Keeping on our toes

They say that you will never stub your toe if you stand still, but you will also never get anywhere. Our health system is not standing still: things are rapidly moving and we are bound to stub the odd toe. In this issue of the Journal we discuss innovations, their benefits and threats (including stubbed toes) and in keeping with the theme of keeping on our toes, our Cochrane Corner directs us to evidence of the best treatment for toe nail onychomycosis.¹

‘Portal’ is a word generically used to describe a gateway between one world and another. For patients, portals into their medical records are truly entrances into a new world. Our guest editorial leads readers through the policy developments that have supported patient portal adoption in New Zealand, warning of its potential to strengthen rather than reduce inequalities in healthcare access.² Carryer and Kooienga interviewed patients of practices both with and without access to patient portals and found there was a general willingness of patients to start (or continue) the patient portal journey.³ Wong and Morgan-Lynch discuss some ethical challenges to be worked through in patient portal use, especially for patients transitioning from childhood to adults.⁴ The other ethics paper in this issue discusses difficult boundaries between ethical clinical practice and the law, in a debate based on a disadvantaged patient many readers may recognise.⁵

We have still put just a tentative toe in the water with respect to patient portals: this is a health system evolution that challenges existing regulatory, payment, and communication pathways, leading us to a future that no one can quite comprehend yet. Gray discusses one way to understand general practice - by using the ‘Çynefin framework’.⁶ Just as patient portals are changing the way primary healthcare is delivered, so also is the role and function of healthcare providers. The changing role and functions of community pharmacy workforce is explored in a paper by Campbell et al.⁷

Three papers will help readers keep on their toes regarding the new non-invasive prenatal testing (NIPT) techniques, safe management of allergies in children and diagnosing rhabdomolysis. These are innovations with potential for increasing inequality because they are available, but only with private payment⁸ or access to limited speciality services.⁹ Filoche et al. summarise the role, advantages and disadvantages of NIPT for New Zealand mothers.⁸ Ameratunga brings our attention to the latest evidence base for early introduction of peanuts and other allergenic foods for high-risk children.⁹ From Singapore, Ruan, Low and Kwan show that aspartate aminotransferase (AST) is the strongest measure to use in diagnosing rhabdomyolisis, a condition increasing in incidence with increasing statin use.¹⁰

We always welcome work from early career GPs. Our Improving Performance paper reports an early career doctor’s audit of the care of obese patients in her general practice placement.¹¹ This audit eloquently expresses a range of cultural and resource challenges to reducing inequality in just one practice.

The clinical and health services research reported in this issue includes research taking a pragmatic new approach taken by a Canterbury team to measure unmet need for referred health services.¹² They did what no one else has done before: actually asking GPs and patients together what services they thought patients needed and then measuring whether they were received, finding that 3.6% did not. The exercise of common sense (ahead of comfortable methods) in research design places this research a step ahead in usefulness. Also in Canterbury, Bidwell and Copeland report on the experiences of participants in a multidisciplinary group for continuing professional education, as a pragmatic model for rural clinicians.¹³ Christie and Hudson join this pair to explain the Pegasus Health pastoral care programme¹⁴ and a new report from the LiLACS NZ study advises doctors to investigate depression in octogenarians who fall.¹⁵

I have learned that Jaye can always be trusted to venture into confronting areas of research. Finally, but by no means least, in this issue she joins with Rowe to report their research about effective therapeutic relationships for patients who self-harm.¹⁶

So as you can see, we have provided a bumper crop of holiday reading that should help keep you on your toes into 2018. May you have a peaceful and refreshing break over this period!