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mechanisms and incentives (continuing education, specialization programmes and
training, and growth opportunities) that motivate and empower health professionals.
We highlight the urgent need to build up a primary care workforce that consists
a different discipline of health professions and a spectrum of primary care providers
which could include: family doctors; generalists trained to deal with multiple chronic
illnesses and ageing-related complications such as decreasing reserves and capacity
manifesting as fragility; primary care doctors trained to provide long-term care, care

for the disabled, and palliative care; and “specialists” who provide primary care.
Concurrently, we recommend the Government to adopt the family and primary

care doctor model to further promote and enable "patient affiliation with a
primary care doctor". While individuals would have the option of changing their
primary care doctor as necessary, the transition should be documented. This will
contribute to promoting access to and continuity in primary care where potentially
the same doctor will be able to consult on different health problems throughout a
patients' life course.

2.3 ENABLE INTEGRATION BY FORMALISING LINKS BETWEEN
SERVICE PROVIDERS AND HEALTHCARE PROFESSIONALS

We advocate for the need to review a wide range of mechanisms to foster
stronger connection between hospitals, sub-acute care providers, and
primary care providers. Such mechanisms include the design of care pathways,
clinical protocols, care plans, and referral and discharge protocols. Of equal
importance are reviews of provider organisations, care settings, information flow

and patient engagement. Integration between hospitals and the community,
especially in a primary care context, can be strengthened and enabled by
formal mechanisms encouraging communication and ongoing dialogue between
providers. Acknowledging that current mechanisms are focused on clinical aspects
of patients’ wellbeing, due consideration should be given to the development of
specific tools which assess the physical, mental, social and spiritual needs of all

patients to ensure the delivery of holistic person-centred care.

2.4 CONTINUOUS ENHANCEMENTS OF MEDICAL AND SOCIAL
CARE INTEGRATION

To cater for patients’ holistic needs and for people with multiple chronic
conditions needing joined up services, there is a need to make sure
that apart from adequate medical and nursing support for desirable
health outcomes, adequate funding, resources and infrastructure are
available for long-term care, rehabilitation and social support. To further
promote the integration between health and social care, we recommend the
Government study funding needs and shared funding mechanisms where
health and social care authorities enter pooled budget arrangements and
agree on integrated spending plans.

2.5 RE-EVALUATION OF THE COMPLEMENTARY ROLE OF THE
PRIVATE SECTOR

The role of the private sector in primary care, health protection, health promotion,

chronic disease management, long-term care and care for defined population
groups should be studied and redefined to enable a more strategic role to emerge.

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