With an ageing population, a stretched health budget, and mounting costs associated with increasing levels of chronic disease, prevention is a priority for all Australian governments. But how effectively is evidence-based preventive care currently being provided in general practice? Rates of cancer screening by general practitioners have improved dramatically,1 but there has been less progress in other aspects of preventive care — for example, fewer than 30% of patients at risk of chronic disease are routinely given advice about diet or physical activity, and only 10% are referred to other health care practitioners for interventions.2

Although some may consider behavioural interventions to be too time-consuming to justify their potential gain, there is evidence that they can be effective in general practice and make a significant contribution to population health.3 Of course, critical drivers to health exist in the social and physical environment, such as socioeconomic status and the availability of safe opportunities for physical activity, and thus preventive care for individuals must complement a population health approach to these problems.

The National Primary Health Care Strategy calls for a more systematic approach to implementing preventive care,4 including provision of appropriate and targeted screening services, health checks for specific population groups and at critical stages of life, and preventive interventions consistent with evidence-based guidelines such as the Royal Australian College of General Practitioners (RACGP) Guidelines for preventive activities in general practice.5 The National Primary Health Care Strategy recognises the importance of population groups in greatest need receiving effective interventions.

To achieve this, we need a multilevel approach to implementing preventive care, including structural aspects (ie, practice, workforce and financial considerations), contextual aspects (including patient considerations) and practitioner aspects (related to changing professional behaviour). Many of the preventive recommendations in the current reform documents are focused on the structural level, recognising that general practice and primary health care are currently not adequately supported or funded for population health approaches to risk reduction and management across local communities and populations.6

The recent rationalisation of preventive health care item numbers (which occurred on 1 May 2010), into four new time-based items (Box), has reduced their complexity, but they still do not provide support for preventive care throughout a person’s life, or facilitate involvement of the whole practice team in preventive care. There is a need to re-examine workforce roles and responsibilities to determine how the mix of primary health care professionals can best deliver preventive care. In the United Kingdom, for example, practice nurses play a key role in several areas of practice. They identify the patients most suitable for health checks, assess risk factors and combined risk scores (using algorithm tools), provide motivational counselling and health education, negotiate behavioural goals, provide opportunistic brief interventions and arrange referrals and follow-up recalls.8

Also important are information systems to support patient recalls and reminders for preventive health checks, to monitor patients for follow-up, and to audit records to determine population coverage and evaluate the impact of preventive care on risk and outcomes. Decision support systems for patients and providers can help assess risk and instigate guideline recommendations.9

The lack of a robust national framework for funding, prioritising, developing and implementing evidence-based guidelines remains a major stumbling block to effective primary care.10 Current guidelines are predominantly developed by non-government organisations with insufficient funding to support implementation. It is essential that we have appropriate measures and means to evaluate the quality and outcomes of preventive care in general practice. What little information is available suggests significant gaps between evidence-based preventive care guidelines and practice.11

Patients should not be considered passive elements in preventive care. Patient health literacy and engagement are directly correlated with uptake and effectiveness of preventive interventions in general practice.12,13 Developing, promoting and utilising self-assessment tools (including risk-assessment tools) may enhance delivery and uptake of evidence-based preventive care. When risk is personalised, patients gain a better understanding of their health, make more appropriate use of screening tests, and improve their perception of risk.14

A more robust evidence base is necessary to overcome professional and patient barriers to implementing evidence-based preventive health measures, such as lack of compliance with and adherence to lifestyle modification. A theoretical understanding of the processes involved in changing the behaviour of health care professionals enables interventions to be better targeted at barriers to practice change.15,16 For example, an understanding of the fit between practitioner behaviour change and current practice routines can help develop tailored roles for members of the practice team in preventive care. This, along with more rigorous design of interventions,17 may result in more successful implementation of evidence-based changes.18

So what could all this change mean in practice? In future, patients will undertake individualised risk assessment at critical points in their lives. GPs will offer evidence-based preventive interventions tailored to a patient’s level of risk. Practice nurses will facilitate assessments and coordinate access to health education and other interventions as appropriate. Practice systems will follow up at-risk patients and provide reminders and information to support evidence-based interventions. Local primary health care organisations will ensure availability of services to support preventive care at the local level, and deliver health promotion and preventive programs targeting risk factors they have identified using data analysis at the population level.

As with all reforms, it is difficult to envisage how such changes can be achieved. Funding targeted at higher-risk groups and people in most need, support for new roles for practice staff, and support from the soon-to-be-established regional primary health care organisations (“Medicare locals”) in providing access to support services and allied health providers, as outlined in the Primary Health Care Strategy, would be a good start.