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More teeth to discipline errant doctors

Country: 
Singapore
Partner Institute: 
Department of Epidemiology and Public Health, National University of Singapore
Survey no: 
(15) 2010
Author(s): 
Lim Meng Kin
Health Policy Issues: 
HR Training/Capacities
Reform formerly reported in: 
Non-Medical Chair, Medical Disciplinary Tribunal?
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes no no no no no no

Abstract

Singapore?s Parliament has passed the Medical Registration (Amendment) Bill aimed at strengthening penalties against errant doctors. Included is a controversial proposal to allow senior legal professionals to sit on the Singapore Medical Council's disciplinary tribunals as either chairman or member.

Recent developments

The new Bill gives the SMC more teeth to protect patients, and more leeway in carrying out its investigations into professional misconduct. The SMC will now be able to impose fines of up to $100,000 instead of the previous maximum  of  $10,000, a sum that was set in 1997. It would also be able to suspend doctors for  longer than the current maximum of three years, with no specified upper limit. 

Also, to speed up the hearing of cases, the number of SMC members would be increased from 19 to 25, and the number of lay persons and doctors eligible to sit in a disciplinary hearing would go up from 80 to 150.

But the part that generated the most debate was a proposal to allow senior legal practitioners to join the SMC's disciplinary tribunals as chairpersons or members. A proposal  which had drawn much opposition from doctors when it was mooted by the Ministry of Health and the SMC a year ago.

Another change to the Act gave the SMC a bigger role in monitoring how doctors, especially those trained abroad, performed.The Bill allows the SMC to consider letting a foreign specialist practise here as long as he had enough experience in his sub-speciality but he would be restricted to his area of expertise. SMC would  also be empowered to obtain feedback on a doctor's performance from other healthcare professionals as well, and not just from the doctor's immediate supervisor.

Yet another change was that, whereas currently only the defendant doctor was allowed to appeal to the High Court on the decision of the Disciplinary Tribunal, now the SMC is allowed to appeal to the High Court if it does not agree with the Disciplinary Tribunal's decisions.

Another armamentarium in SMC's hands now is the power to restrict a doctor's practice by changing his full registration to one that is conditional and supervised.

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual controversial highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low high very high
Transferability strongly system-dependent system-neutral system-neutral
current current   previous previous

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes no no no no no no

Initiators of idea/main actors

  • Government
  • Parliament
  • Patients, Consumers
  • Scientific Community

Stakeholder positions

According to the Minster of Health, the current and past presidents of the SMC had strongly recommended the controversial amendment to include legal professionals. "They have personal experience conducting the disciplinary proceedings and felt strongly that the presence of an experienced legal professional on the disciplinary tribunal would be a significant advantage," he explained to Parliament.

Judging from media reports, the public was generally favorable.

The medical fraternity's response was muted. 

Actors and positions

Description of actors and their positions
Government
Governmentvery supportivevery supportive strongly opposed
Parliament
Medical Members of Parliamentvery supportiveopposed strongly opposed
Patients, Consumers
General Publicvery supportivevery supportive strongly opposed
Scientific Community
Singapore Medical Associationvery supportiveopposed strongly opposed
College of General Practitionersvery supportiveopposed strongly opposed
current current   previous previous

Influences in policy making and legislation

When the controversial proposal to include a legal professional as chairman of the SMC's Disciplinary Tribunal was mooted a year ago, there were protests from both individual doctors and medical associations who saw it as an erosion of physician autonomy and a step backward for medical self-regulation, despite the MOH's assertion that it was primarily concerned that the SMC's disciplinary tribunal should have the benefit of a legal mind in the chair in complicated cases that may be fraught with legal minefields.

After taking into consideration the doctors' concerns in a series of consultations, the Bill was finally tabled with a notable modification: that the lawyer could now be either member or chairman (the original proposal was for chairmanship) of the tribunal and if in the latter capacity, would not have a casting vote in the event of a tie. 

In pushing through the Bill, the Minister of Health said that Singapore needed "efficient, transparent and fair processes in place to ensure that misconduct is dealt with speedily, so as to strengthen the good reputation that our medical profession enjoys". Thus, the need to protect patient's rights against errant doctors remains the prime motivation for the changes found in the new Bill.

The number of complaints lodged with the SMC against doctors has gone up from 66 in 2003 to 96 in 2009, in tandem with the increased number of doctors from 6292 to 9033 over the same period. This works out to about 11 complaints per 1000 doctors a year, which the MOH does not consider to be alarming.

On the issue of transparency, however, the new Bill apparently did not go far enough, for it prompted several Parliamentarians to call for SMC's disciplinary tribunal proceedings to be made public -  since the hearings would still be held behind closed doors. One MP pointed out that when complaints were rejected and the reasons were not known, it would  lead to speculation that the medical watchdog might be protecting members of its own profession. Although the Minister explained that the issue was complicated by the need to protect patients' confidentiality, he nevertheless promised to study the matter "given the rising  level of interest in the issue of transparency".

Actors and influence

Description of actors and their influence

Government
Governmentvery strongvery strong none
Parliament
Medical Members of Parliamentvery strongweak none
Patients, Consumers
General Publicvery strongweak none
Scientific Community
Singapore Medical Associationvery strongweak none
College of General Practitionersvery strongweak none
current current   previous previous
General PublicGovernmentMedical Members of Parliament, Singapore Medical Association, College of General Practitioners

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Expected outcome

Impact of this policy

Quality of Health Care Services marginal marginal fundamental
Level of Equity system less equitable system less equitable system more equitable
Cost Efficiency very low very low very high
current current   previous previous

The changes to the Medical Registration Act can be seen as a trade-off between preserving the interests of the public on the one hand and the principle of medical self-regulation on the other. It would seem that a similar trade-off may be needed between total transparency and the need for some opacity in order to preserve patient confidentiality. 

Overall, the policy is positive for patients who can now expect faster redress against negligent or unprofessional doctors, who would also be subject to tougher penalties. The Ministry of Health has achieved its objective of holding the medical profession to greater accountability.

References

Sources of Information

S Ramesh. Parliament passes Act to strengthen penalties against errant doctors. Channel News Asia 11 January 2010

M Chuang. "Law on doctors' competency strengthened", The Business Times, 12 January 2010

S Khalik. "SMC gets more teeth to protect patients", The Straits Times, 12 January 2010

CC Neo. Doctors, the lawyer is in.  Today. Jan 12, 2010

Reform formerly reported in

Non-Medical Chair, Medical Disciplinary Tribunal?
Process Stages: Policy Paper

Author/s and/or contributors to this survey

Lim Meng Kin

National University of Singapore

Suggested citation for this online article

Lim Meng Kin. "More teeth to discipline errant doctors". Health Policy Monitor, April 2010. Available at http://www.hpm.org/survey/sg/a15/2