Community Awareness and Lifestyle Infrastructure Prescriptions Focus on Prevention

INTRODUCTION .....................................................................................................................1

KEY THEMES AND LEARNING POINTS ............................................................................2

Lifestyle prescriptions: forms ............................................................................................2

Lifestyle prescriptions: processes ......................................................................................3

Lifestyle prescriptions: training .........................................................................................3

Lifestyle prescriptions: infrastructure and support ............................................................3

Lifestyle prescriptions: target populations.........................................................................3

Lifestyle prescriptions: the referral process.......................................................................4

Lifestyle prescription: implementation issues ...................................................................5

Lifestyle prescriptions: the role of the practice nurse........................................................6

Issues and priorities............................................................................................................6

Challenges to implementation of lifestyle prescriptions: The New Zealand example ..............7

What is a lifestyle prescription?.................................................................................................8

What training and resources are required to implement lifestyle prescriptions successfully

within a practice? .......................................................................................................................9

How do we optimise the use by general practice of the tools and resources required for

implementing lifestyle prescriptions? ......................................................................................11

General practice and the referral process.................................................................................13

How do GPs incorporate lifestyle intervention in the patient consultation? ...........................15

Monitoring, evaluation and additional issues for consideration ..............................................17

Appendix A: List of Workshop Participants............................................................................19

Appendix B: Agenda................................................................................................................21

Appendix C: Presentations.......................................................................................................23

Rachel Balmanno.....................................................................................................................23

Nancy Huang ...........................................................................................................................29

Sonya Tremellen ......................................................................................................................32

Mark Harris, Professor of General Practice, University of NSW............................................35

John Litt, Senior Lecturer, School of Medicine Flinders University.......................................38

Appendix D: Commonwealth Model.......................................................................................39

39

GP General Practitioner

IM Information Management

IT Information Technology

JAG Joint Advisory Group

NGO Non government organisation

NHMRC National Health and Medical Research Council

SBO State Based Organisation

SPARC Sport and Recreation New Zealand

SNAP Smoking, Nutrition, Alcohol and Physical Activity

Preventive care is becoming the focus of health care systems both nationally and internationally. In Australia, the release of the Commonwealth’s Focus on Prevention package reflects this growing trend to provide consumers with preventive health care. The Focus on Prevention package was introduced in the 2003-04 Federal Budget, with the aim of shifting emphasis within the health system away from managing the consequences of illness and disease towards disease prevention and health promotion.

The Focus on Prevention package has three components:

The Community Awareness and Infrastructure initiative will seek to raise awareness of the role of health professionals in prevention. The Primary Care Providers Working Together initiative will support small teams of primary health care providers to come together to identify and act on opportunities to reduce lifestyle risk factors, and maintain good health for their patients with chronic conditions. The development of a priority setting mechanism for prevention is a cost-neutral component of the package that will assess the relative efficiency of a range of alternative disease prevention interventions to better inform decision-making.

A major component of the Community Awareness and Infrastructure initiative is the move to

build a national approach to lifestyle prescriptions. Lifestyle prescriptions are tools to be

utilized by general practitioners (GPs) to identify and manage health risk factors in their

patients. Targeted risk factors include smoking, being overweight or obese, poor nutrition, the

misuse of alcohol and a lack of physical activity. Lifestyle prescriptions aim to assist GPs to

set goals with their patients and provide advice and support to address risk factors. Similarly,

lifestyle prescriptions will enable GPs to prescribe patients with preventive actions to lower

the risk of, and support people with, chronic disease and illness.

Lifestyle prescriptions complement a number of other existing activities, initiatives and

working groups. These include the National Obesity Taskforce, the review of the Divisions of

General Practice, the work of the National Health Priorities Action Council and the

Australian Chronic Disease Prevention Alliance, and the recommendations of the Red Tape

Taskforce. In particular, a major support structure for lifestyle prescriptions is the Joint

Advisory Group’s Smoking, Nutrition, Alcohol and Physical Activity Framework for General

Practice (JAG/SNAP Framework).

The introduction of lifestyle prescriptions is being progressed through the Australian

Government’s Focus on Prevention package. Initial research focused on similar state and

international initiatives. These provided suggestions for the structure and form of lifestyle

prescriptions, and highlighted likely implementation issues. The next step in the roll out of

lifestyle prescriptions was the National Lifestyle Prescriptions Workshop (Canberra, 26-27

November 2003).

The aim of the workshop was to seek information and advice from key stakeholders

regarding the national implementation of lifestyle prescriptions. The workshop achieved this

by bringing together stakeholders and providing them with an avenue for sharing experiences

and expertise regarding similar projects that exist and which may inform or impact on the

development of lifestyle prescriptions. The workshop also provided a forum for the

discussion of issues, barriers and challenges that need to be considered in the initiative. A

major objective of the workshop was to inform implementation of lifestyle prescriptions in a

manner that builds on existing activities and infrastructure, in recognition of the financial

parameters around lifestyle prescriptions.

The workshop brought together a full range of expert stakeholders to inform the

implementation of lifestyle prescriptions. The range of participants included (but was not

limited to): representatives from similar international and national initiatives, Commonwealth

officers, representatives of consumer and practitioner groups, and academic informants (the

full list of workshop participants is included in Appendix A). The two-day workshop

consisted of a series of presentations, followed by small group and plenary discussions

guided by key discussion questions. The agenda for the workshop, including discussion

questions, is included in Appendix B.

This report reflects the views expressed by participants of the workshop. The outcomes of

the workshop discussions are reflected in this report, however the report is not an Australian

Government position and does not bind the Department or any participants of the workshop

to any particular course of action.

Key themes and learning points from the workshop have been summarised below.

with some suggestions for change. These changes have been noted below.

local delivery level.

Flexible models are needed for different risk factors that remain linked with each other.

multi-disciplinary professionals (nutritionists, psychologists, practice nurses).

self-administered (for example, in the patient waiting room).

then be used as part of the evidence base and can be reflected back to GPs as evidence for

the efficacy of the program.

processes. For example, both paper and computerised prescription mechanisms should be

available.

own time).

governments, non-government organisations (NGOs), state based organisations (SBOs),

divisions of general practice etc.

kept as simple as possible and do not add a further process burden on General

Practitioners.

of issues. In particular, there is a need to differentiate between population level effects

and individual effects.

groups, for example, Aboriginal and Torres Strait Islander people.

- For example, the name ‘lifestyle prescriptions’ implies that consumers can make the

necessary changes to their lifestyle because they have lifestyle choices. Social and

structural inequities mean that some groups do not have access to as many options for

a healthy lifestyle.

- Need to develop a generic program that can be tailored to ‘at risk’ groups. The point

was made that these programs could build on existing programs (for example, the

Indigenous Well Person’s Health Check).

- Need to ensure that referral sources are affordable for the consumer.

practitioners can refer only when the services are there, and are of high quality.

the type of risk factor, the level of risk, patient’s readiness for change and patient

preferences.

and GP capacity to refer (knowledge, skills ability).

established - for example, service directories, engagement of divisions, use of social

marketing campaigns.

ethical principles).

- Funding and infrastructure blocks.

- Lack of role clarity / failure to engage GPs.

- The potential to overwhelm both GPs and referral providers with sudden influx of

patients.

- Special issues for remote populations and socially disadvantaged populations (access,

affordability etc).

- Concerns about accessibility, affordability, availability and quality of services.

- Need to build capacity of divisions to facilitate the system surrounding lifestyle

prescriptions.

- GP concerns about losing their patients. Some participants noted that GPs may be

reluctant to refer their patients to other professionals, for fear they may potentially

lose a patient whose problem may suitably be addressed in a general practice setting.

Similarly, it was noted that GPs may be uncomfortable referring their patients on to

an unknown provider, due to uncertainty regarding their skills and the quality of care

that would be provided.

- Map service capacity, define and map pathways and partnerships. Evaluate these

referral networks and use this information as feedback for stakeholders and for further

refinement of the pathways/networks.

- Use divisions as advocates and as collaborative links between the local, state and

national level (NGOs, SBOs, government, consumer reps).

- Engage allied health professions (including ensuring that they are adequately funded).

- Increase awareness raising in community and professional groups.

- Work with existing programs; ‘think laterally’.

- Define roles: NGOs, SBOs, government, consumer representatives.

- Improve role definitions at the practice level, especially the role of the practice nurse.

- Improve information sharing between referral networks.

raised were:

- Learn from existing interventions (for example, smoking cessation).

- Incorporate findings of Red Tape Taskforce.

- Recognise that at high level of risk may point to need for intervention by a clinical

psychologist or psychiatrist, while low levels of risk may be manageable by the

general practitioner. Need to equip GPs with knowledge to recognise this.

- Seek to build infrastructure and support mechanisms for sustainability (including

demand management).

were:

- Work is needed at local/state/national level to develop allied health and

multidisciplinary referral destinations.

- Challenge is to link separate risk factors together and with other relevant initiatives.

- Need to create a balance between planning and action. Whilst careful planning is

needed, there is a danger in losing momentum and support etc.

- Attention needs to be given to system development. For example, simultaneous

development of individual practices, the divisions of general practice and other

involved organisations. It was suggested that state based planning initiatives involving

the full range of stakeholders would ensure integration and sustainability. Need to

develop partnerships, training, networks and workforce.

pathways for practice nurses, in order to facilitate the roll out of lifestyle prescriptions.

practice nurse into the key areas of clinical care, clinical organisation, practice

management, integration/liaison and support for the referral process.

nurse has the potential to impact on (as well as the GP).

At the end of the workshop, the key issues and priorities for action were outlined:

- The development and/or the dissemination of national tools including where

necessary the testing of any new tools. These tools are to be wherever possible

computer-based, able to be progressively integrated with existing practice and

Aboriginal Medical Service software and with the capacity for self-administration by

consumers.

- The development of a specific targeted approach for Aboriginal and Torres Strait

Islander populations linked with the Well Person’s Health Check.

- Capacity development in the Divisions to support the rollout of lifestyle prescriptions.

This will include networking and other opportunities to support Divisional staff and

showcase success.

- State and Territory level negotiations to support the rollout of lifestyle prescriptions.

- Awareness raising at all levels.

- Developments should not widen existing inequalities in health status.

- The importance of acting in concert with and/or influence other Commonwealth, State

and Territory and Local Government programs in the interests of developing the

infrastructure to support lifestyle prescriptions.

Implementation of activities should seek to give priority to those populations at most risk.

Green Prescriptions, the New Zealand equivalent to lifestyle prescriptions, is a tool to

improve the general health and wellbeing of New Zealanders, and helps to increase levels of

physical activity in a section of the population considered by GPs to be ‘inactive’. An

overview of the program was presented at the workshop by Ms Diana O’Neill, Senior Policy

Advisor (Health), Sport and Recreation New Zealand (SPARC). (The full presentation is

included at Appendix C.)

The impetus for the program came from the need to target the 30% of the New Zealand

population who are inactive, with the expectation that it will impact upon the level of related

risk factors. Green Prescriptions is a program run via the regional sports trusts, in which an

area manager provides patients with motivational counselling and advice over the telephone,

after an initial consultation with a health professional. The presentation focused on how the

program evolved as various challenges were overcome. After a brief description of the

program, a number of key barriers, and responses to these, were described. The key

challenges described were:

market

prescriptions

sources

health system.

In the plenary discussion that followed, a range of key points were raised:

system has decreased the time taken by GPs to issue a prescription from 5-7 minutes to

about 2 minutes.

Lifestyle prescriptions diverge from Green Prescriptions in that it will seek to work

within existing resources and supports, rather than attract new funding.

manner in implementation of lifestyle prescriptions, rather than only in the evaluative

stage, as in the case of Green Prescriptions.

decreases. Similarly, face to face and group support emerged as more effective than

telephone support in the roll out of Green Prescriptions.

support. Other people with Green Prescriptions may not require support, or may not have

acted on the script.

passed on to a support worker.

Using the Green Prescriptions as a preliminary structure, the participants discussed key issues

surrounding potential forms of lifestyle prescriptions. A few key issues surrounding the

definition of a lifestyle prescription were presented to contextualise the discussion:

offer greater flexibility for GPs and their patients. A linked format for each prescription

would be necessary to allow continuity of prescribing across risk factors.

the GP, a lifestyle prescription will be a process of assessment, advice, information and/or

referral that encourages and supports the management of behavioural risk factors in a

general practice setting.

discuss, written recommendation for action, information, refer.

existing programs and tools and provide information and resources to facilitate

opportunistic intervention by GPs, where appropriate.

The plenary discussion that followed focused on the following points:

The key decisions raised in the group discussions are presented below:

with some suggestions for change. These changes have been noted below.

delivery level should be devised.

JAG/SNAP Framework, Active Script, Enhanced Primary Care packages, Practice

Incentive Payments and Service Incentive Payments).

with each other.

multi-disciplinary professionals (nutritionists, psychologists, practice nurses) need to be

engaged in developing these networks.

and referrals, but of a level of patient support as well.

raise awareness, workforce development activities and organisational development

activities.

technological capabilities (IM and IT) at general practice.

few simple, brief prescription and assessment tools. It was suggested that selfadministered

assessment tools could be considered (for example, available in patient

waiting rooms).

prescriptions, including incentives, role clarification (that is, GPs should not be seen as

experts in the management of all the risk factors), and attention to issues of role overload

(for example, there is a need to ensure that the final model incorporates a brief

intervention that ideally takes up no more than 1-3 minutes of consultation time).

individual level (that is, consumer awareness raising activities accompanied by support

for individual patients).

prescriptions at all levels. There should be coordination of the roles of the

Commonwealth and State and Territory governments, NGOs, SBOs, private sector

organisations, consumer organisations and the Divisions of General Practice. This

includes clear funding and accountability structures.

range of general practice environments, including metropolitan, regional, rural and

remote settings.

local and national level was seen as critical to the success of the initiative. Risk groups

need to be targeted to ensure that the initiative reaches them and does not further

marginalise socially and economically disadvantaged groups. Particular attention needs to

be paid to developing options for consumers who cannot afford the cost of the service

they are referred to and for Indigenous groups.

stages in the design, implementation and evaluation of the program.

sustainable.

of points during the workshop. It was agreed that a decision must be made as to what the

ratio of ‘successful’ to ‘unsuccessful’ patients constitutes an acceptable cost-benefit ratio.

Building on suggestions for possible structures and forms for lifestyle prescriptions, training

and resource issues were considered. The Victorian Active Script program, outlined by

Ms Nancy Huang, Assistant Director of the Victorian Council of Fitness and General Health,

provided a context for this discussion. (Appendix C includes the outline of her presentation.)

The Active Script program took a broad view of ‘education’ in trying to change practitioner

behaviour, using a multifaceted approach. Education strategies were designed to align with

the principles of adult learning models. That is, information should be useful and relevant,

techniques should be experiential and self-directed, and training should be contextualised in

the practice environment. Practice visits, GP health sessions, follow up phone calls,

assessment tools and prescription tools were the most successful training and resources

provided to GPs in the roll out of the program.

The group discussion that followed considered:

The issues raised in the discussions that followed:

practice. This could incorporate case based learning.

back to all the interested parties. Outcomes should be differentiated according to state

level and national level data, and outcomes salient to different organisations and systems.

clarified as part of the training needs analysis.

take place.

training, with particular attention to defining which clients should be referred, and

delineating how referrals should take place.

development initiatives, with a view to incorporating lifestyle prescriptions training in

undergraduate, postgraduate and continuing education programs.

techniques, education for other service providers regarding general practice systems (and

vice versa).

could increase the sustainability of the program.

professionals.

capacity at a practice level.

should be subsequently designed to meet their needs.

difficult to reach, both in terms of low readiness for change and geographical isolation.

guided by the goals of standardisation and quality. In particular, it was suggested that the

stages of change model would be useful when designing assessment tools, and

consideration should be given to self-administered assessment tools.

undertaken. This will avoid redundancy and reduce costs.

suggested that support should be available electronically.

visits should be considered.

Physical Activity guidelines, Royal Australian College of General Practice guidelines,

(National Health and Medical Research Council (NHMRC) Alcohol Guidelines and

existing dietary guides.

assessment tools.

training and resources.

organisations).

prioritised.

The Active Script program was also used as a framework to discuss the optimal use by

general practitioners of the tools and resources required for the implementation of the

lifestyle prescriptions initiative. Ms Sonya Tremellen, Population Health, General Practice

Division of Victoria, advanced a number of imperatives (see Appendix C for the full

presentation):

The key tension in this respect is whether to focus on a disease or the individual. It was

noted that funding sources are likely to be more targeted to specific diseases, rather than

risk factors in individuals.

whatever extent is needed for them to adopt the advice offered by the GP. It was

suggested that the enabler could sit at the division level, to ensure that the GP doesn’t lose

their patient.

exist.

A number of strategies are available for the roll out of lifestyle prescriptions, but the focus

should be on choosing strategies that will build a sustainable program. Key success factors

for building sustainable programs include a strong policy platform, compelling clinical

evidence, compelling business case, GP champions, capacity in the Divisions, and capacity in

practices.

The group discussions that followed considered:

lifestyle interventions?

Key issues raised were:

Medical Benefits Scheme) would improve uptake of the program.

the program.

data being distributed to all stakeholders.

the program; capacity building activities need to occur to support this role.

communication whenever possible. Similarly, the program should be named appropriately

so that it doesn’t appear to be an extra burden.

initiative and how these are being addressed, as well as GP achievements.

The workshop also included discussion of issues surrounding the implementation of the

referral process in general practice settings. A major component of lifestyle prescriptions is

the referral of high-risk patients onwards to specialised health professionals.

Professor Mark Harris, (Professor of General Practice and Director of the Centres for Primary

Health Care and Equity Research in the School of Public Health and Community Medicine,

University of NSW) spoke about general practice and the referral process in reference to the

SNAP risk factors. According to Professor Harris, a number of factors facilitate the referral

process: GP knowledge of the service and the referral provider, low patient cost, ease of

communication and report back. Professor Harris then outlined an approach for both practices

and the divisions for implementing the referral process at five levels – planning, teamwork,

systems, links, and evaluations. (The full presentation has been included in Appendix C).

The discussion session focused on:

Key points raised in the following discussion were:

service environment must have a number of credible, high quality service providers

available.

whether to refer. The level of risk depends on the risk factor (for example, drug use may

be more problematic than smoking).

should be devised in collaboration with the patient. Collaboration with the patient should

include an assessment of the patient’s readiness for change, available resources and

perceptions of stigma associated with their risk factor.

for patients for which this is suitable.

work within the existing funding and infrastructure at all levels (national, state and

territory, divisional and practice).

the patient and GPs.

geographically isolated groups.

professionals.

to implement referral pathways.

pathways.

improve synergy between national, state/territory and local governments, NGOs, SBOs,

private organisations and consumer groups.

professions were funded under the Medical Benefits Scheme.

face should be generated.

services.

A major potential barrier to the successful implementation of lifestyle prescriptions is the

concern that GPs will not have enough time to incorporate lifestyle prescriptions into patient

consultations. Dr John Litt, Senior Lecturer, Department of General Practice, Flinders

University, spoke about how General Practitioners can incorporate lifestyle intervention in

the patient consultation (the presentation has been included in Appendix C).

Dr Litt suggested that effective implementation strategies can be structured within a

CREATIVE framework – Coordinated, Receptive, Effective, Ability, Targeted, Iterative

cycles, Values, Efficient. Key roles for the practice nurse include education and informing

patients, counselling and advice, identifying SNAP risk factors, follow-up, ensuring

appropriate tools are available to conduct assessment and management, linkages and quality

improvement. The key message of Dr Litt’s presentation was that for GPs to be able to

incorporate lifestyle interventions into the patient consultation they need to be within a one to

two minute timeframe.

Group discussion was sought to answer:

in a consultation?

The key issues raised in the plenary discussion were:

greatly help implementation.

available workforce within the health system need to be considered.

interventions and to recognise they will not be the same as those faced by GPs. In rural

areas there is a reasonably high uptake of Practice Nurses, but little evidence that they

will provide lifestyle interventions. A proposed solution is to ensure practices make

internal roles clear - for example, by making lifestyle prescriptions an explicit part of the

practice nurse role.

training stream. Although a fair amount of training is now given in content areas, very

little systematic training is provided in how to build the required support for

implementation (practice systems). Training should be driven by need and not by what

people will choose to go to, as this is usually what they already do well.

to a one on one counselling role. There are four suggested roles for the practice nurse:

clinical care, clinical organisation (for example reminders and recall), practice

management, and integration or liaison with the community.

nutritional advice.

campaigns), and replicate these lessons within the other risk factors. This will help to

identify what both practice nurses and GPs can and should do.

consideration of the broader social determinants of patients’ behaviour.

should not be expected to do everything. The implementation needs to be contextualised

and supported by broader strategic development.

practice is teamwork.

the role of the clinical psychologist in alcohol related issues. Hazardous or harmful

alcohol consumption can be dealt with by GPs, whereas alcohol dependency requires

specialist referral services to a clinical psychologist or psychiatrist.

the GP is potentially quite small and supplemented by support from appropriate people.

There is a need to involve professionals beyond the practice.

implementation of the lifestyle prescriptions initiative.

addressed.

gaps and seek to influence the States and Territories, private sector and NGOs to fill these

gaps.

professionals and multidisciplinary referral destinations.

the Divisions in order to provide these necessary elements such as the IT infrastructure

and the referral system.

building momentum and capacity. Focus on achieving short-term aims that don’t

compromise the credibility of the whole plan in terms of long-term goals or strategies.

to focus on things that are ‘doable’ such as the capacity to influence other established

initiatives.

capacity building and working towards a sustainable model. Ensure that all the correct

implementation components are planned for and measured.

different risk factors.

In response to a number of suggestions by the Commonwealth, the group raised these key

issues:

extent and nature of the activities for the rollout of the lifestyle prescription initiative have

been finalised.

as it provides a useful framework covering reach, efficacy, adoption, implementation and

maintenance. Evaluation is fundamental to the process, as it not only allows for the

monitoring of these five elements but also ultimately for outcomes.

exists (ie ensuring that a type 1 error is avoided). To achieve this, we must plan how to

identify and then use the range of existing data collection vehicles such as the Annual

Survey of Divisions and other population level surveys to monitor the extent and nature

of the implementation and program research.

evaluation of the activities chosen for the rollout of lifestyle prescriptions nationally.

limited. The rollout needs to encompass the allied health providers or their representative

organisations and key organisations in the government and non-government sector whose

support is needed to deliver the referral destinations that GPs will be referring patients to.

development of high level buy-in at the Board and Management levels and not just at the

program or project officer level.

management process should underpin the agreed short-term activities with negotiations

and communication with State and Territory Health and other relevant portfolios (e.g.

sport and recreation) about referral pathways, awareness raising and how lifestyle

prescriptions are positioned in the Health system.

provided in the rollout of lifestyle prescriptions.

earlier rather than later in the rollout process.

accessibility of funding State or Regional Coordinators to develop State and Territory

plans, etc.

Commonwealth, State/Territory and Local Government and non-Government initiatives.

involved in working parties and consultation processes.

that Allied Health Professionals, community health staff, non-government providers and

others outside the health industry (ie sport and recreation) would be interested and should

be considered in areas where Divisions do not show interest. The role of pharmacists

could also be considered in the future.

- The conceptualisation of lifestyle prescriptions may assume a level of choice that

those outside of the mainstream do not have.

- A focus on only individual level behaviour change without attention to broader social

determinants of health status may set people up to fail and decrease rather than

improve self-efficacy.

- In relation to young people, the GP may not be the most appropriate or credible

source of lifestyle information and advice.

primary health care initiatives at the State/Territory and Local level.

infrastructure to warrant specific and targeted initiatives linked (for example) with the

rollout of the Well Person’s or Adult Health Check.

to get support and mentorship and for the showcasing of success.

research.

something new and additional.

capacity to cope with demand.

Rachel Balmanno Department of Health and Ageing

Bill Bellew Director Centre for Health Promotion, NSW Health

Nerida Bellis-Smith Professional Services Director, Dietitians Association of Australia

Andrew Boyden Medical Affairs Manager, Heart Foundation of Australia

Raina Brands Siggins Miller

Margaret Brown Health Consumers of Rural And Remote Areas (CHF)

Bev Buckridge Project Officer, Hastings Macleay Division of General Practice

Fiona Bull Senior Lecturer - Physical & Health Education, University of WA

Nicola Burton Research Officer, QUT School Of Public Health

Debra Cottrell CEO, Goulburn Valley Division of General Practice

Margaret Cox Department of Health and Ageing

Scott Davis Community Quality Use Of Medicines Program Manager, National

Prescribing Service Limited

Lindy Dunn Assistant Director, Department of Veterans' Affairs

Kylie Easton Education and Quality Assurance Program, National Prescribing Service

Helen Egan Executive Officer, Australian Chronic Disease Prevention Alliance

(ACDPA)

Anna Fergusson Programs Coordinator, SA Divisions Of General Practice

Vanessa Firenze Chronic Disease Management Program Officer, Sutherland Division of

General Practice

Nicole Fitzgerald Department of Health and Ageing

Christine Frew National Health Services & Planning Manager, Australian Kidney

Foundation

Jane Giles Manager, Diabetes Outreach in SA

Susan Goodman Health Promotion Officer, Alliance of NSW Divisions

Mark Harris Professor of General Practice and Head of School University of New South

Wales

Bronwen Harvey Medical Advisor, Department of Health And Ageing

June Hicks Nutritional Advocate, Nutrition Australia

Coletta Hobbs SNAP Project Coordinator - Senior Research Fellow, Centre for General

Practice Integration Studies

Nancy Huang Assistant Director, VICFIT

Sarah Hurren Department of Health and Ageing

Mike Jones General Practice Divisions of Western Australia

Helen Kehoe Policy Officer, National Aboriginal Controlled Community Health

Organisations

Ian Kett Executive Director, VICFIT

Klaus Klaucke Director, Tobacco, Drug Prevention & Youth Policy Australian

Government Department of Health and Ageing

Erin Lalor Chief Executive Officer, National Stroke Foundation

John Litt Senior Lecturer, Flinders University Department of General Practice

Elaine Lomas GP Policy Officer, National Aboriginal Controlled Community Health

Organisations

Cate Lombard Manager Health Promotion, VICFIT

Joanne Martin Health Promotion Office,r West Vic Division Of General Practice

Alex McClelland CDM Program Officer, St George Division of General Practice

Danielle McNamara Department of Health and Ageing

Shannon Meikle John Dietitian, Nutrition Australia - QLD Division

David Menzies Senior Project Officer, VICFIT

Janet Michelmore Director, Jean Hailes Foundation

Julie Middleton Professional Development Manager, The Jean Hailes Foundation

Mary-Ellen Miller Workshop Facilitator, Siggins Miller

Diana O'Neill Manager, Active Living Greenscript NZ

Marianna Pisani Health Promotion Section, Department of Human Services

Sue Pluck Consumers Health Forum of Australia

Yolaine Raisin Self-Management Project Coordinator, ACT Division of General Practice

Roslyn Ridgway General Practitioner, Criniti/Ridgway Medical Services

Ann Roche Director, National Centre for Education and Training on Addiction

Margaret Ryan Practice Nurse, Criniti/Ridgway Medical Services

Helen Sherrell Facilitator Scribe, Siggins Miller

Jane Sims Senior Lecturer In Primary Care, University of Melbourne

Ben Smith Lecturer, University of Sydney

Teri Snowdon National Manager: Quality Care & Research, Royal Australian College of

General Practitioners

Tony Stubbs Physical Activity Program Manager, National Heart Foundation Of

Australia - NSW

Sonya Tremellen Population Health, General Practice Division Of Victoria

Joanne Turner Lifestyles Programs Manager, Diabetes Australia

Claudine Wathier-Doucet Chronic Disease Management (CDM) Project Officer, ACT Division Of

General Practice

Judith Watson GP/Physical Activity Program, GP North Division Of General Practice

Leanne Wells National Primary Mental Health Coordinator and Principal Adviser,

Mental Health Australian Divisions of General Practice

Jo Whitfield-Lowe Department of Health and Ageing

Bruce Wight Director, Alcohol, Substance Misuse & Injury Prevention, Department of

Health and Ageing

Dianne Woods Executive Officer NSW, Nutrition Australia

Nicholas Zwar Professor of General Practice, University of NSW

Catharina van Moort Department of Health and Ageing

Health Division)

New Zealand)

Introduction to Topic: Rachel Balmanno, Director, Healthy Ageing and Chronic

Disease Prevention Section.

Discussion points:

Report back from groups, and pen discussion

Introduction to Topic: Nancy Huang, Assistant Director, Victorian Council of

Fitness and General Health.

Discussion points:

Report back from groups, and open discussion

Introduction to Topic: Belinda Caldwell, Population Heath, General Practice

Division of Victoria.

Discussion points:

interventions?

Report back from groups, and open discussion

Mel Miller, Facilitator

Mel Miller, Facilitator

Introduction to Topic: Professor Mark Harris, Professor of General Practice and

Director of the Centres for Primary Health Care and Equity Research in the School

of Public Health and Community Medicine, University of NSW

Discussion points:

Report back from groups, and open discussion

Introduction to Topic: John Litt, Senior Lecturer, School of Medicine Flinders

University.

Discussion points:

consultation?

Report back from groups, and open discussion

Brief presentation by Rachel Balmanno, Director, Healthy Ageing and Chronic

Disease Prevention Section, Strategic Planning Branch, Population Health

Division

Group Discussion

Summary by Mel Miller, Facilitator.

Facilitator to summarise discussions including:

Population Health Division

A lifestyle prescription is a tool for general practitioners (GPs) to use when providing healthy

lifestyle advice to patients.

The development of an approach to lifestyle prescriptions should draw on existing:

and Green Script by Sports and Recreation New Zealand.);

Essentially there are two options for lifestyle prescriptions:

1. a single prescription for use with all lifestyle risk factors (eg National Prescribing Service

(NPS)/ National Heart Foundation of Australia (NHFA) lipid lowering script), or

2. aA number of different prescriptions for the different lifestyle risk factors

It is proposed that the second option for lifestyle prescriptions be adopted as it offers greater

flexibility for GPs by providing a suite of tools and resources that GPs can use as necessary.

Specific lifestyle prescriptions for the different lifestyle risk factors will enable GPs to tailor

their intervention to suit the needs of the patient at the time. Having a suite of lifestyle

prescriptions will enable GPs to choose to focus their efforts on particular risk factors that are

of interest to them or of particular significance for the practice population.

Under the national approach to lifestyle prescriptions being proposed, there will be two

perspectives of lifestyle prescriptions:

1. for the patient, the prescription will be the written lifestyle advice that is provided by a

GP; and

2. for general practice (including the GP, practice staff and Divisional staff) lifestyle

prescriptions will be a process of assessment, advice, information and/or referral that

encourages and supports the management of behavioural risk factors in the general

practice setting.

The use of lifestyle prescriptions follows a five-step model (this model parallels the Five A’s

for Smoking Cessation Guidelines in Australian General Practice). The steps of the model

are:

1. Identify lifestyle issue

2. Assess and discuss

3. Written recommendation for action (lifestyle prescription)

4. Information

5. Refer

It is proposed that the implementation of a national approach to lifestyle prescriptions:

to invent something new and in isolation to what already exists);

practices as the GPs choose; and

to enable them to address lifestyle risk factors with their patients as appropriate.

Sport and Recreation New Zealand (SPARC)

levels of physical activity in a section of the population currently considered by General

Practitioners to be ‘inactive’ (less than 2.5 hours of physical activity per week).

have stable medical conditions and will benefit from increased physical activity. Such

medical conditions include hypertension, obesity, diabetes, osteoporosis, anxiety and

depression. Patients with unstable medical conditions are excluded from the GRx

programme through the risk assessment process.

patients to embark on safe and appropriate physical activity which can be carried out in

their own environment and at little or no cost. Patient compliance and health gains will be

monitored at regular intervals. (Patients may later choose to join a sports club or take on

exercise programmes designed by fitness professionals).

accumulated 30 minutes of moderate physical activity, preferably every day, will improve

the health of most people. Patients can "snack" on activity, for example, three ten -

minute walks instead of one thirty minute walk.

where General Practitioners and Practice Nurses work in partnership with the 17 Regional

Sports Trusts (RSTs) throughout NZ and Sport and Recreation New Zealand (SPARC).

RSTs. Professional staff in the RSTs can ‘usher’ patients into regular appropriate physical

activities, provide personal encouragement, monitor compliance and give feedback to

General Practitioners and Practice Nurses. Patients can access RSTs through an 0800 line

or direct referral from the medical centre.

The 12 April 2003 issue of BMJ presented the findings of the research showing increased

physical activity levels and improved quality of life over 12 months, without evidence of

adverse effects.

Dr Raina Elley’s study identified all sedentary 40-79 year old Waikato patients visiting their

general practitioner over a five-day period. A total of 878 patients were enrolled in the study.

Patients allocated to the intervention group received advice about physical activity and

support from regional sports trust patient support personnel. Patients in the control group

received usual care.

Physical activity during leisure time and total energy expenditure increased more in the

intervention group than in the control group. Measures of self-rated "general health,"

"vitality," and "bodily pain" also improved significantly more in the intervention group.

A trend towards decreasing blood pressure became apparent but no changes in the risk of

coronary heart disease were observed.

Dr Elley’s study has shown that brief advice, coupled with ongoing telephone support, can

change people's behaviour with respect to physical activity and improve general health,

vitality, and bodily pain for at least a year, say the authors.

The conclusion stated is that if implemented widely, a strategy such as GRx could result in

major health benefits for sedentary people.

The entire report can be viewed at: http://bmj.com/cgi/reprint/326/7393/793.pdf.

A randomised trial of Green Prescription (written advice) versus verbal advice on physical

activity levels showed:

to see their GP during that time.

necessary for research purposes).

Research was conducted into known information about the benefits of physical activity and

an international lifestyle seminar was coordinated in May 1988.

The Hillary Commission produced the following studies:

- Life in New Zealand research

- The cost of doing nothing

- Solving the mystery of inactivity

GRx Clinical trials completed (National Heart Foundation under contract to Hillary

Commission). Conducted with 37 Dunedin and Auckland GPs.

Focus groups held with GPs in Auckland, Rotorua, Lower Hutt and Christchurch to discuss

implementation of GRx.

Discussion with health agencies (North Health, National Heart Foundation etc). Development

of GP and patient resources (NHF under contract to Hillary Commission) after consultation

with GPs and GP groups. Pacific Island Heartbeat developed resources for Pacific Island

languages, (Cook Island Maori, Tongan and Samoan).

Launch of GRx in Northern region by Minister of Sport, Fitness and Leisure (Murray

McCully).

Training of Active Living Staff based in regional sports trusts on the implementation of GRx

and their role.

Development of patient resources - walking, swimming, stretching, cycling, running, water

activities and activity and medical conditions. Training of GPs/distribution of resources

through Independent Practitioners Associations. Evaluation started, funded by North Health.

Public media campaign in Northland and Auckland-radio, bus posters and mall displays used

to encourage the public to ask their GP for a Green Prescription resulted in an increase in GP

uptake

Evaluation showed that 65% of Northland and Auckland GPs were “prescribing green”

(sample 317 GPs) and 97% were giving verbal advice about increasing physical activity.

Nation wide roll-out of GRx started through IPAs, Maori health providers and individual GPs

and practice nurses. Extension of computer prescribing of GRx.

Appointment of GRx area managers to liaise between Hillary Commission, RSTs, GPs,

practice nurses and other health professionals.

- Northland-part time

- Auckland-full time

- Waikato, Bay of Plenty, Taranaki, Eastland-full time

- Manawatu, Hawkes Bay, Wanganui, Wellington-full time

- Tasman-part time

- Canterbury-part time

- Otago, Southland-full time (funded by South Link Health IPA)

Calls to 0800 line steady but low in number. Most sports trusts link with doctors and practice

nurses for direct referral. Patients therefore get the support they need in maintaining lifestyle

change. Total referrals for the year July 2002 - June 2003 were 5809 compared with 4925 for

the previous year). GRx patients receive four newsletters a year with advice and information.

Links with health agencies developed through regular contact with area managers. Agencies

include: Heart Foundation, Asthma, Diabetes, Mental Health, Arthritis, Respiratory support

and Maori health workers.

Two part time area manager positions developed to cover Hawke’s Bay and Gisborne and

second Auckland area manager brings total to ten managers (five full time and five part

time).

GPs are surveyed in May and November of each year to establish uptake of GRx.

See the table below for a summary of results and contact SPARC for more information.

A randomised sample is taken of 1000 GPs and a postal survey carried out.

Questions were added from May 2000 about patient follow-up by GPs and GP awareness of

the moderate physical activity message. From May 2001 questions were added about the role

of practice nurses in GRx. Another new question was added to the May 2003 survey to

identify whether GPs issue a GRx to all patients they think one is suitable for, and if not, why

they didn’t.

The May 2003 survey showed that in 31% of the practices surveyed the practice nurse also

wrote a Green Prescription. Weight issues was the main reason given to “prescribe green”

(91%), followed by diabetes (71%) and high blood pressure (62%). When asked what would

encourage GPs to issue more GRx “less paperwork in General Practice” and “more time in

consultation” were the most common responses.

Ministry of Health funding was confirmed for GP support during 1999/2000 and Pharmac

funding for 2000-2004. Increased emphasis on patient support has resulted in more personnel

at regional level for follow-up calls over a three month period.

Research is conducted annually with a small sample of GRx patients to establish the reasons

they were prescribed green, health benefits gained and levels of physical activity since GRx

was received. Most common benefits are “generally feel better”, “feel stronger and fitter” and

“lost weight”.

A project was started in Northland in November 2000 to determine how GRx can better meet

the needs of Maori. Sport Northland has a contract with Te Hauora Whanui to undertake this

work. In 2003 further contracts were signed with Hauora O Te Hiku O Te Ika (Northland)

and Ngati Porou Hauora (East Coast).

There is a comprehensive range of paper resources to support the GRx initiative. For further

information look on the SPARC website-www.sparc.org.nz under Green Prescription or

contact Diana O'Neill, SPARC (Sport and Recreation New Zealand), P O Box 2251

Wellington NZ

Phone: (04) 496 3984. Fax: (04) 471 0813. Email: diana.oneill@sparc.org.nz

Health

Continuing medical education is now an embedded feature of GPs’ lives.A variety of

education methods are used in the general practice setting, and research to date indicates that

the effectiveness of different strategies can be extremely variable. The ultimate goals for GP

training have varied between quality assurance, adoption of clinical guidelines to effecting

knowledge and behaviour change in GPs.

The aim of this Discussion Session is not to provide an exhaustive review of the educational

theory, design and delivery of education intervention for lifestyle prescriptions. This has been

covered in detail in currently available texts within the health and social sciences disciplines.

Rather, this Session aims to stimulate discussion and ideas based on what has occurred to

date within the Active Script Program, and how transferable these may be to other risk factors

as well as other states in Australia.

Ideas and issues canvassed within this Session will form the basis for an implementation

strategy for the development and roll-out of useful resources and training modules for

lifestyle prescriptions across Australia.

Establishing a direct correlation between the acquisition of new skills by learners (GPs) and

patient outcomes as a result of a planned education intervention has been difficult to

demonstrate in the literature. This difficulty is further emphasised where the skill area relate

to the provision of ‘advice’ rather than a direct clinical procedures, such as the injection of a

swollen knee joint. For the Active Script Program, we have taken a broad view of ‘education’

and incorporated a multi-faceted approach to facilitate behaviour change in the GP.

effort to acquire the new skills

experiences and practice as a GP

planning of their education

situations, using problem-centred learning and real-life situations

Evaluation results from the ASP educational strategies will be presented and discussed in this

session in order to critically appraise the advantages and limitations of each of these methods.

In summary, the ASP model worked within the first 3 years to recruit more than 700 GPs

from nine Divisions into its educational interventions. The ASP was perceived to be a

credible and quality program, using best available evidence, to upskill and support GPs in

their role to promote physical activity.

GPs who participated in ASP became more knowledgeable and motivated to provide physical

activity advice to patients in a systematic way. GPs reported that they were assessing,

advising and thinking about inactivity as a risk factor more frequently and systematically as a

result of becoming involved in the ASP activities. Limited patient interviews showed that

advice from their GPs was effective in motivating them to become more active in the short

term.

The evaluation findings also confirmed the progress that has been made toward a sustainable

intervention in general practice. Divisions, especially those with more than one year of

support from ASP, are now incorporating physical activity promotion into core business and

future business plans. The capacity of Divisions to recruit, upskill and support GPs in

promoting physical activity had increased.

In thinking about the training and resource requirements for the successful implementation of

the lifestyle scripts, it is useful to consider these two components:

1. Content - this relates to the actual information to be delivered. It will vary according

to the risk factor involved, incorporating the latest guidelines and evidence for

practice. It can be further determined by conducting a needs assessment of knowledge

or practice gaps.

2. Process - this relates to the method of delivery of the information. It will vary

according to the skill level of program deliverers, the resources available, and whether

we want to affect knowledge, skill or attitude change in the GP.

a) Identify and assess need

b) Define specific and measurable learning objectives for the training and resources

c) Identify appropriate content and process of training opportunities to meet the learning

objectives

d) Develop and deliver training

e) Evaluate outcomes against learning objectives

The training modules and resources already developed for the ASP have made some in-roads

through these steps, especially in the promotion of physical activity. Decisions will need to be

made regarding the transferability of this experience to other risk factors and for other States.

Similarly, other established programs such as Active Practice (NSW National Heart

Foundation), Green Prescription (New Zealand) and QUIT have taken slightly different

approaches to the training and resourcing of GPs. A discussion based on a sound knowledge

of what already exist will be critical in making further progress in the development of a

strategy for lifestyle prescriptions.

There are some key principles that we think are essential to address for optimising GP use of

any tools. Applying these general principles to use of tools & resources required for

implementation of lifestyle prescriptions would be core business for divisions in their change

management role with general practice. There are probably more principles than we’ve

identified here and it would be great to see what else people consider to be critical issues, and

you may want to argue the point on these key principles. Our list is:

data entry etc)

implemented. “Who for” goes to the heart of the program design around the use of

lifestyle scripts. If just a practice decision, then risk failing to ensure adequate community

options etc available. Division level means that implementation can be more

comprehensive.

takes, to whatever extent is needed for them to adopt the advice provided by the GP. The

implementation model needs a corollary to the ‘pharmacist’, but the function could be

fulfilled in any number of different ways eg practice nurse role, professional based at the

division, an Information Line etc

systems – tailored support to do so is often needed. Need to think about whether it is an

opportunistic approach or a planned approach and how each of the systems within the

practice will need to be developed to enable the change to be made.

community for the patient to undertake lifestyle changes. This can range from allied

health referrals to more walking paths in the area.

patient. How will the GP know that the tool is working as a vehicle in this way?

Feedback on what the patient does is important & must be timely – how will this be

achieved?

GPs that systematic prescribing of lifestyle changes makes a measurable difference to the

health of their patients eg reduced BMI etc

A proposition for you to consider – a low cost, product based model vs a more resource

intensive, capacity building model

(like building a ‘house of sticks’)

and sustainable (like building a ‘house of bricks’)

Typical components might include:

laminated sheet

etc

Typical components might include:

sheet

approach, based on evidence

Lessons from previous roll-outs of division-based programs and projects have shown us that

there are two critical areas of work that are needed for effective implementation of population

health programs:

Practice support through divisions is requiring a more sophisticated and resource intensive

approach, where divisions are moving from providing a ‘product consultancy’ service to

more of a ‘process consultancy’:

Linkages at the local level are crucial for ensuring that the community and agencies are able

to respond to the service demands generated by lifestyle prescriptions. Better outcomes from

the GP role in a population health initiative are achieved when there is a shared commitment

from across the primary care sector to achieving a particular health outcome eg increased

level of physical activity

prescription ‘program’ ie which target group, which risk factor?

The Minimum Requirements for an effective ‘roll-out’ to general practice of any change

aiming to achieve health outcomes are likely to include the following (based on our

experience of Immunisation, EPC & CDM programs):

practice contribution is one component.

between what is currently occurring and what the evidence says will improve health

outcomes for GPs’ patients.

financially viable.

‘pay attention’ to the evidence – clinical and business case.

comprehensive range of services to GPs and practice staff that support them to change

what they do.

events etc.

Centres for Primary Health Care and Equity Research in the School of Public

Health and Community Medicine, University of NSW

The lifestyle risk factors are common in general practice patients:

- 32.8% were overweight

- 19.2% were daily smokers, 5.6% who were occasional smokers and 27.0% who were

previous smokers

- 32.9% drank “at risk” levels of alcohol

- 65.3% reported doing less than 150minutes of moderate physical activity spread over 5

sessions per week

The approach to managing these in general practice is summarized by the 5As used SNAP

and other interventions:

alcohol consumption and smoking status

3.readiness to change/motivation

5.motivational interviewing

7.Support for self monitoring of diet (not weight)

8. Appropriate pharmacotherapy (eg Nicotine replacement therapy or acamprosate)

9.follow up with the GP

Referral is a key management tool for all the SNAP risk factors. Referral should be

considered in all patients especially those who are motivated and have significant long-term

risk such as those with obesity or in complex cases.

An Australian study used a case control study to determine if people that were overweight or

hypertensive fared better when their GP referred them to an onsite dietician, when the

indicate that having the GP as a motivator increased attendance to counselling sessions and

caused greater reductions in weight and blood pressure for the patients.

Referrals for lifestyle are infrequent. The BEACH survey in general practice found that 2.3%

Journal of Epidimiology and Community Health 53(5): 311-19.

health and health care delivery in general practice in Australia. AIHW Cat. No. GEP 3. Canberra 2000

assessment conducted as part of the SNAP trials in two divisions in NSW the frequency of

reported referral was low across all four risk factors (See figure) with referrals for smoking

ease of referral in the NSW trial divisions for each risk factor being most difficult for

smoking alcohol and “relatively easy” for physical activity. However this may vary between

divisions and states.

68% of practices in the NSW trial reported that they had computerized directories. While the

frequencies of referral for nutrition, alcohol, and physical activity were highly dependent on

the ease of the referral, access to community directories of services does not on its own lead

to a greater ease of referral for these risk factors.

Specific strategies to improve referral from general practice in addition provision of

information on the referral service include:

information about referral services or options.

Lifestyle prescriptions have been most widely used in physical activity. This usually involves

of the effect of GPs’ use of prescriptions for physical activity determined that for middleaged

adults, verbal advice combined with the prescription was more effective than verbal

activity. Preventive Medicine 26: 866-873.

reduction counselling behaviours of general practitioners. Preventive Medicine 23: 292-301.

activity. Patient Education and Counseling 36(2):181-192.

the promotion of physical activity. National Public Health Partnership. Melbourne, Australia.

been incorporated into software to increase the ease of referral and similar models have been

adopted for smoking.

Ultimately the likelihood of referral depends on the linkages between the practice and referral

services. Anecdotally this has been successfully achieved in those divisions of general

practice where a shared care relationship exists between the services and GPs or where allied

health services have been employed directly by the division of general practice (such as

through the MAHS program). This suggests that it is not only the information and

availability that are important but the communication system underpinning the referral

network. In particular the provision of feedback and a personal relationship appear to be very

important to GPs.

randomised controlled trial of written exercise advice provided by general practitioners. American Journal of

Public Health 88:288-291.

general practice: cluster randomised controlled trial. British Medical Journal. 326:793

Can one person be appointed to coordinate SNAP activities in the practice?

Has a SNAP plan for the practice been developed (with consideration of:

resources, capacity, skills, time, support, motivation)?

Have practice staff and GP roles and responsibilities been clarified?

How do the practice-based SNAP activities link with (a) Division activities? (b):

other community & Public health programs?

What are the benefits and costs in this practice of identifying the SNAP

‘status’ of all patients in the practice?

Are the SNAP activities that you plan to implement, congruent with individual

and practice goals?

How will the implementation strategies be made observable/visible’?

What rewards/incentives can you identify for: GPs, practice staff?

Are there mechanisms to ensure feedback?

What steps can be taken to ensure that the process is supported by the entire

practice?

What strategies have been used to identify the SNAP status of ALL patients?

What attempts have been made to:

- understand the important contextual issues?

- -target both need and goals?

- address the difficulties with implementing SNAP activities?

What steps have been taken to:

- provide an iterative cycle:

- measure need?

- reflect on results?

- ensure implementation?

How have the following values been addressed?

- Congruence with the aspirations/ goals of the practice, staff and GPs

- transparency of the implementation process (activities, communication)

- acknowledgement of prior knowledge, skills and experience

- respect for autonomy

What is required to make implementation of SNAP a routine and sustainable

part of the practice?

What steps have you taken to

- make implementation of SNAPe a routine part of the practice?

- maximise efficiency (value for effort)?

- minimise complexity?

- continuing rewards?

Identify lifestyle issue Assess/discuss Written recommendation for action* Information Refer

Smoking

Overweight

Smoking and

stage of change

Weight and stage

of change

Level of physical

activity and stage

of change

Physical activity

Healthy Eating

Degree of

healthy eating

and stage of

change

Alcohol Alcohol and

stage of change

Eg Quit pamphlet Quitline

Eg overweight &

obesity consumer

information

Eg How to get

started tools,

Guidelines

Eg Healthy eating

Guidelines for

Adults, Older

Australians,

Children.

Weight Clinics and

Medical Specialists

NGO, local/ state

helplines/programs

High risk groups to

physio & human

movement

specialists

Dietician

NGO or local/state

helplines /

websites

Eg Alcohol and

your health

Drug and Alcohol

Treatment

Services

* May include medical and pharmacological management in conjunction with behavioural management