Green Book

Whole-of-practice prevention - Chapter 2.2

Your practice population

Key points

  • Prevention requires consideration of practice populations (without taking away from individual care) – high-quality data is important in obtaining useful information.
  • Every member of the practice team plays a role in preventive care.
  • Your preventive care team will also include people outside your practice (eg PHN QI support officers, allied healthcare providers, disease and consumer peak bodies).

While few would disagree that prevention is an important part of high-quality, comprehensive healthcare, much of the healthcare system (including general practice) is focused on reactive care.

​Although we can intuitively see how prevention can reduce the need for reactive treatment, it can be difficult to change focus when the demand for treatment is so much ‘louder’, more urgent and resource hungry compared to preventive care.

Putting prevention into practice requires a shift from the usual practice of each GP managing the needs of each patient as they present, to taking a step back and looking at your practice population and what its constituents need for good health.

Thinking about your practice population, do you know how many patients you are currently responsible for? This isn’t simply the number of patients registered on your database. Think of your active patients being the ones who currently consider your practice as their Medical Home.

How well do you know these active patients? Can you easily answer the following questions?

How well do you know these active patients?

Table 1

How well do you know these active patients?

Being able to answer these questions accurately relies on having the right information. Some of it may be available through the practice, but other information (eg the socioeconomic status of your patients) might be more readily available through your PHN. Collecting and analysing that information requires teamwork.


Health literacy

The capacity of your patients to acquire, understand and use health information (ie their health literacy) influences how they manage their health and how they interact/communicate with health providers.1,2

There are a number of tools for assessing health literacy levels. Your PHN may be able to provide suitable tools for people in your community

Patients with low health literacy may understand information better when:

  • key points are prioritised
  • plain language is used (and in the patient’s preferred language)
  • images are used
  • questions are encouraged.

One of the easiest ways to improve understanding is using the teach-back method. This involves asking the patient to recall and restate in their own words what they have been told.


Red Book for patients

When a patient asks for a routine check-up, with no specific current concerns, I start by asking what they think are the key areas to be covered in a check-up for their age group. This gives me a good start to understanding their health literacy and their priorities.

I then show them the Red Book lifecycle chart to compare and contrast their thoughts with what the evidence says will be most useful for their health.

It’s a great way to get the conversation started and often helps reframe patients’ expectations when they may be expecting lots of ‘screening tests’ that are of low value and possibly harmful.

– Dr Caroline Johnson, Senior Lecturer, Melbourne Medical School

Now consider an area requiring focus in your practice. Using diabetes as an example, how easily can you answer these questions?

  • Does the practice have a register of all patients with diabetes?
  • Do you know how many have had a glycated haemoglobin (HbA1c) measurement in the last 12 months?
  • Do you know who are the less frequent attenders?
  • For those with a known HbA1c that is high, do you know anything more about this group (eg visit frequency, other risk factors such as obesity and smoking)?

Again, you need to have the information available to answer these questions. Most practice management software systems have the capacity to provide the information – as long as it’s recorded correctly.


When delivering a workshop on the early detection of lung cancer some years ago, I came across a GP working in a rural country town in South Australia. The town had a mine, which employed a large number of the population. This GP was very aware of the high rates of smoking in the local community and so approached the mine to work with him in trying to reduce rates of smoking in the workers. They developed strategies to support workers to restrict their smoking while at work and support them to quit.

I remember this GP because he epitomises for me someone who was able to take a population view of the risk factors in his practice population.

– Prof Danielle Mazza, Green Book Editorial Committee


SA PHN Immunisation Hub

In order to better understand regional levels of immunisation, increase childhood immunisation rates to 95% and decrease the number of hospital presentations/admissions due to vaccine-preventable diseases, the Adelaide and Country SA PHNs have jointly implemented the SA PHN Immunisation Hub (the Hub).

The Hub is a multifaceted approach to:

  • determine low-coverage areas through careful examination of Australian Immunisation Register (AIR) data
  • bridge gaps in immunisation service provision
  • support the skill base of immunisation providers
  • promote the need for a well-immunised community.

The Hub provides education, mentoring and networking for general practice and other service providers, and engagement, advocacy and resources for the community. The PNs found this a valuable opportunity to connect.

This story demonstrates how PHNs can assist individual practices to better understand their practice population.


5-2-1-0 Let’s Go!

The 5-2-1-0 Let’s Go! program is a childhood obesity prevention program. It was developed by the Barbara Bush Children’s Hospital and has been implemented throughout Maine (USA) and in neighbouring states.

The program has a message that’s simple to deliver and easy to understand:

  • 5 or more fruits and vegetables
  • 2 hours or less recreational screen time
  • 1 hour or more of physical activity
  • 0 sugary drinks, more water

Program developers work with schools, childcare and out-of-school programs, healthcare practices and community organisations to change the environments with which children and families interact. They also produce a range of resources (eg toolkits and brochures) for different settings and in different languages.

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