Healthcare Services (Amendment) Bill

Order for Second Reading read.

Mr Speaker: Minister for Health.

6.19 pm

The Senior Minister of State for Health (Dr Janil Puthucheary) (for the Minister for Health): Mr Speaker, Sir, on behalf of the Minister for Health, I beg to move, "That the Bill be now read a Second time".

Sir, the Healthcare Services Act 2020 (HCSA) was passed in Parliament in January 2020. It will replace the Private Hospitals and Medical Clinics Act 1980 (PHMCA), which was enacted in 1980 and regulates the use of premises in which healthcare services are provided. Since 1980, the healthcare landscape in Singapore had undergone many significant changes and it was timely in 2020 to update the regulatory framework to become services-based and premises-neutral, to ensure that our regulatory approach remains relevant and flexible.

The Act is being implemented progressively with licensees coming onboard HCSA in three phases. We started with laboratory, radiological, ambulance and medical transport services in Phase 1 in January 2022 and will be progressing to hospital, medical and dental services in Phase 2 in mid-2023. Lastly, we will onboard the nursing home services in Phase 3, planned for the end of 2023. This phased approach is intended to give licensees sufficient time to prepare for, and adjust to, the new Act, and thus minimise disruption to existing healthcare services.

Since the implementation of HCSA in Phase 1, there have been developments which require further refinement of this legislation.

First, the COVID-19 pandemic has led to changes in how healthcare is delivered. For instance, new models of care such as teleconsulting and home medical services have proven to be effective and efficient. While HCSA is already a services-based framework, it needs to provide more clarity and flexibility on the requirements related to these new models of care, to continue protecting patient safety and enabling new innovations in providing care. COVID-19 also highlighted the need for HCSA to be adjusted to allow us to respond to public healthcare emergencies more nimbly. This includes instances where licence conditions must be changed immediately to address urgent patient safety or public health issues.

Second, we received feedback on several areas of the regulatory framework, which could be improved. This includes misleading advertisements including non-licensable healthcare services or business names. This was a result of engagements with stakeholders to continuously review and update HCSA while preparing for its rollout across existing and new licensees.

And third, there was a need to align the scope of regulatory action for healthcare advertising by licensees and non-licensees. All these have led us to further review HCSA to enhance and future-proof the legislation.

The proposed amendments will allow us to be nimbler in responding to the evolving healthcare landscape and enable premises-neutral care to be delivered across our healthcare settings. It will also strengthen governance to safeguard patient safety and welfare, and protect patients from misinformation, exploitation or abuse.

Sir, I will go through the key features of the Bill and highlight changes to existing legislation.

Clause 4 will amend section 9 to introduce the regulation of four primary modes of service delivery: permanent premises, temporary premises, conveyances and remote provision. Licensees must obtain approval to provide a licensable healthcare service by any of these four modes.

To give some examples, permanent premises are physical, in-person, General practitioner clinics or hospitals. Temporary premises would include ad-hoc health screenings in a community centre's multipurpose hall or when a doctor conducts a house call visit to a patient's home. Conveyances refer to the healthcare service being delivered using vehicles, like ambulances or dental screening buses. Remote provision involves the delivery of healthcare services through virtual platforms such as virtual teleconsultation.

A clear regulatory framework for these various service delivery modes will give providers the confidence to continue to provide and expand home care services, which are critical to enable ageing in the community, in particular for seniors who are homebound, or those at the end-of-life. Bringing medical services closer to the community and into homes will also enhance the convenience to patients and their caregivers and reduce caregiver burden.

For example, home medical providers caring for patients at the end-of-life will now be able to help maximise patients' quality of life and fulfil their aspirations to spend their last days at home. The Mobile Inpatient Care at Home (MIC@Home) is another care model where suitable patients can choose to be managed at home and receive similar clinical care as in the hospital, and this includes regular review by the care team either by home visits, teleconsultation or remote monitoring of vital signs, and even intravenous medication if required.

Under this approval regime, the Ministry of Health (MOH) can prescribe regulatory requirements and impose approval conditions on licensees. MOH can also prescribe the service delivery modes that are not permitted for a licensable healthcare service. This provides licensees with better clarity on the requirements they must meet and allows them to determine the appropriate business model for the delivery of their healthcare services. This also increases public transparency on the nature of healthcare services being provided by each licensee, how they can access these services and how the Ministry intends to regulate the delivery of the various types of healthcare services.

The amendments at clauses 6 to 9, and 12 to 15, in particular the new sections 9, 11A and 11B and the amended section 20, set out the details of the approval regime for this, including the regulatory actions that can be taken against licensees who contravene the relevant regulatory requirements or approval conditions.

At present, MOH issues licence conditions to impose new safety standards, such as in instances where there is a change in the regulatory technical standards due to evolving scientific developments. MOH is now required to provide licensees with a minimum period of 14 days to send in written representation in response to the intent to amend the licence conditions, if any.

To prepare for future emergencies, clause 11 will amend section 14 to remove the 14-day notice period for any modification of licence condition that applies to a class of licensees, where there is immediate or imminent harm to patient safety or public health. This is so that MOH can expeditiously implement new healthcare protocols to protect public health and patient safety under exceptional circumstances.

To further safeguard patient safety and welfare upfront, two other approval regimes will be introduced.

First, for Specified Services which involve more complex or higher risk procedures provided in a licensable healthcare service, and therefore have distinct requirements. Examples of Specified Services are liposuction, endoscopy, or radiation oncology services. In addition to the existing licensing regime for licensable healthcare services, the new section 9A will require licensees to seek approval for the provision of any Specified Service. Having an approval process enables MOH to better verify that all requisite standards are met before a licensee can provide such a service, so that patient safety and welfare are upheld before these services are delivered. This approval regime builds on the approval process that is currently available for special care services in medical clinics and specialised procedures and services in private hospitals under the PHMCA framework.

Second, for the appointment of a Clinical Governance Officer or CGO. Clause 17 will amend section 24 to replace the existing notification regime for the appointment of a CGO with an approval framework. Under HCSA, a CGO is expected to play a crucial role in overseeing the clinical governance and technical aspects of healthcare services. By requiring licensees to seek approval for the appointment of a CGO, MOH can also ensure upfront that a competent and suitable individual is appointed and better safeguard patient safety and welfare.

Besides enhancing upfront safeguards, clause 18 also re-enacts section 28 to introduce flexibility for MOH to vary the scope of restrictions for selected individuals or groups of individuals employed or engaged in different healthcare settings, based on the anticipated risk of patient harm. Under the current HCSA, certain licensees may be prohibited from employing any individual who has committed egregious crimes involving violent acts such as rape or kidnapping, except with the approval from MOH, regardless of the duties performed by the individual. This is done to protect the safety and well-being of more vulnerable patients, as they may not be able to fend for themselves if they are harmed or abused. This is similar to the approach taken under the Early Childhood Development Centres Act 2017.

However, the risk of patient harm varies depending on the role undertaken or performed by these personnel and the nature of the healthcare settings they work in. Hence, clause 18 will repeal and re-enact section 28 to provide some flexibility. The restrictions will apply to prospective employees and those engaged, but not employed, by licensees to undertake work in healthcare settings. For a start, licensees operating in the Institute of Mental Health and all nursing homes and hospices will be required to comply with these restrictions. This is because there have been a number of cases of physical violence or abuse reported at these types of healthcare institutions.

MOH will continue to monitor for any emerging trends that indicate an increased risk of patient harm in other settings and will consider extending these restrictions to other individuals or settings in the future if needed.

The proposed amendments also seek to enable the public to make better informed choices about their use of healthcare services. In particular, the necessity of ensuring that consumers or patients are not misinformed or unduly influenced to inappropriately consume certain healthcare services. We are addressing this with tighter controls on advertising and naming.

Clause 19 will amend section 29 to prohibit licensees from using a specialty name in their names or logos – in any language – if there is no practitioner actively practising the said specialty under the auspices of that licensable healthcare service. To clarify, the specialist must be locally registered to practise the specialty in question, and can either be employed or engaged by the licensee to provide the approved licensable healthcare service under the auspices of the licensee. Specialties recognised under the Medical Registration Act or the Dental Registration Act and their associated terms are the specialty names intended to be covered by the amended section 29. For example, a clinic cannot be called "The Neurology Clinic" or the "The Brain Clinic" if there is no neurologist practising in that clinic. This protects patients from being misled into thinking they are receiving specialty care where the provider is not a specialist.

Licensees are currently prohibited under HCSA from using the terms "Singapore" or "National" in their names or logos except with the approval of the Director of Medical Services. To further prevent public misperceptions, the prohibition against using these terms under section 29 will be amended to extend to the same terms in any language, not just English. To clarify, existing licensees will be allowed to retain their current business names if it contains the terms "Singapore" or "National", unless there are changes in the business name or licensee in future.

To streamline the regulatory framework for healthcare service advertising, some advertising requirements for non-licensable healthcare services will now be regulated under the HCSA regime, and the relevant provisions in the Medicines (Advertisement and Sale) Act 1955 (MASA) will be repealed. These requirements include the prohibition on non-HCSA licensees who claim in healthcare service advertising to "treat" any medical conditions or diseases under the new section 31A inserted by Clause 22. For example, non-HCSA licensees cannot claim that "We treat chronic diseases such as hypertension, diabetes and all cardiac conditions" or that "We are experienced in treating scoliosis".

At present, there is a disparity in enforcement actions between the two Acts, with MASA having significantly lower penalties and a more limited scope of regulatory action, for example, there is no power to take down non-compliant advertisements. The new section 31C inserted by Clause 22 will impose similar penalties for comparable non-compliance in healthcare service advertising regardless of whether one is an errant provider of a non-licensable healthcare service, or a HCSA licensee. This will deter non-HCSA licensees and ensure all healthcare service providers are held to the same high standards when advertising their healthcare services.

Lastly, many stakeholders have also raised concerns about cases of misuse of the title "Doctor" in healthcare service advertising by certain non-registered healthcare professionals. To protect consumers from being misled into thinking that such persons are registered medical or dental practitioners when they are not, the new section 31B inserted by Clause 22 will require any person who is not a registered healthcare professional to state their specific qualifications and a disclaimer that their qualification is not a medical or dental qualification should they wish to use the title of "Doctor", or any derivative in any language, in healthcare service advertising. These restrictions will not apply to registered healthcare professionals such as nurses and pharmacists, as they are regulated under their respective Professional Acts.

Non-registered healthcare practitioners who are PhD holders and wish to use the title "Doctor" in advertisements of healthcare services must also state their qualification and a disclaimer that the qualification is not a medical or dental qualification, in such advertisements. However, for settings beyond healthcare service advertising, for example, the use of "Doctor" by PhD holders in academic articles, this requirement will not apply.

We understand that there are instances of foreign-trained doctors or dentists who have proper medical or dental qualifications, but do not have these qualifications registered with the Singapore Medical Council (SMC) or Singapore Dental Council (SDC). There are also instances of doctors and dentists who have previously registered themselves locally but have allowed the registration to lapse as they are now retired. In both these cases, should these practitioners wish to use the title "Doctor" in healthcare service advertising, the amended Act will require them to additionally include a disclaimer that they do not hold a valid practicing certificate issued by the SMC or SDC. As these doctors and dentists are not locally registered, these incremental restrictions are designed to ensure that they are treated similarly as other non-registered healthcare professionals, for parity.

The amendments at clauses 25 and 28 pertain to the redesignation of the "Director of Medical Services" to the "Director-General of Health". This new designation is a more accurate reflection of the job scope and responsibilities of the Director of Medical Services, which goes beyond medical services to also the control of communicable and non-communicable diseases, the setting of healthcare professional standards and development and enhancing performance of the healthcare system.

Mr Speaker, Sir, Members will see that through this Bill, MOH seeks to enhance and future-proof the regulation of healthcare services, to enable premises-neutral services across any healthcare setting, to put in place better governance, safeguards and clarity in the provision of healthcare services to patients, to empower patients to make more informed choices and to enable the Ministry to address any patient safety and welfare issues expeditiously.

If passed, we intend to implement the Amendments in mid-2023, together with the second phase of the implementation of this Act, with two exceptions. First, the redesignation of the Director of Medical Services will be implemented within two months. Second, the restriction on individuals employed or engaged will be implemented at end of 2023 when the screening process for the prospective employees would be operationalised. With that, Mr Speaker, I beg to move.

Question proposed.

Mr Speaker: Mr Louis Ng

6.37 pm

Mr Louis Ng Kok Kwang (Nee Soon): Sir, this Bill will allow for more informed decision making on healthcare services by requiring greater transparency in the advertising of services. This Bill also introduces an approval framework for licences to providers of healthcare services which will strengthen and refine the regulation of healthcare services.

I thank MOH for conducting a public consultation to prepare for this Bill. MOH's report of the public consultation shows that the feedback was constructive and that the Bill we see today contains changes made due to the public consultation. I hope MOH will continue this good practice of consulting the public before making changes to the law.

I have clarifications in three areas.

My first area for clarification is on the regulation of telemedicine. The Bill will require entities providing telemedicine services to be licensed and regulated. How will MOH regulate the risks posed by telemedicine? COVID-19 has accelerated the use of telemedicine. MOH has also facilitated it through its Licensing Experiment and Adaptation Programme as well as the Voluntary Listing of Direct Telemedicine Service Providers.

Certain risks and concerns may be more prominent in telemedicine than in conventional medicine. The lack of in-person and physical examination may be more likely to prompt instances and claims of misdiagnosis. The online nature of doctor-patient interactions and the relative ease of recording these interactions may also increase the risk of breaches in doctor-patient confidentiality. That is not to mention the role of hackers, fraudsters, phishers and other cybersecurity threats that may see value in gaining access to the vulnerable and personal moments of doctor-patient consultations.

Can Minister provide details and examples on how it will leverage this licensing regime to regulate telemedicine? Will these regulations compel changes to ethical and professional codes?

My second clarification is on the removal of the 14-day notice requirement for modifications of a licence condition. Section 14 will be amended to clarify that a licence condition can be modified without the 14-day notice period if it is necessary to prevent or mitigate immediate or imminent harm to patient safety.

An example provided by MOH of a situation that may require quick changes to licensing conditions is COVID-19. The stakeholder consultations on the amendments raised concerns about frequent updates in healthcare protocols that are understandably disruptive. To help licensees better understand the exceptional situations where licensing conditions may be changed without the required notice, can the Minister provide more examples of such situations?

In MOH's reply to the public consultation responses, MOH said that it will review and see how to improve its communications with licensees during these special circumstances. Can the Senior Minister of State provide details on its review? What steps will it take to improve communications? Will these communication methods be stress-tested ahead of time and not implemented only when the exceptional situations occur?

The section 14 exception for notice is specific only to a situation where there may be harm to patient safety. However, crises in a healthcare setting can also pose harm to healthcare workers. Has the Ministry considered if there are any situations where licensing conditions may need to be changed without notice because of harm to healthcare workers?

My third and last area of clarification is on healthcare advertising controls. The new section 31B will restrict the use of the title "Doctor" in the advertising of a healthcare service. Where the title is used to describe someone who is not a medical practitioner or dentist, the advertisement must provide appropriate disclaimers, such as by stating that the title is not a medical or dental qualification.

But there are other ways for advertisements to mislead consumers without using the word "Doctor". For instance, the advertisements could feature people wearing scrubs, using stethoscopes, operating medical machinery and examining medication.

Can the Senior Minister of State share how MOH will address the risk of misleading advertising through the use of visual imagery?

Further, it is possible that written disclaimers will be insufficient, particularly if the disclaimer is verbose or if the advertisement is cleverly designed. Some consumers, such as those who do not speak English, may also fail to understand the disclaimers. They will see the word "Doctor" but not benefit from the disclaimer.

Can Minister share whether the Ministry considered a full ban on the use of the title "Doctor" in healthcare advertising, given the risk of misleading advertising? After all, is there really an honest reason for a healthcare advertisement to invoke the title "Doctor" without actually referring to a medical doctor or dentist? It is healthcare; let us not let advertisers get too creative. Notwithstanding these clarifications, I support the Bill.

Mr Speaker: Assoc Prof Jamus Lim.

6.42 pm

Assoc Prof Jamus Jerome Lim (Sengkang): Mr Speaker, the proposed amendments to the Healthcare Services Act is part of a multi-year rollout of reforms to healthcare services that aims to bring healthcare governance into the 21st century. As healthcare services as well as their mode of delivery have advanced, it has become necessary to refine regulation in the sector.

The Bill being debated today implements additional enhancements based on feedback from in-consultation with stakeholders since phase one was rolled out, while also accommodating recent changes to the face of healthcare services delivery especially over the past few years. All these are unobjectionable and for this reason, the Workers' Party supports the Bill.

The first part of my speech will sketch out some residual concerns. The second part, briefly asks about the future of healthcare services provision and what it may be for non-doctor medical professionals.

Clauses 2 and 3 of the Bill as well as sections 3 and 8 of the original Act, refine the definition of service facilities so as to weave in the possibility of remote healthcare provisions such as via the Internet or telephone.

Telecare, telehealth or telemedicine have suddenly come into their own, due to the enforced isolation practises, necessitated by the pandemic. Given the confusing jumble of possible terms in this emerging field, it is natural to ask if the language in the legislation is sufficiently encompassing, or if in this case, excessively accommodating.

After all, how does defining service delivery mode to include and I quote, "(a) at permanent premises and (b) at any premises other than permanent premises" lend guidance as to the sort of location that a licensable healthcare service may be provided from? I can guess that the motivation behind why clause 2(f)(b) was inserted but it still strikes me as so universal as to lend no additional constraints at all.

Related to this issue of location is the fact that the Healthcare Services Act is not extraterritorial in nature. I understand why imposing our domestic service delivery standards on other jurisdictions is essentially untenable, but given how it is not only possible, but increasingly likely that the healthcare services value chain becomes ever more internationalised. Think of the proverbial radiographer based in Bangalore for that matter and AI system with service located in Iceland, coded by programmers in India and consulted by scientists in Israel. What sort of regulatory mechanisms are in place to protect patients in Singapore from potential safety failures by foreign providers?

The new section 31 of the Bill deals with advertising. Much of this is commonsensical. Section A prohibits marketing of the treatment of a medical condition by unlicensed healthcare service providers and section B restricts the use of the term "Doctor" in healthcare advertising. The concern here is whether these restrictions would rule out otherwise legitimate medical providers. Non-western healthcare providers naturally come to mind.

I understand that practitioners of Traditional Chinese Medicine, or TCM, do fall within the domain of specified persons, but this still raises two separate issues. First, as far as I am aware, ayurvedic, siddha and jammu practices are not included in this list. Does this Bill then preclude their ability to advertise their services? Is the reason why these groups are not included as specified persons because they do not have official oversight boards? If so, is this sufficient justification for the exclusion, given how they simply lack the critical mass to justify a societal body?

Second, the qualifications require for different accreditation bodies are actually disparate. More specifically, each group often may impose different standards of rigour, insofar as qualification benchmarks are concern. This applies not only to this Bill, but also what a suitably qualified individual means in the original act.

Local midwives, for instance, do not appear to distinguish between different levels, compared to as many as five in jurisdictions, such as the United States. Qualifications within nursing, likewise, have only recently become more differentiated. Advanced practice nurses, senior nurses who possess advanced training and can take on some roles in diagnosis and treatment, date back to only 2006, and currently, only 57 are licensed to prescribe medicine.

Singapore only recognises two categories of TCM practitioners, and for one of these, acupuncture registration is currently only open to qualify registered doctors and dentists. Compare these to the wide range of degrees, sub-specialisations and levels that exist already for doctors.

This naturally begs the question of whether the rigour associated with classifying these different tiers or medical practices are equivalent. And if not, what does this mean for their credibility when it comes to advertising?

To be clear, I am not suggesting that these other traditional medical practices be accorded the same sort of recognition as modern medicine, or that their advertising should not be regulated in some form. Still, it remains unclear to me why non-TCM groups should be prohibited from marketing their offerings.

Conversely, I am left wondering if the qualifications embodied in advertising by the different types of medical professionals are truly comparable. Perhaps a compromise would be to require an additional disclaimer, applicable to non-western medical practices, be included in all advertising efforts from this group.

This notion of differing tiers of medical practitioners as well as the stress in section 31 be about the use of the term "doctor" sparks a more general query. What steps has the Ministry undertaken to fill the niches that currently exists in our healthcare service providers? This is especially pertinent, given the lower coverage of both doctors and nurses in our population.

The latest available data, which applies to 2016, for example, indicates that Singapore has 2.3 physicians per 1,000 people, a little higher than the world average of 1.7, but substantially below the Organisation for Economic Co-operation and Development (OECD) average of 3.8.

It is also pertinent in the light of how our current slate of medical professionals are reportedly burning out, a bipartisan concern that has been raised in this House by, among others, my hon friend Ms He Ting Ru as well as the hon member who just spoke, Mr Louis Ng.

I understand that there are plans to increase the number of advanced practice nurses able to prescribe medication to 700. This is important and will provide some relief to our overworked doctors and fill in the gaps in healthcare services provision for our ageing population.

But what about the other tiers within the nursing profession? Has each tier been filled to an extent that would offer relief down the pipeline of medical professionals? What about increasing the number of recognised universities for basic medical degrees? The list of registrable medical qualifications only numbers to 100, while a few additions have been made in recent years, these are only a small handful.

It is hard to conceive of how a country, like France, with a population and medical school count, almost three times that of Australia, has only one lonely university on the list, versus Australia's eight. Similarly, I fail to understand how Japan, a country ranked first in at least one global index of health systems ranking, has only three of the country's 80 medical schools on the list.

Sir, the bottom line is that, as much as we focus on legislative refinements, the quality of our health services will ultimately be determined by ability to ensure that there is adequate supply of healthcare workers at all levels. This extends from the best doctors we are able to attract from around the world, to the invaluable community health workers that render so much of the behind-the-scenes support to every other role in-between.

Mr Speaker: Leader.

Debate resumed.

Mr Speaker: Dr Tan Yia Swam.

6.51 pm

Dr Tan Yia Swam (Nominated Member): Mr Speaker, Sir, in the past months, there were multiple engagement sessions and email requests to doctors, and I assume all healthcare workers, asking for feedback on the Healthcare Services Act (HCSA). I was involved via the Singapore Medical Association (SMA) as well as the Singapore Medical Council (SMC). However, I would like to know how many doctors actually responded.

It is a challenge for my profession to self-govern and self-regulate sometimes, as most doctors are too busy with providing clinical work, teaching, research, maintaining competencies, and do not forget, doctors are humans too, and have our own personal lives.

Perhaps medical school curriculum needs to further expand their law and ethics segment, to emphasise these administrative components. In addition, the role of SMC versus SMA should be ingrained into medical students, so that as doctors progress in their careers, they value how a professional body can effectively do group representations with MOH in policy engagements.

I welcome the expanded scope of HCSA to include complementary and alternative medicine. But I still ask for consideration to include beauty and wellness services as well, I remain concerned over misleading claims.

I give one classic example, in my work as a breast surgeon, I have been dismayed by a few women who had discovered breast lumps while breastfeeding. They consulted their masseuse or confinement "auntie", who try to massage the lump away, telling them repeatedly: "it is just a blocked duct". While that may be true for most women, a few actually have a breast cancer and they delayed seeing a doctor until months later. People become patients when they see a doctor, but the first health encounter may be well before that.

Finally, as a follow-up to my Committee of Supply (COS) cut, asking you to help us to help you, do remember not to be prescriptive in the implementation but to guide healthcare workers with kindness and patience as HCSA rolls out in the coming months. The above notwithstanding, I support the Bill.

Mr Speaker: Ms Ng Ling Ling.

6.53 pm

Ms Ng Ling Ling (Ang Mo Kio): Mr Speaker, the Healthcare Services Act (HCSA) amendment Bill introduces a slew of changes aimed at better regulating healthcare services and providing greater transparency in their advertising to safeguard public interest in an environment of changing population health needs as our population ages.

I will focus my speech on two of the proposed changes to seek some clarifications on one, the introduction of an approval framework for service delivery modes and specified services; and two, the regulations on the advertisement of non-licensable healthcare services under the Act.

First, approval for the provision of licensable healthcare services. New sections 11(A), 11(B), 11(C), 11(D) give wide-ranging power and responsibilities to the Director-General of Health, currently called the Director of Medical Services, in granting an approval for any permanent premises, conveyance or other services' delivery mode, which I understand, can include telehealth, for licensable healthcare services of a licensee.

Under section 3 of HCSA, health services definition is very broad and can range from, I quote: "assessment, diagnosis, treatment, prevention or elevation of any ailment, a condition, disability, disease, disorder or any injury affecting any part of the human body or mind, nursing or rehabilitation care of an individual suffering from an ailment, a condition, disability, disorder or an injury, assessment of the health of an individual."

While I understand that this new section 11 is an extension to the replacement to the previous Private Hospitals and Medical Clinics Act that is more premise-based, to a more service-based legislation through HCSA first enacted amidst the thick of COVID-19 pandemic in January 2020, I would like to ask how these new sections would be judiciously administered, with a balance between safeguarding patient safety and not stifling the development of new and innovative healthcare services that can benefit Singaporeans?

Furthermore, under clause 15, power is provided that regulatory action may be taken if a licensee contravenes or fails to comply, with any condition or requirement, relating to any approved permanent premises, approved conveyance, approved service delivery mode or approved specified services. My question, again, is how can this clause be judiciously administered in an environment where provision of healthcare services is becoming more complex and diverse?

With the Healthier SG implementation and the stepping up on preventive health, will there be grey areas that will be more debatable and will placing the approvals on such broad areas on one senior public servant, the Director-General of Health, be placing too much onus and burden on one authority?

I note that clause 23 allows appeals to the Minister. I would like to ask at which point might an Advisory Panel or sort, if any, be also involved for appeal cases? One of my personal observations for Singapore's success in riding through and managing COVID-19 pandemic so well, is that we have a panel of highly qualified and respected healthcare experts, with the humility to consult both local and global healthcare experts, and use data and evidence to make recommendations and decisions with our political leaders.

I wonder if MOH should be more explicit in the amendment Bill to provide rooms for having such an Advisory Panel, comprising highly qualified medical and non-medical experts, including researchers, respected and public-spirited health tech experts and even community leaders, who are committed to the best health interests of Singaporeans to present more comprehensive inputs in approvals covered by these new sections?

This is to avoid precluding new or seemingly unconventional healthcare services or service delivery mode that may actually yield better health outcomes at more affordable costs to Singaporeans, without comprehensively assessing them first from more angles.

The next clarification is on the advertisement of non-licensable healthcare services under the Act. The new section 31(A) prohibits the advertisement of any skill or service relating to the treatment of any ailment, disease or condition and so on, affecting the human body such that it induces a person to seek the advice of, or treatment from the advertiser or the person being advertised. However, this prohibition does not apply in relations to an advertisement of a licensable healthcare service by a licensee, or a person acting on the authority of a licensee.

While the intent of the amendment is clear to me in protecting the public from being misinformed or misled by unethical parties, the latter leaves room for ambiguity. Will the section unintentionally deter building of awareness of new service delivery mode attempting to provide a more integrated health and psychosocial intervention to help those with chronic conditions and more complex illnesses, like mental illnesses, which require beyond medicine to treat.

I would like to ask, for example, if a well-trained counsellor who is working within the physical premises or virtual mode of a licensee be able to share about what they can provide for mental health management? How about a TCM practitioner that has a partnership with a licensee, like a GP clinic: can the TCM practitioner publicise its services with the GP clinic?

Mr Speaker, I would like to conclude by thanking the officers in MOH for working so hard over the past few years during COVID-19 pandemic and continually doing so in our efforts towards a healthier population against our fast-ageing society. Future-proofing our healthcare system and protecting our public and patients are of paramount priorities.

A duty of care and doing no harm should be a guiding ethic and principle, not just for doctors, but for all players, including Integrated Plan insurers, third party administrators and online search engine optimisation platform providers that want to contribute a part in managing one of the greatest "wealth" of all mankind – our health. Mr Speaker, notwithstanding the clarifications that I have raised, I support the Bill.

7.00 pm

Mr Yip Hon Weng (Yio Chu Kang): Mr Speaker, Sir, this Bill is a poignant one for me. I had fond memories working on this Bill as a young MOH officer deployed to the Healthcare Regulation Division in MOH. This was in 2011. I recalled that it was a steep learning curve. I had to quickly understand the vast array of medical services, ranging from acute clinical treatment in restructured hospitals, to convalescent care in community hospitals and those in the community. Working with both doctors and administrators, we also had to study the healthcare services and legislations of other countries and learn the best practices. This was with the aim of assessing what can be applied in Singapore, given the unique history and evolution of our healthcare system.

2011 was more than a decade ago. The fact that this Bill has gone through multiple amendments and iterations over the years is a testament to its complexity and multifaceted nature. The crux of the matter is that healthcare is complex. Nothing is static in healthcare. Advancements in healthcare are turbo-charged by technology. The use of mRNA in vaccines is a prime example of how technology that was not originally designed for vaccine use can be leveraged to combat diseases. Given this context, I fully appreciate the challenges that come with moving a Bill such as this through the legislative process.

I seek clarifications on four specific areas in the Bill.

First, Mr Speaker, Sir, I would like to seek clarifications on how the Ministry plans to enhance public education, particularly with regards to clause 19 of the Bill which seeks to amend section 19 of the Act.

This amendment states that licensees are prohibited from using terms associated with specialties in their business names if there is no such specialist employed or engaged by them. They are also not allowed to use the words "Singapore" and "national." However, I am concerned whether existing institutions or companies that contravene the new regulations will be grandfathered. While this may be reasonable, considering the goodwill that these entities may have fostered, I am concerned that this amendment may not achieve its intended goal. This is to prevent patients from being misled into believing that such clinics provide specialist services or are endorsed by the Government. Will these businesses be required to display notices to clarify such matters? Or will there be other measures to ensure that patients are not misled?

Furthermore, what measures will the Government implement to ensure that the public is informed of these new restrictions? We can use this opportunity to guide the public in identifying healthcare establishments that possess the required legitimate expertise as a medical facility to deliver their promised services. In doing so, let the public report on healthcare businesses that are errant. It is important that we weed out healthcare businesses with poor practices. This is especially important for seniors, who are more likely to take business names at face value and be misled.

Second, Mr Speaker, Sir, there is a need for clarification and safeguard concerning clause 11 of the Bill that amends section 14 of the Act. This amendment proposes the lifting of the condition that MOH must give 14 days' notice before changing licensing conditions imposed by MOH on healthcare institutions. While this may be a step to ensure faster responses, there are concerns that healthcare institutions may not have sufficient turnaround time to meet the new conditions that MOH may have imposed and suffer business losses. What measures will MOH impose to balance the business considerations of healthcare institutions and public health?

What are the safeguards in place to ensure that the licensing conditions imposed by MOH are genuinely necessary, to prevent urgent patient-safety issues in extraordinary circumstances? And is there a list of what these special circumstances are?

Third, Mr Speaker, there is a need for greater clarity on the regulation of community services, such as community screening.

What exactly does the regulation of community screening encompass? Does it cover blood pressure screenings conducted by non-healthcare professionals through community blood pressure machines, for example? Have there been incidences whereby the community machines were not calibrated correctly, resulting in false positive or negative screenings?

What about eye examinations performed by optometrists, prescription of hearing aids by audiologists, or even the sale of shoe aids, sometimes carried out at pharmacies or sportswear shops catering to people with foot problems?

That being said, I recognise the need for a balance between regulation, and the costs and accessibility of these services. Healthcare in the community should be both convenient and affordable. And we must not overlook this. How does the Government plan to achieve this balance?

Fourth, Mr Speaker, Sir, will complementary and alternative medicine (CAM) be considered under the scope of the HCSA? This is a growing field. Many people turn to chiropractic, homeopathy, and other alternative therapies to manage their health. A 2016 Singapore Mental Health Study found that 6.4% of the adult population in Singapore used at least one form of CAM for the treatment and management of their mental illness. The pandemic saw a stronger demand for alternative therapies to manage stress and other mental wellness problems. Even though some of these services promise relief for insomnia and other mental health issues, these are generally health problems that should be consulted with a professional.

Many people also seek chiropractic care due to body aches from poor postures and excessive sitting while working from home. Despite not being recognised in Singapore, chiropractic services have been discussed in articles by local mainstream and online publications. These shows the popularity of these services. From 2018, there have also been calls for the chiropractic industry to be regulated, even from within the industry itself. Can the Ministry share an update on its assessment of risks to patient safety and the need for possible regulation?

Has the Government conducted recent studies on the percentage of the population in Singapore that uses CAM on a regular basis? If there is a growing trend, we should consider regulating these services. This is to ensure that they meet the same standards of safety, quality and professionalism, as other kinds of service providers.

In conclusion, Mr Speaker, Sir, as I had worked on this Bill before, in preparing for this speech, I asked myself whether this Bill has met its intents when we first worked on this more than a decade ago. First, does the legislation help to future-proof our healthcare system? Second, does the legislation protect our people who use our healthcare system, which I think is a more pertinent consideration? I must say after reviewing the Bill, the amendments proposed are necessary and commendable. They are an important step forward in ensuring that our healthcare system remains safe, reliable, responsive and in time for the future. I support the Bill.

Mr Speaker: Senior Minister of State Janil Puthucheary.

7.08 pm

Dr Janil Puthucheary: Sir, I thank Members for their support of the Bill, as well as their various comments. If I may just address a few of the issues.

Ms Ng Ling Ling and Mr Yip Hon Weng asked about the administration of the approval framework for modes of service delivery, especially where healthcare services are becoming more complex.

I had pointed out that HCSA was designed to cover a wide scope of healthcare services, including those that have been mentioned by Mr Yip.

MOH takes a risk-based approach. This means that we only license healthcare service providers and require them to comply with the relevant requirements if there are patient safety or welfare risks that we need to control through legislations. We want to guard against overdoing this and ensure that services remain affordable and accessible.

One concrete example, we are reviewing whether to regulate community health-screening services that may involve invasive procedures, such as the drawing of blood, but which may not be provided by a medical practitioner or dentist. Bearing in mind the general aim of making such services, not only more accessible and convenient, but also safe for patients. So, we are closely monitoring the community screening landscape to identify newer models or other types of services where they may pose a higher patient safety and welfare risk, and then explore whether those need to be licensed.

There were a number of questions on telemedicine-related requirements including by Mr Louis Ng and if I may address some of those issues. We had consulted with our various licensees and communicated these to them over the past few months. From a service provision standpoint, telemedicine or remote medical service providers must ensure that the service provided is done so in a proper, effective and safe manner, similar to what you would expect in a medical service from a clinic. For example, they have to ensure the privacy and confidentiality with the medical consult, the integrity and security of patient health records, the timely escalation and referral. Providers will also need to make sure that their doctors using the remote modality are trained and competent to do so.

Our prevailing professional codes such as the Singapore Medical Council's Ethical Code and Ethical Guidelines will continue to apply. Doctors offering telemedicine will thus need to meet both professional practice and clinical service standards which will provide a more comprehensive protection for patients.

That this applies to all healthcare professionals as Dr Tan Yia Swam has reiterated. It is important that all healthcare professionals are ourselves aware of the need to actively self-regulate and participate with that process of self-regulation, including by complying with and reading of the professional codes of conduct as the ultimate objective is to ensure that patients' safety and welfare are not compromised.

There were some questions about healthcare service advertising. Mr Yip had asked whether existing licensees and businesses that contain the restricted terms "National" or "Singapore" will be allowed to retain their names. I mentioned that they can continue to use these terms unless there is a change in the business name or a change in the licensee. We understand that there is some brand equity built up already and rather than mandating that these licensees immediately remove these restricted terms, we will allow them to continue.

Mr Yip also asked about the licensees with specialty names. They may continue to use those names that they already have. But if they provide or purport to provide services within that specialty, we may impose regulatory requirements on such licensees to employ or engage the relevant specialist. Otherwise, we will work with the licensee to amend the business name; otherwise, they will be giving the wrong impression to the public and that would not be in the patient's interests.

I agree with Mr Yip about public education. It is important to complement our regulatory effort, especially around how the public engages with business names and advertising. We will be publishing the intent and scope of these naming restrictions so that the public can understand what is allowed, what is not allowed, and they can have an easily accessible reference.

More public education effort is needed to enable patients to be discerning in their consumption of healthcare services. In line with overall efforts on media literacy, we encourage the public to help one another, and we ask for Members of the House, to also help within the communities in doing so.

We will also continue to encourage the public to perform due diligence and exercise some degree of discretion before engaging the services of any healthcare provider. A list of licensees with the modes of service delivery and Specified Services that they are approved to provide will be published and also made accessible through HealthHub so that the public can check if the healthcare provider they wish to obtain services from has the necessary approvals to provide those services.

We hope that the public will also participate and report errant institutions through feedback channels, which we can then investigate and take the appropriate enforcement action.

Mr Louis Ng brought up some issues around healthcare service advertising that may mislead using visual imagery. I agree with Mr Ng that this risk exists and we have provided restrictions on the use of certain terms, not just in the licensees' names, but in the use of those terms within the logo. However, the extension of restrictions to the use of visual imagery completely may limit businesses' ability to create a brand to distinguish themselves, and I think there is room to significantly overstep.

One example I might provide for Mr Ng's consideration is the use of the heart shape. I think it is quite commonly used in a variety of settings. I do not think anybody would say that it is exclusively the purview of cardiologists, especially if it is the simplified cartoon-shape heart. So, we do need to be quite careful, not to prevent all advertising. We will investigate complaints, however, on a case-by-case basis, and the examples that he cited, if there is a non-licensed provider, or someone purporting to treat when they should not be, and doing so through the use of visual imagery, we would suggest that these cases are reported. We will look at the visual imagery, but we will also take into consideration the overall content and intent of the advertisement before we decide on whether we take an enforcement action. The intent is to make sure that those providing treatment and medical services are appropriately regulated for the safety of the public.

Mr Louis Ng suggested banning the use of the term "Doctor" outright for healthcare service advertising. We tried to have a balanced approach. The title "Doctor" is something that is afforded not only to medical doctors. The PhD holders would also have that title. And having the title of "Doctor" as a medical doctor, does not automatically mean one is licensed but one does have that title. So, we are trying through our approach, to achieve the right balance and make it clear that where you are advertising a healthcare service, the appropriate description is used, including the description of your qualification or lack thereof for the provision of medical or dental services. So, we do not think it is tenable to restrict the title of "Doctor", prevent it completely in all healthcare service advertising. But we think having this mandatory disclosure is a more balanced approach.

Ms Ng Ling Ling had some questions on the co-location of non-licensable healthcare services, such as Traditional Chinese Medicine (TCM) practitioners together with licensable healthcare services. We have prescribed a list of services that can be co-located without needing to seek prior approval and this includes TCM acupuncture services and services provided by registered allied health professionals, such as physiotherapists.

Beyond this list, service providers who wish to co-locate their services must seek MOH's approval and conditions will be imposed, including requirements to comply with for their advertising.

In particular, the advertising must not result in a misperception by patients that the co-located non-licensable healthcare service is actually licensed by HCSA.

Where an advertisement covers both the licensable healthcare service and the co-located non-licensable service, it is the HCSA licensee that is responsible for ensuring compliance with the Healthcare Services (Advertisement) Regulations for the entire advertisement.

I would also like to address Dr Tan Yia Swam's concern. The amendments already cover misleading claims made by non-HCSA licensees, including building and wellness service providers. This means that any salon that purports to treat the medical condition will be in contravention of the law. We continue to encourage the public to exercise discretion. And if the public is aware of such misleading claims, please escalate this to the Ministry for further investigation.

Sir, Members have also asked about the safeguards in the regulatory process. Mr Yip Hon Weng highlighted that healthcare institutions may not have sufficient turnaround time given the 14-day notice period being removed.

I would like to stress again that we are only removing the 14-day notice period for a class of licensees, such as all licensees that provide an acute hospital service and only in situations where there is immediate or imminent harm to patient safety. Such a situation would have significant impact on our healthcare worker safety and our public health safety as well. Members will remember exceptional circumstances that include the recent COVID-19 pandemic. And you can extend this to other public health emergencies that are conceivable, and we would need to be able to react to these in a relatively swift manner.

Based on our experience in COVID-19, licensees can indeed meet the requirements and can do so at a relatively short notice. I would like to assure Mr Yip Hon Weng and Mr Louis Ng that the aim of this amendment is to provide the Ministry with the power to direct groups of licensees to take immediate action. The focus is on saving lives through the quick introduction of safety measures and not on penalising licensees for not being able to comply with the Ministry's direction despite their best efforts.

Ms Ng Ling Ling also asked if it was too onerous to place the burden of approvals on one authority. I would like to reassure her that MOH and agencies that are part of the family, we have a number of Expert Committees and Appeal Advisory Committees that are part of our normal processes. So, when guidance is given by Directors of Medical Services and decisions are made by the Minister, it is informed by a wide group of experts, academics, practitioners and professionals from the associations and various bodies representing healthcare workers, including the Academy of Medicine Singapore, the Singapore Medical Association, Singapore Dental Association, the College of Family Physicians Singapore and our various Expert Committees and Appeals Advisory Boards. These are all very much part of our ongoing process; that is not going to change with HCSA.

There were a number of questions by Assoc Prof Jamus Lim. I would point out that several of his questions addressed healthcare manpower, the professional certification of individuals, pastoral support for healthcare workers who are burning out, the universities and medical schools – none of which is covered by this Bill before the House. I would suggest that he might want to either raise the appropriate Parliamentary Questions or take these up at an appropriate time.

There are some issues that he raised that are indeed covered and I would like to just go through them. The first on the issue of TCM practitioners and other complementary and alternative medical practitioners. They are not prohibited from advertising, from describing what they do. What they are prohibited from is purporting to treat and diagnose medical conditions. I just want to make sure that we have a clear understanding.

The TCM practitioners themselves have their own Professional Board that regulates them. So, that is not something that, under this legislation, we require them to state their qualifications.

Assoc Prof Jamus Lim also brought up the issue of the language around premises. The intent is not to constrain premises. The intent is to regulate the service provisions. So, in describing premises, we have tried to cover indeed as many possible premises and models of service delivery. So, the intent is to look at the service and then specify and agree with the licensee how they will provide that service. Hence, we do need the language to cover the various possibilities of how and where a service will be provided. I hope that addresses Assoc Prof Jamus Lim's query about why we have the language around permanent versus non-permanent versus conveyancing within the Bill.

Indeed, the point he brought up around international providers around the virtual tele-consultations is important. We cannot regulate what people has access to through the Internet, but we do want to educate members of the public to be discerning about where they get their healthcare information from. Ideally, they should get it from identified locally registered licensed healthcare provider. If they do get information online from healthcare providers overseas, that is not something that this Bill is going to be able to regulate.

However, if that advice then requires them to have prescribed medication, consume medication, treatments and services and interventions, those are controlled by a variety of legislation and regulatory frameworks and that is where we can perhaps assure more patient safety. Ultimately, the main thing is that when people look for information, they should be doing so ideally from a licensed, locally registered healthcare provider.

Assoc Prof Jamus Lim also brought up the issue of midwifery professionals and nursing professionals. This Bill does not regulate any of those. This Bill is a Bill to regulate the provisions of services. It is not a Bill to regulate the professional certification of individuals. There are other legislation and regulation for that.

Sir, in conclusion, this Bill introduces changes to future-proof our regulatory framework for agility, to enhance the operational efficiency and clarity, as well as strengthen safeguards to patient safety and welfare to ensure our regulatory regime remains robust, agile and responsive to provide better healthcare services to our population in Singapore.

I thank Members for their support of the Bill. I would also like to take the opportunity here to thank our licensees, healthcare professionals, professional associations and members of public who have contributed throughout our stakeholder consultation exercises, including virtual sessions which have involved more than 1,000 attendees, helping with ideas and suggestions to jointly improve the healthcare services regulatory framework. Mr Speaker, I beg to move.

Mr Speaker: Are there any clarifications? Ms Ng Ling Ling.

7.24 pm

Ms Ng Ling Ling: Thank you, Mr Speaker. I just have one clarification for the Senior Minister of State of Health. On the comment that MOH will take a risk-based approach and impose regulation mainly when there are patient safety risks especially, some GPs, in my constituency has asked, in preparation for Healthier SG, to the best intent, they wonder whether vaccination such as flu vaccine that is in the national vaccination recommendation, is allowed to be done in community clubs where the footfall is higher, where there is more natural flow and there are grassroots leaders who can share the benefit of being vaccinated. But whether that is actually out of premise and whether can they claim the subsidies for flu vaccination? I just wanted to ask: are these imposed after Healthcare Services (Amendment) Bill has been implemented to actually formally ask MOH before they do?

Dr Janil Puthucheary: Sir, I thank Ms Ng for her question. If the issue is the subsidies for vaccination, that is beyond the scope of this Bill. I will encourage the Member to file a Parliamentary Question or bring it up in an appropriate point in time.

If the question is about could GPs perform vaccinations in the community centres and other locations, it is precisely this sort of flexibility that this Bill now provides. The specifics would depend on which GP, which vaccination and which community centre. And so, there would have to be an application made to MOH for approval.

Question put, and agreed to.

Bill accordingly read a Second time and committed to a Committee of the whole House.

The House immediately resolved itself into a Committee on the Bill. – [Dr Janil Puthucheary].

Bill considered in Committee; reported without amendment; read a Third time and passed.