GPFirst

The GPFirst programme encourages patients with non-urgent conditions to first seek treatment at GPs rather than at the acute hospital's Accident & Emergency Department (ED). Should the GPs assess that patients require onward referral to either an Urgent Care Clinic (UCC) or an ED for acute interventions, patients will be referred to the nearest appropriate UCC/ED. Upon arrival at the UCC/ED, patients will be given queue priority over other less urgent cases and $50 off the prevailing UCC/ED fees to offset the charges they had incurred at the GP clinic.

In this way, the programme seeks to shift care from the hospitals to the community and reduce the demand for acute hospital services for non-urgent conditions. GPFirst also aims to foster closer cluster-GP relationships and empower GPs to manage a wider variety of non-urgent medical conditions through continuing professional development in acute care, further enabling the appropriate siting of acute care within the community.

More information on Pitfalls of Common Conditions seen in Primary Care¹.

Children requiring onward referral to Children's Emergency are excluded from the GPFirst programme. Click to find out more about PaedsENGAGE², a pilot programme, led by KK Womens' and Childrens' Hospital and National University Hospital.

Hospital Contact Details

For general administrative or clinical enquiries, GPs may reach out to the participating acute hospitals through the channels found here:

GPFirst
Region	A&E or UCC	Contact Details
East (SingHealth)	Changi General Hospital A&E	Email: gpfirst@cgh.com.sg Tel: 6788 8833 (24 hours)
Southeast (SingHealth)	Singapore General Hospital A&E	Email: gpfirst@sgh.com.sg Note: SGH does not have contact number for GPFirst. All queries are to be sent via email.
Central (NHG)	Tan Tock Seng Hospital A&E	Email: pco@nhg.com.sg Tel: 9727 1081 (Monday to Friday 8.30am to 5.30pm)
North (NHG)	Khoo Teck Puat Hospital A&E Woodlands Health UCC @ Admiralty
Northeast (SingHealth)	SengKang General Hospital A&E	Email: gpfirst@skh.com.sg GPFirst Programme Coordinator Hotline: 6930 4282 (office hours, for GPFirst-related enquiries and replenishment of referral forms) SKH Mainline: 6930 5000 (24 hours, for general enquiries and feedback)
West (NUHS)	National University Hospital A&E	Email: gpfirst@nuhs.edu.sg Tel: 6908 2222 / 6772 3312 Working hours: Monday -Friday: 9am-5pm, excluding public holidays. For non-urgent administrative queries regarding the programme only.
	Ng Teng Fong General Hospital A&E	Email: gpfirst@nuhs.edu.sg Tel: 6716 2323 / 6716 5382 Working hours: Monday -Friday: 9am-5pm, excluding public holidays. For non-urgent administrative queries regarding the programme only.
	Alexandra Hospital UCC	Email: gpfirst@nuhs.edu.sg Tel: 8181 3288 (for clinical related enquiries) 6908 2222 (for general enquiries)

PaedsENGAGE
Region	Contact
PaedsENGAGE GPs in the Western region (i.e. located in Choa Chu Kang, Bukit Panjang, Bukit Batok, Jurong West, Jurong East, Clementi, Queenstown, Pioneer)	NUH POC: Joeann Yeo (Ms) Office Number: 6772 3216 Email address: paedsengage@nuhs.edu.sg
PaedsENGAGE GPs located outside of the Western region	KKH POC: Kendrix Lim (Ms) Office Number: 6394 3031 Email address: paedsengage@kkh.com.sg

Exclusion Criteria (i.e. Cases that should not be referred to the ED/ UCC)

Examples (non-exhaustive) of conditions that generally do not need urgent laboratory, radiological investigations, or emergency procedures/treatment

Minor Trauma/Mild Orthopaedic/Mild Musculoskeletal Conditions:

Simple lacerations less than 5cm for toilet and suturing³
Simple bruising/abrasions
Closed fractures of distal phalanx of lower limbs
Minor burns (less than 5 cm in width)
Ankle/foot with negative Ottawa Rules⁴
Knee injury with negative Ottawa Rules⁵
Back pain with no red flags⁶
Typical red flag symptoms to look out for in patients presenting with back pain

"Red Flag" Symptoms in Back Pain = TUNA FISH

T = Trauma
U = Unexplained Weight Loss
N = Neurologic Symptoms
A = Age >50
F = Fever
I = Intravenous Drug Use
S = Steroid Use
H = History of Cancer (Prostate, Renal, Breast, Lung)

Head injury with no indication for Computed Tomography (CT) scan of the brain⁷
Cervical spine injury with no indication for radiography

Stable Exacerbations of Chronic Disease:

Asymptomatic uncontrolled hypertension⁸

Asymptomatic and uncomplicated poorly controlled diabetes mellitus (Random Blood Glucose <20 mmol/L)

Non-Urgent Acute Conditions:

Headache with no red flags⁹

Dizziness with normal gait and no symptoms/signs of posterior circulation/cerebellar deficits¹⁰

Dengue¹¹ with no indication for admission to acute hospital¹²

Dengue patients who present with typical red flag symptoms may require admission to hospital.

Dengue Red Flags

Hyperemesis >3x per day
Severe abdominal pain
Lethargy, restlessness, altered mental state (AMS)
Bleeding diathesis - epistaxis, melaena, BGIT, menorrhagia, hematuria
Postural hypotension/dizziness
Shock index >0.8 (calculated by: HR/SBP) or Diastolic shock index >2 (calculated by: HR/DBP)
Pale, cold, clammy extremities, delay capillary refill
Unable to eat/drink, oliguria/anuria
Shortness of Breath (SOB)
Hepatomegaly +/- tenderness
Rising HCT with worsening thrombocytopenia

Acute Respiratory Illness with no suspicion of pneumonia¹³
Red eye with No Red Flags¹⁴
Suspected pulmonary embolism with low pre-test probability¹⁵
For Fast Tracking Referrals
For non-urgent Specialised Radiology Investigations (e.g. MRI)
For non-emergent Laboratory Investigations (e.g. Full Blood Count (FBC), Urea and Electrolytes (UE), Liver Function Tests (LFT), Dengue serology)

NB: This list is not exhaustive and UCC/EDs are advised to refine appropriateness referral criteria with their GP partners.

Roles and Responsibilities under the GPFirst Programme

GPs are responsible for informing the patient of the terms and conditions relating to the eligibility criteria for the $50 subsidy off prevailing UCC/ED fees before the referral is made. Specifically, GPs should inform their patients to:

Arrive at the UCC/ED indicated on the GPFirst referral form within the same day* of referral;
With their NRIC/Passport/Work Permit/ Foreigner Pass; and
The original GPFirst referral form provided by the GP at the point of registration at the UCC/ED.

*The GPFirst referral form is valid only on the day of issue, and up to 0200 hrs of the following day if the referral form is issued close to midnight (i.e. between 2200 to 0000 hrs). Patients should be advised to visit the UCC/ED without delay given that the GP had assessed that their condition requires urgent follow up/acute hospital care.

For a GPFirst referral to be valid, the original GPFirst Referral Form (i.e. the serialised hardcopy form provided by participating hospitals or the hardcopy printout generated through the Healthier SG-compatible Clinic Management System (CMS)/Primary Care Digital Services (PCDS)) must be fully completed. GPs may be contacted by the referred hospital if the form is incomplete.

Specialised investigations required and/or non-standard medication prescribed at the UCC/ED/acute hospital will be separately charged.
GPs shall attend Continuing Medical Education (CME) events as appropriate, to ensure that referrals are made appropriately to the UCC/EDs under the GPFirst programme.
The cluster/hospital will monitor the volume and appropriateness of referrals received at their UCC(s) and/or ED(s) through the GPFirst programme.
In the event where a patient seen under GPFirst programme raises concerns to the cluster/hospital with regard to their GP bill, the cluster/hospital reserves the right to seek clarifications from the GP clinic.
MOH reserves the right to change the terms and conditions of the GPFirst programme.

Referral Pathway

Appropriateness Algorithm

To determine if a referral is appropriate and eligible for $50 off the prevailing UCC/ED fee, UCCs/EDs will utilise the following appropriateness algorithm.

Financing

Under GPFirst, patients will pay the prevailing hospital ED or UCC fees less $50 if referred through the GPFirst Programme.

As an existing scheme offering patients a discount on their ED or UCC bill, GPFirst is applicable to both enrollees and non-enrollees.

References

Pitfalls and Red Flags in Common Clinical Syndrome Title: Singapore Family PhysicianVol3 Jul- Sep20 1 3: 3 2 2013; 39(3): 32-36.
PaedsEngage
Continuous Core Content, EMRAP, October 2018 | Volume 2 Issue
Ian Wedmore, Scott Young, Jill Franklin, Emergency Department Evaluation and Management of Foot and Ankle Pain, Emergency Medicine Clinics of North America, Volume 33, Issue 2,2015, Pages 363-396, ISSN 0733-8627, ISBN 9780323375948
Moira Davenport, Matthew P. Oczypok, Knee and Leg Injuries, Emergency Medicine Clinics of North America, Volume 38, Issue 1, 2020, Pages 143-165, ISSN 0733-8627, ISBN 9780323712736
Corwell, Brian N. "The emergency department evaluation, management, and treatment of back pain." Emergency Medicine Clinics 28.4 (2010): 811-839. The emergency department evaluation, management, and treatment of back pain - PubMed (nih.gov)
Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, McKnight RD, Verbeek R, Brison R, Cass D, Eisenhauer ME, Greenberg G, Worthington J. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001 May 5;357(9266):1391-6.
Gauer, Robert. "Severe asymptomatic hypertension: evaluation and treatment." American family physician 95.8 (2017): 492-500. Severe Asymptomatic Hypertension: Evaluation and Treatment | AAFP
ACE Clinical Guideline; When to order CT/MRI for headache
Edlow, Jonathan A., et al. "Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department." Academic Emergency Medicine 30.5 (2023): 442-486.
Schaefer TJ, Panda PK, Wolford RW. Dengue Fever. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan.
HealthXchange, When Dengue Fever Becomes Severe Dengue. [Internet]
Ebell, Mark H. "Predicting pneumonia in adults with respiratory illness." American family physician 76.4 (2007): 560-562. Predicting Pneumonia in Adults with Respiratory Illness | AAFP
Kilduff C, Lois C. Red eyes and red-flags: improving ophthalmic assessment and referral in primary care. BMJ Qual Improv Rep. 2016 Jun 29;5(1):u211608.w4680. PMID: 27493748; PMCID: PMC4964165.
Approach to a Patient with Suspected Pulmonary Embolism – The Society for Vascular Medicine (mypulmonaryembolism.com)

Additional Resources