Chronic disease patients will now have easy access to an enlarged pool of well trained general practitioners (GPs), mostly located in close proximity to their neighbourhoods, to help control and manage their conditions. This is thanks to a national community-based programme that supports GPs in providing long-term quality and cost-effective care for people suffering from common chronic diseases.

Hospitals and specialty centres under the public healthcare groups here – Singapore Health Services (SingHealth) and National Healthcare Group (NHG) – have joined hands to fight chronic diseases like diabetes, hypertension, and high cholesterol comprehensively, in close partnership with GPs, through launching the National Delivering On Target (DOT) programme.

The prevention and management of chronic diseases has become one of the foremost challenges in Singapore as their prevalence is set to grow, with the country experiencing urbanisation and a rapidly ageing population. It is recognised by healthcare systems worldwide that effective management of chronic diseases will not only slow down disease progression, but also reduce the overall burden of healthcare costs by preventing related complications such as limb amputations, blindness, stroke, kidney and heart diseases.

In this respect, primary care is brought back into focus, as GPs play an integral role in delivering optimal lifelong care for patients with chronic diseases, especially the elderly. Widely accessible in the community, they are best positioned to provide primary prevention, maintenance and screening of diseases.

This serves as the impetus for SingHealth and NHG to share resources from their respective chronic disease management programmes to tackle these diseases on a wider scale at the national level.

At the core of the National DOT programme is an infrastructure to equip and support GPs in holistically managing clinically stable chronic disease patients who require long-term care for their conditions.

GPs on the programme are required to attend education sessions updating them on chronic care developments and enrol at least three patients in a customised programme, helping them meet recommended clinical targets for their chronic conditions. The patients are given three free counselling sessions conducted by nurse educators at the Diabetic Society of Singapore and NHG’s Care Management Centres, covering topics like diet, exercise, foot care, and self-monitoring of blood glucose, which are critical for good outcomes in chronic disease management. In turn, the GPs will be updated regularly on their patients’ clinical outcomes (HbA1c, blood pressure, and LDL-cholesterol) for follow-up, which are tracked over an average period of 12 months.

At the same time, specialists from public hospitals and specialty centres will refer patients certified fit for discharge to the trained DOT GPs. The GPs will come up with a one-year patient management plan and send updates on the patients’ health status to the referring specialists for shared care follow-up.

This national programme is an extension of the existing DOT programme introduced by SingHealth in August 2005, which successfully brought about improved clinical outcomes for diabetic patients and received positive feedback from GPs. All 195 GPs who are currently participating in SingHealth’s DOT programme and NHG’s Diabetes Programme and the 673 patients recruited by both programmes, will be incorporated into the national programme. Moving forward, the National DOT programme hopes to double the number of GPs on the programme and discharge about 400 patients to GPs in the first year.

“We believe a good care model for chronic diseases should place patients at the centre, with GPs and other healthcare service providers in the community playing a key role. The success of the DOT programme first implemented by SingHealth shows that if patients see the same GPs consistently for follow-up, they build up a trusting relationship that is so important for good lifelong and cost-effective management of their chronic conditions. They also spend less time travelling to and waiting at GP clinics, which are usually close to their homes. Therefore, extending this programme to the national level will help us build a wider network of GPs well trained in chronic disease management, which will benefit even more patients,” said Dr Shanta Emmanuel, who administers the Chronic Disease Management Programme at SingHealth, and also sits on the National DOT programme committee.

Dr Wong Kirk Chuan, Director, Department for Clinical Integration at NHG and a member of the National DOT programme committee, said: “Chronic diseases are a growing global epidemic and account for almost 60% of the 57 million deaths annually, including Singapore. Locally, more than 8% suffer from diabetes and this number will grow with an ageing population. This new partnership with GPs is aligned to NHG's long term strategy of engaging GPs in proactive, collaborative care for our patients. With the number of GPs set to double in the programme, more chronic disease patients will benefit from a larger platform of shared care between GPs and Specialists."

With GPs regarded as key partners in the fight against chronic diseases, it was fitting that about 200 of them will attend a launch event tomorrow where Guest-of-Honour, Minister for Health, Mr Khaw Boon Wan, will officially unveil the National DOT programme and its new logo.

At the event, Dr Anil Kapur, Managing Director of the World Diabetes Foundation, will also be delivering a keynote lecture titled “Global Burden of Diabetes”, which outlines the global impact of diabetes and highlights the various innovative programmes for the screening, prevention and management of the disease.