circumstances of doctors will be taken into account when assessing the reasonableness of such advice?
Sir, Minister Edwin Tong said in a 2019 speech that doctors must be able to trust the system and that if it is not clear what standards are required of doctors, doctors may end up giving more information than is necessary.
He said, “Ultimately, we can do more harm if we assume that simply giving more information means the patient has more understanding.
Paradoxically, it is the complete opposite. Giving more information could lead to less understanding. Ultimately, no one benefits from this kind of defensive medicine because medical costs will go up, and patients do not get the best advice from their doctors. Patient safety will be compromised.”
I hope we will provide a framework for a system which doctors can trust and that would be fair to the circumstances they face. The system should take into account practical constraints, patient’s preferences, and the types of medical procedures.
Sir, notwithstanding, these clarifications I stand in support of both Bills.
Watch the speech here
Watch the response here