Population health for Singapore: does primary care need strengthening?

INTRODUCTION The World Health Organization declared primary care ‘foundational’ to sustainably achieve universal health coverage (refers to individuals having affordable access to the full range of health services they need).1 Closer to home, Ministry of Health, Singapore, has made primary care a key plank of its Healthier SG strategy to improve population health.2 In Singapore, 80% of primary care demand is served by about 1,800 private general practitioner (GP) clinics and the remaining 20% by 23 public-funded polyclinics.3,4 Numerous policy initiatives have been introduced in our primary care sector in the past two decades to improve care delivery and affordability, including the Chronic Disease Management Programme, Community Health Assist Scheme, Family Medicine Clinics, Community Health Centres and Primary Care Networks (PCNs). The College of Family Physicians Singapore and the family physician community have also increased the rigour of primary care training to ensure a properly equipped medical workforce. Primary care is fundamental for the health of a population and forms the bedrock of any healthcare system. In Singapore, this has been most apparent throughout the coronavirus disease 2019 (COVID-19) pandemic, where primary care, including hundreds of GP clinics, has been at the forefront of concerted efforts that have kept the COVID-19 mortality rates relatively low. However, as trying as the COVID-19 pandemic has been, our primary care system (and the rest of the healthcare system) needs to continually prepare for the brunt of noncommunicable diseases (NCDs) in the coming years. Our current system is optimised for episodic visits and largely based on a fee-for-service model — this is ill-suited for NCD management where quality and consistency are key. FUTURE-PROOFING THE PRIMARY CARE SYSTEM We will experience an increasing burden of NCDs as our population ages. In 2017, eight of our top ten leading causes of disability-adjusted life years were NCDs.5 NCDs pose a formidable challenge — their onset is often insidious and by the time they manifest, patients will continue to experience residual health effects even with appropriate treatment. Many healthcare systems, including ours, struggle with NCDs. Our predilection for treating problems rather than preventing them not only strains limited hospital resources, but it is also fiscally unsustainable and leads to suboptimal health outcomes. The way forward lies in future-proofing our primary care system. There is no magic bullet in dealing with NCDs. Preventing and managing NCDs well requires a life course perspective. What happens in an individual’s daily life matters to their health, not just what goes on in the consult room. This is where primary care is uniquely placed, as it is sited within the community and serves as the first point of contact with health care for the majority of the population. Family doctors care for patients and their families at all stages of life and are more attuned to the context of their patients’ lives compared to most other medical disciplines and the hospital sector. The need for Singapore to future-proof its primary care does not imply downplaying the role of the hospital sector. Hospitals and specialist services will require continued investment to cope with the increasingly complex care needs and work towards value-driven outcomes. However, a strategic rebalance of funding and development — with interventions to preserve health and delay premature complications anchored in primary care and the community — will be necessary for our population’s health goals to be sustainably met. This will require changes in care pathways across settings, upskilling of care providers and perhaps even changes to the curriculum of the various healthcare professional courses. It also requires us to better leverage on technological advances and relook at funding models that do not just solve today’s problems, but will also put us in good stead for the foreseeable future. An effective primary care system for Healthier SG can be delivered through two key thrusts: (a) developing longitudinal family doctor–patient relationships and (b) building connections within and beyond the primary care sector. Developing longitudinal family doctor–patient relationships In contrast to the predominantly transitory healthcare encounters our system was optimised for, managing residents with NCDs requires continuity of care and a trusted doctor–patient relationship.6 This means having a regular family doctor (i.e. a primary care doctor who is trained to provide a continuum of care, including preventive management) who understands well the needs of patients and supports them in achieving their health goals throughout their life course. The proposed national primary care enrolment programme will formalise and facilitate such doctor–patient relationships for more individuals.2 Longitudinal relationships built upon trust are the cornerstone in promoting greater ownership of health by Singaporeans; they also serve as anchor points that help residents navigate the complex health and healthcare system. A regular family doctor will more likely anticipate needs and promote preventive activities (e.g. personalised lifestyle advice) that can be built into the life journey for Singaporeans. Also, such relationships promote mutual accountability and foster trust between the doctor and patient, leading to not only better clinical care but also improved provider and patient satisfaction. Building connections within and beyond primary care Some GPs may practice relatively independently and are not tightly connected with other GPs, their communities or the wider health system. Various initiatives have been introduced to address this, most notably, the PCN scheme that was first piloted in 2015 to support better chronic disease management.7 Backend teams and support services (e.g. allied health, care coordination) will need to grow in tandem with rising chronic disease prevalence to support our primary care clinics to stay abreast and deliver the ‘extras’ in the envisioned care model. Community support is needed to address the social determinants of health, which may be the root causes of disease and illness, so as to prevent ill health and better manage patients living with NCDs.8 Care provision alone is insufficient, and primary care will need to work with the community and forge links beyond the sector, including with hospitals and healthcare clusters, community care providers and partners outside the healthcare system (e.g. community-based organisations) to effectively connect all Singaporeans to what they need to live well and optimise population health. What does all this mean in practical terms? We illustrate this with the following scenario: Nadia is a patient who has enrolled in Healthier SG with her GP, someone whom she has developed a trusted doctor–patient relationship. Under the programme, she is reminded to go for regular preventive check-ups. During one check-up, she is diagnosed with diabetes mellitus. As her GP is part of a PCN, she is able to receive multidisciplinary care and the recommended foot/eye screenings, thus reducing her risk of developing foot ulcers and diabetic retinopathy. Through her GP, she gets connected with a neighbourhood exercise group, which encourages her to maintain a healthier lifestyle. Thus, Healthier SG represents an opportunity to make the necessary system changes to support Singaporeans like Nadia to achieve better health. CONCLUSION Improving population health in Singapore, in the context of Healthier SG, should entail a transformation of the health system that is anchored around trusted family doctor–patient relationships that connect individuals with what they need for good health. ‘Strengthening’ primary care is not just about reinforcing the foundation of our healthcare system; it is about determining how primary care can lend its strength to catalyse the changes required in other parts of our health system to work better together. Acknowledgement We thank Dr Rick Chan, Dr Lily Aw and Dr Roy Teow for their insightful and helpful comments on the manuscript. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.