Parliament No: 11

Session No: 1
Volume No: 83
Sitting No: 13
Sitting Date: 2007-09-20

PARLIAMENTARY DEBATES

SINGAPORE

OFFICIAL REPORT

ELEVENTH PARLIAMENT

PART II OF FIRST SESSION VOLUME 83

Thursday, 20th September, 2007

PHARMACISTS REGISTRATION BILL

Order for Second Reading read.

5.20 pm

The Minister for Health (Mr Khaw Boon Wan): Mdm Deputy Speaker, I beg to move, "That the Bill be
now read a Second time."

The Pharmacists Registration Bill seeks to repeal the Pharmacists Registration Act (Chapter 230 of the
1985 Revised Edition) and to re-enact it with amendments.

The Bill aims to achieve two main objectives.

First, it is to help raise the practice standards of pharmacists.
Second, it is to ensure that our laws remain relevant to the practice of pharmacy today.
In so doing, the Bill will establish a new statutory body, the Singapore Pharmacy Council, and enhance its
powers to enable it to perform its regulatory functions more effectively.

Background
There are almost 1,500 registered pharmacists in Singapore. After nurses and doctors, pharmacists form
the third largest healthcare professional group. The demand for pharmacists will continue to increase to
meet the rising healthcare needs of Singaporeans and also to support the growth in the biomedical
sciences and pharmaceutical research sectors. We will step up local training of pharmacists but we will
also need to augment it by recruiting trained pharmacists from abroad. The Bill will make provisions to
facilitate such foreign recruitment.

Pharmacists work in a wide range of jobs in both the public and private sectors. Traditionally,
pharmacists' role as custodians of drugs is to ensure the passage of safe and good quality drugs to our
patients through proper distribution and dispensing, protecting the patients from counterfeit and
substandard drugs.

Over the years, the profession has progressed from a mere drug focus to a patient focus. While they still
provide the check and balance in the drug dispensing process, pharmacists today also tailor drug therapy
according to the patients' needs, for example, the titration of antibiotic dosages for individual patients.
Pharmacists must therefore update their knowledge and skills through continuing education in order to
provide pharmaceutical care of the highest standard. This Bill seeks to mandate continuing professional
education for all pharmacists.
The pharmacy profession has undergone many changes. With continuing discovery of new drugs and
novel drug delivery systems, there will be new demands on pharmacists. They will play an increasingly
important role as domain experts in drug evaluation, drug use and surveillance.

Patients today have access to better and more potent medicines. But these medicines are not without
side effects or risks. Patient medication management has therefore become more complex due to a wider
range of drugs and treatment regimes. Poly-pharmacy amongst the elderly and patients with multiple
illnesses are situations in which the expertise of pharmacists can be called upon. We need better trained
pharmacists with postgraduate training and specialised knowledge, skills and experience to manage
these complex drug therapies. Through this Bill, we seek to establish a "Register of Specialists" for
specialist pharmacists who are capable of providing advanced medication management.

The current Pharmacists Registration Act was enacted in 1981, more than 25 years ago. We need to
bring it up to date with the modern practice of pharmacy. We also seek to enhance the regulatory role of
the current Pharmacy Board for it to function more effectively. Our proposal is to establish a new statutory
body, the Singapore Pharmacy Council, with enhanced regulatory powers to help maintain good
professional conduct of pharmacists and raise the standard of pharmacy practice.

The Bill will repeal the existing Pharmacists Registration Act but most of the current provisions which
remain relevant will be re-enacted. But several key amendments are proposed, which I will now
elaborate.

First: Compulsory continuing professional education

Like doctors and dentists, pharmacists need to keep up with the latest developments in the field of
pharmacy in order to provide up-to-date, high quality and cost-effective pharmaceutical care. Many
countries, including the UK and Canada, have therefore introduced compulsory continuing professional
education for their pharmacists. We should do the same.

Clause 74 of the Bill will enable the new Pharmacy Council to prescribe conditions for the grant and
renewal of practising certificates. One of these conditions will be mandatory participation in continuing
professional education. Only pharmacists who accumulate the requisite number of points specified by
the Council will be issued with practising certificates, or have their certificates renewed.

Second: Conditional and temporary registration

The growth in the healthcare and biomedical sciences sectors will push up the demand
for more pharmacists. We will continue to ramp up our supply. The National University of
Singapore (NUS) has increased its Pharmacy student intake over the years, from 41 in
1996 to 115 in 2006. This is a tripling in number over 10 years. But we need to do more.
We project a need for 200 additional pharmacists every year for the next 10 years. While
NUS will consider expanding the intake, we will also have to recruit from abroad to
augment our local supply.

The Bill will make provisions to facilitate foreign recruitment. Clauses 17 and 19 will allow, in addition to
full registration, the conditional and temporary registration of pharmacists. The Bill will enable the
Pharmacy Council to conditionally register a pharmacist who holds a prescribed qualification in pharmacy
conferred by a tertiary institution outside Singapore, or any other relevant qualification which in the
Council's opinion is not lower in standing than the prescribed qualifications. These pharmacists will work
under the supervision of a fully registered pharmacist for a certain period of time. On successfully
completing the period of supervision, the pharmacist may apply to the Council to be fully registered.

Temporary registration will be granted to pharmacy experts or pharmacists whose qualifications are
deemed adequate by the Council, and who are temporarily in Singapore for the purpose of teaching,
research or postgraduate study in pharmacy. This scheme, comprising full, conditional and temporary
registration, is modelled against that of the medical and dental professions.

Third: Register of Specialists

Clauses 15 and 18 of the Bill provide for the setting up of a separate register for specialist pharmacists
and the registration of such specialists. Clauses 36 and 37 establish a Specialist Accreditation Board to
define specialities and to determine the requirements for specialist registration.
Pharmacists with specialised expertise are increasingly required, particularly in areas, such as oncology,
cardiology, critical care and geriatrics, to ensure safe, evidence-based and cost-effective use of
medicines for better patient outcomes. Such specialist pharmacists will enable cost-effective drug
prescribing, optimal dosing of drugs, reduction in medication errors and fewer drug-therapy related
complications.

With the advent of molecular medicine, there will also be a need for targeted therapy, to deliver the right
dose of the right drug to the right patient at the right time. Specialist pharmacists in pharmacogenomics
and nanotechnology will support such advancements in disease management from research to
pharmaceutical manufacturing and clinical service.

Responding to this sophisticated demand, we observe a growing number of pharmacists with such
specialist qualifications. They are mostly American Board-certified specialist pharmacists and they are
providing an excellent level of pharmaceutical care to our patients. But we need more.

The establishment of a Register of Specialists will encourage more pharmacists to pursue postgraduate
education in their chosen field. Besides enhancing patient care, this will also make the professional
environment here more attractive to well-trained foreign pharmacists and encourage their inflow into
Singapore.

Fourth: Singapore Pharmacy Council

The Bill will establish a new statutory board, the Singapore Pharmacy Council. Currently, the profession
is regulated by the Pharmacy Board which is a department of the Ministry of Health. Our proposal is to
convert the Pharmacy Board into a statutory board and to enhance its regulatory powers. The Council will
comprise 11 members, nine of whom will be appointed by the Minister, with the Chief Pharmacist and the
Head of the NUS Pharmacy Department (or designate) as ex-officio members. This is provided for in
clauses 3 and 4. The Chief Pharmacist will function as the Registrar.

Clause 5 of the Bill will strengthen the Council's ability to regulate standards of pharmacy practice and
direct the development of the pharmacy profession. The Council will now be able to make
recommendations for the undergraduate courses of instruction, pre-registration training and compulsory
continuing professional education for pharmacists.

Fifth: Enhanced disciplinary and health inquiry framework

Currently, complaints made against pharmacists are dealt with by the Singapore Pharmacy Board. The
Board is empowered to discipline a pharmacist, after conducting an inquiry or after giving the pharmacist
concerned an opportunity to explain himself. The pharmacist may be issued a warning. In more serious
cases, he may be struck off the register.

Part VI of the Bill establishes a more robust disciplinary and health inquiry framework for pharmacists,
modelled after the medical and dental professions. Under this system, complaints that the Singapore
Pharmacy Council receives will be referred to the Complaints Panel. From this Panel, a Complaints
Committee will be instituted to inquire into the complaint. After doing so, the Complaints Committee may
either dismiss the complaint or refer the matter for a full hearing before a Disciplinary Committee.

Clause 42 of the Bill sets out the composition of the Disciplinary Committee. It is empowered to take a
variety of disciplinary actions against errant pharmacists. For instance, under clause 46, it may strike him
off the register or suspend him for up to three years. It may impose conditions to restrict his practice, or to
impose a penalty of up to $50,000. The pharmacist or the complainant aggrieved by the decision of the
Committee may appeal to the High Court.

Clause 50 of the Bill establishes a Health Committee. Its role is to inquire into the physical or mental
fitness of a pharmacist to practise pharmacy, when concerns about the health of pharmacists are
received by the Council. The Health Committee will be empowered under clause 51 to suspend a
pharmacist, restrict his practice, or, in cases of serious impairment, removal from the register.

Sixth: Interim Orders Committee

Inquiries into disciplinary and health matters may take some time to complete and, presently, a
pharmacist who is under investigation is still able to practise. This may not be entirely satisfactory in
some situations as there may be compelling reasons to suspend such a pharmacist from practising, even
before the outcome of his inquiry, either for the protection of the public, or in the interests of the
pharmacist.

Clause 53 allows the Council to appoint an Interim Orders Committee with the power to suspend or
restrict the practice of a registered pharmacist for these reasons, pending the completion of disciplinary
proceedings against him. To safeguard the interests of the pharmacist, measures have been put in place
in the Bill.

Composition of offences
Finally, clause 69 allows the Council, with the approval of the Minister, to prescribe offences which may
be compounded and, where appropriate, to compound such offences.

Conclusion
Mdm Deputy Speaker, our pharmaceutical services have seen many improvements over the years. But
as medical science continues to develop, the pharmacy profession must be given the support and
backing of this House to enable it to keep pace with the rest of the healthcare professions.

Mdm Deputy Speaker,I beg to move.

Question proposed.

5.36 pm

Mdm Halimah Yacob (Jurong): Mdm Deputy Speaker, I rise in support of this Bill.

This is an important and timely Bill that will enhance the practice of pharmacy, upgrade the standard of
professionalism of pharmacists and enhance patient safety. Pharmacists are an integral part of the
healthcare system as they help in administering the drug therapy to patients. In many ways, they act as
the safety net. Together with the doctors, they review the medications prescribed to the patients and
ensure that they are adjusted to fit the needs of the particular patient, taking into account the health
condition and other needs of the patient. As the Minister had described, they provide the "checks and
balances in the medication use process - from doctors' prescriptions to drug administration."

But for a long time, Mdm Deputy Speaker, they seem to be quite a neglected lot. Even the public is not
quite sure what role the pharmacists perform in the whole health care system. In the hospitals, we are not
aware of the important role that they play in drug therapy and, in the private retail pharmacies, their
services are under-utilised. This Bill would therefore provide greater recognition to the work of
pharmacists and it is a progressive step.

So, Mdm Deputy Speaker, I support the Bill and, in particular, I support the creation of the Register of
specialist pharmacists. Currently, there are already pharmacists who specialise in so many fields and the
Specialists Register would give them due recognition. The Specialists Register is also good for the
public, as we now have a register to refer to in the event we need the services of a pharmacist in a
certain area of specialty. Some countries like the US and Canada already have such a register. But we
need to do a lot more to highlight the existence of such a register so that it would be of greater use to the
public. One problem is that, unlike doctors whose areas of specialisation, whether in paediatrics,
oncology or gynaecology, can be easily identified by the public, it is a lot more difficult to know what the
different areas of specialisation of the pharmacists are, especially those in the private sector. So, to make
it easier for the public to access the services of such specialist pharmacists, I would like to suggest that
the Ministry of Health come out with a list of specialist pharmacists, together with their area of specialties,
which could be publicised and made accessible to the public.

Mdm Deputy Speaker, I also strongly support the focus on continuing education, which is critical for
patient safety as pharmacists work in so many different areas in both the public and private sectors and
they too need to keep up with improvements in the standards of patient care. Continuing education will
also further promote the specialisation of pharmacists in the different fields and ensure that only
pharmacists who are adequately trained in the specific fields are allowed to administer drug therapy. For
example, pharmacists who have not had the experience of handling patient care will now have to
undergo a course before handling patients, and this will most certainly enhance patient safety.

Another good move is the Interim Register as there is currently a shortage of pharmacists and the
existing legislation is restrictive. The Interim Register, which allows the Singapore Pharmacy Council to
admit foreign pharmacists with equivalent or relevant qualifications, subject to conditions, would provide
an additional pipeline of pharmacists and help to address the shortage that we are experiencing. I am
sure that the same rigorous qualifications and standards required of local pharmacists would also be
applied to these foreign pharmacists.

Mdm Deputy Speaker, let me now touch on two further areas. There is a concern among Singaporeans
on the increasing cost of medicines, whether medicines dispensed in the public sector or private sector
hospitals and clinics. As a result, we see many Singaporeans flocking to Johor to purchase medicines,
which is not without risk, as there is no certainty that they are not purchasing counterfeit drugs which
could worsen their condition. I would therefore like to urge the Ministry to continue to monitor the price of
medicines to ensure that they are affordable and accessible to Singaporeans. In this regard, I would also
like to urge the Minister to review the list of standard medicines which are subsidised and which are
prescribed in our public hospitals and polyclinics. There are quite a number of medicines prescribed to
patients which are not subsidised although patients are told by their doctors that these medicines are
necessary and critical to their needs. So I urge the Ministry to regularly review the list of standard
medicines to bring it up to date to include new and necessary drugs and minimise hardship on the
subsidised patients.

Let me now come to my final point, Mdm Deputy Speaker, and that is the issue of whether we should
consider separating the two acts of prescribing and dispensing of medicines. Currently, doctors both
prescribe and dispense medicines. While it can be argued that this is convenient for the patient, as the
least that a sick person wants to do is to go to another place to get his prescription, there is, however, a
greater overriding consideration, and that is the patient's safety. The Minister has explained at great
length about the important role that pharmacists perform - if I may quote the Minister again - "...in
providing the checks and balances in the medication use process - from doctors' prescriptions to drug
administration". In the hospitals and polyclinics, this is the practice where doctors and pharmacists work
hand in hand in administering drugs to patients. But among the private sector GPs, this is not the case,
and one has to ask whether, in the light of the current discussion in this House, this is in the best interest
of patients.

Quite a number of countries already separate dispensing from prescribing of medicines, including the US,
UK and, in Asia, Korea and Taiwan. In Japan, this is not mandatory, but patients can ask for this
separation of prescribing and dispensing, and it is estimated that about 50% of the patients have already
done so, indicating that patients do want a second layer of review in the drug administered to them. At
the same time, cost could also be another consideration for such patients.

Mdm Deputy Speaker, I understand that in Singapore's context, this cannot be done overnight as we
need to first educate the public who are not quite clear about the role of pharmacists and who have been
so used to doctors doing both prescription and dispensation of medicines. Perhaps the first step that we
can take is to encourage private practitioners to ensure transparency in their billings. Today, we do not
know how much of the bill that we are paying is for the doctor's consultation fee and how much of it is for
the cost of the medicine. So, if all doctors start by giving a breakdown of their fees, that would be a
positive first step, and I would like to urge our doctors to start doing so. Subsequently, we could make it
easier for patients who want to separate prescribing from dispensing to do so, just like the Japanese
system. In this manner, we would progressively move to a situation where patients are given an option to
have the medicine dispensed either by the doctor or by a pharmacist. I do not know whether this is
feasible at this point of time, but the key consideration for us should be what is in the best interest of the
patient as we know that pharmacists play an important role in providing the checks and balances in drug
administration so crucial to patients' safety. Currently, with doctors prescribing and dispensing medicines
in the private sector, this element is not present.

Mdm Deputy Speaker, I support the Bill. I think this is a progressive and good Bill.
5.42 pm

Dr Lam Pin Min (Ang Mo Kio): Mdm Deputy Speaker, pharmacists are health professionals who
practise the art and science of pharmacy. They typically receive a request for medications from a
prescribing healthcare worker in the form of a medical prescription and dispense the medication to the
patient and counsel them on the proper use and possible side effects of the drugs. In this traditional role,
pharmacists ensure the safe and effective use of medications.

Nowadays, pharmacists also participate in the management of diseases, where they optimise and
monitor drug therapy, often in close collaboration with physicians and/or other health professionals. In
many Western countries, specialties also exist within the pharmacy profession. Some examples would
include oncology, cardiology, psychiatry and nutrition support pharmacists, just to name a few.

Pharmacists are therefore very skilled and professional individuals with specific knowledge that makes
them a vital part of our healthcare team. The proposed changes to the 22-year-old Pharmacists
Registration Act is a major milestone and is necessary to ensure that the pharmacy profession remains
current, relevant and competent, and to bring it to the next higher level of professionalism.

The major changes introduced in this Bill are:

1) Differentiation of pharmacist registration into full, temporary and conditional registration;

2) Introduction of the pharmacist specialist register;

3) Introduction of compulsory continuing professional education; and

4) Establishment of the Singapore Pharmacy Council.

Manpower requirements/registration of pharmacists

Given Singapore's focus on the biomedical sciences and healthcare services, the pharmaceutical
industry is enjoying an important role in our economic prowess. As one of the key strategic manufacturing
sites of the biomedical sciences industry, Singapore currently holds six of the world's top 10
pharmaceutical manufacturing facilities.

With the rapid growth in the fields of healthcare, pharmaceuticals, life sciences and research in
Singapore, there is indeed an increasing demand for pharmacists. Interestingly, there are currently just
0.3 practising pharmacists per 1,000 population here in Singapore, probably one of the lowest among
developed countries, compared to 1.2 in France and Japan, and to 0.4 per 1,000 population in Denmark.

Although the output of locally trained pharmacists in the National University of Singapore (NUS) has
increased from 41 in 1996 to 115 last year, as what the Minister has mentioned just now, this is assessed
to be insufficient. According to the Ministry of Health's projection, ideally, 200 new pharmacy graduates
should be needed very year.

To meet current and future demands, there is an urgent need to recruit from overseas. In order to cater
to this arrangement, one of the amendments to the Act is therefore to allow differentiation of the
pharmacist register into full, conditional and temporary registrations, the latter being relevant to foreign
trained pharmacists.

Whilst there is a requirement to augment the number of pharmacists in Singapore, there is also a need to
be stringent in the selection and recruitment processes as a lowered standard of practice in the
pharmacy profession may result in undesirable or sentinel events, which can affect the well-being and
safety of patients.

I would also like to suggest to the Ministry to identify and publish the list of recognised foreign institutions
for the pharmacy degree so that Singaporeans who choose to study abroad and have the intention to
return to Singapore upon graduation can be better informed when deciding on their varsity of choice.
Pharmacist specialist register

In order to support Singapore's vision of being a medical and biomedical science hub, pharmacists with
specialised expertise are increasingly required. Examples of specialisation include geriatrics, oncology
and cardiology. I would like to suggest the formation of a Specialist Training Committee (STC) to
determine the relevant specialisation required to cater to the special needs of Singapore, taking into
consideration the rapidly ageing trend and the increased prevalence of certain chronic illnesses. The
STC will also establish and maintain structured training programmes for both undergraduate and post-
graduate training in the future. The recognition of pharmacy specialist is also welcomed as it provides a
further route of advancement for pharmacists in Singapore.

Continuing professional education

The introduction of continuing professional education is important in maintaining the standard of

pharmacy practice in Singapore. This is in line with other healthcare professional groups such as the
continuing medical education for doctors and the continuing nursing education for nurses. Participation
in continuing professional education will ensure that practising pharmacists keep current and well
informed of the latest development in their areas of practice and specialty.

As evident from past reports of unexpected adverse events and drug interactions of certain medications,
up-to-date knowledge of such events is crucial to the pharmacists so that they can advise the patients
accordingly when dispensing the drugs.

With the setting up of the Register of Specialists, it will be apt to classify the continuing professional
education requirements to core and non-core, where registered pharmacists must clock sufficient points
in their core area of specialty while the remaining points from non-core educational programmes. This is
similar to that of the medical professional specialist CME requirement.

Singapore Pharmacy Council

The replacement of the current Pharmacy Board with a new statutory body, the Singapore Pharmacy
Council, serves to broaden the role and enhance the regulatory function of the regulatory body. The
establishment of the Singapore Pharmacy Council, is therefore essential to uphold the professional
conduct of pharmacists, set required standards and disciplinary actions, and to provide an avenue for
redress and complaints from patients on errant practitioners.

Conclusion

Madam, for a country as modern and developed as Singapore, we lag behind the United States, Japan,
United Kingdom and Australia in regulating the practice of pharmacy. Given the importance of pharmacy
practice and the effects of pharmaceutical products on a human body, the introduction of this Bill is
necessary and timely.

On that note, I support the Bill.

5.49 pm

Dr Fatimah Lateef (Marine Parade): Mdm Deputy Speaker, I rise in support of the Bill.

Gone are the days when a doctor would register, treat, prescribe medication, prepare the concoction
and elixir all by themselves. Healthcare has evolved to become a very specialised, and, in fact, even a
sub-specialised area. The divide between dispensing and prescribing must be clearly defined. Here, I
would like to clarify one of the Member's earlier query whether we actually break down costs into different
types of treatment that are given.

Currently, in our restructured hospitals, we have the bills being broken down into the cost for consultation,
x-ray as well as prescription of medication. Pharmacists are now the recognised experts in drug use
development, prescription and also monitoring. The Pharmacists Registration Bill will have a major role
in ensuring that professional standards are maintained and it will also introduce what I would term, the
"fitness to practise" regime.

In fact, pharmacists have now taken on a specialist role and they are involved in areas such as
toxicology, poison centre management, psychiatry, oncology and also hazardous material handling.
Thus, the relevance of the specialist register as the industry progresses and evolves, the guidelines for
temporary, conditional and full registrations are stipulated very clearly in this Bill and this is very timely
indeed as we realise the need to recruit foreign trained pharmacists. With our current ratio of only 0.35
pharmacists per 1,000 population, we are indeed below first world standards. Our requirements are about
200 pharmacists per year. And we also have to take into account the fact that we have a turnover in the
industry, knowing that the pharmacists actually do face job stresses and they have competing needs as
well.

I would also like to suggest that the Bill has allowances for the following two points.

Firstly, for a pharmacist who has been on an overseas attachment or posting for a certain period of time,
what would be the criteria for having their full practising certification upon return? This needs to be
clearly stated. Secondly, how about the non-practising pharmacists who wish to keep their certification?
What requirements would they have to fulfil? This would probably have to be in terms of
continuing education programme participation. And if they do decide to come back into active practice, it
would indeed be necessary to have a short period of clinical supervision, depending on how long they
have been out of clinical practice.

Pertaining to continuing professional development, this should be planned along the same lines as those
in existence for doctors, nurses and also, recently, the practice of optometry. As professionals, we
cannot run away from the fact that our knowledge has to be updated all the time. In this Bill, there is
reference to the regulation of the grant and renewal of practising certificates. This is indeed a step in the
right direction to help step up professionalism. And I would urge the Ministry of Health to work closely
with the School of Pharmacy and also with the practising pharmacists to get their inputs and feedback on
this matter.

As the public often is not able to differentiate between pharmacists, pharmacist assistants and the
pharmacist technicians, I would also like to enquire as to whether there are plans to subject the
pharmacist technicians to any form of regulation. Also, we know that many general practice and private
clinics do not employ pharmacists, but instead, they have clinic assistants. We also know that often,
these are the people who do the handing out of medications prescribed by a doctor in these practices.
Whereas it would have not been right to subject them to the same regulations as a professional, such
as a pharmacist, can I put forth the suggestion for them to have certain training and guidelines followed
by certification upon completion of a training course? This would certainly go a long way in helping us
move towards achieving 100% patient safety and safe prescribing.

We have also heard of recent cases where physicians have been found to over-prescribe certain
controlled drugs on a regular basis. Perhaps, with knowledge, training and empowerment of these clinic
assistants, we can reduce the incidence of such cases. After all, one of the objectives of this Bill would
be to enhance standards of patient safety and increase public confidence in pharmacy practice in a very
structured and sustained way.

About the appointment of advisers, besides the appointment of committees with general or special
purposes, I would like to suggest the appointment of a legal adviser or advisers for particular proceedings
of the Council. The Council will make the rules for the functions of these legal advisers who are
appointed. Clinical advisers too would be very useful and they should be specialists or experts in
particular fields and their inputs would come in useful in handling complaints, drawing up guidelines and
inputs on team practices as pharmacists, Mdm Deputy Speaker, are indeed members of the holistic
healthcare team.

Finally, the pharmacy business. Pharmacists must have responsibility for the pharmacy business. If the
business is registered under a person's name, he or she would have responsibility of the pharmacy
business carried out on that premises. All pharmacy businesses must have a pharmacist name, either as
the person in charge or as the adviser. The pharmacist may be the person under whose name the
business is registered, or the pharmacist may be appointed by the person in charge of the premises to
have overall responsibility of the pharmacy part of the business. The Ministry should also consider a
register for retail pharmacy businesses to assist with the regulation process.

Finally, this Bill, Mdm Deputy Speaker, is a step in the right direction as we move towards and strategise
for greater professionalism and, certainly, in our moving towards the future of healthcare in Singapore. I
support the Bill.

5.55 pm

Mr Seah Kian Peng (Marine Parade): Mdm Deputy Speaker Sir, thank you for allowing me to
speak on this Bill.

This afternoon, as I was coming into this Chamber, I met the Minister of State, Mr Heng Chee How. He
told me, in his usual friendly way, that I had the honour of being the last speaker for the last Bill today.
After four long days of debate, I think I got his message loud and clear. So I would keep my short speech
shorter.

First of all, I declare my interest as a Director of NTUC Healthcare Cooperative which runs a chain of
retail pharmacies.

This Bill is a comprehensive one, one which promises to give Singaporeans better healthcare
professionals who are continuously trained, to prepare and deliver their medicines. We read daily of the
new drugs and treatments that are coming online - it helps us sleep better at night - certainly without the
help of Valium - to know that there is a vigilant group of people keeping track of them.

This is important as pharmacists are those whom we rely on to educate us about our medications.
Knowing why we take certain medicines, how to take them, all these will help us to follow the instructions
more faithfully than we would otherwise do.

Madam, the new change in the Pharmacist Registration Bill is in line with the earlier changes in the
Medical and Dental Act. It is also in line with international practice where mandatory continuing
education is already in place in Canada and the UK.

It is a fuller framework than the previous Singapore Pharmacy Board framework, with provision for
registration of professionals, including specialists in areas such as oncology, cardiology, geriatric
medicine and so on. There will be a more varied career path for the practitioners and also better support
for the healthcare system as a whole.

There are three points which I would like to make. The first is on the Singapore Pharmacy Council. This
is a new statutory board which the Bill will set up. I suggest that the nine registered pharmacists, which
will comprise the Council, come from a broad spectrum. I would ask that one or two representatives from
the retail trade be included in the Council. This is to ensure that policies and rules can be more trade
friendly.

Next, on training. Nanyang Polytechnic and, I believe, Ngee Ann and Temasek Polytechnics as well, all
offer diploma courses leading to graduates becoming pharmacy technicians. The recent amendments to
the Dentists Act now allows dental therapists to work under the supervision of a dental surgeon. Could
provisions be made for these pharmacy technicians to work in retail pharmacies where the skills demand
is less exacting for them to dispense and to provide advice under supervision? This would make them
more valuable partners to the pharmacists. Pharmacists would then be freed up for other work.

Alternatively, perhaps these pharmacy technicians could be allowed to dispense items but not
prescription drugs and sign for Schedule 1 poison items in a retail pharmacy environment, again under
the supervision of a cluster pharmacist because, nowadays, cluster pharmacists have to manage a few
stores. This, again, is to help ease the shortage of pharmacists and to allow the retail pharmacy chain to
operate a value added drug store which sells everything except prescription items.
Currently, the Singapore Pharmacy Board accepts overseas pharmacists from countries, including the
UK, USA, Australia and Malaysia for pre-registration training, subject to their passing the forensic law
examinations, whereupon they can be registered and practise as a full-fledged pharmacist. So I am glad
to notice that there are provisions for full registration and conditional registration. This will create an
environment that attracts foreign talent, where under conditional registration, one could work here as a
pharmacist. However, I note that the areas are in patient care, teaching, research or as an expert
consultant.

I would like to ask the Minister for clarification. Out of interest for the retail trade, especially in retail
pharmacy, can it be widened and allow pharmacists from countries like, say, the Philippines or India, to
work in the retail environment under certain conditional registration and subject to their doing on-the-job
training and passing examinations.

Madam, there is a severe shortage of pharmacists in Singapore, despite the National University of
Singapore's efforts to churn out more pharmacy graduates. We heard recently that there are less
than 120 graduates a year. This compares to just 24 in 1982. But high attrition and a growing
market mean that demand is far more than supply. Hence, this request that I am making.

Mdm Deputy Speaker, on that note, I reaffirm my support for the Bill.

6.00 pm

Mr Khaw Boon Wan: Mdm Deputy Speaker, first, let me thank the Members who have spoken in
support of the Pharmacists Registration Bill. As noted by the four Members, pharmacists now play a very
important role in our healthcare system. Pharmacists are the experts in drug use, development,
prescription and monitoring, and they are no longer mere dispensers of medications, but have taken on
many specialist roles.

Dr Lam Pin Min commented that specialist pharmacists are especially needed to support Singapore's
vision to be a medical and biomedical sciences hub. It is therefore timely to set up this specialist register
for pharmacists.

Mdm Halimah suggested that we publish the specialist register and make it accessible to the public, and I
agree. The Singapore Pharmacy Council will do so.

Members also supported the need for continuing professional education. Dr Fatimah asked about the
CPE requirements for pharmacists who were on overseas attachments or postings and the non-
practising pharmacists who wish to return to active practice. The new pharmacist registration regulations
will spell out such CPE requirements. Briefly, pharmacists who have been away from Singapore for more
than 90 consecutive days will have their CPE requirements prorated. Non-practising pharmacists can
keep their names on the Register for up to five years without a practising certificate. But when they wish
to return to active practice, they would have to meet at least half of the required number of CPE points
during the preceding 12 months in order to qualify for a practising certificate. And it is certainly advisable
for such pharmacists to undergo a period of clinical supervision to ensure competency. Our institutions
will provide the necessary support for such pharmacists.

Dr Lam asked whether specialist pharmacists will require special CPE requirements through participating
in CPE activities that will be relevant to their specialty, and the answer is yes.

Dr Fatimah asked if we plan to regulate pharmacy technicians. We now have about 450 pharmacy
technicians in our healthcare institutions. They are either diploma holders in pharmaceutical science and
technology, or they have successfully completed the certified pharmacy technician course. Pharmacy
technicians play a supporting role and they are under the direct supervision of pharmacists. As the
pharmacist takes full responsibility for the actions of the pharmacy technician, I think the current
arrangement is satisfactory, and my Ministry has no plan to regulate pharmacy technicians for now.

Dr Fatimah suggested that the clinic assistants working in private medical clinics without pharmacists
should have proper skills training followed by certification. The Singapore Medical Association currently
runs such a certification programme in partnership with ITE. The general practitioners should encourage
their clinic assistants to attend such a programme so as to upgrade their skills. As clinic assistants come
under the direct supervision of doctors who are ultimately responsible for their work, it is in the interest of
the doctors that their clinic assistants are properly trained.

Mr Seah Kian Peng asked if trained pharmacy technicians can work in retail pharmacies. The answer is
yes, but they must be supervised by pharmacists who will be responsible for their actions.

Mr Seah also enquired if pharmacy technicians can be allowed to dispense non-prescription drugs, such
as pharmacy only medicines (POM) in a retail pharmacy under the supervision of an off-site cluster
pharmacist. This is permissible if there are approved provisions, such as video or tele-pharmacy facilities
in the retail outlet to enable the cluster pharmacist to exercise adequate supervision, even though
remote. Some pharmacies have already been approved for such a purpose.

Mr Seah suggested that the Singapore Pharmacy Council should include wide representation, including
at least one representative from the retail trade. We will bear in mind this recommendation when we form
the Council.

Members have all supported the strengthening of the Pharmacy Council so as to maintain high
professional conduct and standard. As black sheep cannot be completely eliminated, some disciplinary
actions will have to be exercised as needed. Dr Fatimah suggested that the Singapore Pharmacy
Council appoint legal and clinical advisers to help the Council in some of their proceedings. This is a
sound suggestion for the Council to consider.

Dr Fatimah also made some suggestions for the regulation of pharmacy business. The Medicines Act
and its regulations cover all matters pertaining to the regulation of pharmacy business. These are
currently being reviewed and my Ministry will study her suggestions.

Dr Lam noted the shortage in pharmacists and supported the need to train more locally. I
understand that the NUS Pharmacy Department has plans to raise its student intake. We
will also recruit from abroad to augment local training. But in so doing, I agree with Dr Lam that
we must not compromise on quality. Foreign-trained pharmacists will have to meet the same
minimum criteria as our locally-trained pharmacists, and they will need to work under
supervisory framework before they can apply to be fully registered.

Dr Lam suggested that we list the pharmacy degrees that we recognise for the benefit of students who
plan to study overseas, and we will do so.

Mr Seah asked if we can allow pharmacists from countries like the Philippines or India to work in retail
pharmacies under conditional registration. This can potentially be allowed, but the Council will have to
assess the specific pharmacy qualifications to ensure that they are of sufficiently high standard.

Mdm Halimah mentioned the important topic of drug cost and making sure that they are affordable,
particularly for the poor. This is a continuing concern for me. We review drug prices regularly and, in
particular, the composition of drugs on the standard drug list is something that we review at least once a
year. I have an expert committee advising me. They have to look at cost benefits, cost effectiveness and
make their recommendations to the Ministry. And we do periodically add to the list so as to ensure that
drugs will always remain affordable to our people.

I have looked at the composition of the national gross health expenditure, particularly the breakdown in
the various items. Singapore is the lowest among the developed countries in terms of drugs as a
percentage of the gross health expenditure.

Finally, Mdm Halimah asked if my Ministry would rethink the current policy of allowing doctors to both
prescribe and dispense medicine. As noted by her, in many countries, the two functions are kept
separate, with doctors not allowed to dispense medicine, and in so doing, granting the pharmacists the
sole dispensing right. Mdm Halimah felt that such a system might be safer from the patients' point of
view, as there would then be a proper check and balance. She noted that this is already the case in
public institutions but not yet in the private sector.
While a case could be made to grant pharmacists the monopoly in dispensing medicine, our current
system is not without its benefits. First, as noted by Mdm Halimah, patients have the convenience of
consulting a doctor and getting their prescriptions filled in one place without having to visit two places.
Secondly, the system of separating the two functions may end up more costly for the patients. When we
restrict supply and in this case, prevent doctors from dispensing, then we are restricting supply. I doubt it
will enhance consumer interest. The key is whether the providers are competent in
dispensing, and I think there is no doubt that the doctors are as competent as the
pharmacists in doing so. My natural instinct is to expand supply rather than restrict supply of
providers.

My preference is not to replace our current system but I will work to enhance it. The key is to give our
patients the choice to fill the prescriptions at wherever they wish, be it at the doctor's clinic, in a private
pharmacy or even across the causeway. To achieve such an outcome, doctors should provide each
patient with a clearly written, preferably computer printed, prescription. This is already the case in public
hospitals and polyclinics. So Mdm Halimah's proposed first step that we should do, which I totally
support, is that doctors in the private sector should do the same. And given the high cost of medications
prescribed by the specialists, the private medical specialists, in particular, should set the example and
pave the way for this change in practice. They should automatically issue prescriptions to all their
patients without their patients having to ask for them. And if the patients decide to buy the prescriptions
from the medical specialists, then the cost of the medicine should be clearly printed on the clinic bill as a
separate item from the doctor's consultation fee.

We should expect such a level of transparency of all our doctors in Singapore. Our patients should
demand such a standard of transparency. The public sector has demonstrated that it can be done and I
hope the private sector will follow suit, beginning with the medical specialists.

One suggestion that I recently received from a creative pharmacist is that, since our current regime
does not separate the two functions, why not start by looking at those medicines which are
particularly addictive, for example, Subutex or Dormicum, and restrict dispensing right to only
pharmacists for that kind of addictive drugs. That is an interesting idea from this pharmacist. But
when I think it over, there is no guarantee that the black sheep that we find amongst some doctors would
not also appear in the pharmacist profession. However, it raised a different suggestion in my own
mind: perhaps we can consider this as one of the penalties or disciplinary actions that the Singapore
Medical Council can impose on those GPs who are found to be flouting this rule, who are wrongly or
unethically prescribing drugs like Dormicum. Currently, in the tool box of SMC is suspension from clinic
practice. I am going to suggest to them that we consider, in addition to this penalty, one of the penalties
could be to suspend this errant GP a certain period of no dispensing right of addictive medicines. That is
probably something worthwhile for us to think about.

Mdm Deputy Speaker, I believe I have addressed all the comments raised by the Members. I would like
to thank them once again for supporting the Bill.

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. - [Mr Khaw Boon Wan].

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

Source - Web-page accessed on 1 Oct 07:

http://www.parliament.gov.sg/parlweb/get_highlighted_content.jsp?
docID=782634&hlLevel=Terms&links=&hlWords=
%20%20&hlTitle=&queryOption=1&ref=http://www.parliament.gov.sg:80/reports/public/hansard/full/20070
920/20070920_HR.html#1