Who is the goal really for?
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A patient wanted to lose weight. Not because a doctor said so. Not for a better cholesterol reading. The patient was determined to stay healthy enough to keep travelling with loved ones and avoid becoming a burden to family members.
At National University Polyclinics (NUP), that mattered just as much as the number on the scale.
"What matters most to you?"
For decades, chronic disease management has rightly focused on clinical indicators such as blood pressure, blood sugar, cholesterol and weight. These measures remain essential, but they do not always reflect how patients are coping in daily life.
A patient may achieve every clinical target and yet struggle to find time to exercise because of caregiving responsibilities, feel overwhelmed by multiple medications, worry about losing independence, or find it challenging to maintain the lifestyle needed to stay healthy. The numbers may look right. The person may still be struggling.
That prompted clinicians to rethink a long-held assumption: What if a good outcome means more than a good test result? To address this, NUP introduced Personalised Care and Support Planning (PCSP).
Before the appointment, patients receive information to help them better understand their health and are encouraged to think about what matters most to them. This paves the way for a shared discussion during the consultation, beyond a standard review of test results.
“Clinical targets and personal goals are not competing priorities. The aim is to connect them, so that managing a condition helps patients achieve what matters most in life.”
— Dr Chin Chi Hui, Deputy Head, Jurong Polyclinic
Dr Chin Chi Hui, Deputy Head, Jurong Polyclinic, said the aim is not to replace clinical targets, but to connect them to meaningful life goals.
A patient who wants to travel may be more motivated to improve diabetes control; another who wants to remain independent may be more committed to managing blood pressure. A patient who is motivated to continue caring for family may be more determined to adopt healthier lifestyle habits.
The clinical goal remains the same, but the motivation behind it becomes personal.
From clinician-led decisions to shared decision-making
PCSP is built on a simple idea: healthcare decisions should be made with patients, not for them.
Instead of setting goals on a patient's behalf, clinicians and patients agree on priorities, action plans and the support needed to achieve them.
Over three years, the approach delivered measurable improvements:
- Shared decision-making increased from 31 per cent to 56 per cent
- Diabetes-related distress fell by 9.9 per cent
- Patients became 9.4 per cent more confident in managing their health
The findings suggest that when patients help define success, they become more engaged in managing their health.
Patients are the primary managers of their health
One of the biggest mindset shifts has been recognising that patients spend only a few hours each year with healthcare professionals.
For the rest of the time, they are managing their health and conditions on their own.
Dr Chin said chronic disease management is no longer viewed as something done solely by healthcare professionals.
"Patients are the primary managers of their chronic conditions. Healthcare professionals are partners in their care," Dr Chin added.
That can lead to conversations traditional consultations may never fully uncover — about caring for an older parent, balancing work commitments, maintaining independence, managing treatment burden or simply finding time to exercise.
These factors often have a significant impact on health outcomes, yet do not appear in a blood test result.
What is PCSPPersonalised Care and Support Planning (PCSP) is a structured conversation between patients and healthcare professionals that focuses on what matters most to the patient. The approach combines:
The aim is to help patients build the confidence, skills and support needed to manage long-term conditions. |
For Dr Chin, one of PCSP's biggest strengths is that it makes healthcare more relevant to patients' lives.
Rather than focusing only on disease, conversations focus on what patients want to achieve: staying independent, continuing to work, travelling, looking after family and living well.
"Better health is not just about achieving clinical targets. It is about helping people live well and achieve what matters most to them."
So, what matters more than a perfect test result?
For many patients, the answer is simple: being able to live the life they want.
The experience at NUP suggests healthcare works best when clinical goals and personal aims move in the same direction. Success is not measured only by what happens in a clinic. It is measured by whether people can continue doing what matters most to them.
Appropriate and Value-Based CareAppropriate and Value-Based Care (AVBC) starts with a simple question: what outcomes matter most to patients? By measuring outcomes and learning from variation, clinicians can identify what works, redesign care pathways and continually improve care. The goal is not simply to do more, or spend less. It is to deliver better outcomes for patients while making the best use of healthcare resources. |
In consultation with Dr Chin Chi Hui, Deputy Head, Jurong Polyclinic.
