10 years of preventive health in Australia. Part 3 – engaging primary health care

In Australia, primary care providers, including general practitioners (GPs), are responsible for the provision of a diverse range of preventive care across the life cycle including immunisation; early detection of cancers (especially cervical, breast, colon and lung) and genetic conditions; prevention of mental illness, injury and musculoskeletal disorders; and assessment and management of reproductive and women’s health, cardiovascular disease (CVD), diabetes risk, overweight and the SNAP behaviours (Smoking, Nutrition, Alcohol and Physical Activity).^1,2 There has been increased involvement of practice nurses, allied health providers and pharmacists over the past 10 years, especially in immunisation and assessment of cardiovascular and diabetes risk.

Primary care provides a unique opportunity to reach the majority of the Australian population with preventive care. For example, about 86% of the population attend their GPs and 40% attend an allied health provider each year.³ GPs’ role in prevention is well accepted, with most patients seeing them as trusted sources of information and wanting their providers to talk with them about lifestyle behaviours such as diet and physical activity.^4,5 These roles require a broad range of skills and are enhanced by continuity of care to ensure appropriate follow-up and, where appropriate, pathways for referral, all of which are strengths of general practice.⁶ However, because of funding and system barriers, the frequency of provision of advice or referral to behavioural interventions has been relatively low, and there is more evidence for the effectiveness of primary care providers in assessing risk than in providing interventions that improve health outcomes.^5,7–9

Despite policy statements from the government over the past decade supporting the role of primary care in prevention, there has been increasing evidence of systemic and attitudinal barriers to implementing preventive care in primary care including availability of time in consultations and the capacity of the primary care workforce, especially in rural areas.^10,11 Referral pathways to preventive interventions have remained poorly developed both towards secondary and tertiary care and to community resources.^12,13 Low socio-economic groups, people living in remote rural areas and those with low health literacy continue to have poor access to preventive care.¹⁴

In response to these barriers, several initiatives including the use of information technology have been developed over the past decade. The Royal Australian College of General Practitioners has been funded by the Commonwealth Government to develop and implement a behaviour change intervention, ‘Healthy Habits’, to support patients to make lifestyle changes. This includes a mobile app to support goal setting and monitoring of diet, physical activity and sleep, with an online dashboard that allows GPs and practice nurses to monitor and communicate with patients outside the consultation.¹⁵ It also links with community referral pathways such as local Heart Foundation walking groups.¹⁶

My Health Record allows the sharing of information between consumers and providers about some aspects of preventive assessment and management (e.g. immunisations).¹⁷ A new risk assessment tool guiding decisions about the management of physiological and behavioural risk factors for CVD has been developed, although it has not yet been integrated into most primary care information systems.¹⁸ During the COVID-19 pandemic, many primary care activities were delivered via telephone or telehealth, although only a limited range of preventive activities could be delivered in this way.¹⁹ Telehealth is still being used to support the cardiac rehabilitation of patients living in rural Australia.²⁰

The collection of data on preventive activity has been a critical gap in monitoring the impact of preventive policy in primary care. The Australian Institute of Health and Welfare (AIHW) has begun to develop a National Primary Health Care Data Collection that will aggregate and analyse data from general practice collected by Primary Health Networks (PHNs) across Australia. It is already collecting and analysing national quality improvement data collated by PHNs that includes recording of smoking status, height, weight and body mass index, influenza vaccination, alcohol consumption, CVD risk factors and cervical screening.²¹ These data allow better analysis by PHNs of the uptake of preventive activities in each locality and for different population groups so that they can address gaps through quality improvement and targeted programs. However, these have limited levers for change, and in other countries such as the UK, performance incentives have been used, with some effect, to improve population outcomes from preventive activities in primary care.²²

MyMedicare is a voluntary patient registration system introduced in 2023 that aims to formalise the relationship between patients and their primary care teams, potentially facilitating better continuity of care and providing the basis for some performance incentives. Although the initial focus is on patients with chronic conditions, it has the potential to improve multidisciplinary team care and access for children, pensioners and concession card holders and thus facilitate outreach to improve uptake of preventive care for registered patients.²³ However, it will be important to monitor health inequities that may arise. In New Zealand, 6% of the population is not enrolled in primary care and misses out on preventive care.²⁴ Māori and those living in less affluent areas have the lowest enrolment rates.

There are increasing workloads and workforce pressures in primary care, and these are major barriers to the implementation of preventive care. Peer health workers and community health workers are an emerging strategy in Australia for preventive care in primary care, providing care navigation, support for patients to access screening and referral pathways to community services and programs. These have been demonstrated to enhance access to preventive care, especially for culturally and linguistically diverse patients.^25,26 They also played an important role during the COVID-19 pandemic in supporting access to immunisation. However, they are yet to be incorporated into the health system at scale.

Primary care remains an important setting for prevention in Australia. However, implementation requires more than policy statements. It requires strategies to address the system barriers to uptake and effectiveness including funding. This is particularly important if disadvantaged groups are to access the preventive care they need to achieve better outcomes.