Healthcare Services (Amendment) Bill

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.

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.

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.

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.

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?

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.*