Future Primary Care

Professor Gerald Koh

Head (Future Primary Care)
Clinical Director

The FPC programme aims to enable patients to effectively self-manage their chronic diseases in partnership with their primary care providers. This involves the development of a national telehealth platform and incorporating technologies that enable effective and sustainable self-management from home.

Partnering polyclinics on telehealth

FPC’s flagship programme is the Primary Tech-Enhanced Care (PTEC) Home Blood Pressure Monitoring Programme, which empowers patients with hypertension to manage their condition from the comfort of home. Through easy-to-use technology and regular tele-consultations with polyclinic care teams, patients receive consistent clinical guidance and support throughout their health journey.

With the successful rollout of PTEC for patients with hypertension, the programme has now expanded to support patients with diabetes. The Home Diabetes Monitoring Programme similarly enables patients with diabetes to monitor their condition more effectively and stay connected to their care team — without needing to leave home. Both programmes are currently available at all polyclinics across Singapore, and have jointly enrolled more than 22,000 patients to date.

FPC also supports the National Collaborative Care Initiative, through which we work with healthcare Clusters, Synapxe and MOH to develop a national Virtual Professional Consultation (VPC) system. VPC is an asynchronous, provider-to-provider telecollaboration service that enables primary care providers to consult a network of Cluster-based specialists for non-urgent patient care. This enhances continuity of care, supports timely access to specialist inputs, and facilitates clinical decision-making in the community.

VPC is currently available in polyclinics for selected specialties, and is being piloted at GP clinics.

Advancing mental health support in primary care

FPC is partnering with multiple agencies and MOHT’s Integrated Health Promotion (InHealth) team to accelerate the design and implementation of new mental health initiatives for depression and anxiety, with a strong focus on primary care. Key efforts include developing standardised care models and processes under the Digital Mental Health Implementation Committee, creating clinical protocols for primary care physicians, and exploring emerging digital solutions, such as the Mental Health Calculators, to enhance the capabilities and capacities of primary care physicians, and ensure continuity of care. The team is also working closely with stakeholders across the wider mental health ecosystem to ensure these initiatives are fully aligned with national mental health strategies.

In parallel, the FPC team is conducting a randomised controlled trial (RCT) in collaboration with cross-agency partners and the mindline.sg team. This study will evaluate the clinical and cost effectiveness of internet-based Cognitive Behavioural Therapy (iCBT) for anxiety and depression in Singapore, and assess its viability as an effective, acceptable care option within primary and community healthcare settings, supporting its potential integration into routine mental health care. The iCBT tool for the trial is hosted on and supported by mindline.sg, which is Singapore’s national digital mental health first-stop platform that provides 24/7 confidential access to self-assessment tools, psychoeducational resources, and guided self-help programmes.

Supporting innovation by General Practitioners

FPC works with local General Practitioners (GPs) to develop solutions using new technologies, care redesign, process improvement and new private-public partnership business models. Under the General Practitioner Innovation Initiative grant, several pilots were launched in partnership with GPs. This included the development of a shared IT system to bring together primary care and community care providers, and mental health screening for patients with chronic diseases. The learning points from these initiatives will inform MOHT’s ongoing work in supporting Healthier SG.

The CMS Sutra project is a collaboration between the College of Family Physicians Singapore (CFPS) and FPC to provide GPs with a progressive series of independent reviews about the current state and functionalities of the major commercially available Clinic Management Systems (CMSes). This will enable GPs to make an informed decision on the adoption of a suitable Healthier SG (HSG)-compatible CMS, which is mandatory when they embark on their HSG journey. This project has since been completed and handed over to the CFPS, which will continue to offer these reviews.

Partners:

• Agency for Integrated Care

• College of Family Physicians Singapore

• NHG Health

• NHG Polyclinics

• National University Health System

• National University Polyclinics

• Singapore Health Services

• SingHealth Polyclinics

• Synapxe

• Private GPs and all Primary Care Networks (PCNs)

Current initiatives:

• Telehealth programmes for hypertension and diabetes

• Developing care protocols for Healthier SG roll-out

• Supporting the development of a Virtual Professional Consultation system