‘Prevention is better than cure’ makes intuitive sense. Yet there is evidence that some preventive activities are not effective, some are actually harmful. It has been said ‘all screening programs do some harm; some do good as well’.13 Screening of asymptomatic patients may lead to overdiagnosis, causing needless anxiety, appointments, tests, drugs and even operations, and may leave the patient less healthy as a consequence. Therefore, it is crucial that evidence clearly demonstrates that benefits outweigh those harms for each preventive activity.
Determining whether a preventive activity is beneficial, harmful or of indeterminate effect (ie there is not enough evidence on which to base a decision) requires a consistent, unbiased, evidence-based approach.
Cancer screening, in particular, can polarise different sectors of the health profession and broader community. The objective interpretation of evidence, balancing harms and benefits, and considering overdiagnosis and overtreatment is a goal of the Red Book.
In the Red Book, the RACGP provides information to assist GPs in caring for their patients, including in areas where the evidence is uncertain or contentious. Screening activities are only recommended where evidence demonstrates that benefits outweigh harms. Chapter 15 provides some guidance on common tests where this is not the case or where the evidence is either unclear or not available.
Prevention in the practice population
The risk of illness and disease is associated with a range of factors that operate on the individual across the lifecycle. For example, poor nutrition and lack of antenatal care during pregnancy are associated with later risk of chronic diseases in the child. Risk behaviours in childhood may become entrenched, leading to progressive physiological changes that can cause chronic diseases in later life. All these factors are in turn influenced by the social determinants of health, which operate at the local community and broader societal levels; these are poverty, housing, education and economic development (Figure I.3). Thus, it is highly desirable for general practice to think beyond the preventive healthcare needs of the individual patient, towards a practice population approach to primary prevention.
The determinants of health and illness9
Note: Bold highlights selected social determinants of health Reproduced with permission from Australian Institute of Health and Welfare. Australia’s health 2014. Canberra: AIHW, 2014.
General practice has a practical role to play in addressing these determinants and helping to break the cycle that may exist linking social and economic factors to illness and injury. This requires a systematic approach across the whole practice population, not just for those who seek out or are most receptive to preventive care. This 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. It will usually require teamwork within the practice as well as links with other services.
General practice also has a broader role in facilitating health improvement for vulnerable and disadvantaged groups in the local community, in association with other services and providers. In some cases, this may involve advocacy for their needs. Information on local vulnerable and disadvantaged groups and their access to healthcare can be obtained from local Primary Health Networks (PHNs) or state and territory health networks. 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 to preventive health assessment for Aboriginal and Torres Strait Islander people, 2nd edn.