Green Book

Understanding the basics - Chapter 1.1

About prevention

Guidelines for the implementation of prevention in the general practice setting
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  2. Green book resources
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Key points

  • Prevention is relevant to patients across all life stages and applies to the whole natural history of disease.
  • Implementing preventive activities involves recognising the challenges of implementation and using evidence-based strategies to overcome them.
  • Successful implementation of preventive care requires coordination and collaboration within the practice team and with external organisations (eg PHNs).
  • Focusing on prevention is part of a QI approach

The Green Book brings together two main themes: prevention and implementation.

Both of these sit within QI and are inherently associated with behaviour change.

While many general practitioners (GPs) and practice nurses (PNs) discuss lifestyle with their patients, this is only the tip of preventive care.1 Prevention in the healthcare context focuses on the health of individuals, communities and defined populations. It includes all measures that protect, promote and maintain health and wellbeing, and that prevent disease, disability and death.2–4
 

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Prevention in practice requires us to extend our patient-centred approach from individuals and families to the entire practice population.
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I’ve always been taught to do acute episodic care in response to patient demand. But I have realised that to really look after my patients, I have  to do chronic disease management and prevention, and that I need to do in a proactive and planned way.

– Assoc Prof Charlotte Hespe, Green Book Editorial Committee

Prevention is relevant across a person’s lifespan: from pre-conception, fetal stage, childhood and adolescence through to middle age and older. The Red Book shows the preventive activities that apply across age groups.

There are many determinants of health and illness (Figure 2). A preventive approach recognises these and how they interact. It also reaches beyond individuals who seek out or are most receptive to preventive care to encompass the entire practice population.

The determinants of health and illness

Figure 2

The determinants of health and illness

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Note: Bold highlights selected social determinants of health. Reproduced from Australian Institute of Health and Welfare. Australia’s health 2014. Cat. no. AUS 178. Canberra: AIHW, 2014; p. 5.

Just as prevention is relevant across a person’s lifespan, it also applies to the natural history of disease (Figure 3). Preventive measures can be applied at any stage along the natural history of a disease to prevent progression. The stages may be divided into the following:5

  • Primordial – consists of actions to minimise future hazards and address broad determinants of health  (eg environmental, economic, social, educational, behavioural and cultural factors) rather than preventing personal exposure to risk factors, which is the goal of primary prevention
  • Primary – seeks to prevent the onset of disease via risk reduction (eg immunisation, smoking cessation)
  • Secondary – the early detection and prompt intervention to correct departures from good health or to treat the early signs of disease (eg cervical screening, bowel screening, mammography, blood pressure monitoring and blood cholesterol checking)
  • Tertiary – reducing impairments and disabilities, minimising suffering caused by existing departures from good health or illness, and promoting patients’ adjustment to chronic or irremediable conditions (eg prevention of complications). You may also come across quaternary prevention, which is action taken to identify patients at risk of overmedicalisation, to protect them from new medical interventions and to suggest ethically acceptable ones.6,7 Electronic health records may in the future be able to assist us in avoiding unnecessary repeat testing and medication errors, thereby playing a role in quaternary prevention.

In reality, the stages of prevention blur.

Figure 3. Primary, secondary, tertiary and quaternary prevention

Figure 3

Primary, secondary, tertiary and quaternary prevention

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Reproduced from PH3C Primary Health Care Classification Consortium. Quaternary prevention. Erlangen, Germany: PH3C, 2016. [Accessed 21 March 2018].

Effective prevention usually requires teamwork within the practice as well as links with other (clinical and nonclinical) services.

Prevention and health promotion are among the core responsibilities of GPs and PNs.3 Through a range of strategies, GPs and PNs have the potential to influence patients to:

GPs and PNs may also pursue prevention through health advocacy or lobbying within their discipline.

The preventive approach incorporates opportunistic and planned interventions from the perspective of the whole practice as well as for the individual practitioner and patient. It may include auditing medical records to identify those who are missing out, using special strategies to support patients with low literacy, and being proactive in following up patients who are most at risk.8 External help (eg from PHNs) is often needed to support practices in these types of activities. PHNs are able to help in a range of ways, including de-identified data reviews.

The RACGP has developed a resource on Secondary use of general practice data. This resource provides support to decide whether it is appropriate to release de-identified healthcare data at the request of an external organisation.

PHN case study

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A couple purchased a retiring GP’s practice. They were new to the business and sought assistance from us, their local PHN.
 

We assisted them in recruiting a PN by advertising on the PHN website and in monthly newsletters. We provided in-practice training for the PN who had come from a hospital setting – educating the nurse on the cycles of care, using recall reminder systems and maintaining practice protocols such as cold-chain.

We provided software installation and training to the practice, which enabled them to audit their aspects of their practice. With this software, we provided the practice with a report and supported them over the next 12 months in improving their recording of risk factors, patient data entry, and identifying patients with missed diagnoses and billing opportunities. Additionally, this process served as a continuing professional development (CPD) opportunity in quality improvement for the GPs, who now often frequent our free CPD nights.

The business owners felt this help was invaluable.

– Alessandro Luongo, Clinical QI Coordinator, South Western Sydney PHN

Measures to improve access to preventive healthcare by Aboriginal and Torres Strait Islander peoples are especially important, given their higher burden of disease and the barriers that exist to preventive healthcare. More information is available in the National Guide.

Collaboratives case study

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Health and Wellbeing North Ward is a multi-skilled and integrated medical practice offering primary care alongside other allied health providers. As a collective, it focuses on the proactive identification and treatment of risk factors before disease appears, and on patient-centred management of existing conditions.
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The practice has a large Aboriginal and Torres Strait Islander community in its area. To provide holistic and culturally aware care, the practice employs a specialist Aboriginal and Torres Strait Islander healthcare worker. Having a dedicated staff member for this community allowed the practice to:

  • run regular day clinics to address chronic condition management
  • offer consistent appointments for the local Aboriginal and Torres Strait Islander population and the local school that educates Aboriginal and Torres Strait Islander children from the broader area
  • provide home visits to those with access and/or language barriers
  • offer Medicare-rebatable healthcare plans for chronic and mental health conditions through their multidisciplinary set-up.

Patients responded very positively toward the extra care. Patient feedback surveys showed a 95% positive reaction, and practice numbers grew by 38% over two years. The care fostered a sense of loyalty and community among patients, with follow-up appointments kept and measurable improvements in health outcomes.

– Adapted from Improvement Foundation Australia. Australian Primary Care Collaboratives Program, Case study: Health and Wellbeing North Ward, ‘Multi-skilled, holistic agency adopts “wellness” philosophy’. Adelaide: Improvement Foundation Australia, [no date].

Teamwork within an Aboriginal and Torres Strait Islander health service – Health checks

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Patients aged 18 years and over are identified and screened for cardiovascular risk, chronic diseases and smoking via the Medicare Health Assessment for Aboriginal and Torres Strait Islander People (Medicare Benefits Schedule [MBS] item 715).

Suitable clients are invited to participate in after-hours exercise group sessions with a personal trainer, twice a week for two hours. Sessions include advice and education on diet and healthy eating, with the aim to decrease body mass index (BMI), increase health literacy and provide better management of chronic disease. Smoking cessation support is also offered and promoted.

– Fiona Thompson, Clinical Services Manager, Pangula Mannamurna Aboriginal Corporation

Visit 'Key Aboriginal and Torres Strait Islander organisations' for a list of useful contacts

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