The healthcare regulatory framework in Singapore broadly comprises the Ministry of Health (MOH) and its statutory boards and the public and private healthcare providers.
The MOH manages the public healthcare system, which is designed with the twin aims of: ensuring that Singaporeans have access to good and affordable healthcare; and promoting health, as well as preventing and reducing illness. The public healthcare system is currently structured as vertically integrated delivery networks, and is organised by region. As part of the MOH’s Healthcare 2020 Masterplan, some of the public sector healthcare institutions in Singapore will be merged and restructured into three integrated clusters, namely, the central, eastern and western regional health systems.2 Each regional health system will have acute general hospitals, which will cooperate closely with long-term and other integrated care providers, such as community hospitals, nursing homes, home care and day rehabilitation providers, as well as polyclinics and private general practitioners in the region, to provide holistic healthcare to patients.
Healthcare facilities such as hospitals, clinics (including dental clinics), nursing homes and clinical laboratories are regulated by the MOH under the Private Hospitals and Medical Clinics (PHMC) Act and its subsidiary legislation.
Healthcare professionals are self-regulated by their respective professional bodies, which are established under legislation regulating the practise of healthcare (medicine,3 dentistry,4 pharmacy,5 nursing and midwifery,6 among others) in Singapore.
Health products such as pharmaceuticals, medical devices, cosmetics and complementary medicines are regulated by the Health Sciences Authority under the Health Products Act, the Medicines Act, the Medicine (Advertisement and Sale) Act, the Poisons Act, the Sale of Drugs Act and their subsidiary legislation, as well as guidelines promulgated by the Health Sciences Authority and the MOH.
II THE HEALTHCARE ECONOMY
In Singapore, healthcare services are offered through a mixed delivery model, with primary healthcare services, acute hospital services and dental services being offered by healthcare institutions in both the public and private sectors.
Singapore’s healthcare operates on a mixed financing system and is anchored on the twin philosophies of individual responsibility and affordable healthcare for all. The Singapore government’s healthcare expenditure averages about 2 per cent of Singapore’s gross domestic product (GDP).7 Singaporeans are afforded multiple tiers of protection through a combination of government subsidies, mandatory medical savings for working Singaporeans (Medisave), risk pooling via insurance schemes (such as MediShield Life, Integrated Shield Plans, ElderShield), and a government endowment fund that provides healthcare financial assistance for needy Singaporeans (MediFund).
ii The role of health insurance
It is mandatory for all working Singaporeans to contribute a portion of their income to Medisave, which is a national medical savings scheme administered by the Central Provident Fund (CPF) Board. Employees8 contribute a portion of their monthly wages into their personal Medisave account. The savings in the Medisave account can be used by the account holder to pay his or her own hospital bills and those of his or her immediate family members.
Apart from Medisave, all Singapore citizens and permanent residents are also automatically enrolled into MediShield Life, which is a basic national health insurance plan administered by the CPF Board. MediShield Life provides lifelong coverage to help Singaporeans pay for large hospital bills and selected costly outpatient treatments, such as dialysis and chemotherapy for cancer. Coverage can be supplemented by additional private insurance coverage, under Medisave-approved Integrated Shield Plans, which are managed by private insurers.
The MediShield Life Scheme Act 2015 (No. 4 of 2015) provides for the establishment and administration of the MediShield Life scheme. The MediShield Life Scheme Act further provides for the establishment of a MediShield Life Council, whose functions include making recommendations on the policy and scheme to ensure the continued provision of effective protection for Singapore citizens and permanent residents in an affordable and sustainable manner, and reviewing the administration of the scheme.9
iii Funding and payment for specific services
Singapore’s healthcare ecosystem adopts a mixed financing model, which broadly comprises the following tiers of protection: (1) government subsidies; (2) Medisave; (3) MediShield Life; and (4) MediFund.
The first tier consists of subsidies from the Singapore government of up to 80 per cent of the total bill for acute healthcare services rendered through the public hospitals.
The second tier of healthcare financing is via the Medisave scheme, which is a compulsory individual medical savings account scheme, to which all working Singapore citizens and permanent residents contribute a portion (between 8 per cent and 10.5 per cent10) of their monthly wages. Withdrawals can be made by the account holder to pay for hospitalisation and selected outpatient expenses incurred at any hospital in Singapore (e.g., conditions under the Chronic Disease Management Programme, such as diabetes, hypertension, lipid disorders, stroke, asthma, chronic obstructive pulmonary disease, Parkinson’s disease and osteoporosis; certain outpatient vaccinations; and health screenings, such as mammogram and colonoscopy screenings), whether for the account holder or his or her immediate family members.
The third tier consists of MediShield Life and ElderShield, both of which are automatically provided to all Singapore citizens and permanent residents.
MediShield Life is a basic health insurance plan that provides lifelong coverage, including for any serious pre-existing conditions. It is designed to help Singaporeans pay for subsidised treatment in class B2 or class C wards in public hospitals, though Singaporeans can choose to supplement their basic MediShield Life coverage with Integrated Shield plans (IPs), which they can purchase from private insurers. IPs can provide additional coverage and benefits to cover the costs of treatment at private hospitals, or class B1 or class A wards in public hospitals. MediShield Life premiums can be paid for using money from a person’s Medisave account. Where a person opts to purchase an IP, the premiums paid to the private insurer already includes the premiums for the MediShield Life component.
ElderShield is a severe disability insurance scheme intended to provide basic financial protection to Singaporeans requiring long-term care. ElderShield is offered to all Singapore citizens and permanent residents who have a Medisave account when they reach 40 years of age, unless they choose to opt out of the scheme. Enrolment is automatic and a person will be automatically covered by one of the private insurers appointed by the MOH to run ElderShield. Premiums are payable annually upon the policy renewal date, until the person reaches 65 years of age or becomes severely disabled, whichever is the earlier. Policyholders may purchase ElderShield Supplements to gain additional disability benefits coverage.
The fourth tier, Medifund, is a medical endowment fund set up by the government to assist needy Singapore-citizen patients that have financial difficulties paying their remaining medical bills, even after receiving government subsidies and drawing on other means of payment such as Medisave, MediShield Life, and cash. It is intended to provide a safety net to ensure that no Singaporean is denied access to basic healthcare solely because of affordability issues.
In addition to the above, the Singapore government also administers various other subsidy schemes, such as the Community Health Assist Scheme (CHAS) (formerly known as the Primary Care Partnership Scheme) and the Interim Disability Assistance Programme for the Elderly (IDAPE).
Under the CHAS, participating general practitioners and dental clinics will provide common outpatient medical treatment and basic dental services to needy patients who are Singapore citizens at subsidised rates. The CHAS covers 19 chronic conditions, namely, anxiety, asthma, benign prostatic hyperplasia, bipolar disorder, chronic obstructive pulmonary disease (COPD), dementia, diabetes, epilepsy, hypertension, lipid disorders (e.g., high cholesterol), major depression, nephritis and nephrosis, osteoarthritis, osteoporosis, Parkinson’s disease, psoriasis, rheumatoid arthritis, schizophrenia and stroke.
Separately, the IDAPE assistance scheme provides disability financial assistance to a limited group of elderly Singapore citizens who were not eligible to be enrolled in ElderShield at the time of its launch, either because they had exceeded the maximum entry age or had pre-existing disabilities.
Apart from subsidies for the costs of healthcare treatment and services, the MOH also provides drugs subsidies for drugs prescribed through public sector hospitals and clinics (which include specialist outpatient clinics and polyclinics) that are approved under the Standard Drug List (SDL) and the Medication Assistance Fund (MAF). Drugs may be listed on the SDL if they are assessed to be both clinically effective and cost-effective. The MOH regularly reviews and updates the list of drugs on the SDL, taking into account changes in clinical practice, advances in medical science and evolving needs of patients. Drugs approved under the MAF are generally newer and more expensive drugs and financial assistance provided under the MAF is subject to the use of the drug for only those specific clinical conditions for which the drug is assessed to be clinically effective and cost-effective.
III PRIMARY / FAMILY MEDICINE, HOSPITALS AND SOCIAL CARE
Generally, healthcare services in Singapore are available through a broad network of primary, acute, and step-down care providers, from both the public and private sectors. In the primary care sector, private sector providers account for about 80 per cent of the market.11 In the acute care sector, public sector institutions deliver approximately 80 per cent of the care to patients.12 In the step-down care sector (which comprises nursing homes, community hospitals and hospices, among others), the majority of services are provided by voluntary welfare organisations, and costs of such service provision are mostly funded by the Singapore government.13
Primary care and acute care providers are typically general practitioners, who must be licensed under the Medical Registration Act (in the case of medical practitioners) or under the Dental Registration Act (in the case of dental practitioners). Primary care providers are often patients’ first point of contact under Singapore’s healthcare system. Patients can generally receive outpatient medical treatment, immunisation, health screening and obtain other diagnostic and pharmaceutical services from their primary care providers. Patients who require specialised medical attention may be referred to other healthcare professionals with the necessary expertise.
Step-down care services are available for patients or individuals who require intermediate and long-term care. Such services may be home-based, centre-based, or residential. Home-based services are rendered to patients in their homes, and may include medical, nursing and palliative care. Centre-based services are offered at centres located within the community, and they may include community rehabilitation, dementia day care, and social day care services. Residential intermediate and long-term care services are generally provided by community hospitals, chronic sick hospitals, nursing homes, inpatient hospices and sheltered homes. The Agency for Integrated Care, which is established as an independent corporate entity under MOH Holdings (the holding company of Singapore’s public healthcare assets), is the coordinating agency that facilitates referrals to nursing homes receiving subsidies from the MOH.
To facilitate the delivery of integrated healthcare services across the network of providers, all patients who have sought medical treatment from a clinician or healthcare professional at a public healthcare institution since February 2011 will have an electronic medical record (EMR) created and uploaded to the National Electronic Health Record (NEHR) system. This is regardless of the patient’s residency or citizenship status. The NEHR system receives different data types from healthcare institutions and national registries, and these data are consolidated in the EMR of individual patients. A patient’s EMR can be accessed by clinicians and healthcare professionals at public healthcare institutions, community hospitals, nursing homes and hospices, as well as government agencies and general practitioner clinics that have requested to participate in the NEHR, who are authorised to access the NEHR, and who are providing the particular patient with medical care.
The access, security and management of patient data under the NEHR system is protected under a patchwork of legislation which include the Computer Misuse and Cybersecurity Act (Cap. 50A) (CMCA), the Personal Data Protection Act 2012 (Act 26 of 2012) (PDPA) and the PHMC Act, as well as under professional ethical codes that apply to registered healthcare professionals.
Under the CMCA, unauthorised access or modification of patient records under the NEHR system is an offence, which may attract a fine of up to S$100,000 or jail of up to 20 years or both.14
The PDPA, which is the baseline personal data protection law in Singapore, imposes obligations relating to the collection, use, disclosure, access, protection, retention and transfer of personal data. Organisations are required to make reasonable security arrangements to prevent unauthorised access, collection, use, disclosure, copying, modification, disposal or similar risks to personal data in their possession or under their control.15
Pursuant to the PHMC Act and its subsidiary legislation, licensees of healthcare institutions are required to ensure that there are adequate safeguards in place (whether by means of their administrative, technical or physical systems and processes) to protect the medical records of patients against accidental or unlawful loss, modification or destruction, or unauthorised access, disclosure, copying, use or modification.16
Registered healthcare professionals are bound by law and their respective professional ethical obligations to maintain patient confidentiality. For instance, doctors are bound by the provisions of the Medical Registration Act and its subsidiary legislation, in addition to professional ethical obligations under the Singapore Medical Council Ethical Code and Ethical Guidelines.
IV THE LICENSING OF HEALTHCARE PROVIDERS AND PROFESSIONALS
The MOH oversees the regulation of healthcare in Singapore, including the licensing and regulation of all institutional healthcare providers in Singapore.
Healthcare professionals are generally self-regulated by their respective professional bodies:
- a the Singapore Medical Council, which is established under the Medical Registration Act;
- b the Singapore Dental Council, which is established under the Dental Registration Act;
- c the Singapore Nursing Board, which is established under the Nurses and Midwives Act;
- d the Singapore Pharmacy Council, which is established under the Pharmacists Registration Act;
- e the Traditional Chinese Medicine Practitioners Board, which is established under the Traditional Chinese Medicine Practitioners Act (Cap. 333A);
- f the Optometrists and Opticians Board, which is established under the Optometrists and Opticians Act (Cap. 213A); and
- g the Allied Health Professions Council, which is established under the Allied Health Professions Act (Cap. 6B).
ii Institutional healthcare providers
Under the PHMC Act, any premises that are used as a private hospital, medical clinic, clinical laboratory or healthcare establishment must be licensed by the MOH.17 The PHMC Act and its subsidiary legislation also detail the requirements with regard to the types of services that may be carried out at private hospitals, medical clinics and clinical laboratories, as well as the qualifications of persons who manage these healthcare institutions.
Types of licences
The relevant licences and approvals required will depend on the scope of practice proposed to be carried out at the premises.
For instance, a medical clinic licence should be obtained if the premises are intended to be used by a doctor, dentist or other person for: (1) the diagnosis or treatment of persons suffering from, or believed to be suffering from any disease, injury or disability of mind or body, or (2) curing or alleviating any abnormal condition of the human body by the application of any apparatus, equipment, instrument or device requiring the use of electricity, heat or light.18 Medical clinics that offer certain special care services as listed in the Third Schedule of the PHMC Regulations will, additionally, require prior approval from the MOH to offer those services.19
A private hospital licence will generally be required if the premises are to be used for the reception, lodging, and treatment and care of persons who require medical treatment or suffer from any disease.20 All private hospitals (with certain exceptions) will generally also need to offer the following types of services: blood services (including having facilities for the proper storage and administration of blood and blood products), dietetic services, emergency services and nursing services.21 Private hospitals that offer certain specialised procedures or services as listed in the Second Schedule of the PHMC Regulations will, similarly, require additional prior approvals from the MOH to offer those procedures or services.22
Licensees of healthcare institutions must comply with all terms and conditions of their licences, as well as all relevant provisions of the PHMC Act and its subsidiary legislation.23 Failure to obtain the requisite licence or comply with licence terms and conditions is an offence, for which every person having the management or control of the healthcare institution will be liable on conviction to a fine not exceeding S$20,000 or imprisonment for a term of up to two years, or both.24
Application for licence
Applications for the issue of a licence under the PHMC Act must be made through the MOH’s electronic licensing system (eLis) at http://elis.moh.gov.sg.25 The application must be submitted no less than two months before the intended date of commencement of practice. For new licence applications, supporting documents including the following must also be submitted within seven days of the licence application: a fire safety certificate,26 and a floor plan of the new premises (drawn to scale). If the proposed licensee intends to share the premises with other healthcare institutions, additional supporting documents may be required.
The relevant person who must apply for the licence under the PHMC Act depends on the type of healthcare institution licence that is being applied for. There are restrictions on the persons to whom a licence may be issued. A licence for a private hospital will generally only be issued to its owner, or the person having the management or control of the hospital.27 Medical clinic (or dental clinic) licences are generally issued to a medical practitioner or dentist.28 A clinical laboratory licence will generally only be issued to: (1) a Singapore-registered medical practitioner who has the relevant higher qualification and training in certain specified disciplines,29 (2) a person who has a degree in medicine, or (3) any other higher qualification in certain specified disciplines30 that is acceptable to the MOH’s Director of Medical Services and who has at least five years’ relevant working experience in a clinical laboratory acceptable to the MOH’s Director of Medical Services.31 For an x-ray laboratory licence, the applicant or licensee should be a radiologist who is registered with the Singapore Medical Council.32
It is possible for a corporate entity to be the applicant of a licence under the PHMC Act. In the case of a private hospital licence, where the proposed licensee is a company, the applicant applying on behalf of the company must be a person holding a senior position in the company, for instance, the chief executive officer, chief operating officer, chief financial officer, or a director (who is listed as a director in the company profile33).
As part of the application, it is necessary to name the person who will be the manager of the healthcare institution. For private hospitals, the manager should be a person who is responsible for the administration or management of the hospital, such as the chief executive officer or general manager.34 For a maternity home, the manager should be a Singapore-registered medical practitioner, nurse or midwife;35 and for a nursing home, the manager should be a Singapore-registered medical practitioner or nurse.36 The manager of a medical clinic and a dental clinic should be a Singapore-registered medical practitioner and dental practitioner, respectively.37 The manager of a clinical laboratory should be a person who either: (1) has a degree in medicine or a basic degree in a relevant science subject that is acceptable to the MOH’s Director of Medical Services, or (2) has at least five years’ relevant working experience in a clinical laboratory acceptable to the MOH’s Director of Medical Services.38 The manager of an x-ray laboratory should be a qualified radiographer.
For the licensing of new premises, the applicant will also be required to arrange for the premises to be inspected by the MOH’s Licensing, Inspection & Audit Branch, when the premises and facilities are operationally ready. This typically follows the submission of all necessary licence application documents and application fees to the MOH, after the premises have been prepared in accordance with the ‘Guide for Preparation of Medical & Dental Clinics’ (if applicable), and the facilities meet the checklist of requirements set out on eLis.
Depending on the type of licence sought, the MOH may typically require approximately one to two weeks after inspection to process, carry out administrative checks and confirm compliance with the relevant licensing requirements. Delays can be expected if there are deficiencies that need to be rectified.
Other additional licences or requirements may be required prior to the commencement of operation of a healthcare institution. These include licences for certain equipment, such as ultrasound machines, to be used in the healthcare institution, advertising licences for the display of advertisements, and Medisave accreditation.
Risk-based licensing framework
The MOH adopts a risk-based licensing framework, under which all healthcare institutions are categorised as ‘high-risk’, ‘moderate-risk’ or ‘low-risk’. This framework is intended to incentivise licensees to be compliant with licensing requirements. Subject to certain exceptions, licensees that are compliant may qualify for a five-year licence, unless they opt for a standard two-year licence. Hospitals, nursing homes, and medical clinics providing special care or specialised procedures are not eligible for a five-year licence. The MOH may conduct random audits to ensure licensees’ regular compliance with the applicable licensing requirements.
Appeal for refusal to issue a licence
Where the MOH refuses to issue or renew a licence under the PHMC Act, the applicant may lodge an appeal to the Minister for Health, within 21 days of receipt of the notice informing him of such refusal.39 The appeal will be referred to and considered by an advisory committee consisting of three members of the Singapore Medical Council or Singapore Dental Council (depending on whether the appeal is made by a medical or dental practitioner in relation to his or her clinic).40 The report of such advisory committee will be taken into account by the Minister in his or her decision-making.
Suspension or revocation of licence
The circumstances under which a licence issued under the PHMC Act may be suspended or revoked include the following:41
- a the issue of the licence has been obtained by fraud or misrepresentation;
- b the person to whom the licence has been issued is contravening or has contravened or failed to comply with: (1) the PHMC Act or its subsidiary legislation; (2) any term or condition of the licence; or (3) any direction given to him by the MOH or an authorised officer under the PHMC Act or its subsidiary legislation;
- c the MOH has concerns over the character or fitness of the licensee (or, where the licensee is a corporate entity, of the members of the board of directors or committee or board of trustees of the licensee), the ability of the licensee to operate and maintain the healthcare institution in accordance with the prescribed standards, or the suitability of the premises licensed for use as the healthcare institution, or the adequacy of the nursing and other staff that are employed at the healthcare institution’s premises;
- d the private hospital, medical clinic, clinical laboratory or healthcare establishment in respect of which the licence was issued has ceased to operate as such; or
- e it is in the public interest to do so.
Before suspending or revoking the licence, the MOH will generally: (1) give written notice to the licensee of the proposed suspension or revocation; and (2) in the notice, call upon the licensee to show cause within a specified time as to why the licence should not be suspended or revoked.42 If the licensee fails to show cause within the specified time (including any extensions of time that may be granted), or fails to show sufficient cause, the MOH would then give written notice to the licensee as to the date from which the suspension or revocation of the licence will take effect.43
Any person aggrieved by the decision to suspend or revoke a licence may, within 21 days of the date of receipt of the written notice informing of the suspension or revocation, appeal in writing to the Minister for Health, whose decision shall be final.44 Before making a decision, the Minister shall refer the matter to an advisory committee consisting of three members of the Singapore Medical Council or Singapore Dental Council (as appropriate), and the Minister will consider the report of such advisory committee in his or her decision-making.45
iii Healthcare professionals
All medical practitioners must be registered with and hold a valid practising certificate issued by the Singapore Medical Council to practise medicine in Singapore.46 A person applying for registration as a medical practitioner in Singapore may be eligible for one of four types of registrations, depending on his or her educational qualification, knowledge, skill and experience: (1) full, (2) conditional, (3) temporary or (4) provisional registration.47
Medical practitioners that wish to practise as specialists must, additionally, be accredited by the Specialists Accreditation Board and registered under the relevant specialty by the Singapore Medical Council.48 To practise as a family physician in Singapore, a medical practitioner must be accredited with the Family Physicians Accreditation Board and also be registered as a family physician with the Singapore Medical Council.
Subject to certain limited exceptions, the Medical Registration Act makes it an offence for a person to practise medicine, or to advertise or hold himself or herself out as a medical practitioner, otherwise than in accordance with the relevant requirements.49 It is also an offence for a person to wilfully and falsely pretend to be a duly qualified medical practitioner. Each of these offences may, in the case of a first conviction, attract a fine of up to S$100,000 or imprisonment for a term of up to 12 months, or both. For second or subsequent convictions, the offence may attract a fine of up to S$200,000 or imprisonment for a term of up to two years, or both.50
Any person who is refused registration (as a medical practitioner, specialist or family physician) may, within one month of the written notice given by the Singapore Medical Council informing him or her of such refusal, submit a written appeal to the Minister for Health, whose decision is final.51
All registered medical practitioners are required to observe the pronouncements on professional matters and professional ethics issued from time to time by the Singapore Medical Council.52 These include the Singapore Medical Council Ethical Code and Ethical Guidelines, and the Handbook on Medical Ethics. Failure to comply with any professional ethical obligations or the serious disregard of, or persistent failure to meet the standards of ethics prescribed by the Singapore Medical Council may result in disciplinary proceedings being taken against the medical practitioner.53
Existing medical practitioners must renew their practising certificates, which are typically granted for no more than two years at a time.54 Medical practitioners must fulfil the requisite number of continuing medical education points, which is statutorily prescribed, in order to renew their practising certificates.55
There is no strict statutory requirement for medical practitioners in Singapore to maintain medical indemnity insurance. However, it is customary for medical practitioners in Singapore to take up such insurance.
A person who wishes to practise dentistry in Singapore will generally need to be registered with, and must hold a valid practising certificate issued by the Singapore Dental Council.56 A person applying for registration as a dental practitioner in Singapore may be eligible for one of three types of registrations, depending on his or her educational qualification, knowledge, skill and experience: (1) full, (2) conditional or (3) temporary registration.57
Dental practitioners that wish to practise any of the recognised dental specialties must have obtained accreditation from the Dental Specialist Accreditation Board and be registered as a dental specialist with the Singapore Dental Council.
The unauthorised practise of dentistry is an offence, which may attract a fine of up to S$25,000 in the case of a first conviction, and in the case of a second or subsequent conviction, a fine of up to S$50,000 or imprisonment for a term of up to six months, or both.58
It is also an offence for any person other than a registered dentist having in force a practising certificate to take or use the title of dentist, dental surgeon, registered dentist, qualified dentist, doctor of dental surgery, professor of dentistry, surgeon dentist, any prescribed title under Section 31(5),59 or any name, title, addition or description implying, whether in itself or in the circumstances in which it is used, that that person is qualified to heal or treat dental disorders or derangement, whether by dentistry or other means of any kind or description whatsoever.60
Any person who is refused registration (whether as a dental practitioner or specialist) may, within one month of the written notice given by the Singapore Dental Council informing him or her of such refusal, appeal to the Minister for Health, whose decision shall be final.61
All dentists are required to observe the professional pronouncements on professional matters and professional ethics issued from time to time by the Singapore Dental Council, for instance, the Singapore Dental Council Ethical Code and Guidelines.62 Serious disregard or failure to meet the standards of professional conduct and ethics prescribed by the Singapore Dental Council may lead to disciplinary proceedings against the dental practitioner.63
Registered dental practitioners must renew their practising certificates, which are typically granted for no more than two years at a time.64 Dental practitioners must fulfil the requisite number of continuing professional education points, which is statutorily prescribed, in order to renew their practising certificates.65
The Singapore Dental Council strongly encourages all dental practitioners in Singapore to maintain adequate professional indemnity insurance coverage, though there is presently no strict statutory requirement to do so.66
Generally, a person must be registered or enrolled as a nurse under the Nurses and Midwives Act and hold a valid practising certificate issued by the Singapore Nursing Board in order to carry out an act of nursing.67
Depending on the nursing course that the applicant has successfully completed, he or she may be registered as a registered nurse, or enrolled as an enrolled nurse, provided that he or she has also fulfilled all other applicable conditions for such registration or enrolment.68 In addition, any registered nurse who wishes to be an Advanced Practice Nurse must separately apply to be certified as such, subject to the applicant meeting all relevant requirements under the Nurses and Midwives Act.69
Subject to certain limited exceptions,70 the unauthorised carrying out of any act of nursing for a fee or reward is an offence, which may attract a fine of up to S$10,000 (in the case of a first conviction) or a fine of up to S$20,000 or imprisonment of up to six months (in the case of a second or subsequent conviction), or both.71
It is also an offence for a person who is not a qualified nurse to take or use the name or title of nurse in any language, either alone or in combination with any other words or letters, or any name, title, addition, description, uniform or badge, implying that he or she is a qualified nurse or that he or she is qualified to carry out an act of nursing.72 This may attract a fine on conviction of up to S$10,000.73
Any person who is refused registration or enrolment as a nurse, or refused certification as an advanced practice nurse may, within one month of the written notice given by the Singapore Nursing Board informing him or her of such refusal, submit a written appeal to the Minister for Health, whose decision shall be final.74
All registered and enrolled nurses, as well as advanced practice nurses are required to observe the Singapore Nursing Board’s pronouncements on professional practice, professional conduct and professional ethics issued from time to time.75 These include the Singapore Nursing Board Code of Ethics and Professional Conduct (for nurses and midwives), and a Standards of Practice for Nurses and Midwives. Nurses may face disciplinary action by the Singapore Nursing Board for professional misconduct, for instance, in the case of breaches of the professional values and standards set out in the Code of Ethics and Professional Conduct and the Standards of Practice for Nurses and Midwives.76
Nurses must renew their practising certificates annually. Renewal of the practising certificate is subject to the nurse making a declaration of his or her fitness to continue nursing practice, and payment of the relevant fee for the renewal of the practising certificate.77
All pharmacists must generally be registered with and hold a valid practising certificate issued by the Singapore Pharmacy Council to practise pharmacy in Singapore.78 A person applying for registration as a pharmacist in Singapore may be eligible for one of three types of registrations, depending on his or her educational qualification, knowledge, skill and experience: (1) full, (2) conditional or (3) temporary registration.79
Registered pharmacists who wish to practise as specialists must, additionally, be accredited by the Pharmacy Specialists Accreditation Board and registered under the relevant specialty by the Singapore Pharmacy Council.80
Subject to certain limited exceptions,81 the Pharmacists Registration Act makes it an offence for a person to practise pharmacy, or to advertise or hold himself or herself out as a pharmacist, otherwise than in accordance with the relevant requirements.82 It is also an offence for a person to wilfully and falsely pretend to be a duly qualified pharmacist. Each of these offences may, in the case of a first conviction, attract a fine of up to S$25,000. For second or subsequent convictions, the offence may attract a fine of up to S$50,000 or imprisonment for a term of up to six months, or both.83
Any person refused registration as a pharmacist may, within 30 days of the written notice given by the Singapore Pharmacy Council informing him or her of such refusal, submit a written appeal to the Minister for Health, whose decision is final.84
All registered pharmacists are required to comply with, among others, the standards of professional conduct set out in the Code of Ethics issued by the Singapore Pharmacy Council. Serious disregard or persistent failure to meet the Code of Ethics could lead to disciplinary proceedings against a pharmacist for professional misconduct.85
Further, registered pharmacists must renew their practising certificates, which are typically granted for no more than two years at a time.86 Pharmacists must fulfil the statutorily prescribed continuing professional education requirements in order to renew their practising certificates.87
Apart from the above, allied health professionals (which include occupational therapists, physiotherapists, speech-language therapists, diagnostic radiographers, audiologists, clinical psychologists and dieticians), optometrists and opticians, and oral health therapists, among others, are also subject to registration and other requirements.
V NEGLIGENCE LIABILITY
In general, a patient alleging negligence against a doctor must establish that the doctor breached one or more of his or her duties of care owed to the patient, and further that this caused damage to the patient.
The Singapore courts have recognised that the duties of care owed by a doctor to a patient comprise three aspects: (1) diagnosis (establishing what the patient’s medical need is), (2) advice (providing information regarding alternative treatments and the risks attendant on various possible treatments, etc.) and (3) treatment and care.88
The relevant standard of care owed by doctors to their patients in relation to the three aspects mentioned above was laid down by the Singapore Court of Appeal in Gunapathy,89 and more recently, in Lucien Ooi.90 In respect of the diagnosis and treatment of patients, the applicable standard is the Bolam 91 test, subject to the Bolitho 92 addendum.93 In respect of advice given by a doctor to his or her patients, the applicable standard is a modified version of the Montgomery test, as laid down by the Singapore Court of Appeal in Lucien Ooi.
In assessing whether a doctor is liable to his or her patient in the tort of negligence, the courts will have regard to whether the negligence was causative of damage. In medical negligence cases, compensatory damages are typically awarded by the courts to a plaintiff patient for pecuniary losses (such as expenses for medical or nursing care) and non-pecuniary losses (such as pain and suffering, and loss of amenities) that the patient has suffered. Aggravated damages, which also serve a compensatory function, may be awarded for the enhanced hurt suffered by a plaintiff patient due to the aggravation of the injury by the manner in which the doctor committed the wrong or by his motive in so doing, either or both of which might have caused further injury to the patient’s dignity and pride.94 In rare instances, the courts may award provisional damages, that is, an award of damages that is contingent on reassessment of the plaintiff patient’s situation at a prescribed future date.95 The courts in Singapore are generally reluctant to award punitive or exemplary damages in medical negligence cases.96
ii Notable cases
Hii Chii Kok v. Ooi Peng Jin London Lucien and another
The patient in this case had undergone certain diagnostic scans that revealed lesions in his pancreas. On the advice of his surgeon and certain other doctors associated with the National Cancer Centre of Singapore (NCCS), the patient underwent a surgical procedure called the Whipple procedure. The patient suffered life-threatening complications as a result, and had to undergo further operations to overcome these complications. Post-operative tests revealed that the lesions were not in fact cancerous. The patient brought proceedings against his surgeon and the NCCS for, among other things, negligent diagnosis and negligent advice.
The Singapore Court of Appeal took the view that ‘although the law as it was stated in Gunapathy still applies in the contexts of diagnosis and treatment, a different, more patient-centric test is now required in the context of information and advice that doctors provide to their patients’.97 In this regard, the court held that the standard of care applicable to advice given by a doctor to his or her patient should be that under a modified version of the Montgomery98 test.
In other words, the test of whether a doctor has discharged the relevant standard of care in the advice given to his or her patients now involves, broadly, a three-stage inquiry:
- a first, what was the information alleged to have been omitted by the doctor in advising the patient, and was such information: (1) relevant and material to a reasonable patient situated in the particular patient’s position, or (2) information that a doctor knows is important to the particular patient in question;99
- b second (assuming the court is satisfied that the information needed is relevant and material), was the doctor in possession of the information, and if not, ought he to have been in possession of the information (as assessed under the standard applicable to diagnosis or treatment, i.e., applying the Bolam test and the Bolitho addendum);100 and
- c third (assuming the doctor did possess the information), whether there is any reasonable justification why the information, though material and in the doctor’s possession, was nevertheless withheld.101 If the doctor was justified in withholding the information, then the doctor would not be found to have breached the standard of care in relation to his duty to communicate the information.
However, in relation to the diagnosis and treatment by doctors to their patients, the relevant standard of care applicable continues to be the Bolam test, subject to the Bolitho102 addendum. This means that a doctor would not generally be found to be negligent, in relation to the diagnosis or treatment of his or her patient, if he or she had acted in accordance with a practice that has been accepted as proper by a responsible body of medics skilled in the particular area, but only provided that the body of opinion was logically defensible.
ACB v. Thomson Medical Pte Ltd and others 103
The appellant in this case had undergone in vitro fertilisation (IVF) treatment at a fertility clinic operated by Thomson Medical Pte Ltd. After the child’s (Baby P) birth, the appellant and her husband discovered that Baby P had been conceived with the appellant’s ovum and an unknown third-party’s sperm rather than the husband’s.
The appellant sued the clinic as well as a senior embryologist and chief embryologist who were employed by the clinic, and sought to claim damages for, inter alia, the upkeep costs for raising Baby P. One of the principal legal issues in the appeal was whether such upkeep costs were a compensable head of damage. Other issues that the court considered in the appeal proceedings included whether the appellant could seek damages for loss of autonomy suffered, and whether the court was entitled to award punitive damages in the circumstances.
On account of the circumstances, the court denied the claim for upkeep costs as being against public policy considerations. Such a claim depended upon the recognition of the obligations of parenthood as actionable damage. However, the responsibilities of parenthood were, in the eyes of the law, obligations of a legal and moral character. Such responsibilities were incapable of valuation as ‘loss’ in any meaningful sense and could not be the subject of a claim for damages. The parents would have had to prove that the child represented a net loss to them. Such an exercise would, in the court’s view, encourage the exaggeration of any infirmities and the diminution of benefits as might exist in the child, thereby giving rise to a potential conflict of interest between the parents’ private interests in the litigation and their responsibilities as parents.
In relation to the damages claimed for ‘loss of autonomy’, the court held that such a head of damage was not to be recognised as an actionable damage in its own right. The concept of ‘autonomy’ was not only a nebulous one, but the notion of ‘autonomy’ also did not cohere with the requirement of ‘damage’ in the law of negligence which required claimants to prove objective detriment in order to make out a cause of action. Further, the recognition of loss of autonomy would mean that claimants may be able to circumvent existing control mechanisms in the tort of negligence. While the court declined to award damages for loss of autonomy in this case, it left open the possibility that a loss of autonomy could underlie a more specific award of damages in the context of a negligent interference with the plaintiff’s reproductive plans.
Importantly, however, the court recognised that the ‘loss of genetic affinity’ could be seen as an element of non-pecuniary loss, which was akin in some ways to an award for pain and suffering. The court acknowledged that the appellant’s desire to have a child of her own, with her husband, was a basic human impulse, the loss of which would be keenly and deeply felt. The court also noted that the loss of genetic affinity could lead to social stigma and embarrassment arising out of others’ misperceptions, as was the case on the facts. In this regard, the court considered that the appropriate amount of damages in each case would depend on the unique types of harm suffered by the plaintiff who has had his or her reproductive plans disrupted. The harm would, in turn, depend on the precise motivations of each plaintiff in seeking fertility treatment, as well as other relevant case-specific factors, such as the precise manner in which the negligence took place and the personal circumstances of the plaintiff. In the present circumstances, where the court noted an absence of comparable local and foreign precedents, the appellant was awarded damages for her loss of genetic affinity benchmarked as a percentage (30 per cent) of the financial costs of raising Baby P.
As can be seen from the above, public policy considerations are an important aspect in medical negligence cases, whether in the establishment of liability for medical negligence or the award of damages for medical negligence. The Singapore courts are generally slow to award damages for negligence by individual and institutional healthcare providers, even in cases where liability has been established, if doing so would be against public policy considerations.
VI OWNERSHIP OF HEALTHCARE BUSINESSES
As discussed above, the public healthcare system is currently structured as vertically integrated delivery networks, and is organised by region. Currently, all acute hospitals and specialty centres in the Singapore public sector are run as private companies that are wholly owned by the government, but their management resembles that of not-for-profit organisations. Public sector hospitals receive an annual government subvention or subsidy for the provision of subsidised medical services, and are subject to broad policy guidance by the Singapore government through the MOH. This model allows the public sector hospitals in Singapore to have the management autonomy and flexibility to respond more promptly to the needs of the patients.
There are no statutory prohibitions against the ownership of healthcare providers in Singapore. However, there are restrictions on the persons to whom a licence under the PHMC may be issued, that is, for the operation of a private hospital, medical or dental clinic, clinical or x-ray laboratory or other types of healthcare establishments.104 In determining whether to issue or refuse to issue a licence under the PHMC Act to an applicant, the MOH will have regard to, among others, the following matters:105
- a the character and fitness of the applicant to be issued with a licence or, where the applicant is a body corporate, the character and fitness of the members of the board of directors or committee or board of trustees or other governing body of the body corporate; and
- b the ability of the applicant to operate and maintain a private hospital, medical clinic, clinical laboratory or healthcare establishment, as the case may be, in accordance with the prescribed standards.
Consolidations in the healthcare sector may be subject to the provisions of the Competition Act (Cap. 50B), which include a prohibition against anticompetitive mergers.106 In 2015, the Competition Commission of Singapore, which enforces the Competition Act, took a provisional decision to block a proposed transaction involving the acquisition of an equity stake by one healthcare provider of another healthcare provider.107
VII COMMISSIONING AND PROCUREMENT
On a broader level, the MOH has oversight over the healthcare ecosystem in Singapore, in terms of not only the public healthcare infrastructure but also healthcare manpower, and the development and implementation of policies and programmes across the public and private sectors to ensure accessible, affordable, quality and sustainable healthcare.
In the public sector, all acute hospitals and specialty centres currently operate as private companies that are wholly owned by the government through an entity called MOH Holdings.108 These public healthcare institutions generally have management autonomy in their day-to-day operations, including in the procurement of appropriate healthcare manpower to meet demand. Public healthcare institutions may also procure manpower from recruitment agencies to meet short-term and temporary manpower needs.109 In contrast to private sector healthcare institutions, however, those in the public sector are managed akin to not-for-profit organisations and they also receive an annual government subvention or subsidy for the provision of subsidised medical services to patients. The public healthcare clusters also pool their long-term reserves (which they need only to use in the medium to long term) into a common pool and these funds are managed through MOH Holdings.110
The SingHealth Group Procurement Office (GPO) has responsibility over the procurement of drugs, and medical, surgical and other supplies for public healthcare institutions. The GPO functions as an agent for individual healthcare institutions. This means that the GPO will despatch the relevant requests for proposal to potential vendors, review replies therefrom, conduct negotiations and then select ‘strategic vendors’ on behalf of all the individual healthcare institution entities. Each hospital or clinic has its own internal department that manages the specific institutional needs for purchases and inventory of products and services, and will take delivery of the products and services that they require directly from the vendor.111
VIII MARKETING AND PROMOTION OF SERVICES
There are regulatory restrictions on both institutional and individual healthcare providers in relation to the marketing and promotion of the services that they offer.
i Healthcare institutions
Healthcare institutions that are licensees under the PHMC Act are required to comply with the Private Hospitals and Medical Clinics (Publicity) Regulations (the PHMC Publicity Regulations), among others.
The Publicity Regulations sets out restrictions in relation to, inter alia, the content of publicity in Singapore, and the advertising media in which publicity may appear. For instance:112
- a information contained in the publicity must be factually accurate and capable of being substantiated, and must not be exaggerated, false, misleading or deceptive;
- b the publicity must not be offensive, ostentatious or in bad taste such as to undermine the honour and dignity of the medical, dental or nursing profession;
- c the publicity must not contain any information that: (1) implies that the healthcare institution can obtain results from treatment not achievable by other healthcare institutions or create an unjustified expectation from the treatment provided; or (2) compares and contrasts the quality of the services of the healthcare institution with those provided by other healthcare institutions or deprecate the services of other healthcare institutions;
- d the publicity must not contain any laudatory statements (including statements of prominence or uniqueness) or superlatives to describe the services of the healthcare institution;
- e the information contained in the publicity must not contain any testimonial or endorsement of the services, including the services of any employee of the healthcare institution; and
- f the publicity must not provide information to the public in such a manner so as to amount to soliciting or encouraging the use of the services provided by or at any healthcare institution.
Permitted advertising media in which publicity may appear are: newspapers, directories, medical journals, magazines, brochures, leaflets, pamphlets and the internet.113 This is, however, subject to certain restrictions. For instance, the internet must not be used for patient consultation with any employee of the healthcare institution if the patient is not an existing patient of the healthcare institution.114 Publicity brochures, leaflets or pamphlets must contain the date of publication.115
There are also restrictions in relation to the following types of activities involving healthcare institutions:
- a the publicity of a healthcare institution’s services in conjunction with any person;116
- b media interviews where the licensee or an employee of the healthcare institution consents to be interviewed;117
- c public acknowledgement of contributions (e.g., donations, sponsorships or subscriptions) to good causes, by a healthcare institution;118
- d filming on the premises of a healthcare institution;119 and
- e publicity of public workshops, seminars or symposiums organised by a healthcare institution.120
ii Healthcare professionals
The ethical codes and guidelines issued by the relevant professional bodies in the healthcare sector set out restrictions on advertising by healthcare professionals of their services.
For instance, the Singapore Medical Council Ethical Code and Guidelines provide, in relation to doctors’ advertisement of their services, for matters such as the standards of information contained in the advertisements, requirements when giving talks, interviews or writing articles, associations with healthcare organisations (whether professionally or in business), dissemination of professional announcements, and overseas advertisements.
Similarly, the Singapore Dental Council Ethical Code and Guidelines, which apply to dental practitioners, contains guidance in relation to the provision of information about dentists’ services. The guidance relates to matters including content standards (including information provided at public talks, broadcasting and publications), platforms on which dentists may list their service information, association with healthcare organisations, provision of information through websites, electronic communications with patients, use of personal name cards and stationery, as well as professional announcements.
For nurses, the Code of Ethics and Professional Conduct and the Standards of Practice for Nurses and Midwives issued by the Singapore Nursing Board provides, generally, that nurses (and midwives) must refrain from any form of canvassing or advertising that is incompatible with the ethical standards of the profession.121
In respect of pharmacists, the Singapore Pharmacy Council Code of Ethics contains a section relating to the Ethical Code on Advertising. This sets out general principles on advertising by pharmacists, and it also details permissible and prohibited advertising activities in various contexts (such as public speaking and broadcasting, and the provision of information about their services through websites and other media platforms).
IX FUTURE OUTLOOK AND NEW OPPORTUNITIES
The MOH takes an active approach in the regulation of healthcare issues in Singapore. The Healthcare 2020 Masterplan was unveiled by the MOH in March 2012, and has since been progressively implemented. One of the key areas under the masterplan is the ageing population in Singapore, which was projected to be a strong driver for healthcare demand.
In recognition of the fact that telemedicine can assist to meet the healthcare demands of an ageing population and potential shortages of healthcare professionals and caregivers, the MOH introduced the National Telemedicine Guidelines in 2015 to provide leadership and direction in the area of telemedicine. These guidelines are targeted at healthcare professionals and organisations, patients and caregivers. They are intended to provide guidance on best practices in telemedicine interactions, including the respective responsibilities of healthcare organisations and healthcare professionals in relation to: (1) clinical standards and outcomes, (2) human resources, (3) organisation matters, and (4) technology and equipment.
Under the Healthcare 2020 Masterplan, the MOH has worked in tandem with healthcare stakeholders to ensure that its policies, financing structure, support system and programmes support the shift from healthcare provision to the promotion of health upstream, by enabling Singaporeans to take personal responsibility for their health, and empowering patients (and their caregivers) to participate in self-care and management of their medical conditions. In addition to raising awareness among the population of common diseases and health concerns, the MOH also intends to strengthen early screening and intervention, as well as provide support for better disease control measures.
Following the introduction of the Healthcare 2020 Masterplan, the MOH has tackled the issue of seeking to increase accessibility to healthcare by expanding capacity across various sectors of the healthcare ecosystem. This includes opening new acute and community hospitals, as well as progressively adding more beds to these hospitals and to other institutions such as nursing homes. Expansions of polyclinics offering primary healthcare services are also either under way or expected.
Regulatory reforms have also been implemented by the MOH to help ensure that the cost of healthcare remains affordable, and that care is effective and good value for money. For instance, the MOH introduced the MediShield Life scheme (to replace the Medishield scheme) to provide lifelong basic health insurance coverage for all Singapore citizens and permanent residents.
The healthcare regulatory landscape in Singapore is ever evolving. Given the increasing use of telemedicine, and other advances in medicine and technology, changes to the regulations governing the provision of healthcare services in Singapore are to be anticipated. Further developments within the healthcare ecosystem can also be expected under the MOH’s Healthcare 2020 Masterplan, which focuses on three strategic objectives of enhancing the accessibility, quality and affordability of healthcare.
1 Benjamin Gaw is the director and co-head of the healthcare and life sciences practice group at Drew & Napier LLC.
2 The reorganisation is expected to be completed by early 2018.
3 Medical Registration Act (Cap. 174).
4 Dental Registration Act (Cap. 76).
5 Pharmacists Registration Act (Cap. 230).
6 Nurses and Midwives Act (Cap. 209).
7 According to statistics compiled by the MOH and published by the Department of Statistics, over the past 10 years (FY06 to FY15). In Singapore, the total health expenditure is approximately 4.6 per cent of the GDP (The World Bank, 2016).
8 Self-employed persons who earn more than S$6,000 a year in net trade income are also required to make contributions to Medisave, based on their previous year’s net trade income.
9 Section 8(2), MediShield Life Scheme Act.
10 Depending on age group.
11 MOH website, www.moh.gov.sg.
12 MOH website, www.moh.gov.sg.
13 MOH website, www.moh.gov.sg.
14 Section 9, CMCA.
15 Section 24, PDPA.
16 Regulation 12, PHMC Regulations.
17 Section 2, PHMC Act.
18 Section 2, PHMC Act. There are certain exclusions, for instance, in respect of premises that are maintained by the Singapore government or the National University of Singapore, or which form part of the premises of a licensed private hospital.
19 Regulation 37, PHMC Regulations.
20 Section 2, PHMC Act.
21 Sections 21, 22, 23, PHMC Act. Nursing homes, psychiatric hospitals, convalescent hospitals, and maternity homes may not need to.
22 Regulation 18, PHMC Regulations.
23 Section 5(1), PHMC Act.
24 Section 5(2), PHMC Act.
25 Regulation 3(1), PHMC Regulations.
26 Section 20, Fire Safety Act (Cap. 109A).
27 Regulation 13, PHMC Regulations.
28 Regulation 35, PHMC Regulations.
29 The relevant disciplines are those listed in Regulation 56 of the PHMC Regulations.
30 The relevant disciplines are those listed in Regulation 56 of the PHMC Regulations.
31 Regulation 47, PHMC Regulations.
32 MOH’s eLis website, https://elis.moh.gov.sg.
33 As maintained by the Accounting and Corporate Regulatory Authority.
34 Regulation 10(2), PHMC Regulations.
35 Regulation 10(1)(a), PHMC Regulations.
36 Regulation 10(1)(b), PHMC Regulations.
37 Regulations 10(1)(c), 10(1)(d), PHMC Regulations.
38 Regulations 10(1)(e) and 49, PHMC Regulations.
39 Section 10(1)(a), PHMC Act.
40 Section 10(2), PHMC Act.
41 Section 9(1), PHMC Act.
42 Section 9(2), PHMC Act.
43 Section 9(3), PHMC Act.
44 Section 10(1), PHMC Act.
45 Section 10(2), PHMC Act.
46 Section 13, Medical Registration Act.
47 Sections 20, 21, 23 and 24 of the Medical Registration Act provide for full, conditional, temporary and provisional registration, respectively.
48 Section 22, Medical Registration Act. As at the time of writing, the Specialist Accreditation Board recognises 35 specialities (anaesthesiology, cardiology, cardiothoracic surgery, dermatology, diagnostic radiology, emergency medicine, endocrinology, gastroenterology, general surgery, geriatric medicine, haematology, hand surgery, infectious diseases, internal medicine, medical oncology, neurology, neurosurgery, nuclear medicine, obstetrics and gynaecology, occupational medicine, ophthalmology, orthopaedic surgery, otorhinolaryngology/ENT, paediatric medicine, paediatric surgery, pathology, plastic surgery, psychiatry, public health, radiation oncology, rehabilitation medicine, renal medicine, respiratory medicine, rheumatology and urology) and five sub-specialties (aviation medicine, intensive care medicine, neonatology, palliative medicine and sports medicine).
49 Section 17(1), Medical Registration Act.
50 Section 17(1), Medical Registration Act.
51 Section 28(5), Medical Registration Act; Regulations 20(7) and 20A(7), Medical Registration Regulations.
52 Regulation 26, Medical Registration Regulations 2010.
53 See generally, Part 7 of the Medical Registration Act, and Part V of the Medical Registration Regulations.
54 Regulation 25(1), Medical Registration Regulations 2010.
55 Regulation 24(1) and the Fourth Schedule, Medical Registration Regulations 2010.
56 Section 22, Dental Registration Act.
57 Sections 14, 14A and 14B of the Dental Registration Act provide for the full, conditional and temporary registration, respectively.
58 Sections 22(1) and 22(2) read with Section 28, Dental Registration Act.
59 Section 31(5) of the Dental Registration Act empowers the SDC to make regulations to prescribe appropriate titles and conditions under which the titles may be used, if the SDC is of the opinion that any branch of dentistry has become so distinctive that it would be for the convenience of the public or of the dental profession that registered dentists qualified to practise, or practising, in that branch of dentistry should use a distinctive title, subject to the approval of the Minister for Health.
60 Section 26(1) read with Sections 26(2), and 28, Dental Registration Act.
61 Section 15(7), Dental Registration Act, and Regulation 14, Dental Registration Regulations.
62 Regulation 16, Dental Registration Regulations.
63 Paragraph 1 (Introduction), SDC Ethical Code and Guidelines.
64 Section 17(3), Dental Registration Act.
65 Regulation 15I and Third Schedule, Dental Registration Regulations.
66 Paragraph 4.1.10, SDC Ethical Code and Guidelines.
67 Section 26, Nurses and Midwives Act.
68 Sections 14(1) and (2), Nurses and Midwives Act.
69 See generally, Sections 32(2) and (4), Nurses and Midwives Act.
70 Sections 27(4) and 27(6), Nurses and Midwives Act.
71 Section 27(3), Nurses and Midwives Act.
72 An ‘act of nursing’ means an act of nursing in: (1) the observation, care and counsel of the ill, injured or infirm; (2) maintenance of health or prevention of illness of others; or (3) the supervision or teaching of nursing, the proper carrying out of which requires skill and knowledge acquired by undergoing an accredited course of nursing or an equivalent course (Section 26(2), Nurses and Midwives Act).
73 Section 26(1)(a), Nurses and Midwives Act.
74 Sections 21(1) and 32(6), Nurses and Midwives Act.
75 Regulation 21, Nurses and Midwives Regulations 2012.
76 Section III, Code of Ethics and Professional Conduct.
77 Second Schedule, Nurses and Midwives Regulations 2012.
78 Section 28, Pharmacists Registration Act.
79 Sections 16, 17 and 19 of the Pharmacists Registration Act provide for full, conditional and temporary registration, respectively.
80 Section 18, Pharmacists Registration Act.
81 Sections 70 and 71, Pharmacists Registration Act.
82 Section 28(1), Pharmacists Registration Act.
83 Section 35, Pharmacists Registration Act.
84 Section 21(7), Pharmacists Registration Act.
85 Section 3 (Objectives of Code of Ethics), SPC Code of Ethics.
86 Regulation 9, Pharmacists Registration (Practising Certificates) Regulations 2008.
87 Regulation 6 and Second Schedule, Pharmacists Registration (Practising Certificates) Regulations 2008.
88 Hii Chii Kok v. Ooi Peng Jin London Lucien  SGCA 38 at -.
89 Khoo James and another v. Gunapathy d/o Muniandy and another appeal  1 SLR(R) 1024.
90 Hii Chii Kok v. Ooi Peng Jin London Lucien  SGCA 38.
91 Bolam v. Friern Hospital Management Committee  1 WLR 582.
92 Bolitho v. City and Hackney Health Authority  AC 232.
93 Khoo James and another v. Gunapathy d/o Muniandy and another appeal  1 SLR(R) 1024.
94 See, for example, Koh Sin Chong Freddie v. Chan Cheng Wah Bernard  4 SLR 629 at -; ACB v. Thomson Medical Pte Ltd  1 SLR 918 at .
95 See, for example, Koh Chai Kwang v. Teo Ai Ling  3 SLR 610.
96 See, for example, ACB v. Thomson Medical Pte Ltd  1 SLR 918 at -.
97 Hii Chii Kok, at .
98 Montgomery v. Lanarkshire Health Board  UKSC 11.
99 Hii Chii Kok v. Ooi Peng Jin London Lucien  SGCA 38 at .
100 Hii Chii Kok v. Ooi Peng Jin London Lucien  SGCA 38 at .
101 Hii Chii Kok v. Ooi Peng Jin London Lucien  SGCA 38 at .
102 Bolitho v. City and Hackney Health Authority  AC 232.
103  1 SLR 918.
104 See Section IV above.
105 Section 6(3), PHMC Act.
106 Section 54, Competition Act.
107 CCS media release dated 16 March 2015, ‘CCS’s Provisional Decision to Block Parkway Holdings Ltd’s Proposed Acquisition of Radlink-Asia Pte Ltd’.
108 MOH Holdings Pte Ltd is the holding company of Singapore’s public healthcare clusters.
112 Regulation 4, PHMC Publicity Regulations.
113 Regulation 5(1), PHMC Publicity Regulations.
114 Regulation 5(2), PHMC Publicity Regulations.
115 Regulation 5(3), PHMC Publicity Regulations.
116 Regulation 6, PHMC Publicity Regulations.
117 Regulation 7, PHMC Publicity Regulations.
118 Regulation 8, PHMC Publicity Regulations.
119 Regulation 9, PHMC Publicity Regulations.
120 Regulation 10, PHMC Publicity Regulations.
121 Paragraph 10.6, Section II, SNB Code of Ethics and Professional Conduct.