Preventive Medicine in General Practice
Preventive medicine focuses on the prevention of illness, promotion of health and prolongation of life. GPs have a crucial role in all three processes and, because half the mortality from the 10 leading causes of death in the UK can be traced to lifestyle and behaviour, preventive medicine is of utmost importance.
Many GP consultations are for relatively minor ailments which create opportunities to discuss healthy living and the early detection of illness. Also, the trust that builds within the doctor–patient relationship over time allows GPs to motivate their patients to change their behaviour in order to maintain good health. GPs do not work alone here – the entire primary care team, including practice nurses, midwives and health visitors, is geared to promoting health in their patients and local community. In addition, GPs work alongside public health specialists to prevent illness at a community level, which requires a broad knowledge of the socio-economic characteristics and disease epidemiology of their local practice population.
Primary Prevention
This is the prevention of the onset of disease and can also be termed health promotion – defined by the WHO as ‘the process of enabling people to increase control over their health and its determinants, and thereby improve their health’.
GPs have an active role in promoting health in their day-to-day practice, and some examples of health promotion are summarised in Figure 5. Cardiovascular disease accounts for a huge proportion of primary care morbidity and mortality and GPs have a key role in preventing (or delaying) its development. Population strategies include anti-smoking campaigns, promotion of physical activity and dietary advice to reduce obesity and individual strategies are summarised in Figure 5 (see also Chapter 37).
Secondary Prevention
This is the detection and management of disease in its earliest stages or the detection of asymptomatic disease – which is also known as screening. In general practice, screening takes place on two levels.
Opportunistic Screening
Individual asymptomatic patients are screened on an informal or ad hoc basis in clinic. Examples include:
- Registration ‘health checks’ of new patients which measure body mass index (BMI), blood pressure, urinalysis, smoking status and alcohol consumption.
- Annual review of patients on chronic disease registers such as diabetes or ischaemic heart disease, which involves screening for disease complications and depression.
NHS Population Screening Programmes
Screening involves targeting apparently healthy people and offering them information to make informed choices about undergoing tests for specific diseases, while causing the least harm (see Figure 5 for NHS screening programmes).
Before embarking on a screening programme, there are a number of criteria to be met – these are known as Wilson’s screening criteria:
- The condition should be an important health problem
- The epidemiology and natural history of the condition should be well understood
- There should be a detectable risk factor, disease marker or early asymptomatic stage
- There should be a simple, acceptable, safe, precise and validated screening test
- There should be an accepted treatment for the disease and this should be more effective if started early
- The risks of the screening programme, both physical and psychological, should be less than the benefits
- Diagnosis and treatment should be cost-effective
- Case-finding should be a continuous process and intervals for repeating the test should be agreed.
Even if these are met, screening still has its limitations. No screening tool is perfect – there will always be false positives and negatives, which means that while the screened population as a whole benefits, a few patients with the disease will slip through the ‘screening net’ (false negative) and some healthy patients will be wrongly suspected of having the condition (false positive). GPs need to be familiar with these concepts and make sure patients have realistic expectations of what the screening programme can deliver.
Tertiary Prevention
This is the halting of the progression of already established disease. In conjunction with their secondary care colleagues, GPs have a prominent role in tertiary prevention of disease. This involves ‘optimising’ risk factors in patients with pre-existing disease – for example, ensuring that all patients with ischaemic heart disease are taking aspirin and encouraging them to stop smoking.
Quality and Outcomes Framework
The government has introduced measures to incentivise GPs to participate in prevention programmes. In England, this was formalised by the introduction of the Quality and Outcomes Framework (QOF) in 2004, in which GPs are paid for meeting a range of performance targets.
QOF aims to promote evidence-based medicine, standardise the delivery of primary care and reduce health inequalities. It accounts for about 25% of general practice income. It is divided into a number of indicators, against which practices score points according to their level of performance and disease prevalence. The higher the score, the larger the financial reward for the practice.
QOF has four main components:
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