Long-term support for better health
Chronic diseases are common in Singapore, and they rarely come one at a time. Many people live with a combination of diabetes, high blood pressure, high cholesterol, heart disease, kidney problems, breathing issues, thyroid conditions, joint pains and mood or sleep difficulties. These conditions need more than a one-off prescription – they require ongoing care, regular reviews and a plan that makes sense for your life.
At Kenneth Tan Medical Clinic, we provide consultant-led family medicine for people living with one or more long-term conditions. Our aim is to help you stay as healthy, independent and active as possible, while reducing the risk of complications such as heart attacks, strokes, kidney failure and falls.
A family medicine approach to chronic disease
Care in our clinic is provided by Singapore-trained Family Physicians. The practice is led by a Consultant Family Physician with Fellowship of the College of Family Physicians (FCFP), working alongside Family Physicians with postgraduate qualifications such as Master of Medicine in Family Medicine (MMed(FM)) and the Graduate Diploma in Family Medicine (GDFM).
As educators and trainers in Family Medicine, we are familiar with both national care pathways (including those developed under Healthier SG and Primary Care Network (PCN) programmes) and international guidelines for major chronic conditions. Our role is to apply these evidence-based recommendations in a way that fits your individual circumstances, values and goals.
Unlike organ-specific specialists who focus on one system at a time, family physicians are trained to look at the whole person. We pay attention to how your conditions and medications interact with one another, how your health affects your work and family roles, and what matters most to you in daily life. For many people, your Family Physician becomes your main medical point of contact – the doctor who knows your story, sees the patterns over time and helps you navigate the wider healthcare system when needed.
Conditions we commonly look after
We care for a wide range of long-term conditions typically seen in primary care, including:
- Diabetes and pre-diabetes – diagnosis, regular blood tests, medication initiation and adjustment, monitoring of kidney, eye and nerve complications, and practical coaching on food, activity and weight.
- High blood pressure (hypertension) – accurate blood pressure measurement, home BP monitoring, medication review and control of other related risks such as cholesterol and smoking.
- High cholesterol and other lipid problems – interpretation of lipid profiles, starting or adjusting cholesterol medication, and helping you understand how diet, exercise and weight contribute.
- Heart and blood vessel disease – follow-up after heart attacks, angioplasty or stenting; long-term management of angina; and careful use of heart-protective medications to reduce future risk.
- Chronic kidney disease (CKD) – tracking kidney function over time, choosing blood pressure and diabetes medications that protect the kidneys, reviewing other drugs that may harm the kidneys, and planning referrals when advanced care is needed.
- Chronic lung conditions such as asthma and COPD – confirming diagnoses, optimising inhaler regimes, checking inhaler technique, building written action plans and supporting smoking cessation.
- Thyroid and other endocrine problems – ongoing monitoring and dose adjustment of thyroid medication, and integration with your broader cardiovascular and metabolic risk.
- Joint, bone and mobility issues such as osteoarthritis and osteoporosis – pain management tailored to your overall health, fall risk assessment, bone-strengthening medication where indicated, and links to physiotherapy or other therapies.
- Long-term mental health conditions such as anxiety and depression – screening, initial treatment, medication review and coordination with psychology or psychiatry when needed.
- Other long-term issues such as benign prostate enlargement, allergic rhinitis, gout, psoriasis, migraine and chronic liver conditions.
In each case, we will explain whether your condition can be managed mainly in the clinic, or whether a shared-care arrangement with an organ-specific specialist is advisable.
How we work differently from organ-specific specialists
Specialists such as cardiologists, nephrologists, endocrinologists and pulmonologists play an important role when in-depth tests or specialised procedures are needed. However, most of your day-to-day living with chronic disease happens outside the hospital.
As Family Physicians, we:
- Bring together recommendations from different specialists and help you make sense of them.
- Check for overlapping or interacting medications, and discuss whether simplification or deprescribing is possible.
- Balance guideline targets with your age, overall health, side effects and what you want out of life.
- Support you through lifestyle change and self-management over months and years, not just at a single visit.
We are comfortable managing many stable conditions in the clinic once a diagnosis and initial treatment plan have been established. When new symptoms arise, when your condition moves outside the usual range, or when we spot red flags, we will reassess and, if needed, arrange further investigations or refer you back to the relevant specialist.
Chronic care aligned with national schemes and pathways
Our clinic is enrolled in the CHAS and Healthier SG schemes, which are designed to make long-term care in the community more affordable and more coordinated.
Under the Community Health Assist Scheme (CHAS), eligible Singaporeans – including Pioneer and Merdeka Generation seniors – receive subsidies for selected chronic conditions when they are treated at participating CHAS GP clinics. This can help offset consultation, investigation and medication costs for chronic disease care.
With Healthier SG, residents enrol with a regular family doctor and develop a personalised Health Plan together. For those with chronic conditions, the Healthier SG doctor plays a central role in setting targets, monitoring progress and coordinating preventive care and vaccinations. Additional chronic-tier subsidies and medication support may be available for CHAS, Merdeka Generation (MG) and Pioneer Generation (PG) cardholders with higher medication needs, on top of existing CHAS subsidies.
Our role is to help you understand how these schemes apply to you, and to plan your care so that you make good use of the support available. Because subsidy structures and eligibility can change over time, our clinic staff can assist with checking your CHAS and Healthier SG status, but we will always encourage you to refer to the latest official information from MOH and CHAS.
Part of a wider GP and allied health network
Kenneth Tan Medical Clinic is also connected with GP+ Co-operative, a Singapore co-operative formed by doctors to improve healthcare delivery and serve as a quality and price benchmark in primary care. GP+ brings together a network of GPs, Family Physicians, specialists and allied health professionals who collaborate on care, education and service development.
Being part of this network means that when your chronic condition would benefit from input beyond our clinic – for example physiotherapy, podiatry, dietetics, psychology or selected specialist services – we can draw on a trusted ecosystem of partners rather than referring in isolation. This helps keep your care more coordinated and person-centred across different providers.
What to expect during your visit
A chronic care consultation is usually more in-depth than a one-off visit for an acute illness.
We start by reviewing your current conditions, symptoms and medications. We look at your latest blood tests and other results, as well as letters from hospitals or specialists if you have them. We ask how you are coping day to day – including energy levels, sleep, mood, work and family responsibilities – because these factors often explain why certain plans are easy or difficult to follow.
We then examine you, focusing on areas related to your conditions. This may include measuring your blood pressure accurately, checking your weight and waist circumference, assessing your heart and lungs, examining your feet if you have diabetes, or assessing your joints and balance if you have mobility or bone issues. Where appropriate, we may arrange blood tests, urine tests, ECGs or other basic investigations that can be coordinated through primary care.
After that, we discuss your treatment plan. This can involve starting, stopping or adjusting medications; deciding when the next set of tests should be done; and identifying one or two lifestyle changes that are realistic for you right now. We will also highlight warning signs that should prompt an earlier review, and agree on how often you should come back for follow-up.
Over time, we revisit these decisions together. Good chronic disease management is not about chasing every number to perfection, but about finding the right balance between risk reduction, side effects, quality of life and your own priorities.
Why ongoing care matters
Staying engaged in regular follow-up, even when you feel well, makes a real difference. Many complications of chronic disease develop quietly over years. By checking in periodically, we can pick up changes early, adjust your treatment before problems become severe, and help you avoid emergency visits and unplanned hospital stays.
For some people, the goal is to prevent a first heart attack or stroke. For others, especially in later life or with multiple illnesses, the priority is to stay comfortable, mobile and independent for as long as possible. Our job is to understand what you are aiming for and to walk alongside you as your situation evolves.
Small, steady steps – such as improving blood pressure control, quitting smoking, getting more consistent with inhalers, or losing a modest amount of weight – can have large cumulative benefits over time. We see our relationship with you as a long-term partnership, not a series of disconnected visits.
Book a chronic care consultation
If you have been diagnosed with a chronic condition, have multiple long-term illnesses, or are worried about your risk of diabetes, heart disease, stroke or other chronic problems, we are happy to review your situation and work out a plan with you.
You can book an appointment online or call us to speak with our staff.
Please bring any recent blood test results, medication lists and reports from other clinics if you have them, so that we can build on what has already been done and avoid repeating tests unnecessarily.