A diet of fast food and take-out meals was a key reason housewife Chng Kah Sing, who has diabetes and high blood pressure, struggled to keep her blood sugar levels in check in the past.
But with encouragement from nurses to incorporate brown rice and vegetables into her meals, as well as yearly phone calls from a nurse counsellor reminding her to do a blood test, Mdm Chng’s diabetes is now under control.
The 57-year-old is one of the early beneficiaries of the Primary Care Network, a virtual network piloted in 2012 of general practitioners, who deliver care more holistically as a team with nurses and others.
Since the start of this year, eight new Primary Care Networks have joined the existing two – Frontier and NUHS.
The 10 networks comprise 340 general practitioner clinics, which are also clinics on the Community Health Assist Scheme. They will receive support from the Ministry of Health in the form of funding for nurse counsellors and care coordinators, as well as support to establish chronic disease registries.
The extra services available through the networks mean patients have more convenient access to diabetic foot screening and eye screening. The chronic disease registry means their outcomes are more effectively monitored.
The Ministry of Health said S$45 million a year has been set aside to support the Primary Care Network scheme for the next five years.
On a visit to the Mutual Healthcare Medical Clinic in Sengkang on Monday (Jan 15), Senior Minister of State for Health Lam Pin Min said the participation rate of GPs in the scheme was “reasonably good”, but fell short of the ministry’s target of 25 per cent of GPs – or about 375 of about 1,500 GP clinics here, according to last year’s figures.
While some GPs remain apprehensive about “what the whole… scheme is all about”, Dr Lam said participating GPs would be better resourced, have financial support and be able to share resources and best practices.
Mutual Healthcare Medical Clinic’s Dr Wong Tien Hua is part of Frontier Primary Care Network, piloted in 2012 and which now consists of 39 clinics.
Doctors would previously spend four to five sessions with newly diagnosed diabetic patients, but Dr Wong said he can now refer them to a nurse counsellor to work on lifestyle-related issues such as diet, weight management and smoking cessation.
This frees up a doctor to focus on medical aspects such as educating patients about disease management and complications, adjusting their medication and monitoring for side effects, he said.
Frontier network’s nurse counsellor rotates among different clinics.
Frontier’s Primary Care Network leader, Dr Chong Chin Kwang, said tracking of patients’ conditions was more adhoc in the past and is much more systematic now.
Leaders oversee the overall development of the networks, including clinical governance.
Dr Chong noted different GPs have different operational capabilities. “We’re still at the infancy stage and we want to see how to work together to give the best quality of care… It will take time,” he said.
The new Primary Care Networks formed this year from an application call last year are:
- Assurance, led by Dr Jacqueline Yam of AcuMed Medical Group;
- Central-North, led by Camry Medical Centre’s Dr Teo Boon See;
- Class, led by Mission Medical Clinic’s Dr Leong Choon Kit;
- i-CARE, led by Sims Drive Medical Clinic’s Dr Lim Chien Chuan;
- Parkway Shenton, led by Dr Jason Yap;
- Raffles Medical, led by Dr Chng Shih Kiat;
- SingHealth Partners, led by Dr Lily Aw of Lily Aw Pasir Ris Family Clinic & Surgery (SingHealth DOT) and Dr Rick Chan of Kingsley Family Clinic (SingHealth Regional); and
- United, led by Northeast Medical Group’s Dr Chee Boon Ping.