Traditional Chinese Medicine Practitioners (Amendment) Bill

Order for Second Reading read.

4:35 pm

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

The Traditional Chinese Medicine Practitioners Act, referred to as "the Act" in this speech, was enacted in 2000 to safeguard patients' interests and safety, raise professional standards and regulate the professional ethics and conduct of registered TCM practitioners (TCMPs). Under the Act, the Traditional Chinese Medicine Practitioners Board, or referred to as "the Board", was established to register practitioners engaging in prescribed practices of TCM in Singapore, accredit TCM courses for the purpose of registration as well as the Singapore institutions of higher learning offering such courses; regulate the professional conduct and ethics of registered practitioners, and make recommendations on the continuing training and education of registered practitioners.

Since then, MOH and the Board have progressively put in place programmes and frameworks to raise the professional standards of TCMPs in Singapore. In 2013, MOH set up a $3 million TCM Research Grant to encourage collaborative research between researchers in public healthcare institutions, the TCM sector and institutions of higher learning, with the objective of better informing effective TCM practices. A total of $2.6 million has since been awarded to 11 proposals shortlisted from three grant calls. In view of the encouraging response, a further $5 million has been added to the Grant in 2017. Last year, a $5 million TCM Development Grant was also established to support skills development and capability building of the sector. Individual TCMPs are eligible to apply for the Development Grant, capped at $200 per year, to defray the cost of attending TCM classes. Accredited TCM training providers may also seek funding support to conduct local TCM conferences and seminars. As we strengthen professionalism within the TCM sector, MOH has reviewed the Act to ensure that the Act remains relevant and responsive towards the changing practice environment.

The TCMP (Amendment) Bill before us today proposes amendments to the Act to better protect patients' interests and safety, improve the timeliness and fairness of the disciplinary framework for registered TCMPs, and help raise professional standards.

Speaker, allow me now to highlight the major provisions of the Bill.

Continuing professional learning is important to ensure that TCMPs keep themselves current in their professional practice. Continuing professional education has already been implemented for other healthcare professions, such as doctors, nurses and pharmacists.

MOH and the Board introduced voluntary Continuing Professional Education (CPE) in 2013 to enhance the standards and safety of TCM practice. Under the voluntary CPE programme, all registered TCMPs are encouraged to accumulate at least 25 CPE points per year. Clause 5 of the Bill amends section 17 of the Act to provide that the Board may refuse to grant or renew a Practicing Certificate (PC) if the TCMP fails to comply with the prescribed CPE requirements. The target is for all registered TCMPs to accumulate at least 50 CPE points within a two-year period in order to renew their PCs. The requirement as defined would allow some flexibility for individuals to plan their learning without unduly affecting their professional practice.

We developed this CPE points assessment framework after engaging with the TCM community extensively on CPE since 2013, taking note of their concerns on the availability and the range of CPE courses offered and reasonableness of the costs of these courses. We appreciate the constructive feedback and have taken them into consideration, such as expanding the accredited course offerings to include new modes of learning to suit the different needs of TCMPs.

Currently, all complaints against registered TCMPs are investigated by Investigation Committees appointed by the Board. While these cover a wide range of matters, the disciplinary framework does not adequately deal with allegations that a registered TCMP is unfit to practise due to his physical or mental condition. These cases do require a different approach since a health inquiry into the TCMP's fitness to practice is required as opposed to an investigation into an incident or transaction. The current framework also does not enable stoppage orders to be made in extreme situations where a TCMP must be made to immediately stop practising because of serious and imminent risk to the public if there is no stoppage, or if stoppage is required to avoid any actual incident that endangers the public.

Clause 11 of the Bill introduces the new Part IVA of the Act, which sets out the revised disciplinary framework for TCMPs, which I will elaborate next in detail. First, the new section 26A allows a registered TCMP to voluntarily curtail his practice if he believes that: (a) his fitness to practise is impaired by his physical or mental condition; or (b) the quality of the professional services he provides does not meet the standard which is reasonable to expect of a registered TCMP to carry out.

The Board, with the agreement of the registered TCMP, may cancel the practitioner’s registration, suspend the registration for up to three years or impose appropriate conditions on the registration. A disciplinary inquiry does not need to be conducted in order for the Board to accede to the practitioner’s request. However, this avenue will not be available in cases where there is evidence of professional misconduct or there is a pending disciplinary inquiry against the practitioner.

The process in the new section 26A is initiated by the TCMP himself or herself, which encourages practitioners to come forward if they are of the view that they are unable to continue practising at the standard expected of a registered TCMP. This improves the timeliness of the process and allows the Board to resolve appropriate cases expeditiously.

Second, the new Part IVA sets out in the body of the amended Act a revised framework for inquiries into disciplinary matters concerning a registered TCMP. The processes have been streamlined to speed things up and to fit the introduction of a health inquiry. A person may make a complaint against, or provide information about, any registered TCMP to the Board touching on any of the grounds set out in section 19(1). The complaint or information will be reviewed by the Board upon receipt, and for purposes of its review, the Board may require the complainant or TCMP concerned to answer any inquiry or provide any record that the Board considers relevant. The Board may dismiss any complaint or information that is frivolous, vexatious, misconceived or lacking in substance.

However, if the case is not dismissed on any of those grounds, the Board must refer the complaint to an Inquiry Committee.

The Inquiry Committee will have six months to carry out its inquiry from the date of the referral of a complaint to the Committee, unless the Chairman of the Board grants an extension of time. The Inquiry Committee must direct one or more investigators to investigate the facts and circumstances of the complaint. The investigator must give the TCMP concerned written notice of the complaint against him, and the TCMP can provide a written explanation to the investigator. The TCMP also will have the opportunity to appear before the Inquiry Committee, whether in person or represented by counsel, to be heard on the complaint.

Upon completion of its inquiry, the Inquiry Committee will submit a report of its findings to the Board, together with its recommendations on the disciplinary action to be taken under section 19 of the Act against the TCMP. After considering the Inquiry Committee's report, the Board may take such action under section 19 as it thinks fit, or dismiss the case. In appropriate cases, the Board may also refer the complaint back to the Inquiry Committee once more for the Inquiry Committee’s reconsideration or a further report on such matters as the Board may specify.

Third, the new section 26H enables the Board to make an interim order that requires a TCMP to immediately stop his practice for a period not exceeding 18 months. No prior inquiry or investigation is needed before making such an interim order.

But the Board may do so only if there are reasonable grounds to believe that, either there is a serious and imminent risk to the public if there is no such stoppage, or if it is to avoid any actual incident that endangers the public.

[Deputy Speaker (Mr Lim Biow Chuan) in the Chair]

If the Board is satisfied that it continues to be necessary to prevent the TCMP from practising, the Board may confirm the interim order, with or without modifications. Before the interim order is confirmed, the Board must refer the interim order to an Inquiry Committee. The TCMP may make representations or objections against the proposed confirmation to the Inquiry Committee. The Inquiry Committee will then consider the facts of the case before making a recommendation to the Board whether or not to confirm the interim order.

The next group of amendments concerns the disciplinary penalties that may be imposed on a registered TCMP who has been found guilty following a disciplinary inquiry under the new Part IVA.

Currently, the Board may cancel the registration of an errant TCMP if he has been found guilty of professional misconduct or negligence, or any of the other grounds of misconduct under section 19 of the Act. Alternatively, the Board may caution or censure the TCMP, impose a financial penalty of up to $10,000, add, delete or replace conditions on his registration for a period not exceeding three years, or suspend his registration for up to three years.

To provide sufficient deterrence and punishment for misconduct so as to protect the safety and interests of the public, clause 7 of the Bill amends section 19 of the Act to increase the maximum financial penalty that can be imposed from $10,000 to $50,000, where the TCMP is found guilty on any ground in section 19(1)(e) to (k) of the Act. The increase will bring about better alignment with the other healthcare professional Acts and provide greater assurance and confidence to the public that errant TCMPs will be dealt with appropriately as against other healthcare practitioners.

Clause 7(d) introduces further disciplinary penalties that the Board may impose on the TCMP. These include the Board ordering the errant TCM practitioner to give an undertaking, on such terms as the Board thinks fit, to abstain from the conduct that was the subject of the disciplinary inquiry. The Board may also refer the matter for mediation between the TCM practitioner and the complainant. Examples of cases that may be suited for mediation include cases arising from poor service provided to patients and miscommunication.

Taking clauses 7(h) and 9 of the Bill together, sections 19(5) and 21 provide that the Board's decisions on disciplinary matters does not take effect until the thirty-first day after the date of the decision. This is to allow the TCMP sufficient time to consider whether to file an appeal to the High Court against the Board's decision. Similar provisions are found in the Medical Registration Act and the Pharmacists Registration Act. Where there is an appeal to the High Court, the decision of the Board takes effect only when the High Court confirms the decision or dismisses the appeal, or the appeal is withdrawn.

However, this is subject to the new section 19(5A), under which the Board's decision to cancel the registration of the TCMP takes immediate effect if the Board certifies that there are grounds to believe that either there is a serious and imminent risk to the public if the cancellation does not take immediate effect, or it is appropriate or requisite that the cancellation takes immediate effect to avoid any actual incident that endangers the public.

Clause 12 of the Bill repeals and re-enacts sections 28 to 30 of the Act to enhance the enforcement powers of investigators investigating into disciplinary matters concerning registered TCMPs, as well as offences under the Act such as unlawful practice of TCM by unregistered persons.

Currently, for the purpose of investigating into offences under the Act, authorised officers may enter and inspect any premises which are used or suspected to be used to carry out any prescribed practice of TCM, and inquire into the conditions under which the practice is carried out. However, the officers are unable to search the premises or seize evidence without a warrant, which hinders the timely and effective conduct of investigations.

Under the new section 29, investigators appointed to investigate into offences under the Act or its subsidiary legislation may, without first obtaining a court warrant, enter and search a place which is used or suspected to be used to carry out any prescribed practice of TCM, or to keep any document, record or thing used in connection with carrying out of the TCM practice, and to seize evidence for the purpose of investigating an offence under the Act. However, if the investigator is investigating into a disciplinary complaint under the new Part IVA, these powers of entry, search and seizure can be exercised only if: (a) a court warrant has been obtained; (b) the occupier of the place consents; or (c) the investigator believes on reasonable grounds that there is an imminent or immediate danger of serious bodily injury or death to any individual who is receiving or who is about to receive any treatment at the place.

The new section 30 makes it an offence for a person to: (a) provide any document or give information that is false or misleading in a material particular; (b) knowingly obstruct or prevent an investigator in the discharge of the investigator's powers or duties; (c) intentionally alter, suppress or destroy any document or information which the person is required to provide; or (d) fail, without reasonable excuse, to provide any information the person is required to provide.

Finally, the new section 30A provides for the disposal and forfeiture of items seized by an investigator under the amended Act.

Next, I will turn to the other amendments in the Bill, which are mostly of a housekeeping nature.

Taking in feedback from the TCM community, clause 3 of the Bill amends section 3(2) of the Act to increase the maximum size of the Board from nine to 11 members, which allows for a broader representation of the TCM profession on the Board.

Clause 6 repeals and re-enacts section 18 so that the Registrar of the Board is not constrained to publishing a list containing information about all registered TCMPs with a valid practising certificate in the Gazette. Instead, the amendment will allow the list to be published on the Board's website or by other means.

Clause 8 amends section 20 to clarify the types of costs and expenses that the Board may require a TCMP who is the subject of disciplinary proceedings under Part IVA to pay. This includes the cost and expenses of any assessor or advocate and solicitor appointed by the Board for any proceedings before an Inquiry Committee, and reasonable expenses the Board may pay to witnesses.

Clause 14 inserts a new section 34A to provide that the Board may compound any offence under the Act that is prescribed as a compoundable offence. The maximum composition sum is the lower of one half of the amount of the maximum fine that is prescribed for the offence, and $2,000. This empowers the Board to compound such offences without having to rely on section 243 of the Criminal Procedure Code. Mr Deputy Speaker, Sir, please allow me to conclude in Mandarin.

(In Mandarin): [Please refer to Vernacular Speech.] The upholding of practice standards of TCM practitioners is important as the TCM profession matures and develops in Singapore. Therefore, MOH values and encourages the continuing education of TCM practitioners.

We have successfully introduced voluntary CPE in 2013 and received positive feedback. After the passage of this Bill, it will, indeed, be a milestone for the TCM community as we implement compulsory CPE. We are grateful for the feedback from the community on the implementation of CPE and have also taken in their feedback, such as expanding the learning platforms to include accredited online courses, and to award more points for instructors and self-learners.

To support TCMPs in their continual learning, TCM practitioners can tap on the TCM Development Grant, capped at $200 per year, as well as the SkillsFuture Funding, to defray their costs for attending CPE courses.

Besides CPE, MOH also hopes to enhance the regulatory regime by amending the Bill, to further strengthen the disciplinary framework for greater efficiency and to maintain public and patient safety more effectively.

(In English): With this, I seek Members' support for this Bill. Mr Deputy Speaker, I beg to move.

Question proposed.

4.56 pm

Dr Chia Shi-Lu (Tanjong Pagar): Mr Deputy Speaker, Sir, Traditional Chinese Medicine, or TCM, forms an integral and important part of our healthcare landscape. In recent years, both our Prime Minister and our Minister for Health have remarked on the critical role that TCM can play in improving the health of our citizens, particularly within the context of an ageing population. And I too would like to put on record my appreciation to the TCM community for the contributions to Singapore's healthcare. And certainly, TCM remains a medical remedy of choice for many Singaporeans, and indeed we are seeing a new generation of TCM practitioners, with more young Singaporeans choosing TCM as a career, particularly since the introduction of NTU's double degree programme in Biomedical Science and Chinese Medicine in 2005.

The amendments to this Act, which was first passed in 2000, are timely and vital for the TCM sector to grow and achieve its true potential in providing for the healthcare needs of Singapore. I have three comments and clarifications for the Minister.

First, the clarifications to the disciplinary framework are welcome and will certainly improve self-regulation within the TCM sector and increase public trust. Nonetheless, I am concerned that the lack of a more formal disciplinary or inquiry process, and the absence of specific schedules on penalties, and clear definitions of physical and mental fitness for work, may lead to the same issues and criticisms facing disciplinary processes by the Singapore Medical Council today.

For instance, how robust will the renamed Inquiry Committee's decision regarding a practitioner's physical or mental fitness to practise be? This is a challenge that western medicine is also facing. For instance, in the United States, there was a much discussed case or incident where a senior surgeon in his early 70s while supervising a procedure fell asleep during the surgery. This particular surgeon was not performing the surgery itself but concerns were raised. And there were many discussions between the Board of the hospital and various communities but the problem they faced was that it was difficult to prove fitness or unfitness from a mental or physical point of view. Just by going by normal physical and mental tests alone, he passed. The case was finally resolved by the voluntary withdrawal of the physician in question from clinical practice. But these are challenges that have no easy answers. And I would like just to find out, with this Inquiry Committee, how will it deal with such cases?

For other feedback, if there is a complaint to the Complaints Review Committee, for instance, about over-charging, how will such cases be investigated given that there are no generally agreed guidelines and the spectrum of treatments within TCM is very wide? I have heard instances where the cost of TCM treatment could even reach six figures and maybe five figures in many cases. What would be considered an acceptable treatment modality and what would not be considered an acceptable treatment modality, considering that TCM embraces a wide range of treatment philosophies and modalities, some of which may be at odds with one another?

I hope that the Ministry will be able to elaborate on how the procedural aspects of these disciplinary processes can be made more robust and better able to stand up to scrutiny, with these amendments.

Second, the introduction of compulsory continuing professional education is certainly a step in the right direction and will help to maintain professional standards. I would like to ask how the Ministry will assist in ensuring the quality of accredited courses or programmes, and also to ensure that enough of such educational activities are available and also are accessible to practitioners.

There are now over 3,000 TCM practitioners in Singapore, but I note that close to 20% of them are inactive. If these inactive practitioners do not participate in the CPE programme and do not practise, will this affect them if they decide to re-enter active practice in the future and reapply for a practising certificate or licence?

Third, I note also that the maximum number of members of the TCM Board will increase from nine to 11, under the proposed amendments. I would like to ask if the Ministry would consider also increasing the minimum number of members from five to seven, and also mandating a higher minimum number of medical practitioners and, in particular, TCM practitioners to the Board. This would allow for a greater breadth of professional medical opinion in the Board. Thank you, and I support the Bill.

5.01 pm

Mr Chen Show Mao (Aljunied): Sir, the Bill before us aims to regulate and professionalise further the practice of Traditional Chinese Medicine (TCM) in Singapore. It does so through tightening existing disciplinary processes and implementing new mandatory Continuing Education requirements.

The enhancement of professional standards that this Bill aims to bring about is welcomed.

Sir, as TCM practice grows more regulated and professional, I urge the Ministry not to spare complementary efforts to integrate TCM into our healthcare system, to the fullest extent warranted by existing evidence of efficacy and also safety. Since 2013, the Ministry has provided $8 million in funding for collaborative research projects between researchers and practitioners of TCM and those in our Universities and hospitals. As these projects and also research and trials undertaken elsewhere in the world lead to increased adoption of TCM in our healthcare, I hope complementary changes can then also be considered with a view to making the benefits of regulated and professional TCM more easily available to Singaporeans, such as the provision of subsidies for TCM treatment under the Community Health Assist Scheme (CHAS) or under the Pioneer Generation Scheme (PG), the increased scope for payment in MediSave funds for TCM items, or the recognition of medical certificates (MCs) issued by TCM practitioners.

(In Mandarin): [Please refer to Vernacular Speech.] Mr Deputy Speaker, Sir, today's Bill aims to strengthen the regulatory framework for TCM practice in Singapore, and to enhance the professional standards of TCM practitioners through mandatory continuing education requirements, so that local TCM practitioners and acupuncturists can "keep up with the times". I welcome this move.

Mr Deputy Speaker, Sir, we know that TCM and western medicine differ in origin, nature, professional training and industry structure. It follows that effective regulatory regimes would not be the same for both. However, western medicine constitutes the mainstream of modern medicine and healthcare, and has relatively comprehensive professional training and regulatory frameworks worthy of learning from.

Mr Deputy Speaker, Sir, support for TCM in Singapore is premised on its scientific modernisation and integration with modern medical technology. I hope we can lengthen our stride and quicken our pace in this direction, the better to make our contributions in bringing more benefits of TCM to the world.

I hope that TCM remedies which have proven to be effective and safe following thorough clinical experimentation can be integrated into our healthcare system without delay, for the benefit of more patients. At such point, the Government may adopt complementary measures so that TCM may be more widely available to all. Such as the increased scope for payment in Medisave funds for TCM items, the provision of subsidies for TCM treatment under the Community Health Assist Scheme (CHAS) or Pioneer Generation Scheme (PG), or the recognition of medical certificates (MCs) issued by TCM practitioners.

5.06 pm

Prof Fatimah Lateef (Marine Parade): Mr Deputy Speaker, I stand in support of this Bill. The TCM Industry has boomed of late. This could be due to the increased demand for alternative therapies, an enhanced awareness for such therapies and also the fact that there is now more interest and research into this area. When we speak of TCM, it can conjure different images in different persons: ranging from the neighbourhood sinseh shops with herbal smells, to the very established companies such as Eu Yang Sang International Ltd.

During a recent survey by MOH it was noted there are about 10,000 Singaporeans who visit and seek TCM treatment every day. Not a small number at all.

There are always certain code of conduct, etiquette and practice guidelines which will be ascribed to every body of professionals. The same must apply to TCM practitioners, who are also involved in caring for the public and patients and thus must be assessed with accountability as well.

A few points to bring up. Firstly, the Bill, first enacted in 2000, with a view to raising standards and the conduct of practice in the TCM sector is now being reviewed. Since then have there been any cases which required disciplinary action or suspension? If so, what are the common reasons or root causes? I ask about this with an intent to see if we can address some of these in this latest Bill that we are discussing today.

Secondly, I support the formation of the Inquiry Committee when the need arises, versus having a permanent one in place for a certain term because it is more relevant to appoint according to the type of cases, breaches or issues that we are handling at a certain point in time. This way we can appoint the appropriate type of TCM personnel or even specialists to provide opinion and consultation or serve as an expert witness.

Thirdly, pertaining to the compulsory Continuing Professional Education (CPE), I firmly support this. I also have a few suggestions to make.

One, to have the setup of a directory electronically for courses and training being offered for easy access and knowledge of all TCM practitioners. The usual organisers can come together to discuss and brainstorm this and see how best to execute but for those who want to offer ad hoc courses and training, there should be a body of persons looking into the suitability of these courses to ensure certain standards are met.

There must be a secretariat to also monitor and carry out surveillance to track the number of points and warn practitioners of the shortfall if they risk not getting renewal of their practising certificates.

There were some concerns on the cost to be borne by the practitioners themselves for these courses. In the Medical and Nursing profession, for example, established institutions have got a sponsorship scheme and other forms of support for their practitioners. Now, for large TCM groups this may be feasible to offer but for the lone TCM practitioner, there may need to be other considerations given or offer of subsidies or, perhaps, even accredit scheme. This will be for the Ministry to review and consider. Of course, some courses can be offered online though e-learning will also take time and money to set up.

Some offset can take place by offering some of these courses through SkillsFuture or other upgrading grants but that is something to be reviewed with caution. In this context, can the Ministry also update us on the use of the TCM Development Grant. What can this Grant be utilised for? Is it just for education or improvement of practice and setup?

I note also the number of points for CPE required over two years. Can I ask if there will be some flexibility given to the TCM practitioners, especially for the first two years as the running in period? This request is with the consideration that some of our TCM practitioners are in the older generation and they are in solo practice and they may need time to adjust to this, to get used to the new guidelines as well.

Next, can I get some clarification on the term "TCM practitioner" as used in this Bill? Are the people who run the sinseh shops, prescribing herbal type medications in this category as well? How about those who offer massage and tuina services as practitioners as well as the dispensers in the neighbourhood shops? Are they also incorporated into this Bill under consideration?

On the 11 members of the Board, can I suggest also that they represent TCM practitioners who are generalists and also some who are specialists in certain aspects of the practice. But I also note that we may need to have the relevant and adequate numbers of specialists in TCM area for now so, therefore, this is something, perhaps, to be considered later on.

With TCM services the fees, we note can range from as low as $1 to $2 in the neighbourhood and community clinics to the highly priced ones in advanced centres. What is the Ministry’s view on this and will we be moving towards some range standardisation, perhaps, even into different categories of services which are being offered?

And, finally, on the issue of Medical Certificates by TCM practitioners and their recognition by employers, this is a long-drawn issue that has been debated for very often. Are we planning to come up with some standardisation or guidelines? This has always been a controversial issue and I think it will continue to be because of the range of services as well as TCM practitioners that are out there. So, perhaps, some comment from the Ministry on this. All in all, I support the Bill.

5.12 pm

Mr Louis Ng Kok Kwang (Nee Soon): Sir, I stand in support of this Bill. In recent years, Traditional Chinese Medicine (TCM) has become more popular as a career of choice. From 2012 to 2017, the number of practitioners rose by 16%.

However, as the profession swells in ranks, it must keep up its standards. Despite the growth in numbers, degree holders still comprise only 21% of all registered practitioners, according to 2017 data. Some 5.7% of practitioners have no formal qualifications at all.

Practitioners must continue to learn, unlearn, and relearn to keep up with the times. This Bill mandates continuing professional education for practitioners. At the same time, it clarifies and elaborates the mechanisms used to keep practitioners in check.

I agree with these measures, and I thank MOH for holding a public consultation and incorporating views from that consultation into this piece of legislation.

I have five points of clarification to raise.

My first point is about fines.

The Bill raises the maximum fine from $10,000 to $50,000. I agree in principle with the increase, as it strengthens deterrence and punishment in an area where human lives are concerned. However, it is unclear to me why this penalty is less than that imposed on Western medical practitioners. Under the Medical Registration Act, medical practitioners face a maximum penalty of $100,000. In effect, we are saying that Western physicians get fined $100,000 for doing wrong, while TCM physicians get fined $50,000 for doing wrong.

In its response to the public consultation, the Ministry said that that Medical Registration Act more seriously penalises Western physicians for one reason only: that they pose "greater risk of potential harm to patients".

Can the Minister explain how a Western physician might be more dangerous than a TCM practitioner?

Last September, the TCM Practitioners Board fined a physician the maximum $10,000 for recommending that a patient delay her cancer treatment or surgery. The physician conveyed a whole slew of dangerous advice to his patient. He told her that the tumor would grow slowly. He told her that surgery would make the cancer cells proliferate more quickly. He told her that her tumor was not life-threatening.

In addition, he prescribed capsules of ginseng and herb that, at best, provided a false sense of comfort for his patient. We were lucky that the patient’s daughter interceded and that the patient went ahead, promptly, with surgery. But not every patient is so lucky.

I am concerned about the message that this difference in fines sends. When patients sit in a physician’s office, the physician is the figure of authority. TCM physicians are in a prime position to influence the health decisions of patients. In this case, the physician took the patient down a dangerous, life-threatening course of action.

I urge the Ministry to further explain why a TCM practitioner should face a less severe penalty than a Western medical practitioner. My second point is about continuing professional education. I am heartened that the Bill empowers the TCM practitioners board to reject the registration of practitioners who fail to comply with requirements on mandatory professional education.

My question is whether the Board can issue such requirements as part of a punishment imposed on errant practitioners.

In the case I previously mentioned, the Board issued only a fine and a suspension to the practitioner even though it found that he was, "neither remorseful for his conduct nor fully aware of the danger that he posed to that patient."

From that statement, it appears the practitioner did not agree or understand that what he did was wrong. What, then, is stopping him from making similar mistakes of the same nature when he returns to practice? What course of action has been taken to ensure his knowledge base is updated to what the profession demands?

In many industries, it is common for errant professionals to undergo some programme of training or education to rectify their gap in knowledge and understanding. Can the Ministry clarify whether the TCM Practitioners Act equips the Board with powers to require offending practitioners to undergo specific courses of professional training?

My third point is about responding to complainants. The new section 26E details an array of timelines. Upon receiving a complaint, the Board has two weeks to start a review and three months to complete that review. If they refer the matter to an Inquiry Committee, the committee has six months. All in all, it seems that the process can take just under a year, extensions notwithstanding. It is a long time for a complainant to wait.

My questions are as follows: does the Board have an obligation to respond to the complainant with the results of its review? If the review proceeds to the stage where an Inquiry Committee is convened to investigate, must the complainant be notified about the final findings? In either case, is there a requirement that the Board relays information in any prompt manner to the complainant?

It is laudable that we have an extensive framework for investigating complaints. Surely, the point of these investigations is not only to be accountable but also to demonstrate accountability. It then seems important to me that the Board has a duty to reply to the complainant in a reasonably prompt fashion with a response that meaningfully addresses the complainant's concerns.

My fourth point is about sharing the results of investigations with former patients.

If TCM physicians have conducted themselves in a dangerous way, it is possible that they have done it before. For instance, a physician who has given incorrect advice about how to deal with cancer might well have said similar things to other cancer patients.

The TCM Practitioners Act does not appear to mandate that the Board release investigation results to former patients of the errant physician.

Historically, we have seen some cases of misconduct by TCM practitioners reported in the news media. However, it is perhaps not a stretch to say that many TCM patients may not follow the news media closely. Thus they may not be aware that the diagnosis or treatment they received was shoddy. Could the Ministry share whether, and how, it communicates with former patients when physicians are found guilty of misconduct?

My fifth and last point relates to mental and physical condition. Section 6 of the Act bars a person from membership of the board if "he is incapacitated by a mental or physical disability." Section 19 contains a similar phrase. The section allows the Board to cancel the registration of a practitioner if he "is unable to carry out the prescribed practice of TCM for which he is registered safely or effectively by reason of a mental or physical disability." In this Bill, the phrase "disability" is amended to “condition."

I have two questions relating to this point. One, why does one use "disability" while the other use "condition"? Does the Ministry mean to make a meaningful distinction between the two usages? Two, could the Ministry articulate what would constitute a mental or physical condition, or a mental or physical disability? More specifically, what would be a condition or disability that results in incapacity or inability to carry out safe and effective practice? Is a certifying doctor, Western or TCM, required to weigh in? Who is the final adjudicator on this matter of judgment?

Clarifications on this point, I believe, will provide guidance in future when there is any such dispute.

Sir, in conclusion, the Bill is a step in the right direction. It reflects meaningful input solicited through the Ministry's public consultation, and it provides a robust framework with which to regulate a profession that helps manage the health of many Singaporeans. Sir, notwithstanding my clarifications, I stand in support of this Bill.

5.20 pm

Mr Gan Thiam Poh (Ang Mo Kio): Deputy Speaker, I welcome as it will help to raise the standard of professionalism in this sector and increase public confidence in TCM. Many of our elderly across different ethnic groups have been relying on TCM or a combination of TCM and western medical treatments. TCM has made significant contributions to public healthcare in our multi-racial society. It is also gaining recognition and popularity in the west.

The introduction of compulsory Continuing Professional Education (CPE) hours per year will bring TCM professionals in line with the existing practices for our mainstream medical practitioners. I am convinced that it is also beneficial for the TCM practitioners to be kept updated about the new findings, best practices and latest technologies. These will enable them to make better and more accurate diagnosis and care for their patients better.

I certainly support measures to enhance the Ministry's investigative powers and increase the penalties for errant TCM practitioners. Such a move is necessary for the protection of patients and will also increase the confidence of patients in TCM professionals. The reputation and image of the TCM sector will also be lifted by enhanced professionalism and higher standards as a result. For instances where there had been complaints about negligence or misconduct not directly related to the treatment aspects, will there be an avenue for mediation?

Next, I would like to ask the Minister how many complaints have been received so far each year for the past 10 years and whether the rate of such complaints had fallen after the introduction of the registration and certification of TCM. In addition, what efforts have been made to accord the accreditation to "Tie Da" physicians?

I would also like to know how many patients have used TCM services each year for the past 10 years. Will MOH also look into the integration of patient records nationally for better assessment and management of patients by both mainstream and TCM medical practitioners?

(In Mandarin): [Please refer to Vernacular Speech.] Deputy Speaker, Sir, MOH is working together with top TCM organisations to provide continual training for TCM practitioners, which will benefit both the practitioners and the patients. TCM practitioners will be able to learn the most up-to-date, advanced professional knowledge and medical treatment. By doing so, Singapore can become another world-class regional medical hub.

Mr Deputy Speaker: Senior Minister of State Amy Khor.

5.23 pm

Dr Amy Khor Lean Suan: I thank Members for speaking in support of the Bill. Prof Fatimah Lateef, Mr Gan Thiam Poh, Dr Chia Shi-Lu and Mr Louis Ng highlighted the increasing popularity of TCM and the growing number of registered TCMPs in Singapore, and hence the need for a robust regulatory and disciplinary framework and a code of conduct, etiquette and practice guidelines for TCMPs to provide greater assurance and confidence to the public.

Members have also expressed support for the implementation of compulsory CPE to raise the standards of the profession.

Let me now respond to the queries and suggestions made by Members in respect of this Bill.

Prof Fatimah asked if subsidies could be offered to TCMPs to defray the costs of attending CPE courses. As mentioned in my opening speech, individual TCMPs can already apply for the TCM Development Grant launched last year capped at $200 per year to help defray the cost of attending CPE courses.

I am pleased to share that as at the end of last year, over 400 individual TCMPs have benefited from the Grant, with claims of more than $71,000 made. This is in addition to the $90,000 granted to accredited TCM training providers for the organisation of TCM conferences and seminars. We will continue to monitor the utilisation of this Grant by individual TCMPs to defray the cost of attending CPE courses and make adjustments if necessary.

As Prof Fatimah Lateef rightly pointed out, TCMPs can also make claims under the SkillsFuture Funding for their courses. We will continue to encourage CPE course providers to get their courses accredited by SkillsFuture Singapore so that more TCMPs can benefit.

Prof Fatimah Lateef also asked whether there could be some flexibility given to the TCMPs during the first two years of implementation of compulsory CPE. Let me first explain that we introduced voluntary CPE some five years ago and have also undertaken extensive consultations with the industry on the implementation of compulsory CPE. Hence, the TCMPs should be familiar with the CPE framework and guidelines on points accumulation.

Nonetheless, the accumulation of compulsory CPE points will take effect from 2020 after the Bill has been passed. For new registered TCMPs, they will be issued Practising Certificates (PCs) valid until June 2020 and will be required to accumulate 50 CPE points in order to renew their PCs in June 2022. So, they start accumulating points after June 2020 and then in June 2022, they will be required to have the requisite 50 CPE points for the PC renewal.

Of the 2,800 existing TCMPs holding valid PCs, half of them will have their PCs expiring in June this year and the other half in June next year. For those with PCs expiring in June this year, their PCs will be renewed until June 2020. This exercise is to align the existing cohort so that the CPE requirement can start at the same time for all existing TCMPs. Between now till June 2020, the Board will engage the TCMPs and CPE course providers to update them on the revised CPE assessment framework. We strongly urge all TCMPs to actively participate in CPE and familiarise themselves with the online CPE system.

Dr Chia asked how TCMPs who are not currently in active practice will be impacted with the passing of this Bill. As the CPE requirement is uniformly applied to all TCMPs who wish to practice, those who do not currently hold a valid PC will have to fulfil the CPE points requirement before they can apply to resume their practice.

Dr Chia also asked how MOH will ensure the availability and quality of accredited CPE courses upon the implementation of compulsory CPE. On the availability of CPE courses, the Board has been engaging the course providers to organise more courses in anticipation of the implementation of compulsory CPE. To further ensure that there are adequate courses, the CPE course providers will be required to fulfil a minimum number of course-hours per year to maintain their accreditation status.

The Board has established guidelines for the accreditation of CPE providers and courses, such as the credentials of the speakers or instructors, to ensure that they are of acceptable standard.

Prof Fatimah Lateef may be pleased to note that with the online CPE system, TCMPs may log on via the Board's website to search for CPE activities they wish to attend and monitor their CPE points. The system will be enhanced to send reminders at appropriate junctures to TCMPs who are at risk of not satisfying their CPE points requirement to help them fulfil these requirements.

We note Mr Gan's suggestion to integrate records of patients receiving treatment from both mainstream and TCM service providers for more coordinated management of care. However, as TCM is complementary to mainstream treatment and there are clinical and technical challenges that make it difficult to integrate the records, we will continue to work with the TCM community in order to provide a holistic approach towards patient management through other avenues.

For example, the TCM Development Grant supports the TCM service providers to strengthen their operating capabilities including the adoption of IT solutions and enhancement of clinic facilities for TCM clinics.

Prof Fatimah Lateef and Mr Gan Thiam Poh asked for information on the number of complaints received, disciplinary action taken and the trend over the years. The number of complaints received by the Board each year since 2013 has remained relatively constant at less than 10 per year, with about half of these cases requiring disciplinary action against the TCMPs involved.

The cases can be broadly categorised into professional misconduct, negligence, use of western medicines and criminal conviction. The actions the Board can take against a TCMP is dependent on the gravity of the matter the TCMP is guilty of and range from issuing a letter of advice, censure, or the suspension or cancellation of registration.

While the number of cases is relatively low, we need to continue to ensure that the disciplinary framework remains relevant and effective in safeguarding public interest and safety. This will be effected through the proposed three-pronged approach mentioned in my opening speech, namely to enhance the disciplinary framework to improve efficiency, increase maximum financial penalty to provide sufficient deterrence and enhance investigative powers.

The proposed increase in maximum financial penalty from $10,000 to $50,000 is to provide sufficient deterrence and punishment for misconduct so as to protect the safety and interests of the public. This quantum is similar to the maximum financial penalty applicable for dentists, pharmacists, and allied health professionals in the Dental Registration Act, Pharmacists Registration Act and Allied Health Professions Act but lower than the maximum penalty of $100,000 for doctors under the Medical Registration Act (MRA).

We have on balance decided on the $50,000 maximum quantum as TCMPs provide direct outpatient care to patients, similar to the allied health professionals and dentists in general.

To Mr Louis Ng's query on whether the Board informs the complainant of the findings of the inquiry and if it communicates with former patients of the TCMP if the TCMP is found guilty of misconduct, the Board will promptly inform both the complainant and TCMP involved of the Board's findings and decisions in writing once the inquiry process has been completed. Furthermore, upon the conclusion of the case, a press release will typically be issued and published on the Board's website for public access.

I thank Dr Chia for his comments on having clear guidelines for the penalties to be meted out by the Board. The Board has put in place a sentencing framework based on the degree of harm and culpability to assess the seriousness of the offence and to guide the appropriate sentencing.

As deemed necessary, the Board will update the framework. In addition, the Board also engages the Academy of Chinese Medicine Singapore for expert advice on TCM professional matters.

Prof Fatimah and Dr Chia Shi-Lu commented on the representation of the Board. We agree that the Board should consist of experienced and well-versed TCMPs who are conversant with various aspects of TCM practice. Hence, the current composition of the Board requires Board members who are TCMPs to have at least 10 years' experience in the practice of TCM.

Taking into account feedback from the public consultation, the size of the Board will be increased from nine to 11 so that more TCMPs can be included on the Board. We think this would suffice as since its inception, the Board has comprised the maximum number of members allowed under the Act.

Mr Louis Ng sought clarifications on the differences in the use of term "mental or physical disability" in section 6 of the Act which sets out the criteria for disqualification of Board members and "mental or physical condition" in section 19 of the amended Act, which allows the Board to take certain action against the TCMP concerned.

The amendment Bill revises the language in section 19(1)(k) from the term "disability" to "condition" so as to broaden the scope of mental and physical conditions that may render a TCMP unable to practice TCM safely. This will better safeguard patients' interests as the TCMPs are directly responsible for the care of their patients. On the other hand, we recognise that a person may still be able to contribute effectively as a member of the Board even if he was afflicted by a mental or physical condition, like a mild stroke, that does not affect his daily activities and mental capacity. However, this same condition may affect a practicing TCMP's ability to provide safe and effective care.

The Inquiry Committee for conducting a health inquiry relating to a TCMP's fitness to practice should consist of members who have the relevant expertise to inquire into the matter of which it is appointed, for example a member who is a medical practitioner in a relevant field.

Mr Chen Show Mao may also like to note that MOH regularly reviews the regulations and policies on TCM, taking into consideration the advancements in medical science and evolving standards of TCM. For example, based on latest literature on safety of use, MOH has lifted the ban of raw herbs containing berberine (黄连), to allow practitioners more options in the use of TCM in their practice and service to the public. Since 2005, acupuncture has also been allowed in our public hospitals.

We are also happy to note that the research project, supported by the TCM Research Grant, on dry eyes undertaken by the Singapore Eye Research Institute and Singapore Chung Hwa Medical Institution, has shown encouraging results. We hope that this will foster greater research collaborations between Western Medicine and TCM.

Prof Fatimah Lateef asked about the possible standardisation of charges for TCM services and recognition of Medical Certificates (MCs) issued by TCMPs. As TCM plays a complementary role to mainstream medicine in Singapore's healthcare system, MOH will leave it to the employers and companies to decide if they wish to recognise the MCs issued by TCMPs.

Prof Fatimah Lateef also pointed out that there is a range of charges for TCM services. This is due to a correspondingly diverse range of TCM practices and services offered, from charity TCM clinics operated by Voluntary Welfare Organisations to large industry players with chain clinics, catering to all segments of the population. Hence, the charges will continue to be left to market forces.

In response to Prof Fatimah Lateef's request for clarification on the classes of registration, we would like to note that there are currently two classes of registration – practitioners registered as TCM Physicians are able to provide the full range of TCM practice, including acupuncture, while practitioners registered as acupuncturists can only practice acupuncture. To Mr Gan Thiam Poh's query on the accreditation of "Tie Da" (跌打) practitioners, "Tie Da" is considered a form of traditional folk medicine passed down from master to apprentice and hence, Tie Da practitioners are not registered under the Act.

There is also no requirement for the registration of Chinese herbal dispensers, although herbal dispensers with the relevant qualifications can choose to be listed with the Board. There has been a decline in the use of Chinese herb which are mainly available from Chinese medical halls, compared to the use of Chinese Proprietary Medicines that is Chinese medicines in the prepared form, due to the latter's convenience and ease of use.

Notwithstanding this, MOH supports the continuing education of herbal dispensers as part of the upskilling of the TCM industry. Herbal dispensers listed with the Board are also eligible for funding support provided under the Development Grant.

MOH will continue to support and promote the professionalism of TCM practitioners, and ensure consistency and safety of TCM use.

Mr Deputy Speaker, Sir, a robust and efficient disciplinary framework and the upholding of practice standards are important for the safeguard of public safety as the TCM profession matures in Singapore.

We are indeed heartened by the support of the TCM community and the public during our consultation and engagement sessions, as well as the support of Members of this House. Mr Deputy Speaker, Sir, I beg to move.

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 Amy Khor Lean Suan].

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