Civil Law (Amendment) Bill

(9 min) Mr Louis Ng Kok Kwang (Nee Soon): Sir, in recent years, the Singapore Medical Council or SMC has faced several questions about his disciplinary process. Some cases brought to the SMC has 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 and some cases brought by SMC were misguide 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 like to thank MOH for convening the work group to review the taking of informed consent and SMC Disciplinary Process in March 2019. The work group 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 is it. I have some points of clarification on this Bill.

My first point relates to manpower, as many have raised before me. This Bill adds several layers to the SMC's disciplinary process to reach its conclusion. A given case may not 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 limits on the number of non-SMC members who can join the Complaints Panel. But, I worry that this is not enough, after all, we are 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?

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 the SMC, two doctors from 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 work group, only 7% of SMC complaints have been dismissed as frivolous or vexatious. For the other 93% of the cases, this new proposal adds 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 work group who has said that a new committee is not the solution.

The most elegant solution, in my view, is to skip the creation of the Inquiry Committee. 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. Firstly, how many cases does the Ministry forecast will reach the Inquiry Committee but not the Complaints Committee? Secondly, there is an existing problem of some Complaints Committee members avoiding risky decisions and passing the buck to the Disciplinary Tribunal to make a decision, according to the work group. What will be done to ensure Inquiry Committees avoid this same exact practice?

My third point of clarification relates to the dismissal of frivolous, vexatious, misconceived or non substantive complaints by the Inquiry Committee. The Minister had earlier addressed this point substantively and I just wanted to confirm that the Inquiry Committee will share its decisions and reasons with the complainant when it dismisses the complaint.

My next point was addressed by the Minister about the legal advisory unit and I will move on to my fifth point, which is about the avenues now available to the medical council in serious cases.

It can do two things currently. Firstly, escalate a complaint to the President of the Disciplinary Commission and it can do so 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. Secondly, 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 order would protect members of the public or otherwise serve the public interest.

I have three questions on this point.

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 to the medical council to avoid escalating the matter even when a doctor has caused the death of a patient or has 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's 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.

Next, I also thank the Ministry for the direction taken in the Civil Law (Amendment) Bill towards a more patient-centric approach. This is consistent with the growing international consensus on the need for greater patient autonomy and informed consent.

My only concern on this Bill is again 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 one 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 European Union average ratio is 3.8 doctors for every 1,000 patients. The OECD average ratio is 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.

With 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 informed 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 as well. 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 time and manpower may also be overwhelming.

I understand some doctors fear 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 time.

Can the 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 the doctor-patient ratio and consultation time be increased in public hospitals?

Can the 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 himself in a speech in 2019 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 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.

Response from Mr Edwin Tong Chun Fai: 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, 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.

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.

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.

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. 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. 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. 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. 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. 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? 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. 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. 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.

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. 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.

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.

Source: Hansard