Assoc Prof Lee Kheng Hock, Director, SingHealth Community Health Office of Learning (SCHOOL);
Deputy Chief Executive Officer (Academic Medicine & Partnerships),SingHealth Community Hospital;
Senior Research Scientist, SingHealth Centre for Population Health Research and Implementation;
Senior Consultant, Medicine and Continuing Care, Singapore General Hospital

General practitioners (GPs) lie at the heart of Singapore’s Healthier SG initiative with their vital roles in social prescribing and addressing social determinants of health in the community. Discover how the SingHealth Community Health Office of Learning (SCHOOL) collaborates with family medicine physicians to enhance community care.
 

WHAT IS SCHOOL?

SCHOOL, which stands for the SingHealth Community Health Office of Learning, is a centralised training hub established in September 2020 to focus on building competencies among healthcare workers, community partners and volunteers in the intermediate and long-term care (ILTC) sector. It was created to train healthcare and social care employees based on adult learning principles.

Instead of a top-down approach, SCHOOL adopts an inclusive strategy, aiming to bring together peer organisations and providers in ILTC to co-produce training programmes, outcome frameworks, codes of practice, competency definitions and curriculum development. The objective of SCHOOL is encapsulated in the phrase ‘training together’.

Stakeholder partnerships

SCHOOL actively partners with various stakeholders, including the Agency for Integrated Care (AIC), Silver Generation Office (SGO) and Community Networkof Seniors, Social Service Office, Ministry of Health (MOH) and Ministry of Social and Family Development (MSF), professional bodies (e.g., College of Family Physicians Singapore, Academy of Medicine of Singapore), and Institutions of Higher Learning (IHLs) such as the Institute of Adult Learning (IAL), Ngee Ann Polytechnic and the Singapore University of Social Sciences (SUSS).

These partnerships are crucial to SCHOOL’s aim of building up competencies and skills in the workforce to support the shift towards primary and community care, as envisioned by the Healthier SG initiative. SCHOOL focuses on identifying learner groups, mapping out competencies, developing courseware, and designing curriculum with subject matter experts and partners.

KEY SCHOOL MILESTONES

Between 2022 and 2024, SCHOOL led and contributed to numerous initiatives to advance social prescribing and integrated care.

HOW ARE POPULATION HEALTH, SOCIAL PRESCRIBING AND SCHOOL RELEVANT TO THE PRACTICE OF FAMILY MEDICINE?

From its achievements highlighted above, it is evident that SCHOOL is intrinsically linked to both population health and social prescribing. All three are highly relevant to family medicine, aligning with its core principles and addressing the evolving healthcare landscape.

1. Population health and family medicine

Family medicine, by its very nature, operates within a population health context.

Dr McWhinney's principles of family medicine emphasise that a family physician views their practice as a population at risk. This perspective extends beyond treating individual illnesses to proactively maintaining the health of all individuals within their practice, including preventive measures. Family physicians are committed to the person, not just a specific disease or technique, and they seek to understand the context of illness, including personal, family and social factors.

Population health underscores the significance of social determinants of health (SDOH) such as socio economic status, social connectivity, housing and education, which account for a substantial portion of health outcomes.

Family physicians, with their open-ended commitment to the person and their efforts to understand the context of illness, are uniquely positioned to address these broader SDOH.

By understanding the population they serve through methods such as situation analysis involving consultations with stakeholders and needs surveys, family physicians can tailor their approach to address prevalent health risks and inequities.

The growing emphasis on preventive health, exemplified by initiatives like Healthier SG, places family physicians at the forefront of implementing effective health promotion and disease prevention strategies within their communities.

2. Social prescribing and family medicine

Social prescribing is a vital tool for family physicians to operationalise their commitment to population health and address SDOH.

It offers a holistic, person-centred approach to healthcare by connecting patients with a range of nonclinical services in the community to improve health and wellbeing. This aligns directly with the family medicine principle of being committed to the person and understanding their unique context.

Family physicians are often the first point of contact for individuals with diverse health and social needs. Social prescribing empowers them to go beyond treating symptoms and address the underlying causes of patients’ health and well being issues, such as loneliness, social isolation, financial difficulties and lack of physical activity. This approach fosters supported self-care and empowers individuals to take charge oftheir health.

Family physicians, who ideally share the same habitat as their patients and understand their community resources, can effectively leverage social prescribing by referring patients to relevant community assets.

This community-wide network of supportive and healthcare agencies is a core principle of family medicine. The process involves link workers or Wellbeing Coordinators (WBCs) who play a crucial role in connecting patients with community resources, developing personalised plans and providing follow-up.

Family physicians play a role in assessing whether a patient could benefit from social prescribing and referring them to the link worker.

3. SCHOOL and family medicine

SCHOOL directly supports the integration of population health and social prescribing into family medicine practice by providing essential training and capacity building. It equips family physicians and other primary care practitioners with the knowledge and skills to effectively implement social prescribing and address SDOH.

Courses like the ‘Social Prescribing Workshop for Family Physicians’ and the ‘Essentials of Social Prescribing’ introduce key concepts, tools for assessing SDOH, strategies for identifying community assets,and methods for co-developing personalised careplans.

SCHOOL's collaborations with IHLs like Ngee Ann Polytechnic to offer courses like the ‘Health and Social Care Coordinator Course’ help build a multidisciplinary workforce that family physicians can collaborate with.

The involvement of family physicians in upcoming workshops on social prescribing further highlights SCHOOL's role in engaging this crucial group. By training more health and community care workers in social prescribing, SCHOOL helps create a more robust ecosystem of support that family physicians can leverage to improve patient outcomes.

The establishment of the Singapore Community of Practice in Social Prescribing (SCOMP), with which SCHOOL is closely linked, provides a platform for family physicians to share knowledge and best practices, and collaborate with other sectors involved in social prescribing.

The integration of social prescribing into the curriculum of institutions such as Duke-NUS Medical School, partly facilitated by collaborations with entities like SingHealth Community Hospitals (SCH), ensures that future family physicians are also equipped with these essential skills and perspectives.

Furthermore, SCHOOL's focus on population health training equips family physicians with a systems-level understanding of health and the skills to implement population health programmes.

WHAT IS THE ROLE OF SCHOOL IN THE REGIONAL HEALTH SYSTEM?

SCHOOL plays a pivotal role in the SingHealth Regional Health System (RHS) by acting as a centralised training hub focused on developing the workforce needed to advance population health and integrated care, particularly through social prescribing. Its strategy of ‘training together’ emphasises collaborative learning between SingHealth RHS and ILTC partners.

Key aspects of SCHOOL's role within the RHS include:

Building workforce capacity for Healthier SG

SCHOOL directly contributes to the Healthier SG national initiative by building the competencies and skills of the primary and community care workforce to support the shift towards preventive health and community-based care.

By training community connectors and other professionalsin social prescribing and related skills, SCHOOL ensures that the RHS has a well-equipped workforce to link individuals with community resources and promote healthy aging.

Advancing social prescribing

SCHOOL is instrumental in advancing the adoption and effective implementation of social prescribing across the RHS. It develops and delivers a range of training programmes focused on social prescribing,

including workshops for family physicians, courses for health and social care coordinators, and specialised training for WBCs.

These programmes equip practitioners with the skills to assess SDOH, understand patient needs, map community assets and co-develop personalised care plans.

Fostering collaboration andknowledge sharing

SCHOOL facilitates collaboration and knowledge sharing through initiatives like the Singapore Community of Practice in Social Prescribing (SCOMP). SCOMP, supported by SCH, serves as a platform for healthcare professionals, community leaders, researchers and practitioners to connect, exchange knowledge, share best practices and collectively advance social prescribing.

SCHOOL's role in launching and supporting SCOMP strengthens the network of professionals involved in social prescribing within the RHS and beyond.

Developing competency-based training

SCHOOL focuses on developing competency-based training programmes aligned with national skills frameworks (WSQ). This ensures that training is relevant, practical and contributes to professional development and accreditation. The curriculum development process involves working with subject matter experts and partners to map competencies and design effective learning experiences.

Promoting integrated care

SCHOOL’s training programmes foster integrated care by equipping healthcare and social care professionals with the skills to work collaboratively and address patients' complex needs holistically. Courses such as ‘Foundations in Integrated Care’ specifically focus on enhancing understanding and skills in this area.

Supporting the role of WBCs

Recognising the critical role of WBCs (link workers) in social prescribing, SCHOOL provides targeted training to equip them with the necessary skills in assessment, care planning, community resource navigation and communication. This ensures the effectiveness of the social prescribing pathway within the RHS.

Driving innovation and best practices

By engaging with international experts and learning from global best practices, SCHOOL contributes to driving innovation and the adoption of effective social prescribing models within the RHS. The co-development of the Social Prescribing Toolkit with WHO further positions SCHOOL and the RHS as leaders in this field.

Facilitating research and evaluation

SCHOOL's efforts in collecting data and evaluating the impact of social prescribing programmes contribute to building an evidence base for this approach within the RHS. This focus on monitoring and evaluation ensures continuous improvement and informs best practices. The development of new outcome assessment tools by SCH is a part of this effort.

Creating a learning ecosystem

SCHOOL aims to create a virtuous cycle of escalating enablement that embeds personalised care,including social prescribing, into routine practice. By fostering a collaborative learning environment and building a pipeline of competent practitioners, SCHOOL strengthens the overall capacity of the RHS to deliver person-centered and population based care.

Developing a Living Asset Map (LAMP)

While not solely a function of training, SCHOOL supports the development and utilisation of the Living Asset Map (LAMP), a community-driven directory of local resources, by training WBCs and other practitioners on how to use and contribute to this valuable tool. This enhances the effectiveness of social prescribing initiatives within the RHS by ensuring timely and accurate access to community assets.

CONCLUSION

In conclusion, SCHOOL is a vital enabler within the SingHealth RHS, playing a critical role in advancing population health through targeted training programmes, fostering collaboration, driving innovation in social prescribing, and building the workforce capacity needed to achieve the goals of integrated and preventive care, particularly within the context of the national Healthier SG initiative.

Its collaborative approach and focus on competency development are essential for embedding personalised care and improving the health and wellbeing of the population served by the RHS.

GPs can email to SCHOOL@singhealthch.com.sg to find out more about SCHOOL and its programmes.
 

Associate Professor Lee Kheng Hock heads SCHOOL, the training arm of SingHealth’s Regional Health System, focusing on health-social care integration. A senior consultant in family medicine, he pioneered Singapore General Hospital’s transitional home care and introduced social prescribing in 2019. Trained in adult education and motivational interviewing, he develops courses such as the WSQ Implementing Interventions in Health and Social Care Programme.

In 2024, Prof Lee led his team to win the inaugural National Community Care Excellence Team Award under the National Medical Excellence Awards 2024. In the same year, he also received the Smart Ageing Leader Award by the Golden Age Foundation for advancing healthy ageing and population health.