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The COVID-19 pandemic was a catalyst for the introduction of additional telehealth funding (telehealth item numbers) for general practitioner (GP) consultations through the Medicare Benefits Schedule (MBS) in Australia. This study evaluated the impact of telehealth funding on costs to the MBS for GP consultations from January 2017 to December 2021. An interrupted time series analysis assessed MBS costs (initial and monthly growth) for GP consultations (in-person, videoconference, telephone) before and after additional telehealth item numbers were introduced. From January 2017 to February 2020, total MBS costs for GP consultations were, on average, $545 million per month compared to $592 million per month from March 2020 to December 2021. There was an initial cost increase of approximately $39 million in the first month after additional telehealth funding was introduced ( p = 0.0001). Afterwards, there was no significant change in monthly costs ( p = 0.539). The introduction of additional MBS telehealth funding increased overall MBS costs for GP consultations. This increased cost for GP telehealth services could save costs to society if it translates into improved continuity of care, decreased hospitalisations, reduced productivity losses and improved patient outcomes. Future policy reform should incorporate a cost–benefit analysis to determine if increased MBS costs for GP consultations are a good investment.

BackgroundSafer prescribing in general practice may help to decrease preventable adverse drug events (ADE) and related hospitalisations.AimTo test the effect of the Safer Prescribing and Care for the Elderly (SPACE) intervention on high-risk prescribing of non-steroidal anti-inflammatory drugs (NSAIDs) and/or antiplatelet medicines and related hospitalisations.Design & settingA pragmatic cluster randomised controlled trial in general practice. Participants were patients at increased risk of ADEs from NSAIDs and/or antiplatelet medicines at baseline. SPACE comprises automated search to generate for each GP a list of patients with high-risk prescribing; pharmacist outreach to provide education and one-on-one review of list with GP; and automated letter inviting patients to seek medication review with their GP.MethodThe primary outcome was the difference in high-risk prescribing of NSAIDs and/or antiplatelet medicines at 6 months. Secondary outcomes were high-risk prescribing for gastrointestinal, renal, or cardiac ADEs separately, 12-month outcomes, and related ADE hospitalisations.ResultsThirty-nine practices were recruited with 205 GPs and 191 593 patients, of which 21 877 (11.4%) were participants. Of the participants, 1479 (6.8%) had high-risk prescribing. High-risk prescribing improved in both groups at 6 and 12 months compared with baseline. At 6 months, there was no significant difference between groups (odds ratio [OR] 0.99; 95% confidence intervals [CI] = 0.87 to 1.13) although SPACE improved more for gastrointestinal ADEs (OR 0.81; 95% CI = 0.68 to 0.96). At 12 months, the control group improved more (OR 1.29; 95% CI = 1.11 to 1.49). There was no significant difference for related hospitalisations.ConclusionFurther work is needed to identify scalable interventions that support safer prescribing in general practice. The use of automated search and feedback plus letter to patient warrants further exploration.

Introduction: Reforms have been introduced since 2000 to make New Zealand’s health system primary care-led. A competent health management workforce is necessary to provide leadership for the goals of the reforms to be realised. Aim and objective : To review New Zealand’s key primary health care policies from 2000 to 2016 and consider their implications for management and leadership. Methods : A document analysis was undertaken using qualitative content analysis. Eligible documents were identified through the websites of relevant government and non-government agencies, World Health Organisation, and through Google Scholar. Findings :Two key policy trends relating to primary health care were identified. Firstly, a population health orientation to improve access to health care through community participation, and secondly, an integrated approach to promote collaboration within the health system, and between the health system and other sectors. The inferred management and leadership skillsets required to realise these policies included relationship management and collaboration, change management, and leadership. Conclusion: New Zealand’s primary health care sector underwent substantial reform between 2000 and 2016. Management and leadership capabilities need to be strengthened and developed for the benefits of the reforms to be realised.

Purpose Training to improve health management and leadership competence is recommended. However, there is limited evidence showing the impact of training on competence. The purpose of this paper is to evaluate the evidence for the impact of training and professional development on health management and leadership competence. Design/methodology/approach A systematic review was conducted using a mixed-methods design. Studies using qualitative, quantitative or mixed-methods design were included. The following electronic databases were searched to October 2018: CENTRAL, CINAHL, EMBASE, ERIC, NEDLINE and PsycINFO. Study eligibility and methodological quality were assessed independently by two review authors. Data from qualitative studies were synthesised using thematic analysis. For quantitative studies, odds ratio (OR) or mean difference (MD) and 95% confidence interval (CI) were calculated for each intervention. Where appropriate, qualitative and quantitative data were integrated into a single synthesis using Bayesian methods. Findings In total, 19 studies were identified for inclusion in the review. Training and professional development interventions using flexible, multiple training techniques tailored to organisational contexts can improve individual competence and performance. Such training is typified by a leadership development programme. There was insufficient evidence to determine the effects of interventions on organisational performance. Originality/value This is the first systematic review evaluating the impact of training and professional development interventions on health management and leadership competence.

BackgroundDespite cardiovascular disease (CVD) risk prediction equations becoming more widely available for people aged ≥75 years, views of older people on CVD risk assessment are unknown.AimTo explore older people’s views on CVD risk prediction and its assessment.Design and settingQualitative study of community-dwelling older people in New Zealand.MethodA diverse group of older people was purposively recruited. Semi-structured interviews and focus groups were conducted, transcribed verbatim, and thematically analysed.ResultsThirty-nine participants (mean age 74 years) of Māori, Pacific, South Asian, and European ethnicities participated in one of 26 interviews or one of three focus groups. Three key themes emerged: poor knowledge and understanding of CVD and its risk assessment; acceptability and perceived benefit of knowing and receiving advice on managing personal CVD risk; and distinguishing between CVD outcomes — stroke and heart attack are not the same. Most participants did not understand CVD terms, but were familiar with the terms ‘heart attack’ and ‘stroke’, and understood lifestyle risk factors for these events. Participants valued CVD outcomes differently, fearing stroke and disability — which might adversely affect independence and quality of life — but were less concerned about a heart attack, which was perceived as causing less disability or swifter death. These findings and preferences were similar across ethnic groups. All but two participants wanted to know their CVD risk, how to manage it, and distinguish between CVD outcomes. Those who did not wish to know perceived this as something only their God could decide.ConclusionTo inform clinical decision making for older people, consideration of an individual’s wish to know their risk is important, and risk prediction tools should provide separate event types rather than just composite outcomes.

An objective measure could support GPs' clinical judgement and aid discussions about the need for on-road testing or driving cessation

Social workers form part of many healthcare teams. This role can involve in-depth conversations with clients and home visits. These encounters can reveal sensitive information, not all of which may...

PURPOSE Avoidable hospitalizations due to adverse drug events and high-risk prescribing are common in older people. Primary care physicians prescribe most on-going medicines. Deprescribing has long been essential to best prescribing practice. We sought to explore the views of primary care physicians on the barriers and facilitators to deprescribing in everyday practice to inform the development of an intervention to support safer prescribing. METHODS We used a snowball sampling technique to identify potential participants. Physicians were selected on the basis of years in practice, employment status, and practice setting, with an additional focus on information-rich participants. Twenty-four semistructured interviews were audio-recorded, transcribed verbatim, and analyzed to identify emergent themes. RESULTS Physicians described deprescribing as “swimming against the tide” of patient expectations, the medical culture of prescribing, and organizational constraints. They said deprescribing came with inherent risks for both themselves and patients and conveyed a sense of vulnerability in practice. The only incentive to deprescribing they identified was the duty to do what was right for the patient. Physicians recommended organizational changes to support safer prescribing, including targeted funding for annual medicines review, computer prompts, improved information flows between prescribers, improved access to expert advice and user-friendly decision support, increased availability of non-pharmaceutical therapies, and enhanced patient engagement in medicines management. CONCLUSIONS Interventions to support safer prescribing in everyday practice should consider the sociocultural, personal, relational, and organizational constraints on deprescribing. Regulations and policies should be designed to support physicians in practicing according to their professional ethical values.

ABSTRACTGeneral practitioners are increasingly approached to participate in research and share de-identified patient information. Research using electronic health records has considerable potential for improving the quality and safety of patient care. Obtaining individual patient consent for the use of the information is usually not feasible. In this article we explore the ethical issues in using personal health information in research without patient consent including the threat to confidentially and the doctor-patient relationship, and we discuss how the risks can be minimised and managed drawing on our experience as general practitioners and researchers.

This article describes the unwieldy gonorrhoea notification process in New Zealand following recent legislative reforms.1 We seek changes to improve control of this serious infectious disease

This essay describes a physician's experience of the sudden, unexplained death of her brother and her family's discovery of the genetic cause.

In assessing overseas-trained general practitioners (GPs) applying for specialist recognition in Australia, the Royal Australian College of General Practitioners (RACGP) sets a minimum requirement of 2 days per week ‘undertaking general practice activities’ over the 3 years prior to application. The RACGP does not consider academic practice (i.e. relevant teaching and research) to be a ‘general practice activity’, thereby blocking overseas-trained full-time academic GPs from specialist recognition in Australia. The actions of the RACGP have implications for access to quality primary health care in Australia.

There is uncertainty about the long-term benefits and risks of diabetes medications in older people. We investigated differences in hypoglycaemia, cardiovascular disease (CVD) or mortality in older people according to diabetes medication, using linked national hospitalisation and mortality data from New Zealand. Adults aged ≥65 years dispensed diabetes medication in 2010 with a baseline glycated haemoglobulin (HbA1c) level (n=18099, mean age 73 years, 50% female) were included and stratified into four groups: metformin-only (42%); metformin-plus-other-oral-hypoglycaemic/s (27%); other-oral/s-only (11%); and any-insulin (20%). Time to first event was analysed with Cox models adjusted for sociodemographic factors; clinical history (prior hospitalisation for diabetes or CVD, and comorbidities); glycated haemoglobin; and CVD medications. Over 7-year follow up, 16% of participants experienced hypoglycaemia, 36% a CVD event and 31% died. Compared with metformin-only, insulin and other oral hypoglycaemic/s were associated with five- to 10-fold long-term increased risk of hypoglycaemia, and increased risk of CVD and death although adjusted survival curves showed no important separation between medication groups for CVD and death with the possible exception of insulin. Although confounding by indication is unable to be eliminated, this study raises further questions about the use of second-line diabetes medications in older people.

INTRODUCTION Practice size and location may affect the quality and safety of health care. Little is known about contemporary New Zealand general practice characteristics in terms of staffing, ownership and services. AIM To describe and compare the characteristics of small, medium and large general practices in rural and urban New Zealand. METHODS Seventy-two general practices were randomly selected from the 2014 Primary Health Organisation database and invited to participate in a records review study. Forty-five recruited practices located throughout New Zealand provided data on staff, health-care services and practice ownership. Chi-square and other non-parametric statistical analyses were used to compare practices. RESULTS The 45 study practices constituted 4.6% of New Zealand practices. Rural practices were located further from the nearest regional base hospital (rural median 65.0 km, urban 7.5 km (P < 0.001)), nearest local hospital (rural 25.7 km, urban 7.0 km (P = 0.002)) and nearest neighbouring general practitioner (GP) (rural 16.0 km, urban 1.0 km (P = 0.007)). In large practices, there were more enrolled patients per GP FTE than both medium-sized and small practices (mean 1827 compared to 1457 and 1120 respectively, P = 0.019). Nurses in large practices were more likely to insert intravenous lines (P = 0.026) and take blood (P = 0.049). There were no significant differences in practice ownership arrangements according to practice size or rurality. CONCLUSION Study practices were relatively homogenous. Unsurprisingly, rural practices were further away from hospitals. Larger practices had higher patient-to-doctor ratios and increased nursing scope. The study sample is small; findings need to be confirmed by specifically powered research.

ABSTRACT INTRODUCTION High-risk prescribing in general practice is common and places patients at increased risk of adverse events. AIM The Safer Prescribing and Care for the Elderly (SPACE) intervention, comprising audit and feedback plus practice mail-out to patients with high-risk prescribing, was designed to promote medicines review and support safer prescribing. This study aims to test the SPACE intervention feasibility in general practice. METHODS This feasibility study involved an Auckland Primary Health Organisation (PHO), a clinical advisory pharmacist, two purposively sampled urban general practices, and seven GPs. The acceptability and utility of the SPACE intervention were assessed by semi- structured interviews involving study participants, including 11 patients with high-risk prescribing. Interviews were audio-recorded, transcribed verbatim and analysed using a general inductive approach to identify emergent themes. RESULTS The pharmacist said the SPACE intervention facilitated communication with GPs, and provided a platform for their clinical advisory role at no extra cost to the PHO. GPs said the feedback session with the pharmacist was educational but added to time pressures. GPs selected 29 patients for the mail-out. Some GPs were concerned the mail-out might upset patients, but patients said they felt cared for. Some patients intended to take the letter to their next appointment and discuss their medicines with their GP; others said there were already many things to discuss and not enough time. Some patients were confused by the medicines information brochure. DISCUSSION The SPACE intervention is feasible in general practice. The medicines information brochure needs simplification. Further research is needed to test the effect of SPACE on high-risk prescribing.

Nerve injuries usually present as pain, numbness, or weakness, and can have devastating consequences for patients. Procedures that are common in primary care can cause nerve injury. Iatrogenic nerve injuries are largely preventable by understanding nerve anatomical course and surface anatomy, and the risky interventions and regions. Most knowledge of nerve anatomical course is derived from early work on cadaver dissection, but modern imaging techniques more accurately map nerve anatomical course in living bodies. We provide an overview of nerve injuries in primary care, discuss updated nerve anatomical course and surface anatomy based on modern radiological evidence, and make recommendations to guide safer interventions in primary care. In New Zealand’s primary care treatment injury claims dataset there were 69 nerve injuries over 4 years (2% of primary care injuries).1 Venepuncture was the leading cause of nerve injury (27; 39%), followed by intramuscular injection (17; 25%), and steroid injection (15; 22%). Venepuncture injured the cutaneous nerve of the forearm (14), and the median (9) and radial (4) nerves; intramuscular injections injured the sciatic (11), lateral cutaneous (3), and axillary (3) nerves; steroid injections injured the median (12, carpal tunnel) and ulnar (3, medial epicondyle) nerves; intravenous cannulation in the forearm injured the superficial radial nerve (4); and minor surgical procedures injured the spinal accessory (3), common fibular (1), sural (1), and ilioinguinal nerves (1). Most nerve injuries were minor, but 17 (25%) were assessed as having major or serious potential consequences. …

Background: High-risk prescribing, adverse drug events, and avoidable adverse drug event hospitalizations are common. The single greatest risk factor for high-risk prescribing and adverse drug events is the number of medications a person is taking. More people are living longer and taking more medications for multiple long-term conditions. Most on-going prescribing occurs in primary care. The most effective, cost-effective, and practical approach to safer prescribing in primary care is not yet known. Objective: To test the effect of the Safer Prescribing And Care for the Elderly (SPACE) intervention on high-risk prescribing of nonsteroidal anti-inflammatory and antiplatelet medicines, and related adverse drug event hospitalizations. Methods: This is a protocol of a cluster randomized controlled trial. The clusters will be primary care practices. Data collection and analysis will be at the level of patient. Results: Recruitment started in 2018. Six-month data collection will be in 2018. Conclusions: This study addresses an important translational gap, testing an intervention designed to prompt medicines review and support safer prescribing in routine primary care practice. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12618000034235 http://www.ANZCTR.org.au/ACTRN12618000034235.aspx (Archived with Webcite at http://www.webcitation.org/6yj9RImDf) [JMIR Res Protoc 2018;7(4):e109]

Modern technologies sanction a new plasticity of physical form. However, the increasing global popularity of aesthetic procedures (re)produces normative beauty ideals in terms of perfection and symmetry. These conditions limit the semblance of freedom by people to control their own bodies. Cultural emancipation may come from principles in Eastern philosophy. These reveal beauty in authenticity, including imperfection. Wabi-sabi acclaims beauty in common irregularity, while kintsugi celebrates beauty in visible signs of repair, like scars. These principles resist pressure to medicalize dissatisfaction with healthy bodies and invite multi-sited interventions to educate taste and aesthetic choices.

Overuse of medicines and medical interventions, patient safety, and rising costs are among the greatest challenges facing modern health care. Because medical malpractice systems are thought to be a driving factor, it is logical to consider alternative medical regulatory structures.1 New Zealand’s experience with no-fault compensation for medical injury and separate medical professional accountability processes may provide insights. Now that the no-fault system has been fully in place for a decade, it is timely to reflect critically on potential lessons for health systems around the world. The three main functions of a medical regulatory system are to provide compensation for injury, accountability, and deterrence, and mechanisms that enable learning. In 1974 New Zealand introduced a publicly-funded accident compensation scheme with the goals of minimising the incidence and impact of injury. The scheme provides assistance with the cost of treatment and rehabilitation for all personal injuries, regardless of fault, and in exchange bans suing for compensatory damages. Medical injury has always been covered under the scheme. Consequently, in New Zealand there is no culture of suing doctors for damages and doctors pay comparatively low medical indemnity fees of around £790 per annum. Doctors are held to account under separate processes including the Medical Council of New Zealand’s competence and fitness to practise processes, an independent patient complaints system, and a separate disciplinary process. The patient complaints system was introduced in 1994 on recommendation of a 1988 government report that found wanting the prior accountability processes in an environment where patients were unable to sue.2 In …

A taste test for expensive jamon highlights the importance of asking the right research question, say Katharine Wallis and Nicholas Zwar

New Zealand’s treatment injury compensation claims data set provides an uncommon no-fault perspective of patient safety incidents. Analysis of primary care claims data confirmed medication as the leading threat to the safety of older patients in primary care and drew particular attention to the threat posed by antibiotics. For most injuries there was no suggestion of error. The no-fault perspective reveals the greatest threat to the safety of older patients in primary care to be, not error, but the risk posed by treatment itself. To improve patients’ safety, in addition to reducing error, clinicians need to reduce patients’ exposure to treatment risk, where appropriate.

BackgroundHigh-risk prescribing places patients at increased risk of adverse drug events (ADEs). High-risk prescribing and ADE hospitalisations are increasingly common as people are living longer and taking more medicines for multiple chronic conditions. The Safer Prescribing and Care for the Elderly (SPACE) intervention is designed to foster patient engagement in medicines management and prompt medicines review.AimTo pilot the SPACE intervention in preparation for a larger cluster randomised controlled trial (RCT).Design & settingA pilot study in two general practices. Study participants were all patients at increased risk of an adverse drug reaction (ADE) from non-steroidal anti-inflammatory drugs (NSAIDs) and/or antiplatelet medicines. The primary outcome was the proportion of participants receiving high-risk prescribing at 6 months and 12 months compared with baseline.MethodThe SPACE intervention comprised automated practice audit to identify and generate for each GP a list of patients with high-risk prescribing for these medicines; an outreach visit by clinical advisory pharmacist to deliver education and to go through with each GP their list of at-risk patients and indicate in a tick-box the intended action for each patient; and a mail-out from GPs to selected patients containing a medicines information brochure and a letter encouraging patients to discuss their medicines when they next see their GP.ResultsSPACE can be delivered within existing primary care infrastructure. The rate of high-risk prescribing was reduced at 6 months following the delivery of the intervention, but these improvements were not evident at 12 months.ConclusionSPACE prompts medicines review and shows promising signs of supporting safer prescribing in general practice in the short term. A randomised trial of SPACE started in 2018.

A 76-year-old woman was admitted to hospital from the rheumatology outpatient clinic for investigation of fatigue, malaise, emotional lability, muscle weakness, productive cough and postural hypotension. She had been taking prednisone 60–40 mg daily for 6 weeks for suspected giant cell arteritis, along with six other regular medications, and had recently finished a course of antibiotics. During her admission she underwent many investigations (mostly negative) and treatments (largely harmful). When the diagnosis of adverse drug reaction was eventually reached, her medications were withdrawn and her symptoms gradually resolved. She was discharged home 1 month after admission, vowing never to return following her ‘stormy course’. Adverse drug reactions are a common cause of avoidable hospital admissions in the elderly, estimated to cost billions every year. The single greatest risk factor for adverse drug reactions is the number of medications a person takes. Deprescribing to reduce potentially inappropriate medication is a possible way forward.

As in most other areas of human experience, fashions in healthcare and in healthcare research come and go. They come about because a good idea is articulated, often as a sound bite that makes intrinsic sense, and they go because a few intrepid researchers are prepared to investigate the substance behind the sound bite and they come to realise that the logic is not supported by the reality. The original logic is supplanted. Over the last 20–30 years, there have been some notable fashions in healthcare that have lit up the globe like a comet and then died. Just as there have been passing fashions in surgery (eg, routine tonsillectomies) and medications (eg, hormone replacement therapy), so also have there been passing fashions in quality improvement (QI) and QI research. Kieran Walshe in his bibliometric research tracked the frequency paths of different QI terms used between 1988 and 2007.1 ‘Patient safety’ was a relatively low frequency term (along with ‘clinical governance’ and ‘six sigma’) from 1988 to 1999, when suddenly it took off following the release of the Institute of Medicine's ‘To Err is Human’2 report, surpassing almost all the other QI terms, along with ‘six sigma’. The rise in evidence-based medicine, arguably itself a fashion, is largely responsible for deposing fashionable good ideas. Evidence-based medicine, although not immune to criticism,3 is different from other fashions in that it has infiltrated every part of every health system—the idea, at least, if not always the practice—and it has not gone away. It is a concept that has captured health systems globally and become embedded as a value, an aspiration and an expectation of healthcare, even more now than it was when the idea first lit up the world more than 40 years ago. Epidemiological research that measures, compares, tests and …

To discover the effect of the 2005 'no-fault' compensation reforms on medical professional accountability for harm in the context of overall trends in New Zealand's medical professional accountability processes 2001-2010.Data for the 5 years before and after the 2005 reforms were compared including compensation claims to the Accident Compensation Corporation (ACC), ACC reporting to the authorities, patient complaints to the Health and Disability Commissioner and outcomes, referrals to the Medical Council and outcomes, and disciplinary proceedings and outcomes.Following the 2005 compensation reforms, claims for compensation increased, ACC reporting overall increased but ACC reporting to the Medical Council decreased; patient complaints increased but the Health and Disability Commissioner investigated fewer complaints and referred fewer doctors for discipline while maintaining steady referrals to the Medical Council; referrals to the Medical Council decreased, and the Medical Council conducted fewer performance reviews and referred fewer doctors for discipline; disciplinary proceedings decreased but more hearings ended in guilty findings.Accountability via compensation decreased following the 2005 'no-fault' compensation reforms, contributing to an overall decrease in medical professional accountability for harm.

INTRODUCTION The Department of General Practice and Primary Health Care at the University of Auckland is considering developing a Master of Primary Health Care (MPHC) programme. Masters level study entails considerable investment of both university and student time and money. AIM To explore the views of potential students and possible employers of future graduates to discover whether there is a market for such a programme and to inform the development of the programme. METHODS Semi-structured interviews were conducted with 30 primary health care stakeholders. Interviews were digitally recorded, transcribed and analysed using a general inductive approach to identify themes. FINDINGS Primary care practitioners might embark on MPHC studies to develop health management and leadership skills, to develop and/or enhance clinical skills, to enhance teaching and research skills, or for reasons of personal interest. Barriers to MPHC study were identified as cost and a lack of funding, time constraints and clinical workload. Study participants favoured inter-professional learning and a flexible delivery format. Pre-existing courses may already satisfy the post-graduate educational needs of primary care practitioners. Masters level study may be superfluous to the needs of the primary care workforce. CONCLUSIONS Any successful MPHC programme would need to provide value for PHC practitioner students and be unique. The postgraduate educational needs of New Zealand primary care practitioners may be already catered for. The international market for a MPHC programme is yet to be explored.

Uncertainty in medical practice is ineradicable, despite great scientific advances over the last century. Uncertainty provokes fear, not just in patients but also in doctors. Patients cope with theirfear by seeking the advice and reassurance of doctors; doctors, on the other hand, cope by denial and self-deception. But today, in this scientific, truth-seeking age doctors are encouraged to share their uncertainty with patients in order to 'empower' patients and improve doctor-patient relations. While in theory doctors might agree with this approach, in practice they continue to deny it and instead whistle happy tunes--deceiving both themselves and their patients. A disclosure of uncertainty requires an acknowledgement of uncertainty and, in practice, the ability of doctors to acknowledge and to tolerate uncertainty is limited. Whenever I feel afraid, I hold my head erect. And whistle a happy tune, So no one will suspect I'm afraid. While shivering in my shoes, I strike a careless pose. And whistle a happy tune, And no one ever knows. I'm afraid. The result of this deception, Is very strange to tell. For when I fool the people I fear, I fool myself as well!

A 5 month old black infant presented to the Emergency Department in the spring with generalised seizures. He was found to have severe vitamin D deficiency and hypocalcaemia. The baby had been born healthy in the autumn at 45.5 degrees south to parents of African extraction, had been fully breast-fed since birth and had spent some time in day care over the winter months. His mother was a professional working woman who had not taken any vitamin or nutritional supplements during pregnancy or lactation.

Part 4A of the Health Act 1956--'National Cervical Screening Programme' (NCSP)--provides programme evaluators with unprecedented powers of access to personal health information, overriding both a woman's right to health information privacy and a doctor's duty of confidentiality. Such overriding of important ethical concepts is not justified, at least in the primary care setting where much of the information that may be accessed is irrelevant to a programme evaluation and that which is not irrelevant is not essential. In addition to being unethical, Part 4A is unnecessarily offensive to practitioners: it imposes increased compliance costs onto practitioners who take cervical smears, it threatens them with hefty fines for non-compliance, and also introduces liability into previously protected quality assurance activities. By offending both women and practitioners, and by undermining the trust that necessarily exists between them, Part 4A risks the support of those on whom the NCSP relies for its ongoing success--women and practitioners.

Uncertainty in medical practice is ineradicable, despite great scientific advances over the last century. Uncertainty provokes fear, not just in patients but also in doctors. Patients cope with theirfear by seeking the advice and reassurance of doctors; doctors, on the other hand, cope by denial and self-deception. But today, in this scientific, truth-seeking age doctors are encouraged to share their uncertainty with patients in order to 'empower' patients and improve doctor-patient relations. While in theory doctors might agree with this approach, in practice they continue to deny it and instead whistle happy tunes--deceiving both themselves and their patients. A disclosure of uncertainty requires an acknowledgement of uncertainty and, in practice, the ability of doctors to acknowledge and to tolerate uncertainty is limited. Whenever I feel afraid, I hold my head erect. And whistle a happy tune, So no one will suspect I'm afraid. While shivering in my shoes, I strike a careless pose. And whistle a happy tune, And no one ever knows. I'm afraid. The result of this deception, Is very strange to tell. For when I fool the people I fear, I fool myself as well!