Patient centred care

Learn ways to better understand your patient population and improve on delivering patient centred care.


It is essential that practices know their patient population to deliver patient centred care. To effectively identify and care for a practice population, underlying systems and having accurate information in clinical software is key. 

Integrated patient care aims to improve patient care through better coordination of services. Planning an integrated approach to patient care can improve efficiency as well as your patients’ experience of care.


Dr Carolyn Ee discusses patient centredness in cancer control

Questions to consider when assessing your patient population 

  • Do you know the age distribution of your active patients (e.g. what are the needs of your patient groups and what community resources are available to assist them to meet these needs)?
  • To what ethnic, cultural and language groups do you provide regular care? For example, does your practice have supportive materials for your Aboriginal or culturally and linguistically diverse populations?
  • Do the communities these patients belong to have specific needs or challenges? For example, do you provide care for rural and remote regions/refugees/communities affected by natural disasters/people living with a disability? 

A family history screening questionnaire can help identify individuals who require a more detailed assessment of their family history of cancer or other conditions.1  

The RACGP Family history screening questionnaire (PDF) can be used as part of the person’s assessment at their first visit to a practice.  

  • The tool identifies patients who need a more detailed assessment of their familial risk of cancer, heart disease or diabetes. A positive response to any question requires follow-up with a more detailed assessment of the family history.
  • Given family history can change, it is recommended that the questionnaire be repeated at least every three years.  
  • People with low health literacy may need support to complete the questionnaire.
  • When available, an Aboriginal health worker can assist a person with the form, if needed. 


Focus populations

Some focus populations will remain under-screened or not seek help on preventative health. The reasons for this are often complex and include a range of social, cultural, individual and environmental factors. For example:

  • previous negative experiences
  • lack of transport
  • language barriers
  • low health literacy
  • attitudes and beliefs that prevent participation. 

For example:

  • cancer is incurable and/or predetermined1
  • the false belief that certain cancers are not a risk for some communities (e.g. believing that people with a cervix who have not had sex with men are not at risk of cervical cancer)2
  • fear of treatment
  • shame (including the belief that cancer is a result of behaviour in present or past lives)1.

Utilise the support of your local PHN to provide dashboard reports to identify focus populations. 
You could work with your PHN representative to develop targeted reports utilising clinical audit tools.

Focus populations

Position statement on Aboriginal and Torres Strait Islander health 

“We acknowledge the profound social and emotional impact of discriminatory policies and practices, including the forcible removal of children from their families[6] and the years of failure of governments and health professionals to act effectively to protect and improve the health and wellbeing of Aboriginal and Torres Strait Islander peoples.[7]

“Over 200 years of loss and dispossession and the systematic disempowerment of Aboriginal and Torres Strait Islander people cannot be addressed without the genuine commitment of governments, non-government organisations and the wider Australian community.

“Health and medical professionals and their representative organisations have a clear role to play in this process. Solutions must draw on the strength and resilience present in Aboriginal and Torres Strait Islander communities today, and should be developed in partnership with Aboriginal and Torres Strait Islander people and communities.”

- Extract from the Royal Australian College of General Practitioners' Position statement on Aboriginal and Torres Strait Islander health

It is important that the primary care team has the knowledge and skills required to provide appropriate care with Aboriginal people.

This includes understanding:

  • the impact of discriminatory policies and practices on Aboriginal people’s health and interactions with the health system
  • the diversity within the Aboriginal community in Australia
  • how to provide culturally appropriate and safe care
  • how to communicate effectively with Aboriginal people
  • the impact of ‘deficit discourse’ on perceptions, policy, practice, and health outcomes for Aboriginal people.

What is ‘deficit discourse’? 

Deficit discourse represents people in terms of deficiencies and failures. Deficit discourse places responsibility for problems with individuals or communities, overlooking the larger socioeconomic structures in which they are embedded.

Deficit discourse impacts educational attainment, health and wellbeing and contributes to external and internalised racism.10

These are suggested actions that can support healthy lifestyle choices and increased participation in cancer screening by Aboriginal people.

  • Build a culturally competent team to ensure they have the knowledge, skills and attitudes required to provide appropriate care to Aboriginal people. This can be achieved by recruiting Aboriginal staff and/or encouraging staff to complete suitable training. The RACGP has Cultural Awareness Training and Cultural Safety Training guidelines (PDF) for more information on training options.
  • Work in partnership with your local Aboriginal community – your PHN, local health district Aboriginal Health Unit and/or local Aboriginal Community Controlled Health Organisation (ACCHO) can support your practice to strengthen linkages with community members, organisations and health workers, and local cancer screening and preventative health champions. There are 38 ACCHOs across NSW. Find your closest service here.
  • Ensure your practice consistently asks all patients if they identify as Aboriginal or Torres  Strait Islander. The RACGP Accreditation standards for general practices states that practices record the Aboriginal status of patients in their patient health records. This benefits Aboriginal people by ensuring improved access to prevention and screening initiatives and additional health care opportunities.  It is not just about asking Aboriginal patients if they are Aboriginal – it is about ensuring that every patient has been given an opportunity to identify if they are of Aboriginal or Torres Strait Islander origin.
  • Provide health assessments that integrate cancer screening and preventative health. 

The RACGP has a guide on identifying Aboriginal and Torres Strait Islander people (PDF) in general practice.

"About 50% of Aboriginal people access Indigenous-specific primary health care services, but the other 50% access general primary healthcare services. Asking all of your clients about Indigenous status is particularly important because GPs have a really big role to play in regards to prevention and early detection of cancer.”  

- Professor Gail Garvey, Kamilaroi woman, Senior Principal Research Fellow and Deputy Division Leader, Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research

This varies between metropolitan and rural/remote areas with highest rates of access to mainstream primary health services occurring in metropolitan areas, with up to 75% of Aboriginal people accessing mainstream health services.9

Providing health assessments for Aboriginal people and incorporating prevention and cancer screening into health assessment templates is an important step in supporting improved cancer screening participation and healthy lifestyle choices.

Watch the Cairns video case study to see an example of a 715 Health Check.

Aboriginal Health Checks  
  1. National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people (PDF)

  2. Adolescents and young people (12-24 years) (PDF)

  3. Adults (25-49 years) (PDF)

  4. Older people (50+ years) (PDF) 

Ensure your practice and assessment spaces are comfortable, and culturally safe and appropriate. Five steps towards excellent Aboriginal and Torres Strait Islander healthcare (PDF).

  • It is important that Aboriginal people who have an abnormal cancer screening results are offered support to undertake further diagnostic tests and treatment. Your practice can seek advice from Aboriginal health and community services in your area to develop your policy and processes for supporting and engaging Aboriginal people with abnormal cancer screening results. Speak to your PHN or seek information via HealthPathways.
  • Use resources and programs designed for Aboriginal people. Refer to the cancer screening and prevention sections of this toolkit for information and resources specific for Aboriginal communities. 

Ensure your practice has a good understanding of the health needs of the cultural groups within your practice population. This can be achieved by:

  1. Analysing practice data
  2. Routinely recording ethnicity, country of birth, language other than English spoken at home and cancer screening status
  3. Working in partnership with local community and health organisations, and community champions
  4. Inviting patient/client feedback to inform delivery of care. 
  • RACGP’s Criterion C1.4 – Interpreter and other communication services (PDF) provides guidance on ensuring patient rights and practitioner’s professional obligations regarding communication of health information and recommendations. 
  • The Translating and Interpreting Service (TIS) is available 24 hours a day, every day of the year on 131 450.
  • The NSW Health Refugee Health Service’s Translated Appointment Reminder Translation Tool allows you to translate appointment details into your client’s language. The form is generated immediately for the client at the time the appointment is made.
  • Availability of Plain English and translated educational materials at your practice that reflect your patient demographic may improve engagement with health promotion messages. Refer to the cancer screening and prevention sections for information and resources specific for culturally and linguistically diverse communities. 

Refugee Communities  
  • Each year many people from refugee backgrounds settle in Australia from regions where they have endured conflict, persecution and dislocation from their homes, families and culture. These people will be typically unfamiliar with Australian healthcare systems, services and procedures. You will find information here to support a whole of practice approach to assist primary to deliver high quality on arrival health care for people from refugee backgrounds.
  • The refugee health assessment template supports the delivery of refugee health assessments in line with current clinical recommendations, and assist primary care providers to complete the Refugee Health Assessment Medicare Item (Items 701, 703, 705, 707).

Find more information on the Refugee Health Assessment template.


Do any of your patients need, or prefer to speak languages other than English? 

You can access an interpreter through the Translating and Interpreting Service (TIS National) Doctors Priority Line - 131 450.

General Practitioners and medical specialists can use the service when providing services that are

  • claimable under Medicare
  • provided in private practice; and 
  • provided to non-English speaking Australian citizens or permanent residents.

It is available at all times, for the cost of a local call from a landline and gives you priority access to more than 2600 interpreters and more than 160 languages and dialects.

To register for the Doctors Priority Line, complete the online client registration form on the TIS National website.

Socioeconomic factors are important determinants of health and wellbeing. On average people in the lowest socioeconomic group are more likely to smoke and are at risk of underscreening.5,6

Cancer screening and prevention programs must prioritise reaching those populations that underuse their  screening services to ensure equitable access to preventive services.6

There are screening tools that can be used to detect low literacy levels. Prioritising key points, using plain language, using images, arranging follow up and tailoring resources are important for these patients.

Teach-back is another technique that can be utilised, patients should be asked to use their own words to explain back to the GP they understand what has been said. 

Watch the above video on teach back—a technique for clear communication. You can also view this video on YouTube.

  • RACGP’s Criterion C1.4 – Interpreter and other communication services (PDF) specifies requirements for meeting the needs of patients with communication impairments. 
  • Negative experiences, such as physical/sexual abuse , sexual exploitation  and discrimination by health staff , may impact participation in breast and cervical screening by people with disability. Check that your clinical team has the skills to support trauma-informed provision of screening tests and communication about screening. The RACGP’s Abuse and violence – working with our patients in general practice includes a section on people with disabilities. 
  • Seeking feedback from patients with disability and/or working with a local Disable People’s Organisation to develop and prioritise ideas for improvement, will strengthen your practice’s delivery of patient centred-care for people with disability. 
  • Create a supportive environment by displaying promotional materials that feature people with disability. Refer to the cancer screening and prevention sections for information and resources specific for people with disability. 

People living with mental illness are more likely to develop comorbid physical illness and die earlier than the general population. Health behaviours such as smoking, and alcohol are common and there is reduced access to health services due to reasons such as, financial constraints and stigma/discrimination among health care providers.8

Many LGBTQI (lesbian, gay, bisexual, transgender, queer and intersex) people experience specific barriers to accessing mainstream health services relating to their gender and/or sexuality. 

Ensure that your practice has a good understanding of LGBTQI terminology and health issues, as well as strategies to be inclusive of LGBTQI communities. 

Here are some suggestions for information and education:

  • ACON’s Pride Training offers a wide range of training, information and educational services to assist health professionals and service providers with all aspects of LGBTQ inclusion. ACON’s TransHub has information for clinicians on Creating Welcoming Environments.
  • The ‘Rainbow Tick accreditation program’ supports organisations to understand and implement LGBTIQ+ safe and inclusive service delivery and provides national recognition for those that meet Rainbow Tick Standards.
  • Actively create an affirming and supportive environment for LGBTQI people at your practice, including displaying promotional materials that are inclusive of this community and inviting patient feedback on opportunities for improvement.
  • Language for body parts supports a patient centred approach. LGBTQ communities may use alternative words for different body parts (i.e. ‘front hole’ instead of ‘vagina’ or ‘chest’ instead of ‘breast’). It is encouraged that health professionals discuss with their patients their preferences are identified. Find out more
  • RACGP have developed a fact sheet (PDF) to support correctly collecting and recording information about patient sex, gender, variations of sex characteristics and sexual orientation. This fact sheet assist practices to address accreditation requirements relating to patient records. 
  • Participate in education to assist the primary care team to become familiar with and sensitive to diverse terminology, experiences, health issues, standards and referral pathways with respect to trans, gender-diverse and non-binary (TGDNB) clients. Visit AusPath to access a free e-learning module.

People living in remote and very remote areas generally have poorer access to health services than people in regional areas and major cities, along with educational and employment opportunities, and income. Further, they are more likely to have higher rates of risky health behaviours, such as smoking and heavy alcohol use and lower rates of bowel, breast and cervical cancer screening and higher rates of potentially preventable hospitalisations. 

People living in remote areas of Australia may need to travel long distances or relocate to attend health services or receive specialised treatment.7 


1. RACGP, “Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting (Green Book) 3rd ed,” Royal College of General Practitioners, East Melbourne, 2018

2. Australian Institute of Health and Welfare (AIHW): Analysis of cancer outcomes and screening behaviour for national cancer screening programs in Australia. Canberra: AIHW, 2018.

3. Cancer Institute NSW. Project overview for the NSW Pap Test Register Electronic Reminder Service for GPs (Internal document). Sydney: Cancer Institute NSW, 2016

4. Australian Institute of Health and Welfare 2018. Australia’s health 2018. Australia’s health series no. 16. AUS 221. Canberra: AIHW.

5. Australian Govt. AIHW. 5.1 Health across socioeconomic groups: Australia’s health 2016. [Internet] Accessed 15 Aug 2022. Available from: 

6. Nuche-Berenguer B, Sakellariou D. Socioeconomic determinants of cancer screening utilisation in Latin America: A systematic review. PLoS One. 2019 Nov 25;14(11):e0225667. doi: 10.1371/journal.pone.0225667. PMID: 31765426; PMCID: PMC6876872. 

7. Australian Institute of Health and Welfare. (2019, 2nd April, 2020). Rural and remote Health. Available: 

8. Aus Govt. AIHW. Mental health services in Australia: Physical health of people with mental illness. [Internet]. Accessed online: 15 Aug 2022. Available from: 

9. Aboriginal and Torres Strait Islander Health Performance Framework:–to17-regular-gp-health-service

10. The Lowitja Institute, Deficit Discourse and Aboriginal and Torres Strait Islander Health Policy: