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Chronic conditions

Chronic conditions are the leading cause of illness, disability and death in Australia, and cause most of the burden of ill health, as reported by the Australian Institute of Health and Welfare.

Maria Magno is helping boost cancer screening rates in the local Filipino community as part of the Community-led Cancer Screening project.

Pervasive chronic conditions in Australia include arthritis, asthma, back pain and back problems, cancer, cardiovascular diseases, chronic obstructive pulmonary disease, diabetes, chronic kidney disease, mental and behavioural conditions (including mood disorders, alcohol and drug problems and dementia), and osteoporosis.

The personal, social and economic impacts of disease become more complex and burdensome with each additional condition. And while chronic disease is found across our society, the most vulnerable tend to be impacted most frequently and profoundly.

How can we help?

To limit the impact of chronic conditions across the region, we commission activities that simultaneously:

  • increase the efficiency and effectiveness of medical services, particularly for patients at risk of poor outcomes
  • improve coordination of care to ensure patients receive the right care, in the right place, at the right time.

Our work in the prevention and management of chronic conditions is underpinned by our knowledge of the North Western Melbourne Primary Health Network (NWMPHN) region. By understanding and identifying needs, we can prioritise and plan our activities to target populations most in need.

2019–20 highlights

  • Community-led Cancer Screening Project

    Communities in Brimbank and Wyndham were engaged to identify barriers to cancer screening and prioritise and co-design intensive community-based activities to improve cancer screening rates. Community members weren’t just involved in the design – they helped deliver the program, boosting engagement and breaking down barriers to testing.

    This project, led by NWMPHN, in partnership with Victorian Aboriginal Community Controlled Health Organisation and Cancer Council Victoria, focused on increasing community participation in bowel, cervical and breast cancer screening programs.

     Learn more about the project in the NWMPHN region.

     Learn more about the project in other Victorian PHNs.

    Making time to talk about bowel cancer screening: A guide for community groups

    Created in 2020 as part of the project, this guide aims to help local communities talk about the importance of bowel cancer screening, and share the message with friends, families and networks. Read our news story and find out how you can help share the guide.


     Project logic

     Local cancer screening community profile






  • Cancer Screening Intensive Quality Improvement program

    Eight general practices took part in an intensive quality improvement program aimed at improving their cancer screening rates and processes. Some of the quality improvement activities they undertook included improving recall processes and letters, introducing new patient registration and reception processes, and promoting and increasing services offered.

    All eight practices completed the program, and all demonstrated greater than 10 per cent improvement for at least two screening measures.

    Results included:

    • cervical screening: an extra 1178 patients having a cervical screen recorded at one practice – an increase of 78 per cent
    • faecal occult blood test (FOBT): an extra 357 patients having FOBT accurately recorded at another practice – an increase of 35 per cent.

     Read our case study

  • Intensive Quality Improvement – preventing chronic disease

    Five practices partnered with our primary health team in a project aimed at preventing and managing chronic disease. The 12-month project concluded in November 2019. The practices focused on improving three chronic disease risk factors, with two education workshops and ongoing engagement during the project period.


    • All practices saw increases in their recording of blood pressure results (highest increase: 18 per cent), smoking status (highest increase: 39 per cent), alcohol status (highest increase: 250 per cent) and BMI (highest increase: 45 per cent).
    • Invitation letters were sent to 420 patients, and 170 completed osteoporosis screening with MeasureUp’s DEXA van as a result. Thirty-seven patients were then diagnosed with osteoporosis and 79 with osteopenia.

     Read our case study

  • Optimal Cancer Care Pathways HealthPathways project

    The Optimal Cancer Care Pathways (OCP) HealthPathways project is helping primary health adopt and implement OCPs at the point of care. The model will reduce unnecessary clinical variation of cancer care within primary health across Victoria.

    The fourth and current tranche of work aims to use HealthPathways to embed the OCP framework into primary care.

    In 2019–20:

    • 56 pathways were published containing 14 OCP guidelines across the five platforms
    • there were 16,558 pageviews of these pathways across the state.

     Learn more about the statewide OCP HealthPathways project

Regular activities to limit the impact of chronic conditions

  • Supporting primary care

    To encourage consistent, best-practice care for chronic conditions in primary care, we offer chronic-disease-specific training, education, information, resources and business tools.

    Read how we support primary care providers to manage hepatitis B and hepatitis C.

  • Workforce development

    We support primary care nurses to take a greater role in the management of chronic conditions.

    Read how general practices and primary care nurses are supporting patients to better understand and manage their chronic conditions through the CareFirst program.

  • HealthPathways Melbourne

    HealthPathways Melbourne is an online resource that gives GPs localised, best-practice information to help assess, manage and refer patients. A range of pathways have been developed for chronic conditions. Health Pathways logo

    Read how HealthPathways Melbourne supports our work in implementing Optimal Care Pathways for cancer.

  • Regional collaborations

    To improve coordination of care across the health system, we collaborate with all levels of government, general practices, primary health care service providers, local hospital networks, non-government organisations, the private sector, consumers and carers.

    Read about Stepping Up, a new model of care to support the management of diabetes in general practice, which we are working on with cohealth, The Royal Melbourne Hospital and Merri Health.

Optimal Care Pathways for cancer

  • About the project

  • Optimal Care Pathways prostate cancer seminar

    NWMPHN hosted Dr Anita Munoz, a GP and HealthPathways clinical editor, urologist Dr Homi Zargar, and nurse practitioner Dave Gray to discuss screening, referral, diagnosis and management of prostate cancer, and the role of general practice. The seminar video is broken into five parts, which you can watch below.

    Note: RACGP acknowledges the personal learning value of various activities. Visit for more information on self-directed activities.

Part 1: Prostate Screening and referral requirements (26min)

Part 2: Diagnosis and management options (35min)

Part 3: Survivorship and the role of general practice (14min)

Part 4: GP management treatment of complications (17min)

Part 5: Questions (15min)

Other education

  • Malignant melanoma webinar: An update for GPs

    In Australia, the risk of dying from melanoma by your 85th birthday is now one in 118. GPs play a vital role in early detection, which helps to prevent the worst effects of the disease and saves lives. Listen to a recording of the webinar to learn the latest about diagnosis of malignant melanoma and advances in investigations and treatment from leading clinical specialists. (A video-recording and transcript is expected soon: see the RACGP website.)