The role of Australian primary health care

in the prevention of chronic disease

Mark Harris, Executive Director, and Jane Lloyd, Research Fellow,
Centre for Primary Health Care and Equity, University of NSW
Centre for Obesity Management and Prevention Research Excellence in Primary Health Care

Abstract
Primary health care has an important role in assessing, preventing and managing smoking,
hazardous drinking, poor diet and physical inactivity. The 5As (ask, assess, advise/agree, assist
and arrange) provide a framework for analysing the steps involved in preventive care and in
defining the optimal roles of providers and services at the practice level. There is evidence for
the effectiveness of interventions provided by practice nurses, allied health providers and
group programs. However these providers are currently under-utilised in preventive care and
more effective teamwork within and between primary health care services is needed.
Information systems including e-health records, decision support and web tools and resources
facilitate a systematic approach to preventive care. Despite evidence of how to prevent
chronic disease in primary health care, there remain gaps in preventive care in practice and
inequities in access to preventive care by disadvantaged population groups. The role of
Medicare Locals is to facilitate practice change, as well as to develop partnerships with state
health services, local government and non-government organisations to coordinate and broker
new preventive services and programs and to integrate clinical and population health
approaches to prevention. Reforms to funding, workforce, patient enrolment, and primary
care organisation and structure remain important to the implementation and maintenance of
preventive activities in primary health care.

28 September 2012

This review was commissioned by the Australian National Preventive Health Agency
1. AIMS
In 2008 a paper was prepared for the National Preventative Health Task Force on the role of primary
health care in preventing the onset of chronic disease, with a particular focus on the lifestyle risk
factors of obesity, tobacco and alcohol. This identified a number of options for the future including
resources to support brief interventions, financial incentives for preventive care, health risk
assessment, a network of referral services, addressing the needs of socially disadvantaged groups, the
role of Divisions of General Practice, patient registration, and further research. This is an update of the
2008 paper. During the intervening four years there have been developments in the role of nursing
and allied health and the creation of new primary health organisations ‘Medicare Locals’ which bring
together a broader range of health professional and community interests.

The specific research questions which this paper attempts to answer are:
 What is the evidence for effective primary health care interventions to address the behavioural
risk factors?
 What inequities exist and what is the evidence for effective primary health care interventions
to address them?
 How can the evidence for the prevention of chronic disease be translated into practice, and
how might Medicare Locals facilitate the uptake of evidence, including effective team
approaches to preventive care?

2. INTRODUCTION
There is a rising prevalence of chronic disease globally [1]. Although there has been a decrease in
preventable deaths from chronic cardiovascular and respiratory diseases, the prevalence of chronic
diseases such as diabetes is increasing associated with the ageing of the population and worsening of
some of the risk factors for chronic diseases [2]. This places an increasing demand on health services
as well as contributing a major social and economic burden to society [3].

The risk factors for chronic disease include overweight and obesity, physical inactivity, poor diet,
smoking and excessive alcohol consumption. Smoking is the only risk factor with a favourable trend,
decreasing over the past two decades. Risky alcohol consumption, poor diet and obesity are all
increasing [4]. The median body mass index of adults increased from of 25.7 in 1995 to 26.3 in 2007–
08 with an increase in the proportion who were obese from 19% to 25%. There was little overall
change in physical activity. The quality of the diet deteriorated with the age-standardised proportion
who consumed less than the recommended serves of vegetables increasing from 88%to 93% in men,
and from 84% to 90% in women from 2004-5 to 2007-8 [4]. Health risks operate across the lifecycle to
cumulatively increase the prevalence of chronic disease [5]. Thus the increasing rates of insufficient
physical activity, risk alcohol consumption and poor diet in those aged 12-17 years from 2004-5 to
2007-8 are likely to be translated in increased prevalence of chronic disease decades into the future.

Both chronic diseases and their risk factors are in turn influenced by the social and economic
determinants of health [6]. These shape the physical and social environment in which people are born,
develop, live, work and age. The social determinants of health are mostly responsible for health
inequities - the unfair and avoidable differences in health status and the social gradient between those
who have higher and lower incomes, education and social status. For example there is evidence of a
social gradient in the prevalence of cardiovascular diseases and diabetes according to both education
and income. There are also social gradients, in the prevalence of smoking, risky alcohol consumption
and obesity, with education and income [7] (see Figure 1).
2
Figure 1: Obesity prevalence by quintiles of socioeconomic disadvantage (SEIFA) 1989/90 to 2001.
Source AIHW

These inequities need to be addressed by a mix of strategies including population and public health
interventions to address the social determinants of ill health. Primary health care also provides an
opportunity to address some of these problems. This is because of its high population reach (with
more than 88% of the population visiting a general practitioner at least once a year for example [8])
and acceptance by patients of the role of primary health care providers in preventive care [9, 10].
Patients with the physiological and behavioural risk factors for chronic conditions frequently present in
general practice, providing an opportunity for primary prevention [11]. In 2007-08, 59% of general
practice encounters were with patients who were overweight or obese, 26% with those who drank
alcohol at risky levels and 17% with those who smoked daily [11].

3. THEORETICAL FRAMEWORKS FOR UNDERSTANDING PREVENTION IN PRIMARY

HEALTH CARE
A key framework for understanding the way in which prevention is implemented in primary health
care is the 5As [12, 13]. This includes the following actions by health care providers:-
 Ask: systematic identification
 Assess: multiple risk, readiness to change, health literacy
 Advise/Agree: tailored information, motivational interviewing, goal setting
 Assist: referral to intensive interventions
 Arrange: follow up, maintenance

The 5As has been widely adopted internationally in addressing the behavioural risk factors (Figure 2)
[14, 15]. It provides a framework for organising interventions across the behavioural and physiological
risk factors and for the involvement of different providers and services within a patient-centred model
of care.

3
Figure 2: The 5As for behavioural risk factors in Australian general practice.

The 5As has been used as a framework for the recommendations of the Royal Australian College of
General Practitioners Guidelines for Preventive Care for the past four editions [16]. It has also been
incorporated into several other Australian guidelines including the recent National Health and Medical
Research Council Guidelines for Management of Overweight and Obesity in Adults, Adolescents and
Children. These multiple guidelines provide consistent advice. Their recommendations have been
synthesised into standards of care for preventing chronic disease as part of a national research project
aiming to put preventive evidence into practice (The PEP Study). The standards of care (Figure 3) are
intended to provide a quick reference point for primary health care providers on the patients targets,
how often they ought to be assessed and how to work with patients to reach these targets.
Synthesising the guidelines recommendations is seen as an important step to facilitating the uptake of
guidelines in primary health care.

5As Assess Advise/Agree Assist/Arrange

Smoking status Advise to quit. Set

and readiness quit date. Refer to Quitline
Smoking to change if Stop
smoker every Consider Arrange follow up
visit pharmacotherapy

Ask about
2 fruit
Nutrition portions of fruit
and vegetables
Brief advice to reduce
saturated fat and
increase fruit and
Refer high risk to a
dietitian or group diet
program 5 veg
per day every 2 vegetable portions (2+5) Arrange follow up Low fat
years

Ask about Advise <2 drinks per

quantity and < 2 St
Alcohol frequency of
alcohol intake
day and no more
than four drinks on
Arrange follow up
Drinks
any one occasion
every 3-4 years

Ask (every 2 years)

30min
Physical about minutes of
moderate physical
Advise 30min of moderate
activity most days of the
Refer high risk to
exercise
professional or PA /day
activity per day and
activity number of days per
week
week (>2.5 hrs wk) program. Arrange
follow up

Refer high risk

Measure BMI to a dietitian or 5-
Weight (Wt/H2) and Waist
circumference 2
Individual including
both physical activity
group diet
program.
10%
yearly and diet Arrange follow Wt
up loss

Figure 3: Behavioural risk factors and guideline recommendations across the 5As

4
 Behavioural risk factors for chronic disease occur in context of peoples’ lives and circumstances. The
social ecology of health provides an important concept for preventive care because it highlights the
multiple influences on patients and providers behaviour. These influences can operate at the
individual, family, community, organisational level and beyond. The social ecology of the patient can
either support and maintain change or act as barrier to it [17]. The influences include:
 individual material and psychological factors;
 interpersonal ties, roles and responsibilities, social norms;
 work organisation and access to health care; and
 neighborhood factors including the availability of food and a sense of belonging to the
community.

The psychological and organisational context of the practitioner (attitudes, norms, routines, inter-
professional and inter-organisational relationships) creates capacity for, or prevents the
implementation of best practice preventive care (Figure 4) [18].

Practitioner Environment Patient Environment

System:
Workforce, Nation:
finance, Programs Policy, regulation,
Preventive economy, media
Care:
Local:
Quality improvement, Ask, Community:
partnerships, service Assess, Environment,
development Advise/ workplace,
Agree education, transport
Assist and
Practice: Arrange Family:
Organisation, systems, Culture, language,
linkages, attitudes and family support,
skills mix health literacy
Figure 4: The social ecology of the patient and practitioner in preventive care

The social ecology model is useful because it identifies the influences on behaviour. However, further
work is required to understand how to capitalise on the positive influences to support preventive care
and mitigate against the negative influences.

5
4. EVIDENCE BASED MANAGEMENT OF RISK FACTORS
The Standards of Care in Figure 3 provide an overview of the 5As for behavioural risk factors. In this
section the evidence behind these recommendations are described in greater detail.

4.1 Assessment
The recommendations for the assessment of individual risk factors are outlined in Figure 5. These are
usually assessed in clinical practice in order to inform decisions about risk, diagnosis and management.

Figure 5: Recommendations for assessment of individual risk factors

Smoking: Smoking status should be assessed for every patient over 10 years of age ideally at each
consultation [19].
Nutrition: Every 2 years patients should be asked about number of portions of fruit and vegetables
and amount of saturated fat eaten per day [16].
Alcohol: Every 2-4 years, patients should be asked about the quantity and frequency of alcohol intake
aged 15 years and over [20].
Physical activity: Every 2 years, patients should be asked about the current level and frequency of
physical activity [16]
Weight: Every 2 years, patients’ body mass index (BMI = Weight in Kg/Height in metres 2) and waist
circumference should be measured [21]. For children and adolescents BMI percentile charts should be
used to monitor growth.
Blood pressure: Blood pressure should be measured in all adults from 18 years of age at least every
two years [16].
Cholesterol: Adults should have their fasting blood lipids assessed starting at 45 years of age, every
five years [16].

Other factors that may modify the approach include the patient’s readiness to change and health
literacy. There are five basic stages of patients readiness to make changes in their lifestyle:- pre-
contemplation, contemplation, determination (ready), action and maintenance during which the
person has differing levels of motivation or readiness to change [22, 23]. Stage of change can be
assessed for each of the lifestyle behaviours and weight. This allows health professionals to tailor their
advice, which has been demonstrated to be effective in supporting change in lifestyle behaviours [24].

Low socioeconomic groups often suffer poor health literacy which impedes their capacity to adopt and
follow preventive care [25-27]. In Australia less than a third of people without a school qualification
achieved adequate health literacy levels [28]. Health literacy is the “cognitive and social skills which
determine the motivation and the ability of individuals to gain access to, understand, and use
information in ways which promote and maintain good health” [29]. Assessment of health literacy
helps to tailor appropriate messages and approaches [30]. A simple screening tool has been developed
to assess health literacy in clinical practice (See Figure 6).

Figure 6: Brief Health Literacy Screening Questions [31]

A. How often do you need to have someone help you read health information materials?
B. How often do you have problems learning about your medical condition because it is difficult to
understand written health information materials?
C. How confident are you filling-in medical forms by yourself?
6
It is important to identify which patients have lower health literacy levels, because patients with low
health literacy are less likely to receive preventive care [25]. Patients with low health literacy are less
likely to ask questions and providers often incorrectly assume that these patients are not interested in
their health care [32]. Primary health care providers can better support patients with low health
literacy by, for example, limiting advice to between three and five key points, being specific and
repeating key points, drawing pictures, using illustrations or demonstrating with models, and
confirming patients understand what they need to know [33].

A large number of clinical practice guidelines emphasise the value of multiple risk assessment in
primary health care. Two risk assessments are recommended in Australia:
 Absolute Cardiovascular Risk assessment – which should be performed for all adults aged 45
years and older (from 35 years for Aboriginal and Torres Straits Islander people) every two
years. This assesses the risk of a cardiovascular event over the next 5 years. Calculation uses
information on the patient’s age, sex, smoking status, total and HDL cholesterol, systolic blood
pressure and if the patient is known to have diabetes or left ventricular hypertrophy [34]. This
is used to support patient education and decision making about management.
 The Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK) – which should be performed
every three years on patients 40 years or older (from 18 years for Aboriginal and Torres Straits
Islander people) [35]. This assesses the risk of developing type 2 diabetes over five years based
on the patients age, sex, ethnicity, family history, past history, smoking, diet, physical activity,
BMI and waist circumference. This is also used as a screening tool for decisions about further
investigations and interventions to prevent diabetes (in those who are high risk but not yet
diagnosed as having diabetes).

The increasing number and complexity of preventive assessments and interventions has resulted in
calls for health checks which allows more comprehensive assessments and interventions than is
possible opportunistically when patients present for other conditions [36]. These have been
demonstrated to improve the frequency of the assessment and management of behavioural risk
factors in primary care [37]. Our own research in 2007 on the 45-49 year health check demonstrated
that health checks were acceptable to GPs and patients and increased the frequency of preventive
assessments and brief advice but not referral or health outcomes [38, 39]. Furthermore there was
some evidence that the uptake of health checks by low socioeconomic groups may be the same as, or
better than for high socio-economic groups [40]. However a recent systematic review has shown little
impact of health checks on health outcomes [41]. This examined a very heterogeneous group of health
checks (defined as screening general populations for more than one disease or risk factor in more than
one organ system). This suggests that health checks should be focused – offering specific evidence
based preventive interventions for at risk population groups.

Practice nurses have an important role in conducting part or all of the health checks in general practice
[42, 43]. These roles may include identifying patients for health checks, assessing their risk factors and
combined risk score (such as AUSDRISK score), providing motivational counseling, education and
negotiating behavioural goals, and arranging referral and follow up. In Australia in 2009 health checks
occurred in 7.6% of encounters with a practice nurse [44] indicating that there is scope for a greater
role.

7
4.2 Brief interventions in primary health care: Advise/Agree
Advice should be tailored to readiness to change and health literacy. Where patients are unsure,
motivational interviewing should be offered to help them to decide to act to improve their lifestyle
behaviours.

Smoking cessation
All patients who smoke, regardless of the amount they smoke, should be offered smoking cessation
advice [19, 45]. Brief counselling interventions and pharmaco-therapies delivered in primary care are
effective in increasing smoking cessation [46, 47]. At an individual patient level, primary care providers
can influence smoking rates by systematically providing opportunistic advice and offering support to
all attending patients who smoke.

Alcohol
Brief advice to patients with at risk levels of drinking in general practice has been demonstrated to
reduce alcohol consumption by about 6 standard drinks per week [48-50].

Physical activity
All adults should be advised to participate in 30 minutes of moderate activity on most, preferably all,
days of the week (at least 2.5 hours per week). This has been demonstrated to confer cardiovascular
health improvements independently from the impact on weight [51]. Brief interventions to promote
physical activity have been shown to be effective in some studies [52, 53].

Diet
Brief lifestyle advice should be given to reduce saturated fat, and sodium and increase fruit and
vegetable portions (2+5 portions) as these are associated with lower risk of cardiovascular disease and
diabetes. Brief advice can improve dietary choices[54].

Weight
Patients who are overweight or obese should be offered individual lifestyle education. Goals should be
negotiated and achievable. Weight loss of 5% of body weight can confer significant benefits in terms of
prevention of chronic disease [21]. This may be achieved with a lifestyle program which aims for a
600Kcal or 2500 KJ energy deficit and increased physical activity (increasing to 60 minutes of moderate
intensity five days per week) supported by behavioural counselling. However on their own, brief
interventions are unlikely to be able to achieve and maintain weight loss in obese patients [55]. More
extensive interventions (involving three or more sessions) by practice nurses have achieved sustained
weight loss [56, 57]. In children interventions which combine counselling, education, written
resources, support and motivation have been effective [58].

Multiple risk factor approaches

Some trials have been conducted of providing standard exercise and nutrition information in general
practice followed by individual or group education and counselling sessions among high risk or obese
general practice patients [59, 60]. However there has been insufficient evidence of impact on
physiological risk factors such as blood pressure or lipids [61].

8
4.3 Assist (refer)
Especially for diet, physical activity, weight, and multiple risk factors there is increasing evidence that
brief interventions in general practice are important and valuable, but insufficient to achieve and
maintain behaviours and physiological changes [62]. Referral programs need to be of sufficient
intensity (usually at least six sessions over several months) to be effective and sustainable. An
essential component of all these are that they are integrated with primary health care providers
involved in initial assessment and long term follow up. If they are not integrated then referral rates are
likely to be low and long term maintenance poor.

These can be delivered in a number of ways including by:-

 group and individual programs;
 phone or internet;
 different professionals including practice nurses, dieticians, exercise physiologists and
psychologists, health educators and peer educators; and
 different organisations (health, non-health, private and public).

Group and individual programs

Both group and individual programs have been successful in assisting patients to achieve changes in
diet, physical activity and weight. However there is some evidence that group programs may be more
effective in patients from low socioeconomic backgrounds or with low health literacy and may assist in
the maintenance of behaviour change [63]. Further research is required to identify which delivery
method is most effective for different populations and geographical locations.

Different providers
A number of studies support an effective role for practice nurses in risk assessments, patient
education and counselling for blood pressure, cholesterol, smoking, diet, physical activity and reducing
CVD risk [56, 64]. In 2009, a randomised trial in the Netherlands investigated the effectiveness of
practice nurses as substitutes for GPs in CVD risk management after one year follow up [65]. The study
compared GP preventive care to practice nurse preventive care by examining changes to patient risk
factors for CVD. The study found that practice nurses achieved results equal to GPs. Interventions by
nurses or educators are more likely to report efficacy in changing patient levels of physical activity
than other health professionals [66, 67]. Interventions by practice nurses, allied health (dieticians,
exercise physiologists), medical assistants and psychologists have all demonstrated effectiveness in
weight control programs [56, 68-71]. Education provided by dieticians is likely to achieve greater
changes in diet behaviours than by other providers [68]. However this needs to be combined with long
term support in general practice to ensure that it is incorporated into overall management of other
risk factors. There is some evidence that multicultural health workers can be effective in delivering
preventive education [72].

Private and public providers

There is evidence for cost effectiveness of referral of patients to some private weight reduction
programs in comparison with intensive interventions by GPs [73]. However cost and other access
issues may be significant barriers to low income patients taking up referral [74].

Internet and phone delivery

An increasing number of support programs delivered by phone, web, text and social media have been
developed to provide support for changes in the behavioural risk factors. Phone counselling has been

9
shown to support changes to and maintenance of diet and physical activity behaviours [75, 76]. An
effect of internet and web based interventions on behaviour change has been demonstrated but less
so when maintenance was the goal [77]. However one study comparing in person and internet
delivered weight loss support in primary care showed both methods achieved and sustained weight
loss at 24 months [78].

4.4 Arrange
Maintenance of behaviour change is the major goal of long term monitoring and support. There has
been emphasis on relapse prevention strategies in relation to alcohol and smoking [79, 80].
Maintenance of weight loss is a major challenge because most patients regain weight lost within one
year following an intervention [81]. Trials that appear to be more successful in achieving and
sustaining weight loss have been those which provide a longer duration intervention which involves
face to face contact [82].

5. TRANSLATION OF EVIDENCE INTO AUSTRALIAN PRIMARY HEALTH CARE PRACTICE

There are implementation gaps in relation to evidence based preventive practice targeting the
behavioural risk factors in Australian primary health care. These include gaps in: assessment, advice,
referral, and maintenance.

5.1 Evidence to practice gaps in access to preventive interventions

There are high levels of assessment of the behavioural and physiological risk factors in primary health
care. These tend to be high for blood pressure, weight and smoking and lower for waist circumference,
diet and physical activity [83]. However the frequency of multiple risk factor assessment using
cardiovascular risk calculators or the AUSDRISK questionnaire is much lower. Previous research has
focused on the initial implementation and short-term use of cardiovascular absolute risk (CVAR)
assessment by Australian GPs, and found variable evidence of uptake [84-87]. Most GPs use CVAR
assessment in their practice primarily to motivate patients to change their behaviour and adhere to
management rather than to inform their own decisions about pharmacotherapy or referral. Time and
practice capacity are barriers to its greater use. Patients who sustained changes to their behaviour
following CVAR assessment had internalised the benefits to their health and received support from
family and friends. Those who relapsed attributed this to their own lack of motivation and extrinsic
factors [88]. Only one study has been conducted on the usage rate of AUSDRISK by general
practitioners (GPs) in clinical practice finding that only 36% were aware of AUSDRISK [89].

Overall, advice on prevention or nutrition and weight occurred in only 1.2% of general practice
encounters in 2009 [44]. In terms of single risk factor assessment, about half of those assessed to be at
risk are offered brief advice or management by GPs and other primary health care professionals (with
higher rates for smoking) [18]. Barriers to offering advice include lack of provider skills in behaviour
change techniques, negative attitudes (about their effectiveness), normative expectations of patients
and other providers and factors operating in the environment of the practice including time, funding,
availability of support [39]. These have been analysed using the Theory of Planned Behaviour as a
framework in our previous research (Figure 7) [39, 90, 91].

10
Figure 7: Factors influencing delivery of preventive care in general practice [39]

Only small proportions of patients who are at risk of chronic disease are referred to and attend other
providers or services for more intensive interventions. These represent less than 10% of those
identified to be at risk and motivated to change their behaviour (Figure 8). Factors influencing referral
include being assessed as “ready for change”, coordinating the referral process and reducing access
barriers such as cost [92]. The low rate of referral by GPs has been found in other studies in Australian
general practice [93, 94]. At-risk patients who do not yet have chronic disease are not well-serviced by
the referral pathways (such as public hospital services or private allied health providers) used by GPs
for people with chronic disease, (who are generally older, in poorer health and may be eligible for
access to subsidised private referral). Many GPs express doubts about the effectiveness of referral
options, preferring to manage the risk factors within the practice despite the difficulty in doing this.
There are also practical difficulties in communication between general practice and the other services,
waiting lists for public allied health services, delays in entry into group programs, the availability at
suitable times and places and some reluctance on the part of patients to be referred especially to
group programs.

While there have been improvements in the number of patients whose behavioural risk factors are
assessed, large gaps between guideline recommendations and practice remain for providing advice
and referral for at-risk patients.

11
Figure 8: Proportion of patients receiving assessment advice or referral; Health Improvement in
Practice study, 2009

5.2 Inequities
Inequities in access to preventive care mean that these gaps in preventive care are not equally
distributed across different population groups. Although disadvantaged populations experience
significantly greater mortality and morbidity relative to advantaged individuals, they may be less likely
to receive appropriate preventive care [95]. General practices in socio-economically disadvantaged
areas tend to have fewer long consultations with their patients which provide opportunities for
planned preventive care [96, 97]. Patients with poor educational attainment and health literacy are
more likely to report chronic illness, but less likely to visit their GP for preventive care [98]. As a result
reductions in health risks such as smoking, have occurred to a greater extent advantaged than
disadvantaged populations [99]. Despite inequities in the distribution of risk factors such as obesity,
rural people and those from low educational backgrounds are less likely to be referred from primary
health care for interventions [92].

Aboriginal Australians are at greater risk of chronic disease and have high rates of obesity, smoking,
hazardous alcohol consumption and poor diet [100]. However there is evidence that they miss
opportunities for preventive care [101]. Although annual health checks for Aboriginal people are
funded under Medicare and there is a package of incentives to support better chronic disease
prevention [102], in mainstream primary health care there are low rates of identification of
Aboriginality and uptake of annual health checks and Closing The Gap initiatives in general practice.
Aboriginal Community Controlled Health Services mainly provide primary health care and some
specialist care to many Aboriginal communities across Australia. Aboriginal Community Controlled
Health Services take a holistic and culturally appropriate approach to patient care [103] and tend to
utilise a greater number of allied health professionals including, but not limited to Aboriginal Health
Workers, in the care of their patients .

Refugees struggle with high rates of long term illness often complicated by psychological problems,
poor health literacy and poor knowledge of the Australian health care system. There is only 49%
uptake of Medicare funded health assessments among new arrivals [104]. Many asylum seekers have
no access to primary care [105]. Missed opportunities for prevention and early intervention leader to a
greater burden of chronic disease in later life.
12
These inequities are associated with factors operating at the patient, local community, provider,
practice and systems levels. Structural, organisational and patient factors all play a role in explaining
these gaps in preventive care in general practices in disadvantaged communities [106] including access
to general practice, time available for consultations, competing demands on work time, and higher GP
stress. GPs may charge co-payments for preventive care visits which are likely to restrict access to
preventive care particularly for low income people in areas with restricted choice of practice such as
rural and remote areas. Figure 9 illustrates the barriers to preventive care in primary health care in
disadvantaged communities.

Patient Practitioner/Practice Local health system

Language, culture and literacy
Openness of patients to
disclosure of risk factors and
barriers
Knowledge and attitudes to
health
Priority given to health vs. other
priorities
Social factors – family stress,
unemployment
Co-morbidity – depression and
other physical conditions
Workload – demand on GPs, GP
time
GP attitude to effectiveness of
referral services
Access to GP – bulk billing
Funding for nurses to do
prevention – GP based funding
Access to referral programs –
cost transport, location,
availability, waiting time, delay in
entry into programs,
coordination of entry/referral
Waiting time for public services
Workforce availability of nurses
and health educators

Figure 9: Barriers to Preventive Care in Disadvantaged Practices [107]

6. FACILITATING IMPROVEMENT
Strategies that can be applied to address these translation gaps and inequities operate at the following
levels: practice organisation, primary care organisations, greater integration between clinical and
community based programs and broader health system policies and strategies.

6.1 Practice organisation – how is care organised at the practice level?

The optimal model of care involves providing both opportunistic preventive care for all patients
together with planned preventive health checks at particular life stages and for higher risk populations
for whom intensive assessment is justified. In balancing between these needs, we need to consider
both the feasibility and effectiveness in practice [108]. For example highly targeted approaches to
planned care for an infrequent but high risk group of patients may be difficult to implement because
they are too difficult to incorporate into practice routines. On the other hand universal planned
preventive care may have low cost effectiveness.

The organisation of care across the 5As needs to be underpinned by practice systems including the
roles of staff members, information and business management systems, and linkages with other
services and providers [109]. Decision support systems have been integrated into e-health record
systems in general practice providing prompts for preventive care and tools for health risk assessment.
The introduction of e-health records and decision support systems have been associated with
improvements in preventive care [110]. There is however variability in the inclusion of specific fields
for particular risk assessments (such diet or physical activity) or preventive interventions in e-health
records which reduces their effectiveness.

13
The development of teamwork both within primary health care services (including between clinical
and non-clinical staff) and between services is critically important to the effectiveness of interventions
to address the behavioural risk factors [111-113]. The expansion of the number and roles of practice
nurses provides an opportunity for this to be developed within the practice. Creating teamwork across
providers who are in different locations and organisations is more difficult [114]. The development of
a range of models of integrated services including the “GP-Superclinics” provides a structural basis for
this to occur [115]. However these represent only a very small percentage of primary health services in
Australia and there is a need for strategies which develop teamwork and integrated preventive care
within the majority of primary health care services.

There is limited evidence for how effective intra-professional teamwork can occur for preventive care
in primary health care settings. Observational research in Canada found that the physical layout of
clinical space and the organisation of clinical practice influenced the approach to and the effectiveness
of teamwork [116]. A qualitative study of 121 primary health care professionals explored the different
types of communication used within primary health care teams. The study found that communication
occurs through formal (e.g. regular team meetings, computer-assisted communication) and informal
(opportunistic, hallway conversations) processes. Informal communication was seen as the most
common form of information sharing and was the preferred approach for patient care issues. The
study found that the approachability, availability and the proximity of team members can influence
effective team communication. Remuneration for attendance at team meetings was seen as a way of
increasing attendance at team meetings [117]. Further research is required to understand how to
facilitate effective intra-professional team work within organisations, and across primary health care
and outside allied and community health service and providers.

6.2 Primary care organisations – potential and actual roles

Since their inception, Divisions of General Practice (Divisions) were seen as potential vehicles for
facilitating improved preventive care and addressing health inequalities [94, 118, 119]. Over the past
decade, most of the effort on prevention by Divisions has focused on supporting general practices to
improve their preventive care. In a feasibility study, Divisions were supported to take multi-strategy
approaches involving practice visits, training, resource provision and linkages with referral services.
This brought about changes to the organisation of the general practices involved and their reported
frequency assessment and delivery of behavioural interventions [94, 120].

Divisions have been involved in a number of programs to improve the quality of preventive care in
general practice. The National Primary Care Collaboratives have worked with Divisions to provide an
intensive model for quality improvement at the practice level. An approach to outreach facilitation has
been developed and applied intensively by the National Prescribing Service (NPS) facilitators based in
the Divisions (with the focus primarily on medication management) [121]. Facilitation needs to be
flexibly applied to enhance clinical preventive service delivery which is tailored to meet the varying
needs of practices and their patient populations based on clinical audit [111]. This approach is being
developed in our Preventive Evidence into Practice (PEP) partnership project in Australia [122], and is
the focus of programs being implemented in Ontario Canada and the US [123-125].

The provision of referral services for prevention by Divisions has been variably successful. In many
Divisions, lifestyle management programs aiming to prevent diabetes were established [126]. However
these suffered from generally low referral rates from practices. The reasons for this were complex and
included the criteria for referral. Similar programs have been more successful especially where the
referral criteria were broader, the programs more flexible and where referral was facilitated at the
practice level [92, 120]. It is important that lifestyle programs are suitably accredited both to help
ensure that they are effective and to help to address GP concerns about their effectiveness [127].

14
The newly established Medicare Locals have a wider remit to not only facilitate practice improvement
in preventive care through the development of staff practice capacity and information systems but
also to develop more integrated service networks and population health [128]. These provide a basis
for improving the integration between general practice, private allied health, state community health
services and Aboriginal Community Controlled Health Services. Their initial tasks include identifying
the health needs of local areas and developing plans for locally-focused and responsive services and
programs (including health promotion and preventive health programs). The latter may include
preventive programs that are brokered through coordinators or Internet or phone based services
which are jointly owned and operated.

Lessons from overseas

Health improvement was a major focus of the activities of Primary Care Trusts in England. These
developed capabilities to undertake their role in health improvement and to address
poverty/deprivation as priorities. For example they commissioned physical activity referral programs,
smoking cessation programs, local strategies for overweight and obesity [129]. This involved them
working closely with public health observatories to assess needs and develop plans. However they
faced significant capacity constraints due to their size [130] and recent reforms have transferred
responsibility for health improvement to clinical commissioning groups and local government.

Similar expectation were raised for primary health organisations in New Zealand especially in
addressing the preventive health needs of Maori and Pacific Island populations who suffer the greatest
burden of disease. Their approach includes strategies to make “mainstream services and programs”
more accessible for disadvantaged groups as well as targeted programs including outreach services
[131]. Some funding has been provided through the primary health organisations to general practice
for preventive care services provided and increased access by disadvantaged group. In planning these
the primary health organisations have worked closely with the District Health Boards who have
provided data and epidemiological expertise.

6.3 Integration between clinical and community based and public health programs
To be effective, clinically based interventions need to be linked to community based programs and
resources accessible to disadvantaged communities. The clustering of risk factors suggests a different
approach from current approaches to single lifestyle behaviours is required [99]. This needs to be
facilitated at the local level, using a socio-ecological approach [17] to identify appropriate partners at
individual, organisational, community and state levels that provide more tailored interventions for
particular populations [15]. It is widely recognised that addressing health inequality in Australia
requires action to address social determinants of health at all levels of the health sector in
collaboration with government, business, civil society groups and the community [132].

The Centers for Disease Control and Prevention program WISEWOMAN successfully developed
partnerships between clinical services and non-government organisations (such as the heart and
stroke foundations), local government and local community organisations including church groups in
the delivery of preventive programs [133]. This has allowed much greater reach for programs and
helped to ensure their sustainability beyond the initial funding period. It also allowed greater use of
technology supported coaching and counseling interventions for diet, physical activity and weight
control [134]. These programs had to be registered and licensed to ensure quality and fidelity with the
aims of the program.

In the past, Divisions developed local partnerships with state health, local government, non-
government and community organisations and Aboriginal organisations to support preventive health
especially for diabetes prevention, self-management and physical activity [135]. These have been

15
largely voluntary partnerships with Divisions taking a brokering role in facilitating referral from general
practice and in some cases funding services.

Smoking
Alcohol
%
Nutrition
Physical activity
Weight

0 20 40 60 80 100

Figure 10: Proportion of Divisions of General Practice with prevention programs involving
collaboration with other organisations, Annual Survey of Divisions 2010-11 [136]

Without the development of integrated services and programs, primary health care and public health
in Australia are unlikely to be able to address the fundamental challenges they both face in preventing
chronic disease and reducing health inequities. This involves collaborative planning with state Local
Health Districts and integrating the delivery of prevention programs. It is expected that Medicare
Locals will be able to develop partnerships with state, local government and non-government
organisations to address the social determinants of health as well as health promotion programs.
However although there is good will, there are as yet no mechanisms for the development of truly
integrated and jointly owned programs. The recent COAG National Primary Health Care Strategic
Framework provides an opportunity for this to be negotiated between Commonwealth and State
funded services and organisations.

6.4 Health system strategies

Workforce:
The introduction of practice nurses has been a major strategy for addressing the capacity constraints
in general practice especially in under-served areas. In Australia, 60% of practices employ at least one
practice nurse. There is an increasing number of encounters involving a practice nurse — the
proportion more than doubled from 4.2% in 2005–06 to 9.0% in 2008–09 [44]. This is likely to be an
underestimate of their contribution because these figures are based on Medicare Claim Data and
much of the practice nurse’s role might not be claimed through Medicare. Practice nurse skills in
chronic disease prevention and management have been demonstrated to be under-utilised [137]. A
third of practice nurses report spending half of their time conducting health checks and other
preventive activities. However, over 80% want to be more involved and receive more training [138].
While the role of practice nurses is expanding, there is potential for a far greater role in the prevention
of chronic disease.

16
Prevention of chronic disease requires the involvement of a broad multidisciplinary team including
allied health workers who are able to provide more intensive but accessible interventions. However
there are major disparities in the distribution of allied health workers especially in remote, rural and
low socio-economic areas and little evidence that these are narrowing [139]. While information
technology (including the use of NBN enabled tele-health and web based programs) may help mitigate
these workforce shortages, continuing effort will be needed to expand the allied health workforce in
these areas.

Information systems:
The use of information systems is being increasingly recognised as important in strategies to address
the lifestyle risk factors in primary health care. There are effective roles for the use of information
technology within each of the elements of the 5As including identification of risk and reminder
systems, assessment of risk, provision of patient information and education, and continuing support
including peer support [140]. The computerisation of general practice, development tools for audit
and decision support and introduction of the Patient Controlled Electronic Health Record provide a
good basis for this [141]. However levels of computerisation in community and allied health services
are lower and there is much work to be done in adapting the various systems at practice levels and in
local networks to be able to comprehensively address the behavioural risk factors across the 5As.

Patient enrolment
Patient enrolment with a primary care practice or organisation provides a basis for shared
responsibility between patients and practices for preventive care as well as a basis for funding of this
care. This would also allow practices to know the population they are responsible for providing care to,
and therefore assist in anticipatory care including recall [142]. Although a trial is being conducted on
diabetes, this does not cover primary prevention. This continues to be an area which needs further
development especially for high risk patients.

Financing:
Funding needs to encourage both integration and improved quality of preventive care. Most Medicare
funding in Australia rewards occasions of service. Relatively few mechanisms exist to reward team
based care, population coverage or equity of access, and these factors need to be addressed without
further increasing the fragmentation and complexity which is already a serious problem for providers.
Further there is only very limited evidence that particular funding mechanisms improve the frequency
and quality of preventive care [140, 143]. In Australia, there is some evidence that incentives the
Practice Incentive Program (PIP) provide may have contributed to improvements in anticipatory care
of diabetes [144, 145]. Thus a flexible mix of funding mechanisms may be desirable for preventive care
in primary health care. These mechanisms might include funding for preventive care provided by
nursing and allied health providers, that rewards population coverage of preventive care and
encourages joint programs involving providers in general practice, private allied health, Aboriginal
health and state funded community services. This may include funding through Medicare Locals.

Equity
There are numerous threats to equity of access to preventive care. Aboriginal Australians suffer
significantly worse health status at the same time as having less access to health services [146]. Rural
populations also are at higher risk of chronic diseases but have less access to primary care services
[147]. Refugees struggle with high rates of long term illness often complicated by psychological
problems, poor health literacy and poor knowledge of the Australian health care system. Efforts to
address these inequities in primary health care have included enhanced universal programs (such as
more frequent health checks under Medicare) as well targeted programs for specific groups (such as
nicotine replacement therapy for disadvantaged groups, nutrition and physical activity education and
support programs for Aboriginal and other disadvantaged groups, and training for health professionals
17
to provide culturally appropriate care). The latter are usually delivered locally but need to complement
universal programs.

Other systems issues

The 2008 discussion paper highlighted a series of options for policy and practice. A number of these
have been discussed above. Others are outlined below:-
Health risk assessment: The uptake and use of these tools (such as the CVD absolute risk assessment
and AUSDRISK) is still low especially in support of clinical decision making. The development of
management guidelines (in addition to those for assessment) will help. However much more
promotion and facilitation of their use will be required including their incorporation into health record
systems.
Lifescripts: Lifescripts remain relevant to lifestyle interventions in primary health care. Although
electronic templates have been provided for the five most frequently used IT systems in general
practice, they are still not fully integrated allowing data to be imported and exported from the record.
It will be important that these and other information resources are integrated into the PCEHR.
Performance Indicators: The development of performance indicators for primary health care focused
on the behavioural risk factors should remain on the agenda of the National Health Performance
Authority. Draft indicators for general practice have been developed by the RACGP. However these
should capture interventions across the 5As – not only assessment.

7. RESEARCH AGENDA
There continue to be gaps in our knowledge about preventive care in primary health care. These
include gaps in knowledge about the most effective interventions in families with young children and
adolescents, interventions for disadvantaged patients with low health literacy and how to maintain
behaviour change especially in relation to diet, physical activity and weight. At the local level, there is
need for further research into how effective partnerships can be developed to deliver preventive care
and to link clinical care with population health initiatives. At the system level there is need for further
research to evaluate the effectiveness of funding and financing models and ways to develop
integrated preventive care between providers, patient enrolment, the optimal use of information
technology including decision support and Patient Centred Electronic Health Record (PCEHR) to
support joined up preventive care and how to provide equity of access to preventive care.

Further research is required to better understand the skills and contributions of a multidisciplinary
team for preventive activities in primary health care. Thus while the important role of practice nurses
is not in doubt, further work is required to identify how GPs and practice nurses might work together,
and with allied health professionals to prevent chronic disease. Further research needs to examine:
 which allied health professionals ought to be involved in preventive care for different groups of
patients;
 the specific skills and expertise required by GPs, practice nurses and allied health professionals
in preventing chronic disease;
 how the skills and knowledge of these different professional groups complement and reinforce
one another as part of a distributed preventive health team; and
 how effectively clinical decisions are made in a team environment and how to facilitate mutual
understanding among team members.

Research is also needed to inform the role of Medicare Locals both in developing population health
plans and partnerships to achieve these and in supporting practices to improve their preventive care.
18
8. CONCLUSIONS
In this paper we have demonstrated that primary health care can be effective in the prevention and
management of the behavioural risk factors. Assessing chronic disease risk, readiness to change and
health literacy are important in tailoring interventions to the needs of patients and providing care
which is most effective and equitable. However there is still more work to be done in translating this
into practice.

Over the last two decades the focus in primary health care has been changing from acute care to the
prevention and management of chronic disease. This has required changes to the organisation of
primary health care practices and the involvement of a greater number of team members. As the
nature of care changes, and as teams grow in scope and size, and engage with providers outside the
practice, communication becomes more complex [148-150]. Further research is required to identify
which allied health professionals ought to be involved in preventive care for different populations and
how the organisation of the practice can best support the roles of practices nurses and allied health
providers. In essence, the effective and comprehensive implementation of the 5As requires highly
functioning teams that communicate well and tailor their care to patient needs. However, we are still
developing strategies to facilitate the development of effective team-work both within the practice
and between different services.

Primary health care providers such as GPs and practice nurses have a particularly important role in the
identifying, assessing at risk patients and offering brief interventions and long term follow up.
However this is often insufficient and more intensive education and support are required from a range
of providers and services including community based programs. Prevention requires the organisation
of care within the practice as well as across different organisations. Facilitating this is an important
role for Medicare Locals and needs to be incorporated into their population health planning. There is
also a need for them to forge partnerships with state health services, local government and non-
government organisations to achieve their goals.

The transition towards a more equitable and accessible primary health care system is a key plank of
health reform. The establishment of Medicare Locals provides an opportunity for many of the barriers
to prevention in primary health care to be identified and local strategies to be developed to address
them. These need to be combined with further system level changes to funding, workforce and
information systems to be most effective.

19
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