"Many of these conditions are preventable and controllable, especially when the patient is determined to alter their lifestyle. This is where family doctors can play a part in preventive health."
– Dr Theresa Yap, General Practitioner, Yang & Yap Clinic
 
When patients show up at Dr Theresa Yap’s clinic, they can expect more than just a consultation for their coughs and colds. In her 35 years as a GP, Dr Yap has kept a lookout for patients at risk of developing or escalating chronic conditions such as heart diseases, diabetes and hypertension.
 
“Many of these conditions are preventable and controllable, especially when the patient is determined to alter their lifestyle. This is where family doctors can play a part in preventive health,” said Dr Yap.
 
Despite her hectic schedule in the clinic, she takes the time to advise obese patients with a family history of diabetes to go for screening, coax patients with heart diseases to quit smoking, and get patients with hypertension and diabetes to monitor their daily blood pressure and blood sugar level.
 
When SingHealth launched the Delivering on Target (DOT) programme to promote community-based chronic disease management with GPs islandwide, Dr Yap needed no persuasion to come on board.
 
“I feel a great sense of satisfaction when I help patients maintain or  improve their conditions. It’s also more convenient for patients to visit their GPs,” she shared.
 
"A trusted GP knows his patients and families intimately and is well-trained to take care of patients with stable chronic conditions.”
- Dr Emily Ho, Director, Singhealth Regional Health System
 
Indeed, GPs are important partners in building a person-centred care network, where a community of health and social service providers work together to help patients stay healthy. They play an anchor role in ensuring patients have access to appropriate and quality care near home, and refer them back for specialist care in the hospitals if their conditions worsen.
 
Dr Emily Ho, Director, SingHealth Regional Health System explained: “Our healthcare system is evolving from episodic hospital care to more community-based, person-centred care. A trusted GP knows his patients and families intimately and is well-trained to take care of patients with stable chronic conditions.”
 
Partnering GPs has led to better outcomes for patients at Singapore General Hospital and the National Heart Centre Singapore (NHCS). This is evident in the Standardised Care for Optimal Outcomes, Right-Siting and rapid Re-Evaluation (SCORE) programme started in 2011.
 
Some 1,500 NHCS patients whose conditions had stabilised were identified for follow up care by primary care providers. Preliminary studies show that the programme is effective in maintaining patients’ stable conditions and achieving a reduction in LDL levels, or what is commonly known as “bad cholesterol”.
 
The STOP Diabetes screening programme launched in April 2016 enlists the help of GPs to identify and encourage relatives of diabetic patients to be screened for diabetes. Being involved is satisfying but has its own set of challenges for GPs, such as the need to manage non-compliant patients and extra paperwork.
 
“But when you care for your patients,” said Dr Yap, “It is worth the effort. This is how we can make a difference for them.”
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To find out more about STOP Diabetes, email stopdiabetes@singhealth.com.sg or call 67025486 / 67025485