Transforming Population Health - The Role of GPs in the Community

As strategic nodes in the neighbourhood, GP (General Practitioner) clinics play an instrumental role in Singapore’s population health landscape through preventive and chronic care. We caught up with Dr Melvyn Tan, a GP in Ang Mo Kio to get his perspectives on the role GPs can play in improving overall population health in Singapore.

Q: Please tell us more about your core job scope as GP, and what drew you to the practice. 

A: I graduated from the medical school in 1998 and have been a General Practitioner (GP) at AMK Family Clinic since 2004. What got me into primary care was the opportunity to manage a variety of medical conditions, which requires a broad skillset. It also allows me to take on a people-centric approach and gives me the chance to see patients of all ages, from very young babies to seniors in their golden years.       

As a GP, I assist patients and their family members throughout their life stages, by providing support and advice to help them cope with changes in their physiological and health status. My duties also include picking up early developmental abnormalities in children, recommending vaccinations for the young and old, looking out for ageing issues such as sarcopenia, assisting with smoking and drinking cessation, and even doubling up as a counsellor when they face problems within the family.

Q:  What does population health mean to you?

A: Population health should be facilitated within the neighbourhood, where the infrastructure and surrounding amenities can complement diverse health programmes. For example, residents living in East Coast have the luxury of the sea and beach for more outdoor activities as compared to those living in Bukit Timah! Residents, organisations, and healthcare providers [in the] neighbourhood will have a stronger sense of ownership in amalgamating health programmes, and a concerted effort from these agencies is required to work on a consolidated approach to better population health.
 
Q:  You have been serving your Ang Mo Kio neighborhood for 17 years. Have you noticed any significant changes in the community’s health?

A: In the past, GPs were mostly handling acute problems like cough, cold and flu, and screenings were not widely encouraged. People used to only visit the doctor when they found something wrong with their health and it could end up being too late by the time disease struck!

Today, the upcoming silver tsunami along with the increase in life expectancy in Singapore is expected to lead to a rise in the prevalence of chronic diseases within the population, especially in a high-stress society like ours. Hence, GPs have been shifting their roles to include encouraging patients to take up health screening [as part of daily practice], a timely move given that Singaporeans are also becoming more affluent and health-conscious.

The group that raises the most concern is still the elderly, many of whom have not gone for screenings and might require advice on lifestyle changes. Thanks to the nationwide War on Diabetes, there is now an increased awareness on preventive care. However, the challenging part is that most do not take proactive steps to change even with [our] repeated advice, as they do not sense anything wrong yet.

Q: In your view, how have GPs been involved in driving preventive health and the role be further enhanced to improve outcomes for patients?

A: GPs are also recognising how preventive health is applicable to patients with chronic disease. Other than the usual medication regime and referrals for further interventions that GPs prescribe, we now offer lifestyle recommendations to prevent further complication of patients’ conditions. This is important in keeping patients healthy in the community.

One limitation is that GPs do not have enough time during each consultation session to do thorough counselling with our patients! The Primary Care Network’s (PCN) nurse counsellors have been a great help, as these professionals fill the gap by providing dedicated counselling for patients and complementing the GP’s clinical review.

GPs can still do more than the usual chronic illness screenings. In fact, many also offer their expertise for other types of screenings for early detection and treatment of diseases such as cancer. Personally, I would like to do more with regards to mental health and geriatric care in the community as these are pertinent issues on the rise.
 
Q:  How can hospitals work with GPs and community partners to encourage better health and chronic disease management?

A: Public healthcare institutions like hospitals and polyclinics engaging the GPs directly is the first step to increase GPs’ involvement in population health. Programmes like TTSH’s Community Right-Siting Programme (CRiSP) help GPs to continue management even after patients are discharged from the hospital’s Specialist Outpatient Clinics. In addition, having access to a network of specialists also provides us the assurance that we can readily receive advice to help us better manage our patients.

For patients with social issues, GPs may also require support to connect with social care partners –TTSH’s Community Health Team has provided invaluable help in facilitating this link-up. The PCN has also provided much-needed help when it comes to lifestyle counselling and follow-up for patients.

Finally, I feel that more preventive health campaigns can be rolled out at a nationwide level to encourage regular tests and health screenings, as well as to keep the public informed of GP clinics in their residential areas which provide such services.