Review of the National Cervical Screening Programme - November 2011

Review of the National Cervical Screening Programme 2011

From the November 2011 AWHC Newsletter

The need for regular independent reviews of New Zealand’s National Cervical Screening Programme (NCSP) was one of the measures introduced in the wake of the report of Ministerial Inquiry into the Under-reporting of Cervical Smear Abnormalities in the Gisborne region in 2001 – known as the Gisborne Cervical Screening Inquiry.¹

In January 2011 Jeffrey Tan (Australia), Roberta Howlett (Canada) and Linda Thompson (New Zealand) were appointed to undertake an independent review of the NCSP. The review committee was established by and accountable to Associate Minister of Health, Tariana Turia. The committee’s report was published in August 2011 and contains 39 recommendations.

Despite the National Screening Unit’s attempt to put a positive spin on the review committee’s findings, many of the observations about the current state of affairs within both the National Screening Unit and the NCSP eerily echo evidence and warning statements given in some of the submissions made to the Gisborne Inquiry.

In September 2000 Sandra Coney, director of Women’s Health Action, warned the Gisborne Inquiry in her final submission:

“The history of the NCSP and the Ministry's relationship with it requires that the future involvement of the Ministry of Health be treated with caution” and in arguing for the establishment of a national cancer control agency separate from the Ministry she recommended that the NCSP be located within such an agency.²

The “Report of the Parliamentary Review Committee regarding the New Zealand Cervical Screening Programme”³ contains the following statements:

“The Ministry of Health has restructured many times in this past decade, inevitably affecting the NSU and the NCSP.” (page 8)

“From 2001 and 2011, reports and inquiries on cervical screening highlighted concerns and recommended change in the development, management, autonomy and leader-ship of the NSU.” (page 43)

“Ministry of Health restructuring over time has confirmed a management structure within the organisation that may have had the effect of compromising clinical leadership.” (page 44)

“Multiple changes within the Ministry of Health carry the risk of loss of institutional knowledge and screening expertise. High staff turnover has translated to lost expertise. The impact on providers and screening participants has been noted with respect to limited or no communicat-ion about changes with the loss of continuity and key contacts.” (page 45)

“Externally there is a perception of a general ‘dumbing down’ of both the NSU and NCSP. Feedback has indicated an impression externally of a pervasively disorganised and reactive culture, disconnected relationships with stakeholders and poor co-ordination.” (page 45)

The women’s health groups who attended and closely followed the Gisborne Inquiry were strongly opposed to the prospect of the NCSP remaining within the Ministry of Health due to some of the very problems identified in this report.

After the Gisborne Inquiry, the NZ Cancer Control Trust was established in February 2001.⁴ Unfortunately the NCSP remained within the Ministry of Health.

Ethnicity and Inequalities

The Parliamentary Review Report noted that increasing participation in the NCSP and reducing disparities in the screening coverage for Maori, Pacific and Asian women are hugely important issues that have yet to be fully appreciated and addressed.

Echoing concerns expressed by women’s health groups over the past few years regarding the establishment of the HPV vaccination programme, the report stated: “there is room for improvement in the organised programme via improved collaboration and integration with the HPV immunisation programme and improved alignment with New Zealand’s cancer control strategy.”

Six of the 39 recommendations concerned improving coverage, participation, equity, access and reducing the burden of disease.

Quality Assurance and Monitoring

A woeful and utterly negligent lack of monitoring is one of the issues that led to the Gisborne Inquiry – prior to 2000 the NCSP had never been monitored despite repeated calls from women’s health groups during the late 1990s for an audit of the programme5 – and while the review commend- ed progress in the resources that have been expended on quality initiatives, the report stated that “consultation and collaboration between the NSCP and key stakeholders require significant improvement” as “awareness of current NCSP quality activities is very limited.” (page 8)

There were six recommendations on quality assurance and monitoring issues.

Workforce Issues

Once again echoing the concerns repeatedly raised during the Gisborne Inquiry, the report stated:

“From 2001 to 2011, reports and inquiries on cervical screening highlighted concerns and recommend-ed change in the development, management, autonomy and leader-ship of the NSU.” (page 43)

“Enhanced leadership capacity – including population health, public health and screening expertise – is urgently required within the NCSP to improve the depth and breadth of expertise and experience within the NSU and NCSP.” (page 9)

Despite the major problems identified during the Gisborne Inquiry regarding clinical leadership within the NCSP, followed by the recommendations from the Office of the Auditor-General Ministry in 2002/03, the report noted “Ministry of Health restructuring over time has confirmed a management structure within the organisation that may had had the effect of compromising clinical leadership," and warned “Clinical experts and advisors must remain as the linchpin in any clinical programme.” (page 44)

There were six recommendations on workforce issues.

The NCSP Register

The register has been a thorny issue since the very beginning of the NCSP and Sandra Coney’s submission to the Gisborne Inquiry contained a detailed account of the repeated attempts women’s health groups made to keep the establishment of New Zealand’s first screening programme focused on cervical screening rather than the register, despite the ongoing intransigence of the Ministry of Health.⁵

The report noted that “complaints to the NCSP have highlighted the need for ongoing public education efforts to inform participants that their screening information is included in the NCSP Register and to advise them of their withdrawal options.” (page 10)

There were six recommendations concerning the NCSP Register.

Organisational & Structural Issues

The issue of representation for consumer and priority women’s groups was dealt with under this heading. The report stated:

The two remaining NCSP advisory groups must have a stronger role and function to ensure an adequate voice and presence for consumer and women’s groups. These include the NCSP Advisory Group and the Maori Monitoring & Equity Group.”

As a first step in the NSU’s plan to merge Maori, Pacific and other health promoters into one hui, the NSU held a National Leadership & Workforce Development Forum in March 2011. However, the report noted that the NSU still needs to consider whether other priority women’s groups are sufficiently covered by these arrangements.

The review also advised that cervical screening be integrated with other health programmes, and the whanau ora approach must be given priority.

There were four recommendations on organisational and structural issues.

Issues around colposcopy and the HPV vaccine were also addressed in the report.

Finally, the review committee recommended that future reviews be undertaken at 5-yearly intervals instead of every 3 years.

Future Directions

The report ends with a brief section on future directions and refers to the confusion around the respective roles of NCSP and the NSU. The original plan was for the NCSP to provide a service that would reduce the burden of disease from cancer of the cervix. “This would encompass the women who participate, health promotion activities, smear takers and assessment services, laboratories and related staff, treatment services, monitoring agents and evaluation teams.

The NSU is the primary, but not the only, agency responsible for facilitating the organisation of all these activities, but for some, NSU should not have direct control. NCSP is larger than the NSU. Some organisational, accountability and leadership problems are apparently related to a contrary NSU philosophy that the NCSP is merely one of several screening programmes. NSU’s intended role was to facilitate and support NCSP, and it should operate accordingly.

NSU is a major stakeholder regarding successful implementation and maintenance of a cervical screening programme, with a role to facilitate the organisation and cooperation of all the stakeholders and partners.

Yet the main stakeholders have to be the women of New Zealand; without that focus, participation and effectiveness may be reduced.”

The Parliamentary Review Commit-tee’s Report was released with little fanfare. It remains to be seen whether the 39 recommendations will be implemented or whether it will be consigned to history as just another report that highlighted concerns about the NCSP.

Health Promotion Agency

Meanwhile the government is in the process of establishing a Health Promotion Agency to take over the health promotion and social marketing roles of both the Alcohol Advisory Council (ALAC) and Health Sponsorship Council (HSC).⁶

It is not clear if the new agency will also be undertaking all the other work currently done by both councils.

Word has it that for some utterly unfathomable reason the new Health Promotion Agency may also be taking over the NSU’s health promotion and social marketing activities. Whoever thought that this was a good idea obviously has no understanding of the history and role of screening, or the risks involved in removing these important tasks from the NCSP.

Once again the NCSP is about to become the victim of yet another round of governmental restructuring. When will they ever learn?

References

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