Quality, Safety, the Foundation of Value
Mr Tony, whose story is featured here, is a persona created from available information.
Life Had Other Plans
At 60, Mr Tony had been living with diabetes for several years. He took his tablets most days and the occasional supplements. Like many people, he kept an open mind about anything said to be good for health.
One evening, he felt unusually thirsty, weak and light-headed. His family took him to the hospital’s Emergency Department (ED). The doctor found that his blood glucose was very high. He received treatment for his immediate symptoms and was monitored until he was stable enough to go home. As his diabetes still needed close attention, follow-up by a medical team was important.
A Clear Next Step After Emergency Department (ED)
Connecting Patients to Long-Term Community Diabetes Care
Days after returning home, Mr Tony received a call from the hospital’s Primary Care Partnership team. They learnt that he had been managing his condition largely on his own. During the conversation, he shared that he was looking forward to a vacation with his daughter and Maya, his granddaughter. The team listened to his concerns, explained why regular reviews mattered and arranged an appointment with a GP near his home. With a convenient arrangement and a clear reason to return, Mr Tony felt supported to keep his appointment and take better control of his diabetes.
This initiative, connecting patients to long-term community diabetes care, is a part of the work done through the Singapore’s National Diabetes Mellitus Collaborative from 2022 to 2025. By building stronger links between the hospital and a network of primary care clinics, more patients without regular diabetes care could be connected promptly with follow-up care nearer their home or workplaces.
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Doing More to Look Ahead
Coordinated Care for Diabetic Feet
Mr Tony began regular follow-up with the GP near his home. Later, when most weekdays were spent looking after Maya’s while his daughter was at work, he switched to the polyclinic near his daughter’s home. The care team explained what to look out for and coordinated his foot checks with other appointments where possible. That meant one less trip to make and one less date to forget. The team had taken time to listen and understand him and made care easier to fit into daily routines. Mr Tony felt he could count on them for a good care plan, and he did his part by attending his appointments and caring for his feet. With a family vacation coming up, staying steady on his feet meant he could look forward to some easy hikes, while giving his family less reason to worry about him.
This coordinated approach to foot surveillance is part of DEFINITE Care, a wider NHG programme bringing its polyclinics, GP network and hospitals together so diabetic foot problems can be prevented, detected and treated earlier. By coordinating care across different specialists and settings, the programme recorded an 80% reduction in minor amputations and a 35% reduction in major amputations over 18 months, compared with an earlier cohort.
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Another Health Concern
Earlier Access to Physiotherapy
Some months later, Mr Tony developed persistent back pain. It disrupted his sleep, made it harder to keep up with Maya and left him worried about the family vacation ahead. When he mentioned the pain to the doctor at the polyclinic, he was referred to a physiotherapist there. The physiotherapist listened to how the pain affected his daily life and worked with him on goals that mattered, including sleeping better, moving comfortably and preparing for the trip. Mr Tony learnt exercises he could continue safely at home. Disciplined about his recovery, he practised them regularly and gradually grew more confident in his movement. He also felt reassured that specialist care remained available if he needed it.
NHG Polyclinics’ RAPID Physio care pathway gives patients with muscle and joint conditions earlier access to physiotherapy assessment and treatment at a polyclinic. Physiotherapists consider how pain affects activities that matter to each patient, teach exercises and practical ways to manage symptoms at home, and arrange referral to hospital specialists when needed.
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