Australia: the healthiest country by 2020
National Preventative Health Strategy – the roadmap for action

vii - Refocus primary health care towards prevention

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There is a place for preventative health in all elements of the healthcare system, including within the acute care and hospital setting, community health and across primary healthcare. The NHHRC is tasked with the review of Australia's healthcare system, and the Primary Health Care Expert Reference Group with reform for primary healthcare. The Preventative Health Taskforce has both contributed to their work and sought advice from the Commission and the Expert Reference Group in developing this Strategy.

The primary healthcare setting is one of the most important sectors of the health system for prevention. It provides essential services for all Australians, connecting care across the life course, and offers many opportunities for primary prevention. Primary healthcare also has a great capacity to care for Australians across a very wide range of disciplines, including medicine, nursing, physiotherapy, occupational therapy, dietetics, pharmacy, psychology, chiropody and naturopathy.

The Taskforce agrees with the WHO Commission, the NHHRC, the Primary Health Care Taskforce, submissions provided to the Taskforce and those with whom the Taskforce consulted in stressing that:

Primary healthcare reform is the single most important strategy for improving our health and making the health system sustainable. Community-level prevention and primary healthcare is essential to restoring universalism and efficiency in Australian healthcare.[99]

The connection between primary healthcare and preventative health

'Primary healthcare has a central role to play in addressing preventative health needs for local populations, particularly through interventions targeted at the individual or small group level' (Quote from submission)

Preventative healthcare starts in the community, where people are born, grow up, raise their families, work and grow older. Primary healthcare is the gateway to a healthy life for Australian communities at each of these life stages, and is an important setting for the delivery of preventative healthcare.

Primary healthcare includes services to the community that are accessed directly by the general public. It is often, but not always, the first point of contact with the health system when a person has questions about their own or their family's health. There is an expectation from the public that, when they visit a primary healthcare provider, they will receive information and assistance regarding preventative health issues.[100]

On average, Australians visit a GP five times a year and almost everyone uses a primary healthcare service at least once a year. Yet relatively few primary care encounters in Australia involve risk factor assessment and intervention. The evidence shows that there are significant gaps in prevention activities for chronic disease in general practice, including the infrequency of assessing alcohol consumption and smoking, and counselling about hazardous drinking, smoking, physical inactivity and diet.[101]

In 2005–06, 34.6% of general practice encounters were with overweight patients (over 22% being obese), nearly 26% with those who drank alcohol at risky levels and 17% with daily smokers.[102] Less than one in five patients were routinely asked about their drinking,[103, 104] two-thirds were asked about their smoking,[105] only a third were asked about exercise and physical activity, and about 15–30% of patients received some form of dietary advice.[106] Importantly, less than one in five GP consultations involved an intervention to support behaviour change.
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The role of primary healthcare in preventing chronic disease

'The primary healthcare system has an important role within a whole-of-society, integrated approach to tackling chronic disease' (Quote from submission)

Early in 2006, COAG's Plan for Better Health for All Australians[107] identified the importance of promoting healthy lifestyles, including addressing alcohol use, nutrition, smoking and physical activity. Strategies to promote healthy lifestyles include:

• Supporting the early detection of lifestyle risks and chronic disease through a 'Well Person's Health Check' in general practice for middle-aged people with one or more identifiable risks that lead to chronic disease.
• Supporting lifestyle and risk modification through referral to services that assist people who are wanting to make changes to their lifestyle.

Example: lifescripts
Lifescripts is a 'lifestyle prescription' program which provides a suite of resources (including waiting room materials, assessment guidelines, assessment tools and prescription pads) implemented through Divisions of General Practice. Resources are accompanied by training and practice visits to support their use.[108]

In 2006/07 the Annual Survey of Divisions showed that 85% of Divisions had a Lifescripts project. In relation to the behavioural risk factors, 40% had smoking projects, 46% nutrition, 54% alcohol and 55% physical activity.[109] Most of these projects involved education and support for practices, with 42–49% of Divisions providing direct diet or physical activity services for patients, mostly through the employment of allied health staff.

Targeted prevention for disadvantaged populations

In addition to population-wide prevention measures, targeted preventative activities are required to address the health needs of individuals and communities where:

• Existing basic services may not cope with the level of illness and need present in the community (such as in some Aboriginal and Torres Strait Islander communities)
• There are adverse health outcomes resulting from factors that may discriminate against disadvantaged groups (such as the cost of services or discrimination)
• There are specific cultural factors and conditions that make mainstream basic services inappropriate (such as Indigenous health and refugee health services)

Although disadvantaged populations experience significantly greater mortality and morbidity relative to advantaged individuals, they may be less likely to receive appropriate preventative care.[110, 111]
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Example – immunisation

• Single parent and migrant families and those where the parents are unemployed, on a low income or have low education levels are at risk of lower levels of age-appropriate immunisation.[112, 113]
• General practices in socioeconomically disadvantaged areas tend to provide immunisations less frequently and have fewer long consultations with their patients.[114-116]

Both structural and patient factors may explain poorer preventative care status, rather than differentials in a practitioner's care for disadvantaged patients relative to more advantaged patients within the same practice.[117] General practices may charge co-payments for preventative care that are likely to restrict access to preventative care, particularly for people on a low income living in areas with a restricted choice of general practices, such as rural and remote areas. Also, there is some evidence that general practices situated in disadvantaged areas may respond to financial incentives for better quality of care, including preventative care.[118]

Strategies that have been shown to be effective in improving access to preventative care in primary healthcare include:

• Doctor and specialist nurse clinics focused on preventative care[119]
• Outreaching services (such as nurse-run clinics for the homeless)[120, 121]
• Reducing cost and other barriers to access
• Developing culturally appropriate services, and increasing the skills and resources that will enable people to adopt more health-promoting lifestyles[122, 123]

Example: Wisesoman
In the United States, the WISEWOMAN project coordinated by the Centers for Disease Control and Prevention (CDC) has demonstrated cost-effective interventions for improving preventative care in disadvantaged groups.[124, 125] The project uses a socio-ecological model to identify partners at individual, organisational, community and state levels, and tailors interventions to the target populations and settings.[126] Elements include:

1. Screening of risk factors for cardiovascular disease and other chronic diseases
2. Lifestyle interventions linking up a wide range of primary healthcare providers and services
3. Assurance of access to treatment and medication required
4. Follow-up visits for monitoring and evaluation

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Integrating primary healthcare practices

While general practice provides an important setting for primary healthcare, other models of integrated primary healthcare should also be considered. For example, Primary Care Partnership organisations have been established in Victoria. These provide a structure for integrated health promotion and prevention activities engaging a wide range of community organisations as well as Divisions and State Health.[127]

Critical success factors for integrated primary healthcare
The following are critical to an integrated primary healthcare system that puts preventative health at the forefront of quality practice. A system that:

• Provides a viable option for people to enrol based on residential location in a comprehensive primary healthcare system – especially those who are disadvantaged or who have multiple needs
• Responds to the changing health needs of people throughout their lives and to those of their families
• Provides quality preventative healthcare in the most appropriate setting
• Promotes patient- and community-centred preventative healthcare with genuine options for community involvement in planning and service delivery
• Develops blended payment models that provide for payment of clinicians through a combination of fee for service, salaries, capitation and performance-based payments accompanied by a single funds holder for primary and community care and public healthcare, ideally funded through a 'needs adjusted' capitated formula
• Harnesses and coordinates the contribution to preventative health made by a wide range of health professionals
• Networks primary care organisations, avoiding silos and gaps in care
• Provides a comprehensive clinical governance and quality audit system
• Introduces an electronic patient record

Funding primary health care

A regional fundholding model for primary health care is more likely to prioritise prevention as future health benefits are reaped by the fundholder. The activities of large single fundholders such as Veterans Affairs, transport accident and WorkCover agencies illustrate this principle. Also, the Northern Territory Government is currently rolling out a primary care reform model, similar to that described here, to promote high-quality, efficient care for the prevention and management of chronic disease,[128] following successful implementation in Katherine West.[129]
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Options for the further development of the role of primary healthcare in behavioural risk factor management need to be considered within the context of broader primary healthcare reform and changing population health priorities for prevention. The measurable benefits are likely to include improvements to access and to the quality of preventative interventions. Mechanisms need to be established to enable these to be monitored more effectively than at present.


In summary
The Taskforce notes the current limitations of the primary healthcare system in Australia in its ability to address lifestyle factors, and considers that a primary healthcare setting which works effectively for prevention should at a minimum be able to:

• Systematically identify people at risk and effectively assess the level of risk and readiness for change
• Deliver appropriate interventions on-site or refer to external services
• Have in place referral processes that allow ready access to appropriate, quality-assured lifestyle modification providers and programs
• Monitor and assess outcomes and sustain improvements over time

To achieve this, the primary healthcare sector requires:

• A multidisciplinary workforce with relevant skills and expertise
• Appropriate tools and resources
• Information systems that provide risk data on the practice population
• Effective linkages to wider community services

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