Doctors have significant opportunities to provide preventative care

Doctors, particularly general practitioners, provide long-term and continuous care to many patients, and often develop an ongoing relationship with them which can lead to an increased sense of respect and trust. Doctors are not only aware of their patients’ medical conditions and concerns, but also very often the circumstances of their lives, and that of their families. Nearly ninety percent of all Australians visit a general practitioner at least once a year¹. These factors make doctors pre-eminent in identifying the presence of risks to individuals’ health, as well as the particular factors in their lives that contribute to those risks.

Preventative care is a regular feature of doctor-patient consultations

For doctors, preventative care is core business. General practitioners, in particular, routinely incorporate prevention into their patient consultations as part of providing comprehensive ‘whole-of-patient’ health and medical care. An estimated 20.5% of all clinical treatments provided by general practitioners in 2008-09 involved types of health advice, education and counselling that could be considered preventative². As a matter of course, doctors will actively screen and be constantly alert to risk factors for chronic conditions. In each year from 2000 to 2006, nearly 10 million patient encounters involved general practitioners providing preventative advice and counselling³.

The forms of preventative care that doctors regularly provide include:

• Immunisation at all appropriate stages in the lifespan;
• Screening and early identification for:
  • healthy child development;
  • communicable diseases, particularly for teenagers and at-risk groups, and
  • chronic conditions, including hypertension, diabetes, cardiovascular conditions and mental health, as well as promotion of screening for certain cancers.
• Preventative advice and counselling about general health and specific health risks which is targeted to the patient’s age, gender, family history and current health status;
• Educating patients, improving health literacy and improving patients’ capacity to maintain their own health.

There is no ‘one-size fits all’ prevention consultation that doctors can provide to all their patients. Individuals will differ in the seriousness of the problem they confront, and in their motivational state, readiness to change, and receptivity to advice. Individual patients will also differ in whether they need follow-up and continuing advice, support and care. The circumstances under which an issue requiring preventative care and advice arises in a consultation will also differ. Sometimes these risk issues will be the key patient concern, and will be raised early in a consultation. At other times, they will be issues that are addressed incidentally and opportunistically in a consultation that is about another matter, perhaps toward the end.  Doctors have the skill and awareness to respond flexibly to these changing circumstances.

Doctors coordinate preventative care

Not only do doctors provide preventative care directly to their patients, they also play a central role in coordinating the preventative care that patients may need from other health care professionals. Doctors have a sound understanding of when to refer or recommend further action to their patients. Referral by a GP to specialist medical practitioners or allied health professionals can have positive impacts on the effectiveness of early detection outcomes. Referring doctors also have access to reports and feedback from a patient’s consultant specialists and allied health consultants, and synthesise these to recommend further courses of action.

Doctors play significant roles in prevention beyond the consultation context

Doctors command a high level of respect and credibility in the eyes of the public. This gives doctors the opportunity to promote good health and prevention in the broader community. Preventative health messages in public media and education campaigns will be reinforced when doctors provide them or when they are endorsed by the doctors’ peak professional association. This reassures the public that these messages and campaigns are evidence-based.

Doctors can also play a role in highlighting the social, economic and environmental factors that can lead to health risks and poor health outcomes for individuals or groups of people.

Many doctors engage in ‘outreach’ initiatives in prevention and health promotion such as Dr Yes and Youth Friendly Doctor programs.  These programs involve doctors or medical students visiting schools to provide information and advice about a range of health issues relevant to young people. Other doctors routinely visit locations frequented by at-risk groups who may not regularly visit doctors, such as middle aged men, and provide preventative health information and advice. Many doctors’ practices also provide group education sessions for patients on risks to health and on maintaining good health.

The preventative care doctors provide is effective, reduces demand on the acute care system and pressure on rising health care costs

Immunisation is significant among the preventative care measures that doctors provide. There is ample evidence that immunisation is very effective in controlling the spread of communicable diseases. Doctors are often at the forefront in administering population screening programs for conditions, such as certain cancers, and for identifying the early signs of diseases and chronic conditions in their individual patients. The earlier the detection of these diseases and conditions, the better the chance of positive outcomes from treatment and reducing the potential costs to the health care system of treating these diseases. Indeed, when risk behaviour and incipient conditions are detected early and addressed, this reduces a need for the acute care that would otherwise inevitably arise later.  

A considerable amount of the preventative care that doctors provide is in the form of patient advice, counselling and information. There is substantial evidence that brief counselling interventions and referral is effective⁴. For example, very brief advice from a GP to quit smoking results in a 2-3% increase in quitters after one year, and this can be increased with active follow-up. The evidence-base for the effectiveness of brief interventions for hazardous alcohol consumption is also credible. For example, a five minute session of advice about hazardous drinking can produce a significant reduction in alcohol consumption⁵. There is also some evidence of short-term effectiveness of brief GP advice (coupled with provision of literature resources) in patients’ weight reduction⁶, and indications that GP advice and monitoring of exercise regimes can have an effect⁷.  

The effectiveness of all these forms of preventative care is dependent on doctors having the most up to date information and best-practice guidelines. The potential benefits of doctors in preventative care will also be maximised when individuals have the right level of health literacy to know when to see a doctor. This capacity for health awareness needs to be built across the entire population, including among Indigenous Australians.

THE AMA POSITION

The opportunities that doctors have to provide effective preventative care need to be supported and continually strengthened. The AMA considers the following proposals to be important in this regard.

Screening and Immunisation

• The AMA affirms the value of national screening programs for the early detection of diseases which pose a significant threat to health at a population level.
• Medical practices play a central role in health screening and immunisation, particularly GPs who either conduct or supervise the provision of screening and immunisation. This important role should be fully recognised when national screening and immunisation programs are planned and implemented.
• The AMA supports childhood immunisation in accordance with National Health and Medical Research Council recommended schedules as a prerequisite to school entry, unless there are medical contraindications.
• Written consent should not be considered a prerequisite to immunisation.
• The AMA is committed to working with governments and agencies involved in the care of children to ensure the universal uptake of childhood immunisation.

Information and Resources to Support Prevention in Medical Practices

• Preventative care can be more strongly integrated into medical practice through:
  • dissemination of best-practice information to doctors about the most effective forms of intervention in a routine clinical setting for different health risk factors; and different population groups such as adolescents and youth;
  • the packaging of information and guidance on conducting brief interventions into printed and on-line resources for doctors’ use in clinical settings, together with materials (eg. literature) for patient use;
• Doctors’ skills and effectiveness in providing best-practice counselling and patient education could be supported through stronger incorporation into medical training of counselling skills and screening techniques, and the ongoing availability of continuing professional development in these. This training should include practical components.
• Improved information about, and linkages to, referral services and therapists in local areas for preventative follow-up should be more available to doctors. Reliable information about the effectiveness of popular schemes and self-management programs in health prevention (eg., Weight Watchers) should also be made more available.
• Funding should be improved for medical research directed at the basic causes of diseases, and how to limit complications, damage and disability from established diseases.
• The educational goals of all medical schools should include the teaching of broad concepts of health, health education and the prevention of ill-health.

Supporting doctors’ community and outreach preventative care

Some of the population groups that would most benefit from early intervention for health risks are under-represented in patient populations. These include adolescents and teenagers, who are susceptible to a range of harmful risk behaviours, including substance abuse.

• Targeted efforts are needed to normalise and reinforce the value of routine doctor attendance among teenagers, young adults, and at-risk or marginalised groups. These efforts could include public awareness campaigns and information provision in schools;
• Medical professionals should be supported to develop new, and extend existing, outreach prevention initiatives in the community, targeted for at-risk population groups, including youth and men;
• Public education and mass media campaigns conducted by governments on health prevention should recommend, where appropriate, that the public should seek further advice from a medical practitioner. Doctors should also play a role in quality assuring these campaigns, to ensure they are appropriately evidence-based.
• The promotion of health and the prevention of disease should be express goals of all health services, and most particularly, of doctors.
• Medical practitioners have a duty to encourage individuals to bear some responsibility for maintaining their health.

Flexible funding support for patients

• Funding arrangements for patient rebates should reflect the fact that there is no ‘one-size fits all’ type of patient consultation suited to effective preventative care. Funding should allow for the flexible and efficient provision of preventative care in medical practice. For example, there should be MBS patient rebates for services provided by medical practices undertaking group educational and preventative health sessions.

AMA PUBLIC HEALTH & CHILD AND YOUTH HEALTH COMMITTEE, 2010

References

1. General Practice Activity in Australia 2008-09. C. Bayram. H. Britt, et. al., AIHW, 2009.
2. General Practice Activity in Australia 2008-09. C. Bayram. H. Britt, et. al., AIHW, 2009.
3. “Preventive Activities in General Practice”, Helena Britt, GP Review May 2007.
4. Putting prevention into practice. Guidelines for the implementation of prevention in the general practice setting. Royal Australian College of General Practitioners, 2006.
5. “The long-term effectiveness of brief interventions for unsafe alcohol consumption: a 10-year follow-up”, Wutzke, S., et. al.,  Addiction 97(6), 2002 pp. 665-675.
6. Literature Review to Reduce the Burden of Harms from Poor Nutrition, Tobacco Smoking, Physical Inactivity and Alcohol Misuse,  Dalziel, K, et. al., 2006 Centre for Health Economics, Monash University.
7. See for example, ‘Half of patients given exercise prescriptions are more active”, British Medical Journal 337, 2008.