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A greater role for SMA, a greater role for the profession - that is the common thread that runs through the three official announcements in the past month, two from the Ministry and the third from the Singapore Medical Council (SMC).  The Minister's speech on the 27th April and the new Guidelines on Advertisement approved by the Director of Medical Services (DMS) on 6th May 1997 are land-mark documents and are printed in full in this edition of the SMJ.  The third document is found in the first issue of the official SMC Journal 'SMC - In Touch' released last month.  In it, the President of the SMC, Professor Balachandran emphasised the need for greater self-regulation in the profession and spelled out the role SMA should take in ethical and practice issues.

The Minister's Address
The Minister's address touched on issues ranging from the importance of research and training, professional audit, balance billing and professionalism amongst others.  The speech deserves to be carefully studied, reflected and discussed.  We hope that you could send in your views to the editor of the SMA News.

SMA welcomes the new initiatives on research and post-graduate training of doctors.  We have in the past year emphasised their importance in the SMJ.  We now pledge the professions support for the implementation.

The issues of medical audit and balance billing are not new.  These were raised when the 'Private Hospitals and Medical Clinic Act' and the white paper on 'Affordable Healthcare' were tabled in Parliament in the early 1990's.  The SMA had submitted memorandums to the Ministry then.  However, the manner in which they may be implemented now deserves attention.  We hope that the spirit of involvement and engagement of the medical profession through the SMA and other professional bodies would continue.

Medical audit, when used in a positive manner, can be a process of continual improvement.  The parameters of audit should be drawn up in consultation with the profession so that it would not be perceived incorrectly as a witch hunt or 'bad apples'.

The issue of 'balance billing' raises more gall especially amongst some private specialists.  Its implementation would make Medisave claims an 'all-or-none' proposition.  There is concern expressed that even if doctors' bills are kept to within limits set in 'balance billind but the private hospital components do not fall in line, then defacto the patients (of these private doctors) would still be denied use of Medisave.  We hope that in the coming months, there would be more dialogue and feedback sessions to discuss these and other issues raised by the Minister in his landmark speech.

Advertising Guidelines and the SMA's three roles
The new gazetted guidelines on advertisements by healthcare establishments should be studied with reference to the relevant sections of the SMC Ethical codes governing advertisements by registered medical practitioners.

The SMA was consulted when the guidelines were being prepared by the Ministry.  We have engendered discussion and debate on the issue last year within the profession.  We believe that the guidelines could have been more circumscribed.  We note however, that some of SMA concerns presented to the Ministry with regards unnecessary liberalisation have been taken into account.  We accept the Ministry's view in a letter dated 9th May 1997 that SMA could be the 'intermediary between the doctors and the Ministry on the matter of advertisement'.  The official roles given by the Ministry of Health to SMA are:
(1)that SMA will act as a channel of feedback for the medical professions views on medical advertising, as well as interact with nonhealthcare bodies involved in advertising such as CASE and ASAS;
(2) that SMA will provide a consultancy service to all who wish to produce medical advertisement in accordance with the Guidelines; and
(3) that SMA will publish a directory of licensed healthcare establishments for sale to the public.

In a related vein, the SMC has also announced that 'the SMA has now been encouraged by the SMC to set up a body to advise doctors on the setting up of private clinics especially with regard to name-plates and providing information to the public'.

We are already actively playing the first role.  The SMA Council is now in the process of drawing up our terms of reference and the operational procedures in serving as a 'consultancy service' as regards advertisements.  SMA's 'interpretations of the guidelines would be published as they are drawn up.  This is to ensure that not only doctors but all healthcare establishments understand and comply with the profession's consensus as to where the profession's perceived 'out-of-bounds' markers should be.  We have therefore won the
'moral authority' of deciding for all including healthcare establishments what we consider ethical in medical advertisements.

We are also studying various options as regards publication of the directory mentioned.  The key decision we have to make is how to integrate relevant professional information of SMA members and non-members into the directory such that it would become the official and comprehensive reference for everyone in Singapore including members of the public.  We would ask your feedback and cooperation in the coming months.

A greater role in ethics
'We are masters of our profession and we must self-regulate'.  This is the dictum spelled out by the SMC President, Professor Balachandran in his message in the first issue of the SMC official publication.  He further wrote that the 'SMA has to take greater responsibility to advise its members on conduct and leave it to the Council (SMC) to deal with only heinous offences or gross negligence that constitutes infamous conduct in a professional respect'.

The SMA has traditionally played an effective, though 'unofficial' role in ethical matters through its ethics committee.  In accepting thisofficial' responsibility, the SMA has enlarged its ethics committee and is undertaking a major revision of its ethics handbook to make it more useful and up-to-date when used along side the SMC Ethical Codes.  We are also rethinking our role in professional indemnity and are discussing with various medical defence organisations as to what our roles could be.

We are writing out the operating procedures of the ethics committee.  A draft of the procedures is printed on page 230 of the scientific section of this issue to facilitate feedback.  This is to ensure that the processes are transparent and fair and have the all support of all our members.

These are new roles - significant roles won by our resolve to be counted in the past year.  These are heavy responsibilities but they are also the mark of a new confidence in the medical profession.

Cheong Pak Yean