Panel recommends 23 changes to medical disciplinary process in light of growing mistrust in system

The Workgroup to Review the Taking of Informed Consent and SMC Disciplinary Process, comprising (from left) Adjunct Assistant Professor Tan Tze Lee, Dr Lee Yik Voon, Senior Counsel Kuah Boon Theng, who co-chaired the work group, and Dr Wong Chiang Yi
The Workgroup to Review the Taking of Informed Consent and SMC Disciplinary Process, comprising (from left) Adjunct Assistant Professor Tan Tze Lee, Dr Lee Yik Voon, Senior Counsel Kuah Boon Theng, who co-chaired the work group, and Dr Wong Chiang Yin, during a press conference on Dec 3, 2019.PHOTO: ST

SINGAPORE - A slew of changes to the Singapore Medical Council's (SMC) disciplinary process, including the setting up of an independent Disciplinary Commission and a committee to filter out frivolous complaints, has been proposed by an official panel on Tuesday (Dec 3).

The 23 recommendations come after two high-profile cases this year in which the judgments by the SMC's disciplinary tribunals were declared potential or actual "miscarriages of justices" by the Court of Three Judges, which is the final body of appeal for cases dealt with by the disciplinary tribunal.

In issuing its recommendation, the Workgroup to Review the Taking of Informed Consent and SMC Disciplinary Process noted that there had been an "erosion of trust in the system" among doctors and patients, and that "growing disquiet and pessimism within the medical fraternity (has) been brewing for some time".

It added: "The profession clearly has been harbouring serious doubts about the ability of (the SMC's disciplinary) process to produce fair outcomes... if these pressing issues are not tackled swiftly and effectively, they will continue to fester and have serious ramifications."

The work group, appointed by the Health Ministry, also came up with another three recommendations and these deal with the taking of informed consent.

They were based on views given at more than 30 town halls and engagement sessions the panel held with insurers, patient advocacy groups, representatives of professional bodies and more than 1,000 doctors working in different types of medical practices. 

Speaking at a press conference on Tuesday, its co-chair Kuah Boon Theng said: "The aim is to improve the process so that it can consistently give us fair, expeditious as well as proportionate outcomes."

CURRENT PROCESS

At present, a complaint received by the SMC will either be referred directly to a disciplinary tribunal (DT) or sent to a complaints committee (CC).

The CC can then choose to refer it to a DT, issue a letter of advice or warning, dismiss the complaint or recommend mediation.

 
 
 
 

A complainant whose complaint was not referred to a DT and disagrees with the CC's decision could appeal to the Health Minister.

In the current process, a new CC has to be formed each time a complaint is filed, with an SMC member as its chairman.

As such, some complaints can take up to six years to process owing to the amount of manpower and resources needed to tackle each case, as well as a lack of doctors to sit in the CCs and DTs, resulting in a backlog of cases.

For instance, SMC processed 417 complaints last year, out of which 279 were brought forward from past years.

Only 192 of these were concluded, while a total of 217 were adjourned to this year.

OTHER CHALLENGES

Aside from a lack of manpower, the work group found several key issues with the current process.

One, a common complaint was that the private law firms which SMC relied on might be more concerned with delivering convictions and penalties, rather than the broader concerns of SMC and the medical profession.

Two, many doctors felt they were not given timely notice that a complaint had been made against them.

Three, there were concerns that the CC and DT processes were not independent, as SMC was perceived to have played the role of the investigator, prosecutor and judge.

Four, CC and DT members were found to lack familiarity with their powers and how to properly exercise them, resulting in "serious injustice and a waste of resources".

Additionally, resources were spent on managing a significant number of complaints which were found to be without merit.

PROPOSED CHANGES: STRUCTURE

To tackle the problems, the group proposed setting up an Inquiry Committee (IC) to filter out complaints that are frivolous, vexatious, misconceived or lacking in substance early.

The IC would be able to dismiss complaints, issue letters of advice, recommend mediation or refer them to the CC.

 
 
 

The work group also recommended removing the requirement that the chairman of a CC must be an SMC member, and establishing an independent Disciplinary Commission which would in turn appoint a DT, thus preserving the latter's independence.

It further recommended creating a legal advisory unit and a separate prosecution unit to improve access to legal resources for CCs and DTs. This would accompany the gradual phasing out of private law firms for prosecution of DT cases.

PROPOSED CHANGES: PROCESS AND PROCEDURE

Other recommendations in this category include a stricter timeline of 18 months to be set as a target to dispose of complaints, and that the IC and CC be empowered to make cost orders against complainants lodging frivolous and vexatious complaints.

These include doctors filing complaints against each other as a result of a business dispute, spouses in divorce proceedings complaining that doctors would not divulge their partner's information and relatives complaining they were not consulted about a patient's treatment, when the patient had already consented.

"It's important to send a signal that (such) complaints are frowned upon and shouldn't be used as a weapon to achieve some other end," said Ms Kuah.

PROPOSED CHANGES: MEDIATION

The group also recommended that mediation play a bigger role in the disciplinary process, by allowing the SMC to direct complainants and doctors to participate in mediation at an earlier stage.

Noting that only about 2 per cent of complaints each year were referred for mediation, Ms Kuah said many concerned minor lapses, failures of memory and poor record-keeping, and could have been resolved amicably.

Mediation provides a forum for patients to seek redress directly from a doctor, and enhances rehabilitative and restorative outcomes.

PROPOSED CHANGES: APPEALS

The group recommended that the right to appeal to the minister be replaced with the right to request the decision be reviewed by a Review Committee (RC), to counter the perception that the minister would end up prolonging the investigation process in order to err on the side of caution.

As the RC would ideally comprise doctors and legal experts, it would also be able to tap more resources more efficiently, said Ms Kuah.

PROPOSED CHANGES: TRAINING

Finally, the group proposed that members of ICs, CCs and DTs be provided with specialist training, as DTs have on several occasions made mistakes, like accepting a guilty plea without assessing if a charge is supported by facts and evidence.

"This has to be a continual process... they have to be up to date with decisions, cases and precedents," said Ms Kuah.

The Health Ministry has accepted the recommendations and the work group hopes they will be passed into legislation by the middle of next year.

SMC's president Chee Yam Cheng said his council has already started implementing several measures to improve its disciplinary processes, such as enhancing training and reviewing its caseload.

Professor Chee added: "SMC is optimistic that the recommendations put forth by the work group will help SMC strengthen the disciplinary processes."