Drivers of access to cardiovascular health care for rural Indigenous Peoples: a scoping review.

INTRODUCTION: Māori (the Indigenous Peoples of Aotearoa New Zealand) are disproportionately represented in cardiovascular disease (CVD) prevalence, morbidity and mortality rates, and are less likely to receive evidence-based CVD health care. Rural Māori experience additional barriers to treatment access, poorer health outcomes and a greater burden of CVD risk factors compared to Non-Māori and Māori living in urban areas. Importantly, these inequities are similarly experienced by Indigenous Peoples in other nations impacted by colonisation. Given the scarcity of available literature, a systematic scoping review was conducted on literature exploring barriers and facilitators in accessing CVD health care for rural Māori and other Indigenous Peoples in nations impacted by colonisation. METHODS: The review was underpinned by Kaupapa Māori Research methodology and was conducted utilising Arksey and O'Malley's (2005) methodological framework. A database search of MEDLINE (OVID), PubMed, Embase, SCOPUS, CINAHL Plus, Australia/New Zealand Reference Centre and NZResearch.org was used to explore empirical research literature. A grey literature search was also conducted. Literature based in any healthcare setting providing care to adults for CVD was included. Rural or remote Indigenous Peoples from New Zealand, Australia, Canada, and the US were included. Literature was included if it addressed cardiovascular conditions and reported barriers and facilitators to healthcare access in any care setting. RESULTS: A total of 363 articles were identified from the database search. An additional 19 reports were identified in the grey literature search. Following screening, 16 articles were included from the database search and 5 articles from the grey literature search. The literature was summarised using the Te Tiriti o Waitangi (Treaty of Waitangi) Framework principles: tino rangatiratanga (self-determination), partnership, active protection, equity and options. Themes elucidated from the literature were described as key drivers of CVD healthcare access for rural Indigenous Peoples. Key driver themes included input from rural Indigenous Peoples on healthcare service design and delivery, adequate resourcing and support of indigenous and rural healthcare services, addressing systemic racism and historical trauma, providing culturally appropriate health care, rural Indigenous Peoples' access to family and wellbeing support, rural Indigenous Peoples' differential access to the wider social determinants of health, effective interservice linkages and communication, and equity-driven and congruent data systems. CONCLUSION: The findings are consistent with other literature exploring access to health care for rural Indigenous Peoples. This review offers a novel approach to summarising literature by situating the themes within the context of equity and rights for Indigenous Peoples. This review also highlighted the need for further research in this area to be conducted in the context of Aotearoa New Zealand.

Development of a rural strategy for an urban-based medical program: a pragmatic reality.

INTRODUCTION: Health disparities between rural and urban areas in Aotearoa New Zealand are exacerbated by rural workforce issues. Traditionally, undergraduate medical programs are urban-based, and reconfiguring the curriculum to meet the needs of rural communities is challenging. The aim of this project is explore how urban-located universities might develop and implement a rural strategy. Evaluation of a rural strategy may lead to the strategy's ongoing improvements designed to increase the rural workforce. METHODS: This is a qualitative study involving semi-structured interviews with purposively selected key stakeholders. Enquiry included the systematic identification of processes required to develop a rural strategy, including possible facilitators and challenges to be addressed. Qualitative analysis of de-identified data was conducted using a thematic approach. RESULTS: Fourteen stakeholders were interviewed: four rural GPs, two rural hospital doctors, four administrators involved in placing students, and four senior medical academics with involvement in the regional and rural programs. Five overarching themes were identified: (1) developing rural pathways into medical school, (2) improving and expanding rural exposures, (3) developing rural GP pathways, (4) implementing interprofessional education and (5) having a social mission. CONCLUSION: These findings align with the literature relating to developing rural strategies for universities. However, this study also suggested that rural health interprofessional programs may have a role. A key finding was that the social mission of a university may not be visible to rural stakeholders. Reorientating an urban-located university to having a rural strategy requires moving past having policy around social accountability to operationalising it.

A novel methodological approach to participant engagement and policy relevance for community-based primary medical care research during the COVID-19 pandemic in Australia and New Zealand.

Community-based primary care, such as general practice (GP) or urgent care, serves as the primary point of access to healthcare for most Australians and New Zealanders. Coronavirus disease 2019 (COVID-19) has created significant and ongoing disruptions to primary care. Traditional research methods have contributed to gaps in understanding the experiences of primary care workers during the pandemic. This paper describes a novel research design and method that intended to capture the evolving impact of the COVID-19 pandemic on primary care workers in Australia and New Zealand. Recurrent, rapid cycle surveys were fielded from May 2020 through December 2021 in Australia, and May 2020 through February 2021 in New Zealand. Rapid survey development, fielding, triangulated analysis and dissemination of results allowed close to real-time communication of relevant issues among general practice workers, researchers and policy-makers. A conceptual model is presented to support longitudinal analysis of primary care worker experiences during the COVID-19 pandemic in Australia and New Zealand, and key learnings from applying this novel method are discussed. This paper will assist future research teams in development and execution of policy-relevant research in times of change and may inform further areas of interest for COVID-19 research in primary care.

Socio-demographic profile of medical students in Aotearoa, New Zealand (2016-2020): a nationwide cross-sectional study.

OBJECTIVE: To determine the socio-demographic profile of all students enrolled to study medicine in Aotearoa New Zealand (NZ). DESIGN AND SETTING: Observational, cross-sectional study. Data were sought from the Universities of Auckland and Otago, the two NZ tertiary education institutions providing medical education, for the period 2016-2020 inclusive. These data are a subset of the larger project 'Mirror on Society' examining all regulated health professional enrolled students in NZ. VARIABLES OF INTEREST: gender, citizenship, ethnicity, rural classification, socioeconomic deprivation, school type and school socioeconomic scores. NZ denominator population data (18-29 years) were sourced from the 2018 census. PARTICIPANTS: 2858 students were enrolled to study medicine between 2016 and 2020 inclusive. RESULTS: There were more women (59.1%) enrolled to study medicine than men (40.9%) and the majority (96.5%) were in the 18-29 years age range. Maori students (rate ratio 0.92; 95% CI 0.84 to 1.0) and Pacific students (rate ratio 0.85; 95% CI 0.73 to 0.98) had lower overall rates of enrolment. For all ethnic groups, irrespective of rural or urban origin, enrolment rates had a nearly log-linear negative relationship with increasing socioeconomic deprivation. Enrolments were lower for students from rural areas compared with those from urban areas (rate ratio 0.53; 95% CI 0.46-0.61). Overall NZ's medical students do not reflect the diverse communities they will serve, with under-representation of Maori and Pacific students and students who come from low socioeconomic and rural backgrounds. CONCLUSIONS: To meaningfully address these issues, we suggest the following policy changes: universities commit and act to Indigenise institutional ways of knowing and being; selection policies are reviewed to ensure that communities in greatest need of doctors are prioritised for enrolment into medicine (specifically, the impact of low socioeconomic status should be factored into selection decisions); and the government fund more New Zealanders to study medicine.

Teaching medical students in general practice when conducting remote consults: a qualitative study.

BACKGROUND: Telehealth involves real-time communication (telephone or video-call) between patients and health providers. The COVID-19 pandemic propelled general practitioners to conduct most consultations remotely, seeing patients face-to-face only when required. Placement opportunities and experience for medical students were reduced. Initially online learning programmes replaced clinical attachments. Subsequently, clinical teachers supervised students to engage in remote consultations, either in clinics or from their homes. This study aimed to explore the experience of New Zealand general practitioners undertaking clinical teaching with medical students when telehealth consulting. METHODS: Semi-structured interviews with general practitioners who had taught medical students whilst consulting remotely. General inductive thematic analysis of transcribed interviews. RESULTS: Six female and four male participants aged 40 to over 65 years. Participants often focused on general practicalities of telehealth consultations and effects on the patient-doctor relationship, and needed direction to consider remote consultations with students, which added to the interactions. Four themes were identified: changes needed in teaching delivery format; direct comparison with face-to-face; challenges and advantages to remote teaching, each with subthemes. DISCUSSION: Clinicians needed to determine practical logistics and develop skills for both remote consulting and teaching. New format and structures of consultations needed planning. Differences from face-to-face teaching included scene-setting for the consultation and supervision factors. Telehealth teaching conferred new opportunities for learning but also challenges (e.g. consent, cues, uncertainty). Remote consultations are likely to remain a significant mode for doctor-patient interactions. Preliminary guidelines for teaching and learning using telehealth need to be developed and embedded into medical programmes and then evaluated.

Envisioning a Tiriti-responsive New Zealand Health Plan: lessons from district health boards' annual plans.

AIMS: Over recent decades, a body of research has established the presence of pervasive health inequities experienced by Maori. Work to identify the root causes of inequities has focused on the unequal distribution of the determinants of good health, access to healthcare, and racism. This study contributes to a small but growing field of work which engages with Te Tiriti o Waitangi to critique key health documents, focusing on district health boards' (DHBs) annual plans. METHODS: A qualitative, directed content analytical approach was used to investigate whether DHBs' 2019/2020 annual plans were consistent with the principles of Te Tiriti o Waitangi, as identified by the Wai 2575 Waitangi Tribunal inquiry. RESULTS: While annual plans contained actions that aligned with the principles of active protection and equity, comparatively few related to the principles of options, partnership, and tino rangatiratanga. Overall, DHB actions operated to constrain options available to Maori and efforts to exercise the Tiriti-guaranteed right of tino rangatiratanga in the provision of health services. CONCLUSION: While DHBs' annual plans expressed commitment to Te Tiriti o Waitangi, their content did not give effect to these commitments. Significant shifts are necessary if future New Zealand Health Plans are Tiriti-responsive documents that deliver Tiriti-responsive health services.

Treatment Harms in Paediatric Primary Care.

The aim of this study was to describe the epidemiology in children of harms detectable from general practice records, and to identify risk factors. The SHARP study examined 9076 patient records from 44 general practices in New Zealand, with an enrolled population of 210,559 patients. "Harm" was defined as disease, injury, disability, suffering, and death, arising from the health system. The age group studied was ≤20 years of age. There were 193 harms to 141 children and adolescents during the 3-year study period. Harms were reported in one (3.5%) patient aged <2 years, 80 (6.6%) aged 2 to <12 years, 36 (4.9%) aged 12 to <18 years, and 24 (7.5%) aged 18 to ≤20 years. The annualised rates of harm were 36/1000 child and adolescent population for all harms, 20/1000 for medication-related harm (MRH), 2/1000 for severe MRH, and 0.4/1000 for hospitalisation. For MRH, the drug groups most frequently involved were anti-infectives (51.9%), genitourinary (15.4%), dermatologicals (12.5%), and the nervous system (9.6%). Treatment-related harm in children was less common than in a corresponding adult population. MRH was the most common type of harm and was related to the most common treatments used. The risk of harm increased with the number of consultations.

A place-based evaluation of a healthy homes initiative.

ISSUE ADDRESSED: Limited qualitative evaluations of healthy homes initiatives exist in the literature and even fewer look past physical health benefits to wider health outcomes. A qualitative evaluation of Manawa Ora, a healthy homes initiative implemented by a Maori health provider in Northland, New Zealand, was conducted to ascertain the wider health benefits a healthy homes initiative. METHODS: Participants of Manawa Ora were recruited; their experiences were analysed through qualitative semi-structured interviews. RESULTS: Two main themes emerged from the semi-structured interviews. "Becoming active actors" pertains to improved health, both physical and mental, following the program. It also describes the way participants have redirected their focus from their illness to broader, more purposeful activity. "From a simple space to a place with meaning" highlights the way Manawa Ora improved the home environment by creating a "place" that holds meaning. CONCLUSIONS: Healthy homes initiatives can improve physical health as well as wider health outcomes. Through the provision of beds, bedding, insulation and heating, Manawa Ora has created a "therapeutic place" out of the home that promotes healing and well-being. SO WHAT: Greater focus on connections to place in public health initiatives may bring about wider health gains.

Understanding and experience of climate change in rural general practice in Aotearoa-New Zealand.

BACKGROUND: Climate change is already affecting Aotearoa New Zealand (Aotearoa-NZ). The public health effects are varied and complex, and rural primary care staff will be at the front line of effects and responses. However, little is known about their understanding and experience. OBJECTIVES: To determine understanding, experiences and preparedness of rural general practice staff in Aotearoa-NZ about climate change and health equity. METHODS: A mixed-methods national cross-sectional survey of rural general practice staff was undertaken that included Likert-style and free-text responses. Quantitative data were analysed with simple descriptive analysis and qualitative data were thematically analysed using a deductive framework based on Te Whare Tapa Wha. RESULTS: A proportion of survey respondents remained unsure about climate science and health links, although many others already reported a range of negative climate change health impacts on their communities, and expected these to worsen. Twenty to thirty percent of respondents lacked confidence in their health service's capability to provide support following extreme weather. Themes included acknowledgement that the health effects of climate change are highly varied and complex, that the health risks for rural communities combine climate change and wider environmental degradation and that climate change will exacerbate existing health inequities. CONCLUSIONS: The study adds to sparse information on climate change effects on health in rural primary care. We suggest that tailored professional education on climate change science and rural health equity is still needed, while urgent resourcing and training for interagency disaster response within rural and remote communities is needed.

Understanding the barriers and facilitators that influence access to quality cardiovascular care for rural Indigenous peoples: protocol for a scoping review.

INTRODUCTION: Maori (the Indigenous peoples of New Zealand) are disproportionately represented in cardiovascular disease (CVD) prevalence, morbidity and mortality rates, and are less likely to receive evidence-based CVD healthcare. Rural Maori experience additional barriers to treatment access, poorer health outcomes and a more significant burden of CVD risk factors compared with non-Maori and Maori living in urban areas. Importantly, these inequities are similarly experienced by Indigenous peoples in other nations impacted by colonisation. Given the scarcity of available literature, we are conducting a scoping review of literature exploring barriers and facilitators in accessing quality CVD healthcare for rural Maori and other Indigenous peoples in nations impacted by colonisation. METHODS AND ANALYSIS: A scoping review will be conducted to identify and map the extent of research available and identify any gaps in the literature. This review will be underpinned by Kaupapa Maori Research methodology and will be conducted using Arksey and O'Malley's (2005) methodological framework. A database search of MEDLINE (OVID), PubMed, Embase, SCOPUS, CINAHL Plus, Australia/New Zealand Reference Centre and NZResearch.org will be used to explore empirical research literature. A grey literature search will also be conducted. Two authors will independently review and screen search results in an iterative manner. The New Zealand Ministry of Health Te Tiriti o Waitangi (Treaty of Waitangi) Framework principles will be used as a framework to summarise and construct a narrative of existing literature. Existing literature will also be appraised using the CONSolIDated critERia for strengthening the reporting of health research involving Indigenous Peoples (CONSIDER) statement. ETHICS AND DISSEMINATION: Ethical approval has not been sought for this review as we are using publicly available data. We will publish this protocol and the findings of our review in an open-access peer-reviewed journal. This protocol has been registered on Open Science Framework (DOI:10.17605/osf.io/xruhy).

Understanding barriers to diabetes eye screening in a large rural general practice: an audit of patients not reached by screening services.

Introduction Diabetes is a leading cause of blindness in New Zealanders, yet a significant proportion of patients with diabetes are not reached by diabetes eye screening. Aim Our study audited patients with diabetes in a large New Zealand rural general practice, to identify addressable barriers preventing patients from attending diabetes eye screening. Methods All patients who had missed a diabetes eye screening appointment at the Dargaville Hospital Eye Screening Clinic between 2018 and 2021 were identified. Demographic information, laboratory and disease status data were recorded and analysed. Semi-structured telephone interviews were undertaken with 66 patients exploring barriers to diabetes eye screening. Descriptive statistical analysis was performed on quantitative data and a thematic analysis on qualitative results. Results One-hundred and fifty-four (27%) of 571 patients invited to screening missed at least one appointment; of these, 66 (43%) were interviewed. Quantitative analysis suggested Maori patients were less likely to be reached, with a 20% higher number of missed appointments than European patients and a higher glycated haemoglobin (HbA1c). Maori patients reported greater barriers to attending eye screening. Common barriers identified by participants were transport, work and family commitments, financial, health and lack of appointment reminders. Discussion Increased barriers for Maori patients could explain the reduced ability of the screening service to reach Maori patients. In order to address inequity and increase overall screening rates, diabetes eye screening and primary care services need to improve the booking system, facilitate transport to screening, engage patients and their whanau and build trust.

Disruption to the doctor-patient relationship in primary care: a qualitative study.

BACKGROUND: Starfield described the importance of system-level components of primary care (first contact, continuous, comprehensive, coordinated), on countries' health systems. It is postulated that, at the individual level, interpersonal interactions and relationship-centred care are central to primary care. AIM: To explore the impact of COVID-19 on disruption to the doctor-patient relationship and subsequent development of new models of care. DESIGN & SETTING: A series of 11 cross-sectional surveys of New Zealand (NZ) urban and rural primary care doctors, nurses, and managers, from May 2020 to February 2021, to understand and monitor responses to the pandemic. METHOD: Using inductive content analysis, cumulated qualitative data from doctors were examined through the lenses of the doctor-patient relationship, its disruption, and resulting changes in models of care. RESULTS: There were 1519 responses to the surveys, representing 482 unique participants. The majority (86%) of responses were from doctors. The following four key themes emerged: moving to transactional consultations; task-shifting with team changes; creating a production line; and diminished communication and coordination across services. CONCLUSION: The advent of the pandemic led to severe and ongoing strain on practices requiring rapid change to the model of care. Team members took on new roles for triaging, testing, and separating patients with respiratory and non-respiratory symptoms. There was a rapid move to telehealth, with policies developed on where face-to-face consultations were necessary. Practice strain was exacerbated by disruption to coordination with secondary and other referral services. As new models of general practice develop, further disruptions to development of doctor-patient relationships must be avoided. This work extends Starfield's system-level paradigm to the individual level, with the core value of primary care the doctor-patient relationship. Successful sustainable models are likely to be where relationships are treated as of central importance.

Scope and activities of Māori health provider nurses: an audit of nurse–client encounters.

Introduction The activities and consultations undertaken by Maori health provider nurses are likely broad and operate within a Maori nursing model of care. However, there is little quantitative evidence to document and describe these encounters with clients. The Omaha coding system provides a mechanism in which to quantify nursing encounters through classifying client problems by domain, interventions and specific targets relating to interventions. Aim The aim of this study was to document the types of encounters and interventions undertaken by Maori health provider nurses. Methods An audit was undertaken of patient encounters occurring within a Maori health provider between 1 January 2020 and 31 December 2020. Encounters were randomly selected and problems, activities and interventions coded utilising the Omaha coding system. Simple descriptive statistics were used. Results A total of 5897 nurse-client encounters occurred over the study period. Overall, 61% of the audited nurse-client encounters related to the physiological domain and only 6% of encounters were related to the psychosocial domain. And 29% of nursing interventions involved teaching/guiding/counselling and a further 29% of interventions were case management. Discussion The wide variety of conditions seen and the number of interventions carried out indicate the broad scope of Maori health provider nurses. However, there were likely undocumented problems, which could reflect the medicalisation of the electronic health record. Redesigning electronic health records to apply more of a nursing and Maori health provider lens may facilitate more inclusive ways of documentation.

COVID-19 impact on New Zealand general practice: rural-urban differences.

INTRODUCTION: In countries such as New Zealand, where there has been little community spread of COVID-19, psychological distress has been experienced by the population and by health workers. COVID-19 has caused changes in the model of care that is delivered in New Zealand general practice. It is unknown, however, whether the changes wrought by COVID-19 have resulted in different levels of strain between rural and urban general practices. This study aims to explore these differences from the impact of COVID-19. METHODS: This study is part of a four-country collaboration (Australia, New Zealand, Canada and the USA) involving repeated cross-sectional surveys of primary care practices in each respective country. Surveys were undertaken at regular intervals throughout 2020 of urban and rural general practices throughout New Zealand. Five core questions were asked at each survey, relating to experiences of strain, capacity for testing, stressors experienced, types of consultations being carried out and numbers of patients seen. Simple descriptive statistics were used to analyse the data. RESULTS: A total of 1516 responses were received with 20% from rural practices. A moderate degree of strain was experienced by general practices, although rural practices appeared to experience less strain compared to urban ones. Rural practices had fewer staff absent from work, were less likely to use alternative forms of consultations such as video consultations and telephone consultations, and had possibly lower reductions in patient volumes. These variations might be related to personal characteristics of rural as compared to urban practices or different models of care. CONCLUSION: New Zealand rural general practice appeared to have a different response to the COVID-19 pandemic compared to urban general practice, illustrating the significant strengths and resilience of rural practices. While different experiences from COVID-19 might reflect differences in the demographics of the rural and urban general practice workforce, another proposition is that this difference indicates a rural model of care that is more adaptive compared to the urban one. This is consistent with the literature that rural general practice has the capacity to manage conditions in a different way to urban. While other comparable countries have demonstrated a unique rural model of care, less is known about this in New Zealand, adding weight to an argument to further define New Zealand rural general practice.

The whitewashing of contracts: Unpacking the discourse within Maori health provider contracts in Aotearoa/New Zealand.

Maori health providers emerged in Aotearoa/New Zealand in the 1980s as a mechanism to achieve self-determination for Maori communities. However, the contracts funding Maori health providers limit expressions of self-determination and fail to reflect Te Tiriti O Waitangi, the founding treaty of Aotearoa/New Zealand. Significant health reforms are proposed in Aotearoa/New Zealand, including the creation of a Maori Health Authority that will commission services from Maori health providers. This paper aims to critique the government contracts provided to Maori health providers in the light of the health reforms. A discourse analysis was undertaken on contracts held by a Maori health provider. The study was informed by a Kaupapa Maori congruent methodology that centralised Maori knowledge. The contractural language utilised a variety of discursive techniques that ultimately limit the power of Maori health providers. These discursive techniques included the redefinition of Maori concepts of self-determination, the use of rhetoric that was not matched by action, reshaping Maori health priorities to reflect the funders' priorities and the application of a deficit lens to Maori health issues. The discursive techniques present in these contracts is consistent with previous work demonstrating a failure of funders to centralise Maori knowledge and ways of being. Success of the proposed health reforms and the Maori Health Authority should require dismantling of non-Maori ways of commissioning and contracting, otherwise there is the continued risk of discriminatory contracting practices limiting the expression of self-determination for Maori health providers.

Making sure the New Zealand border is not our Achilles heel: repeated cross-sectional COVID-19 surveys in primary care.

AIM: Quick COVID-19 Surveys are an international collaboration designed to rapidly analyse and disseminate a primary care perspective on the pandemic and associated health response. In this paper we present results from surveys relating to opening the New Zealand border. METHOD: Three surveys were distributed to primary care practices between May and December 2020. A range of primary care member organisations distributed the survey augmented by snowballing. Quantitative data were analysed using descriptive statistics and qualitative data through an inductive process and grouped into themes. RESULTS: Respondents became increasingly supportive of opening a trans-Tasman border but not internationally. Two broad themes were evident: (1) making sure that the border is not an Achilles heel and (2) effective strategies to reduce local transmission. These themes highlight primary care's concerns around management of the border and the management of local spread respectively. CONCLUSION: The results highlight concerns around border control from a primary care perspective. The border control issues raised by primary care have proven to be prophetic at times and reflect the role that primary care has as observers of society. The survey mechanism provides a template for rapidly eliciting a primary care voice for future health issues.

Epidemiology of healthcare harm in New Zealand general practice: a retrospective records review study.

OBJECTIVES: To determine the epidemiology of healthcare harm observable in general practice records. DESIGN: Retrospective cohort records review study. SETTING: 72 general practice clinics were randomly selected from all 988 New Zealand clinics stratified by rurality and size; 44 clinics consented to participate. PARTICIPANTS: 9076 patient records were randomly selected from participating clinics. INTERVENTION: Eight general practitioners examined patient records (2011-2013) to identify harms, harm severity and preventability. Analyses were weighted to account for the stratified sampling design and generalise findings to all New Zealand patients. MAIN OUTCOME MEASURES: Healthcare harm, severity and preventability. RESULTS: Reviewers identified 2972 harms affecting 1505 patients aged 0-102 years. Most patients (82.0%, weighted) experienced no harm. The estimated incidence of harm was 123 per 1000 patient-years. Most harms (2160; 72.7%, 72.4% weighted) were minor, 661 (22.2%, 22.8% weighted) were moderate, and 135 (4.5%, 4.4% weighted) severe. Eleven patients died, five following a preventable harm. Of the non-fatal harms, 2411 (81.6%, 79.4% weighted) were considered not preventable. Increasing age and number of consultations were associated with increased odds of harm. Compared with patients aged ≤49 years, patients aged 50-69 had an OR of 1.77 (95% CI 1.61 to 1.94), ≥70 years OR 3.23 (95% CI 2.37 to 4.41). Compared with patients with ≤3 consultations, patients with 4-12 consultations had an OR of 7.14 (95% CI 5.21 to 9.79); ≥13 consultations OR 30.06 (95% CI 21.70 to 41.63). CONCLUSIONS: Strategic balancing of healthcare risks and benefits may improve patient safety but will not necessarily eliminate harms, which often arise from standard care. Reducing harms considered 'not preventable' remains a laudable challenge.