eMJA: Harris & Mercer, Reactive or preventive: the role of general practice in achieving a healthier Australia

GP in Action

Reactive or preventive: the role of general practice in achieving a healthier Australia

The time has come to expand the role of general practitioners in population health

MJA 2001; 175: 92-93

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General practitioners in Australia provide much preventive care, including screening for diseases and risk factors, vaccination and preventing complications of chronic disease. Profession leaders, supported by Commonwealth, State and Territory governments, now advocate extending the patient-centred clinical role of the general practitioner (GP) to include more emphasis on the health of practice populations and local communities¹ (Box 1). This extended role builds on the value and trust that the community has in GPs and the access that GPs have to most of the population.^3,4 The aim is not only to tilt the balance between the curative and preventive roles of the GP, but also to develop a more systematic approach to prevention for the whole practice population. This shift presents a particular challenge in Australia, where patients are not formally linked to practices, as they are in the United Kingdom and New Zealand.⁵

General practice provides numerous opportunities for preventive care. The Royal Australian College of General Practitioners (RACGP) recently published the extensively revised fifth edition of its Guide to preventive care in general practice,⁶ also known as "The Red Book". This is a synthesis of evidence-based guidelines from Australian and other sources and provides recommendations for everyday use in general practice (Box 2). By implementing these recommendations, GPs can make a real contribution to reducing the burden of disease in Australia.

At a recent national symposium, the Joint Advisory Group on General Practitioners and Population Health (JAG) developed a consensus statement on the role of GPs in population health, along with a strategic framework to take this forward. JAG comprises representatives from the General Practice Partnership Advisory Council (which includes representatives from general practice, consumer and Indigenous health groups and the Federal Government) and the National Public Health Partnership (which includes government health officials from each State and Territory). One of the new strategies is SNAP, which aims to enhance the screening, assessment and management of behavioural risk factors through brief interventions on Smoking, Nutrition, Alcohol and Physical activity. These interventions are made during consultations, and are supported by systems in the practice and the local Division of General Practice, which also provides education, information systems, community education and referral mechanisms.⁹

However, there are many practical barriers to the shift towards preventive healthcare. GPs are weary of change and wary of new responsibilities. Many lack time, and some lack the specific skills required, such as techniques to change patient behaviour. The current Medical Benefits Schedule rewards mainly episodic care, rather than preventive care for groups of patients in a practice. The Enhanced Primary Care Medicare items and Practice Incentives Program payments need to be extended to support preventive activity not only in specific groups such as older people, but across practice populations.

Preventive care requires approaches that are evidence-based, systematic and sustainable. Specific requirements include:¹⁰

individuals in the practice dedicated to helping coordinate and organise preventive activities (eg, practice nurses);
health promotion resources, such as patient questionnaires, posters, pamphlets, audiotapes, videotapes and library resources developed specifically for general practice;
structured records and health summaries, as well as patient-held records;
electronic reminder and decision-support systems;
patient education resources for use in consultations; and
liaison with community and population health organisations and services (eg, local health promotion units, support and healthy lifestyle groups), and systems for referring patients.

Efforts to build GPs' capacity to use information technology (IT) are well under way in Australia. Electronic support tools for clinical decision-making, recall and reminder systems and patient education and information are essential for effective preventive care. However, existing software for GPs is not well suited to these tasks, nor to data collection and analysis at practice or Division levels. A standardised architecture for IT systems must be developed.

It is also difficult to ensure access to preventive care for all patients. Some groups have increased risk of diseases because of social or other factors (eg, their place of residence, economic resources, skills and lifestyles).⁷ Paradoxically, while poorer health means disadvantaged groups are major users of general practice, they are also the lowest users of preventive care services.¹¹ Any strategies to develop the role of GPs in population health must address this "inverse care law". Disadvantaged groups may need to be specifically targeted in general practice, and the financial barriers addressed, especially in rural areas where fewer GPs bulk bill. The Divisions of General Practice need to support GPs' adopting a more systematic approach to preventive care within their practices. The Divisions also have a key role, along with universities and vocational training consortia, including the professional Colleges, in helping GPs understand and practise evidence-based preventive healthcare, organise preventive interventions, and reach and care for disadvantaged groups.

Nevertheless, GPs cannot achieve this alone. Most are fully occupied with their current roles and have limited capacity to take on new ones. There is a need to expand and train the workforce within general practice to include people other than GPs, such as practice nurses. Evidence from the UK suggests that these nurses can play a key role in developing preventive activity within general practice.¹² This strategy needs to be evaluated urgently in Australia.

Stronger links to other services are also needed at a Division level. There is a need to develop programs shared between Divisions of General Practice, population and community health and Indigenous health services to identify and address the needs of local communities and groups for better preventive healthcare.¹³ It is important to recognise that there is already a cadre of trained public health specialists who can provide support and leadership in this area.

This is not a short-term task. It will take a decade for this role to be fully developed. However, it is time to start.

Mark F Harris
Chair, Joint Advisory Group on General Practice and Population Health
Professor of General Practice, University of New South Wales, Sydney, NSW

Paul J T Mercer
Chair, Preventive and Community Medicine Committee
Royal Australian College of General Practitioners, Melbourne, VIC

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1: Definition of population health

The General Practice Partnership Advisory Council and National Public Health Partnership Group define population health in the context of general practice as²
The prevention of illness, injury and disability, reduction in the burden of illness and rehabilitation of those with a chronic disease. This recognises the social, cultural and political determinants of health. This is achieved through the organised and systematic responses to improve, protect and restore the health of populations and individuals. This includes both opportunistic and planned interventions in the general practice setting.

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2: Some recommendations on preventive activities for general practice by the Royal Australian College of General Practitioners ⁶

Condition (% of total DALYs)	Recommendation

Tobacco (12.1% male, 6.8% female)	Smoking status should be assessed for every patient over the age of 10 years. Patients who smoke, regardless of the amount, should be offered brief advice to stop smoking.
Physical activity (6.0% male, 7.5% female)	All adults should be advised to participate in 30 minutes of moderate activity on most, preferably all, days of the week.
High blood pressure (5.1% male, 5.8% female)	Blood pressure should be measured in all adults from age 18 at least every 2 years.
Alcohol (6.6% male, 3.1% female)	All patients should be asked about the quantity and frequency of alcohol intake from age 14 years. Brief interventions to reduce alcohol consumption should be offered to all patients with potentially hazardous levels of drinking.
Obesity (4.3% male and 4.3% female)	Body mass index and adult abdominal circumference should be measured every 2 years for patients who appear overweight or underweight. All patients identified with higher risk should be advised to modify energy intake and physical activity habits.
High blood cholesterol (3.2% male, 1.9% female)	"At risk" patients should be screened between the ages of 20 and 75 years as part of absolute cardiovascular-disease risk assessment. Screening of healthy people without risk factors is recommended every five years starting at age 45.
Diabetes (4.7% male, 4.1% female)	All patients should be screened every 3 years from age 65. Screening should commence at age 50 in those with other risk factors, and at age 35 in Indigenous Australians and people from the Pacific Islands, Indian subcontinent or China.
Breast cancer (6.9% female)	Screening every two years by mammogram is recommended for women aged 50-69 years. Clinical breast examination is not recommended as a routine screening test.
Bowel cancer (4.4% male, 3.8% female)	Screening by faecal occult blood testing is recommended every 2 years for all people aged over 50 years. However, opportunistic case finding only is recommended for general practice until current trials to determine the optimal type of tests are completed. Colonoscopy is recommended every 1-2 years from age 25 years for those at high risk.

DALYs = age-standardised disability-adjusted life-years in 1996.^7,8

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