A Primary Care Network (PCN) is a network of General Practitioners (GPs) supported by nurses and care coordinators which provides holistic and coordinated care to patients with chronic conditions such as diabetes, hypertension and hyperlipidaemia. This team-based care approach ensures patients are better cared for in the community.
The PCN Application Call was launched on 1 April 2017. From 1 January 2018 onwards, successfully awarded PCNs (and their GPs) were able to tap on funding and administrative support to implement team-based care to better monitor and manage their patients’ healthcare needs. The PCN scheme also provides participating GPs with a platform for the cross-sharing of best practices for patient care. to enable the three paradigm shifts needed to sustain our healthcare system beyond 2020 - Beyond Hospital to Community, Beyond Quality to Value, and Beyond Healthcare to Health. To effect these shifts, we need to transform our primary care to ensure that good quality and affordable care is accessible and delivered in a sustainable manner in the community.
GPs, like yourself, are located close to your patients’ homes, as a result, you play an instrumental role in the management of our ageing and increasingly complex chronic patient population.
To support your role in providing more holistic chronic disease management for your patients, funding and administrative support is now available to you under the PCN scheme.
How do PCNs work?
First, the patient consults a PCN GP for his or her chronic condition(s). As a PCN GP, you will assess and diagnose the patient’s condition and your clinic may wish to register the patient on the PCN’s Chronic Disease Registry (CDR) if applicable. The patient should also be referred to see a nurse counsellor and the relevant ancillary services such as Diabetic Foot Screening or Diabetic Retinal Photography, if necessary.
The care coordinator at the PCN-HQ level will then work with the respective clinic assistant to schedule the patient for the ancillary service appointment. Upon completion of the ancillary service(s), the doctor will review the test results and follow up with the patient.
The patient’s progress and clinical outcomes will be tracked and monitored to ensure that they follow through with their personalised care plans and treatment. The overall aim is to help patients better manage their chronic conditions and improve their health outcomes.
How joining a PCN will benefit my patients?
Through the PCN, your patients will now be able to access more holistic chronic disease management which includes the provision of ancillary services, such as nurse counselling, diabetic eye and foot screening which might not be readily available in the current GP clinic settings.
The primary care coordinators from the PCN will also help patients coordinate with other healthcare providers when they require other services (e.g. referral to podiatry services). Your patients will have access to nurse counsellors for individualised advice to manage their chronic conditions, including lifestyle and dietary modifications.
There will be closer monitoring of their chronic conditions for earlier intervention and the care coordinators will help to schedule services when appropriate for a more seamless patient experience.
How joining a PCN will benefit me as a GP?
Participating GPs would be able to manage patients with chronic conditions in a more holistic manner through the PCN. With additional government funding, the PCN GPs would be better supported to provide team-based chronic care for their patients and monitor their patients’ outcomes more closely. The PCN would also tap on better economies of scale for ancillary services (e.g. diabetic eye & foot screening).
As part of the PCN, participating GPs may also be provided with IT funding and support to increase the clinic productivity and smoothen the operational process. In addition, the PCN-HQ will organise regular meetings for cross sharing of best practices and seminars (i.e. Continuous Medical Education).
GP-led PCNsGP-led PCNs are driven and coordinated by solo GPs partnering together to form a network. The role of the Clinical Lead is held by a Family Physician, while the role of the Administrative Lead can be held by the same PCN leader or by any other GP identified by the group.
The GP-led PCNs are as follows:
Diabetic Foot Screening (DFS)
As part of the holistic chronic disease management, your diabetic patients will be scheduled for periodic foot screening to identify any diabetic-related foot issues that can lead to amputations if not well-managed. Advice on proper foot care and footwear will also be provided.
Diabetic Retinal Photography (DRP)
The PCN patient care coordinators will help to arrange for periodic DRP screening for diabetic patients to enable early detection of any diabetic-related eye conditions. This will ensure early intervention to reduce the risk of complications that can lead to blindness.
Nurse Counselling and Education
Your patients will be able to learn more about their chronic condition(s) from PCN nurse counsellors who will provide them with personalised advice on positive lifestyle changes and empower them to self-manage their condition(s).
Each PCN clinic will remain as an independent business entity, which means the day-to-day business-related decisions (e.g. consultation fees, operating hours) will still be determined by the individual clinic.
In terms of chronic disease management, the PCN GP Lead will work closely with all the PCN GP clinics on the clinical aspects of patient care (e.g. sharing of best practices, cross-learning), while the PCN-HQ will coordinate the operationalising of the PCN Chronic Disease Registry and the ancillary services for chronic disease management.Criteria for Clinics to join a PCN
As a pre-requisite, your clinic should participate in all of the following MOH core schemes in order to join a PCN:
Community Health Assist Scheme (CHAS)
Chronic Disease Management Programme (CDMP)
Public Health Preparedness Clinic (PHPC)
Vaccination and Childhood Development Screening Scheme (VCDSS)
You may wish to approach AIC for more information on the enrolment process. Do feel free to contact your account manager, you may find out who your account manager is here.
Criteria for Chronic Patients to be enrolled into the Chronic Disease Registry
The patient should be a Singaporean Citizen or Singapore Permanent Resident at the time of enrolment, and clocked at least one chronic follow-up visit within the last 6 months. He/she can only be enrolled on the subsequent visit if the next visit is within 6 months of the last visit.
Patient consent prior to inclusion in the Chronic Disease Registry
The Notification provides adequate notice on patients’ deemed consent for data sharing (comprising patients’ personal and medical data) under the PCN scheme, as long as these patients are seeking care at your GP clinic for their chronic condition(s). As such, you do not need to obtain explicit consent from these patients under the PCN scheme, provided that you have displayed the Notification within the premises of your clinic (e.g. at the clinic’s counter) and brought it to patients’ attention.
However, in the event that explicit consent has been obtained from the patients (e.g. you further explain the nature and purposes of data sharing and patient agrees to share his/ her data), you should still document that patient has been advised on and agreed to the data sharing (e.g. in the patient’s case notes or you may also use the consent form that AIC has shared with the PCNs).
Please refer below for listings of PCN GP clinics in alphabetical order and by PCN: