Speech by Mr Ng How Yue, Second Permanent Secretary, Ministry of Health, at the National Healthcare Group (NHG) Primary Care Forum, 13 Oct 2017

Adjunct Associate Professor Chong Phui-Nah, CEO, National Healthcare Group Polyclinics

Distinguished guests,

Ladies and gentlemen,

Good morning. 

Introduction

1    It is my pleasure to join you today at NHGP’s Primary Care Forum 2017. I would like to take this opportunity to extend a warm welcome to our experts from overseas – Dr Paul Grundy and Professor Martin Fortin.  We look forward to your sharing, and I wish you a pleasant stay in Singapore.

Growing Role of Primary Care in our Healthcare Landscape

2    The theme of this year’s Primary Care Forum, “Primary Care: The Cornerstone of Sustainable High Performing Health Systems,” highlights the importance of developing a strong primary care system. The burden of chronic diseases has increased in tandem with an ageing population. The Primary Care Survey conducted by Ministry of Health (MOH) in 2014 showed that chronic attendances in polyclinics rose from 40% in 2010 to 51% in 2014. A strong primary care foundation is key to ensuring that patients with chronic conditions are managed well and anchored in the community. This allows them to continue to go about their daily lives, enjoying good quality of life. It also reduces the need for costlier downstream interventions, including hospital admissions.

3    MOH’s vision for primary care is “One Singaporean, One Family Doctor”, with primary care as the first and continuous line of care for patients. Supporting this vision are two of MOH’s strategic thrusts. The first is the shift “beyond hospital to community”. Primary care will play an essential role in transforming our healthcare delivery model from one built around the hospital, to one that can meet the needs of Singaporeans closer to home. The second shift is “beyond healthcare to health” and the family doctor will be an important player in nurturing a healthy nation through preventive health efforts.

4    In line with these shifts, MOH has embarked on various transformative efforts to strengthen the role of primary care.

Transformative Efforts to Strengthen the Role of Primary Care

Set-up of National University Polyclinics (NUP) as Part of the Re-Organisation of Healthcare Clusters

5    MOH had reorganised the public healthcare system into three integrated clusters in the Central, Eastern and Western regions. As part of this reorganisation effort, a new polyclinic group – the National University Polyclinics (NUP) – has been set up to serve patients in the Western region. This will equip each cluster with their own primary care capabilities. The aim is to allow for better integration between the polyclinics, hospitals and private sector or VWO healthcare partners in each region.

6    This is a timely move. The number of polyclinics will rise in tandem with the growth of primary care as a key foundation piece of the healthcare system. Therefore, the aim of the re-organisation exercise is to future-proof our primary care system, as we position the three polyclinic groups for scalable growth.

7    At the same time, we call upon all three integrated clusters, polyclinic groups and GPs to work together as one healthcare system.  An increasingly integrated primary care system will be essential for us to meet the growing healthcare needs of our population.

Shift Towards Team-Based Care

8    NHGP has partnered MOH in various primary care transformative efforts. This includes the implementation of the new team-based care model in several of its polyclinics. Under this new care model, patients are seen by a regular, multi-disciplinary team of healthcare professionals. The team consists of doctors, nurses, and care coordinators, who are supported by allied health colleagues. A team-based approach leverages on the diverse skills and expertise of different healthcare professionals. This is crucial as the care needs of patients become increasingly complex, straddling across multiple domains and settings.

9    The team-based care pilot implemented in NHG Polyclinics since 2015 showed significant improvements in diabetes clinical outcomes, preventive health indicators, and diabetes-related hospital admissions. It is a step in the right direction to re-organise our primary care teams, in order to allow them to juggle, coordinate and integrate care for patients, especially those with multiple co-morbidities. I would like to share the story of one such 72-year-old gentleman who had multiple conditions including heart failure; a chronic lung condition that left him breathless and osteoporosis. His complex medical condition made him prone to recurrent falls, and required multiple emergency department and Specialist Outpatient Clinic (SOC) visits within a year to keep his chronic diseases under control.

10    However, since his enrollment into a care team at Toa Payoh Polyclinic, his visits to the hospital and fall incidences have significantly reduced. The patient has been managed by the same care team, allowing his nurses to gain a deeper understanding of him as an individual, including his health needs and priorities. The nurses were able to provide an individualised and targeted approach to his health education and counselling sessions. This allowed the patient to be actively engaged in managing his own condition, with guidance and monitoring by the healthcare team. With this team management approach, acute episodes of his heart condition has also been successfully managed by the primary care team, without the need for hospital admissions. 

Mental Health in Primary Care

11    I am heartened to know that as part of its care transformative efforts, the polyclinics have also developed capability and capacity to manage patients with stable mental health conditions. This includes general conditions such as depression, anxiety disorders and insomnia. We know that there is a strong correlation between chronic medical conditions and mental health conditions. Persons with chronic medical conditions are more vulnerable to developing mental health conditions and vice versa.

12    NHGP has therefore taken a step in the right direction in introducing the Family Physician-led, Health and Mind Service (HMS) at Ang Mo Kio, Yishun and Woodlands Polyclinics. I am glad to know that NHGP is also partnering hospitals within the regional health systems, to manage persons with stable dementia in its polyclinics. These efforts will increase accessibility of care for patients. 

Towards A Sustainable, High Performing Primary Care System

13    While we have embarked on many initiatives, the transformation of our primary care sector is still at the nascent stage. Much work remains to be done. We believe that greater transformative efforts can be achieved, via a three-fold approach of:  forging closer partnerships between the public and private primary care sector; increasing patient empowerment; and harnessing the use of technology for care innovation.

One Integrated Primary Care System

14    Firstly, it is important to develop an integrated primary care system. Today, the workload distribution between the polyclinics and the private sector is uneven in both volume and complexity of chronic patient workload. While 20% of the primary care manpower works in polyclinics, polyclinics see 40% of total chronic care attendances. 

15    A more sustainable primary care system can be achieved through closer collaborations between the polyclinics and GPs. In this regard, NHGP has worked well with other primary care partners such as Raffles Medical Group (RMG), Unity Family Medicine Clinic (FMC), and solo GPs in Ang Mo Kio. To date, NHGP has right-sited more than 20,000 chronic patients to GPs and Family Medicine Clinics. These residents now enjoy the convenience of visiting a GP or FMC located in their neighbourhood.

16    We hope that these close partnerships can also be extended to the Primary Care Networks (PCNs). Under a PCN, GPs are brought together in a virtual network to share common resources like funding, ancillary and administrative support to develop a strong framework of chronic disease management across primary care. This allows holistic care to be delivered via a linked-in multi-disciplinary team of doctors, nurses and other supporting staff. Over time, we hope the polyclinics can continue to forge partnerships with PCNs in their region. These partnerships can facilitate collaborations in care integration, right-siting and professional development.  

Patient Empowerment

17    Secondly, enabling the development of a close relationship between the doctor and patient is important. Today, fewer than half of all Singaporeans have a regular family doctor.  A key step towards ensuring a sustainable primary care model is to shift away from the mind-set of transactional and episodic care for patients and providers, to one of relationship-based care. A trusting relationship with a regular family doctor can more effectively empower patients in self-management of conditions, and positive lifestyle modification. This is especially crucial in the management of conditions such as diabetes, where early disease detection and an individualised approach to ensure adherence to lifestyle modification are critical. It is therefore heartening to know that NHGP has introduced personalised health education sessions for diabetic patients to enhance their self-management skills, such as stress management.

18    In recognising the importance of empowering the public to take greater ownership of their health, MOH has also enhanced the “Screen For Life” programme. This supports the shift towards anchoring preventive health and chronic disease care in the community.  This is aligned with MOH’s vision for “One Singaporean, One Family Doctor” and to make screening and follow-up accessible and affordable to all Singaporeans. 

Use of Technology for Care Innovation

19    Finally, while the task to transform primary can appear daunting, the use of technological advancements can help to surmount some of the challenges. I am glad to know that NHGP has leveraged technology to implement innovative initiatives. In March this year, NHGP introduced locker services for patients with chronic conditions to collect their medication from 7-eleven convenience stores across the island. Patients can now skip the queues at the polyclinics, and collect their medication at a time and location of their convenience.  With growing pressure on primary care, and concomitant resource constraints, NHGP should continue with innovations that not only reap better healthcare outcomes, but also improve on manpower productivity and efficiency. 

Conclusion

20    I believe that SHP and NUP have also embarked on innovative and transformative efforts, and I look forward to seeing all three clusters working, in close partnership with the GPs, to bring primary care to greater heights.

21    I wish all participants a fruitful time at this conference.