The third edition of the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people (National Guide) is a joint initiative of the National Aboriginal Community Controlled Health Organisation (NACCHO) and The Royal Australian College of General Practitioners (RACGP). The National Guide is a practical resource intended for all health professionals delivering primary healthcare to Aboriginal and/or Torres Strait Islander peoples. Its purpose is to provide health professionals with an accessible, userfriendly guide to best practice in preventive healthcare for Aboriginal and Torres Strait Islander patients.
Every chapter of this edition has been extensively revised, and we are pleased to include several new topics to support healthcare providers to broaden preventive care on priority health issues, such as fetal alcohol spectrum disorder, family abuse and violence, and ways to optimise child health and wellbeing. In this third edition, we continue to emphasise five types of preventive interventions: immunisation; screening for asymptomatic disease; chemoprophylaxis (using medication to prevent the onset of disease and complications of existing disease); counselling and other ways to encourage client behavioural change; and primary healthcare influences over environmental factors.
The third edition of the National Guide revision process developed several products:
- the National Guide (print and electronic), which contains evidence statements, recommendations, risk calculation tables and an outline of the development of the National Guide package
- the Evidence Base to the National Guide (electronic only), which contains the collection of evidence underpinning the guide and recommendations
- a child lifecycle summary chart (print and electronic) listing activities recommended at each age group 0–17 years
- a young people lifecycle summary chart (print and electronic) that synthesises recommendations for those aged 12–24 years
- an adult lifecycle summary chart (print and electronic) listing activities recommended at each age group from 10 years.
The National Guide is intended for all healthcare providers delivering primary healthcare to the Aboriginal and Torres Strait Islander population. This includes general practitioners (GPs), Aboriginal and Torres Strait Islander health workers and practitioners, nurses, specialists with a role in delivering preventive care, and educators and students.
The National Guide makes specific recommendations regarding the elements of a preventive health assessment across the lifecycle. The recommendations aim to prevent disease, detect early and unrecognised disease, and promote health in the Aboriginal and Torres Strait Islander population while allowing for variations based on regional and local circumstances. The health status of Torres Strait Islander peoples is very similar to that of the Aboriginal population, and the information in the National Guide can be applied to both population groups.
Why preventive health assessments are necessary
Life expectancy was around 10 years lower for Aboriginal and Torres Strait Islander people in 2010–12 when compared with other Australians.1 There is strong evidence that the delivery of clinical preventive health services, especially within a primary healthcare context, improves health outcomes.2
Access to high-quality primary healthcare forms the foundation for the Australian Government’s National Aboriginal and Torres Strait Islander Health Plan 2013–2023 to improve health outcomes for Aboriginal and Torres Strait Islander people and their families.3 However, there are often missed opportunities for the prevention of chronic disease and associated complications in the Aboriginal and Torres Strait Islander population, and systems to identify if clients are of Aboriginal and/or Torres Strait Islander origin are often variably implemented.4,5
When preventive opportunities are missed, this leads to a higher use of hospital care, which in turn increases health costs. The Aboriginal and Torres Strait Islander population has much higher rates of hospital admission for almost every health problem than other Australians.6
The social determinants of health
Some users have asked us: ‘Why doesn’t the National Guide include a chapter on the social determinants of health?’ In short, the answer is that every chapter guides users to consider the social determinants of health – the conditions in which people are born, live, grow, work and age, and health system factors that may reduce inequities. It is often forgotten that health system factors such as access to appropriate, affordable and acceptable primary healthcare are also social determinants of health.7
These and other social determinants of health are mostly responsible for health inequities – the unfair, unjust and preventable disparities in health status seen between populations. Within the Australian health system, healthcare providers have a responsibility to shape their service provision to overcome barriers to healthcare access, and to enhance, and be accountable for, the quality of care they offer.8,9
Healthcare providers should consider the individual context of their patients, their social history, their biopsychosocial risks, the patient as a person, in order to form a therapeutic alliance and to share power and responsibility. These are the hallmarks of the patient-centred healthcare professional.10 The social determinants of health may be broad and intersectoral,11 but patient-centred healthcare systems ‘can and do yield health equity gains’.7
How to use the National Guide
Using the recommendations
All health professionals delivering primary healthcare to Aboriginal and/or Torres Strait Islander clients should use the recommendations to enhance the clinical care they provide. The National Guide aims to complement the RACGP Guidelines for preventive activities in general practice (Red Book) by dealing with health issues that are specific to the Aboriginal and Torres Strait Islander population.
Cross-referencing with the Red Book
The chosen subject areas in the National Guide represent the key health issues that are amenable to primary healthcare intervention and contribute to morbidity and mortality in the Aboriginal and Torres Strait Islander population. Where issues common in the general Australian population have not been dealt with in this guide (eg urinary incontinence), GPs are encouraged to cross-reference with the Red Book, which is available on the RACGP website. The Red Book is a synthesis of evidence-based guidelines from Australian and international sources and provides recommendations for everyday use in general practice.
Using local guidelines
To optimise preventive health assessments, healthcare providers (particularly in regional and remote areas) are also encouraged to refer to local guidelines where they are appropriate and available. Many of the recommendations in the National Guide describe health problems that may be of concern only in certain regional areas. For example, trichiasis screening is only appropriate for an elderly Aboriginal client who was raised in a trachoma-endemic area (refer to Chapter 6: Eye health). In addition, many recommendations highlight the importance of clinical discretion in decision making. For example, making a decision to apply or not apply a 5% increment to the estimate of absolute cardiovascular risk will depend on the context and specific characteristics of your individual patient (refer to Chapter 11: Cardiovascular disease prevention).
Appraising current preventive practice
Healthcare providers should use the National Guide to systematically appraise current preventive practice, especially where recommendations for the general population have previously been applied to Aboriginal and Torres Strait Islander clients. Providers may also benefit by appraising certain screening activities for which there are ‘Good Practice Points’ (GPPs) – that is, expert opinion–based recommendations but little current evidence. Inappropriate preventive interventions may draw resources away from activities known to improve the health of the Aboriginal and Torres Strait Islander population (eg risk factor modification and immunisation programs).
Identifying your Aboriginal and Torres Strait Islander clients, and why
Implementation of preventive health assessments requires healthcare providers to identify the target population. Research shows that where general practices take systematic action to improve their identification processes, there is a corresponding increase in the numbers of correctly identified patients.5
Identifying Aboriginal and Torres Strait Islander status is a necessary precondition for participating in the Closing the Gap initiative agreed upon by the Australian Government and the Council of Australian Governments in 2008. Without practice awareness, a patient who is of Aboriginal and/or Torres Strait
Islander origin cannot benefit from the various Australian Government measures such as the Practice Incentives Program Indigenous Health Incentive,12 the Pharmaceutical Benefits Scheme (PBS) co-payment measure,13 and specific Medicare rebates for assessments related to preventive health.
All health professionals have an important role in facilitating the identification of Aboriginal and Torres Strait Islander clients. In order for a person to identify as being Aboriginal and/or Torres Strait Islander and accept this being recorded on their medical records, a culturally supportive and culturally safe environment needs to be established and continuously demonstrated.
The RACGP resource for the Identification of Aboriginal and Torres Strait Islander people in Australian general practice aims to help health professionals identify their Aboriginal and Torres Strait Islander clients.14 In addition, the Five steps towards excellent Aboriginal and Torres Strait Islander healthcare provides a simple outline to support practices to offer Aboriginal and Torres Strait Islander preventive health assessments.15
Implementation of preventive health interventions
Most preventive interventions are best delivered opportunistically during clinical encounters in primary healthcare settings. Others are delivered through integrated approaches between primary healthcare providers and other services such as in the planning and delivery of breast cancer screening.
Using multiple strategies
Clinical information systems that support opportunistic screening through electronic reminders and outreach programs, such as the offer of vaccination in non-traditional settings, are proven strategies to enhance disease prevention and health promotion.
A preventive assessment may be undertaken in a single session between client and health provider, which may or may not simultaneously address other concerns the patient may have, or be delivered incrementally over a number of sessions. Whether clinic-based or community-based, systems used to deliver a preventive assessment need to support a holistic assessment of the client in recognition of the interdependence of many risk factors and determinants of disease.
Undertaking the interventions and follow-up
Implementation of a preventive health assessment should be undertaken by healthcare providers who have the capacity to undertake, or to arrange for, appropriate management of any abnormalities found during the assessment. Healthcare providers should always plan to follow up the patient who has had a preventive health assessment. Specific Medicare rebates can assist in this process. Providers should also be aware of the potential psychosocial impact of preventive care, particularly when screening results in the diagnosis of a new condition. Informed consent should be obtained prior to undertaking screening and other preventive interventions, and adequate counselling should be provided when the patient is advised of the result.
For quality assurance, health services may also undertake ‘health systems assessment’ to explore their systems and processes for preventive healthcare. The Kanyini ‘health systems assessment tool’ (adapted from the Wagners Chronic Disease Model for health systems assessment)16 is one example of an adapted Aboriginalspecific tool that can be used with or without a facilitator to explore clinic processes.17
Appropriate health policies
Supportive health policies, such as financial incentives and workforce training, can encourage healthcare providers to offer preventive health assessments. Those who have been screened may also require treatment, and consequently, an effective screening program may increase the demand for care where existing health service resources are already limited. Any plans to reduce premature and excess Aboriginal and Torres Strait Islander morbidity and mortality will require increased investment in health system capacity to manage previously unrecognised diseases.
The RACGP’s Standards for general practices (5th edition) can be applied to assess if a practice can provide tailored information to patients on preventive care, and if it has systems for quality improvement activities.18
Aboriginal Community Controlled Health Services also have contractual obligations to report on national key performance indicators, several of which pertain to preventive healthcare delivery.19 The National Guide can inform the evidence underpinning these indicators, and ensure they are ‘fit for purpose’ to support quality improvement. Indicators should be evidence-based, reflecting research, clinical expertise and patient values. Indicators may also unintentionally restrict clinical decision making if they prioritise the use of certain clinical tools over other equally suitable ones. Other unintended consequences may arise if indicators homogenise clinical decision making without considering the diversity of Aboriginal and Torres Strait Islander peoples and their health needs, thereby undermining patient-centred care.
Medicare rebates for preventive health assessments are available for all Aboriginal and/or Torres Strait Islander people of any age through an annual health assessment. This is possible through the Medicare Benefits Schedule (MBS) rebate item number 715. The National Guide contains advice on almost all elements of the requirements to claim this and many other rebates. Identification of your Aboriginal and Torres Strait Islander clients is essential to enable access to Medicare rebates for preventive health assessments.
The Department of Health has also developed resources that list and provide support to claiming these Aboriginal and Torres Strait Islander–specific MBS items.20 GPs are advised to check the requirements in the current online MBS before claiming these and other MBS items supporting preventive healthcare and follow-up assessments. GPs need to be aware of, and comply with, the requirements of the specific MBS descriptors when providing services.
Primary Health Networks
Primary Health Networks (PHNs) have an important role to play in coordinating the delivery of primary healthcare within their regions. One of six priorities set by the Australian Government is for PHNs to focus on the health of Aboriginal and Torres Strait Islander peoples,21 such as through a strengthened primary healthcare model of care, and preventive healthcare assessments. Healthcare providers can contact their local PHN to receive service support for the delivery of preventive health assessments.
The National Guide is available on the NACCHO and RACGP websites.