Healthier SG: Singapore’s multi-year strategy to transform primary healthcare

Primary healthcare has become the nexus of the Singapore government’s response to an ageing population, growing chronic disease burden, and accelerating healthcare expenditure. Singapore’s primary healthcare landscape is dominated by general practitioners (GPs), who see 80% of the country’s primary healthcare clinic attendances. In the public sector, polyclinics (multi-doctor practices) offer heavy subsidies for primary healthcare services and medicines. As such, a significant number of patients with chronic diseases requiring long-term medication prefer to visit polyclinics since out-of-pocket payments are much lower.¹

From July 2023, a major reform known as Healthier SG is being implemented in phases over the next few years. Healthier SG aims to nurture an ecosystem that supports better health by leveraging the primary healthcare system and community partners. Its main feature at this stage is the enrolment of individual residents with GPs of their choice and the creation of personalised health plans for each enrolled resident. The empanelment of residents with GPs is aimed at fostering strong patient-doctor relationships. This can place GPs in a stronger position to encourage patients to receive preventive care such as health screening, adult vaccinations, and continuing care thereafter. GPs will also connect residents with community partners to support their health and social needs.² The enrolment of GPs and residents into Healthier SG is voluntary. Residents remain free to obtain primary healthcare services outside of the GP clinic they have enrolled with.

As the roll out of Healthier SG commences, we highlight three areas critical for the success of this health reform.

Ensure that GPs’ needs are considered

While GPs in Singapore have traditionally focused on providing acute and episodic primary healthcare, Healthier SG involves a significant expansion in their scope of work, including time- and resource-intensive tasks such as social prescribing, preventive monitoring, administrative requirements and more complex drug inventory management (because the government will provide a range of subsidised drugs). As most private GPs operate as solo practices, they may feel overwhelmed and lacking in capacity to take on these new work arrangements amid their already heavy duties.

While GPs will be compensated by the Ministry of Health for their expanded work scope through per capita (based on enrolment) and completion of certain clinical and process indicators, concerns have been raised by GPs that the payments do not commensurate with the additional time and resources required to manage these new responsibilities. The payment model should be reviewed to ensure that GPs are fairly compensated for the tasks taken up by them. A detailed onboarding process is also needed to inform GPs of the clinical requirements and administrative processes to receive funding. These concerns may be reflected in the rate of GP clinics enrolled into Healthier SG, which is less than half as of April 2023. While 712 out of 1800 GP clinics have enrolled into Healthier SG, many more Healthier SG clinics will be needed to serve Singapore’s population of 4.07 million residents.3, 4, 5 As Healthier SG continues its implementation process, more needs to be done to encourage GPs to enrol into this initiative.

In addition to administrative issues, there are concerns that GPs may not be prepared to provide new forms of care such as social prescribing. Due to the heterogeneity of the social service landscape and referral procedures, GPs may not be aware of the services available, which provider is most suitable, or the processes to refer a patient. Additionally, skills in motivational interviewing and counselling are essential to draw out an individual’s values, persuade them to adopt healthy behaviours and connect them to appropriate community partners.^6,7 These require training as well as establishing strong functional relationships with community services. While the Ministry of Health aims to have at least one family medicine specialist (doctors who have completed post-graduate family medicine training) within each clinic in the next seven years, there is a need for immediate clinical and management upskilling so that GPs will be ready to be on the frontlines of Healthier SG come July this year.²

Promote digital solutions

Singapore has embraced digital health innovation to power its health reforms. Healthier SG will leverage the Healthy 365 mobile application (H365) to nudge residents to participate in Healthier SG and reward healthier lifestyle choices.⁸ The app, along with wearable fitness trackers provided for free to residents, keeps track of dietary intake, physical activity and sleep patterns among other parameters. At the same time, GP clinic management systems (CMSs) are being upgraded to be compatible with Healthier SG. Apart from enabling doctors to enrol residents, record health plans, make referrals and submit data to the government, Healthier SG-compatible CMSs will be integrated with Singapore’s National Electronic Health Records (NEHR) information system.⁹ This is a significant improvement which will enable healthcare providers across public and private sectors to seamlessly access patient health records. Residents can also see their health records and test results through the HealthHub mobile application, empowering them to be more informed and responsible for their health.¹⁰ The initial focus of these efforts aims to support the development and documentation of a core health plan; the full benefit of IT capabilities will depend on the effective dissemination of a comprehensive system to share data across providers and between providers and patients and their caregivers.

Foster trust

Trust is essential to effective primary healthcare and this involves understanding the value of an accountable doctor-patient relationship for both acute and long-term needs over the life course. Furthermore, the adverse financial gradient between GPs and polyclinics might hinder this relationship as many patients requiring long-term medication prefer to seek care at polyclinics, where they can receive highly subsidised services and medicines.^11,12 Residents have been used to seeing GPs for minor acute conditions in a largely transactional mode and will require a mindset shift to appreciate the role of GPs in preventive and promotive healthcare.¹³ Seeds of trust should also be planted by demonstrating to residents that GPs are motivated to be accountable for the new forms of care provided under Healthier SG. Apart from giving financial incentives (free first health plan consultation, reward points credited into H365 and free nationally recommended screenings and vaccinations) to residents who enrol in Healthier SG, it will be crucial for residents to appreciate the value of an accountable longitudinal relationship. This will involve more than community education; it will require ongoing positive experiences by individuals, their family, friends, and neighbours.

The viability of Healthier SG further depends on trust between providers and the government. Healthier SG has significantly enlarged the government’s involvement in primary healthcare. GPs will have to work closely in new ways, including accountability for performance standards. But trust must work both ways as GPs lose much of their traditional independence. GPs need to be assured that the government is looking out for their interests and that ongoing challenges to implementation will be addressed with a governance structure that maximises their sense of agency.

Healthier SG represents a welcome transition to rebalancing the health system in a way that optimises the health and well-being of Singaporeans. During the COVID-19 pandemic, GPs in Singapore stepped up to meet the population’s needs in vaccinations, testing and managing cases. The unity and determination demonstrated during the pandemic give us much confidence that the primary healthcare sector can deliver on the aims of Healthier SG. To fully realise the potential of Healthier SG, it is imperative that the needs and operational processes of GPs are understood and taken into account, practical digital solutions are maximised, and trust is fostered between residents and providers and between GPs and government.

Contributors

CDF and HXC contributed equally as joint first authors. CDF and HXC conceptualised the manuscript, CDF and HXC wrote the original draft and JY provided overall supervision. All authors reviewed and edited the manuscript. All authors agreed on the finalised version for submission.

Declaration of interests

The authors declare no conflict of interests.