GPFirst: A journey of changing attitudes and improving patient care

This year’s winners of the National Medical Excellence Awards (NMEA) Team Award 2021, the GPFirst team from Changi General Hospital, share how effective community partnerships allowed them to relieve the pressure on the Accident and Emergency department and drive better quality of care.

With socioeconomic and lifestyle factors playing a large role in one’s overall health, healthcare is no longer constrained to within hospital walls. Now, successful delivery of care requires cooperation from a range of stakeholders within the community.

This was something the team from Changi General Hospital (CGH) kept in mind when they developed GPFirst, a programme aimed at diverting patients with non-urgent conditions from the Accident and Emergency (A&E) department to General Practitioners (GPs).

The team, comprising Clinical Associate Professor Steven Lim, Senior Consultant, Accident & Emergency, Dr Oh Hong Choon, Assistant Director, Health Services Research; Clinical Associate Professor How Choon How, Director, Primary Care, SingHealth Office of Regional Health and Ms Priscilla Goh, Manager, CGH Primary Care Integration and GP Engagement, was united by the belief that reducing pressure on the A&E department can improve quality of care.

“When mild to moderate conditions are treated by GPs, it enhances the A&E’s ability to achieve greater streamlining of valuable resources to focus on emergency care, thus providing more timely treatment,” Dr Lim, who was the former chief of the emergency department at CGH, explained.

Patients who are unsure or with non-urgent conditions gain from more “timely assessment and treatment” at clinics near home, Assoc Prof How said. The benefits of this can accrue in the long run. “Your family’s GP will become more familiar with your medical conditions and share personalised advice or set longer-term care plans with you.”

Between 2014 to 2019, Assoc Prof Lim has seen the number of walk-ins to the A&E department without a doctor’s referral drop by over 36 percent, and the number of non-urgent cases fall by 14 per cent. This has benefitted over 33,000 patients—a huge credit to the GPFirst team’s research and collaborative efforts.

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Getting into the mind of a patient through research

Their success stemmed from solid qualitative research to understand why a patient would go straight to the A&E. The research was done with Singapore University of Design and Technology (SUTD). It started with a series of focus group discussions and was followed by a survey to tease out the factors affecting a patient’s decision on where to seek medical treatment.

Dr Oh noted that the choice of a qualitative method like this was crucial. “Essentially, our study offers critical insights into how patients weigh the pros and cons of A&E and primary care services, based on their own needs and knowledge about the local healthcare ecosystem,” he said, explaining that the method chosen enabled the team to have a better understanding of the situation without using a predetermined theory that would otherwise limit the research findings.

“Ultimately, this can help formulate potential interventions to further reduce non-urgent A&E visits effectively so that patients with emergency conditions can receive timely care when they reach A&E,” said Dr Oh.

The first round of research helped to identify several key factors that influence a patient’s choice between going to a GP or the A&E. One of these included the out-of-pocket costs that patients need to bear. Results from the focus group discussions then formed the basis behind a subsequent patient preference survey for the programme team to quantify the relative importance of these factors.

The survey findings illuminated that that patients’ choices of GP or A&E were highly sensitive to GP referral discount if they were expecting a shorter waiting time at A&E.

Together, the results offered evidence which justified the introduction of a fee subsidy of$50 to A&E patients referred by a GPFirst partner clinic in the GPFirst programme to encourage patients to consult their GPs first for non-urgent medical needs.

Bringing care to the community though engagement

“The main objective is to bring care right into the heart of our communities and reduce the reliance on the hospitals or polyclinics,” said Assoc Prof How. “With this in mind, CGH has been collaborating with our healthcare and community partners to integrate care for our community in the east”.

For example, the team tapped on the networks of the People’s Association, community centres, and resident committees for outreach events focused on educating people about the appropriate use of emergency services and the benefits of visiting a GP. In the initial stages of the public education campaign, they also worked with Gametize Pte Ltd to develop a “GPFirst Challenge” mobile app to engage the public with educational quizzes, photo challenges and more.

“As GPs are one of the team’s most crucial partners, we organise discussions and updates between our GP partners and our specialists colleagues regularly to deliver better care together,” Assoc Prof How said.

Channels to boost capabilities

Resources have also been channeled to boost the ability of GPs to go beyond diagnosing and managing existing chronic conditions for optimal health.

Feedback from the GPs, combined with referral data and an analysis of trends, led to the launch of a structured Continuous Medical Education (CME) Programme, updated yearly to equip doctors with the latest research-based healthcare developments. A GPFirst Aide mobile app was also developed to provide GPs with a set of “red-flag” conditions to look out for, and a 24-hour hotline started for GPs to have easy access to the CGH A&E consultant on duty.

To date, these engagement efforts have strengthened CGH’s relationship with GP clinics in the region, with more than 80 per cent of them continuing to participate in the regional primary care programmes.

“This will allow us to collectively grow and integrate primary care more seamlessly, so together we can take steps towards better population health,” Ms Goh said. The GPFirst programme has since been developed on a national scale, and is currently implemented at Sengkang General Hospital, Woodlands Health Campus and Khoo Teck Puat Hospital.

Partnerships are the cornerstone of population health

Reflecting on the journey thus far, Assoc Prof Lim mused that the ultimate goal is for “patients to be treated at the best point-of-care based on their condition, while ensuring that health care resources are appropriately and efficiently utilised”.

The fact that the GPFirst team clinched the National Clinical Excellence Team Award at the National Medical Excellence Awards 2021 is therefore not just a recognition of their efforts, but also a reminder of the importance of public-private partnerships in raising the standards of healthcare.

This, he shared, is the future of medicine: Where hospitals work hand-in-hand with the communities surrounding them.

“With engaged communities and an informed public, people are empowered to make better health choices,” Assoc Prof Lim concluded.

The team’s efforts were recognised at the 2021 National Medical Excellence Awards for their outstanding contributions and achievements in establishing the GPFirst programme, a public-private healthcare GP partnership that encourages patients to seek timely treatment at their GPs instead of the A&E for appropriate conditions.