Cervical Cancer Inquiry Hearing Tuesday 18 April
TUESDAY 18 APRIL 2000
THE HEARING RESUMED AT 9.40
A.M.
JUDITH GLACKIN recalled (On former oath)
XXD
BY MR CORKILL (continues)
MS SCHOLTENS: We have with
us copies of the funding authority agreements and their
successors from 1993 through to 1997. if the committee is
interested in looking through them, they are available. The
performance indicators will be copied today and made
available also.
MR CORKILL: I wonder if you could take
up volume 11, which is the volume of Tairawhiti documents,
and go, please, to about p10, it’s a document with the
heading “Programme” on it “Visit of Fiona Sanders Francis
and Peter Miller to the Tairawhiti cervical screening
programme implementation unit”, do you have that .....
yes
Apparently in July 1989 those two individuals from
the implementation unit visited various health professionals
in the Tairawhiti area, correct ..... yes.
Including at
the end of the day a meeting with Dr Bottrill .....
yes.
Now the next page in the bundle is the document
which records the various meetings they held with members
of the Area Health Board and so on ..... yes.
This
document does not have a date on it but we conclude it must
have been July 89 ..... yes.
And with reference to Dr
Bottrill, there is a series of entries on p5 of that
document, do you have that ..... I do.
And the writer
recorded under the heading “Impressions: wants to avail
himself of the minimal data entry system, does not employ
any cytology assistants and has never tried to even though
he doesn't particularly want to continue screening all the
slides himself.” Laid back to the point of almost falling
over, experienced recent ill health, has developed his own
data base, suggested he take his completed laboratory forms
to the board for punching, doesn't want to read any slides
than his current 20/day, interested. in the form
particularly in relation to the number of forms we would
require general practitioners to fill out”. Now, with
regard to the point he was laid back to the point of almost
falling over, does that suggest to you that those from the
implementation unit thought that he was not as focused or as
vigilant as one would expect
MR HODSON:
objection.
MR CORKILL: I asked the witness what she
thought those words in the document meant, it is an
inference I am asking her to draw from her perspective
only.
MR HODSON: it is entirely a matter for the
committee.
CHAIR: I agree Mr Hodson that it is a matter
for the committee what inferences are drawn from the
document. It seems the Minister of Health has overall
respbty in a broad sense for the running of this programme
and therefore I would be interested to know what if anything
the Ministry thought if it were to read a document such as
this.
MR HODSON: when I have the opportunity I will
take the matter further and ask them what they did.
MR
CORKILL: could you respond to the question? What did the
Ministry make of that observation ..... I can't respond to
that. I think these were draft notes, as indicated, this is
not any form of formal Ministry document. It certainly
implies that Dr Bottrill was perhaps less than focused, but
I think the point has been made that I'm only being asked to
comment on a text written by somebody a long time ago in
circumstances I wasn’t involved in.
CHAIR: would
information of this type about the performance of a
pathologist have come to the Ministry’s attention at the
time that the information was obtained ..... this was in
1989. I actually believe that Dr Boyd was at that point
responsible for the primary care programme – he may be able
to help you with this.
In terms of trying to find out
whether specific knowledge of this type could have got back
to the Ministry and what the Ministry might have done in
respense the appropriate person to ask those questions is Dr
Boyd ..... I believe so if the issue were the performance of
a pathologist. This information was gathered in the context
of a visit to assess the readiness of Tairawhiti for the
National Cervical Screening Programme
But it is
information that comments on performance of a pathologist
..... the attitude of a pathologist I believe.
Are you
saying to me that the Ministry of Health if it gets
information which comments on the attitude of a pathologist
if that information is not obtained in the context of an
inquiry into the pathologist’s performance but it comes to
your attention in another context you disregard it ..... no,
I'm saying that Dr Boyd would be better able to comment on
what would be done with information of this type in
1989
And at the moment if the Ministry got this type of
information, firstly could it get this information ..... if
this information came to attention, for example through a
Ministerial letter to a minister, the Ministry would ask the
Health Funding Authority to investigate and report. The
ministry would not do so itself directly, although there are
instances where concerns about services received by an
individual occur, that the Ministry will either contract
with someone to investigate – I'm aware we have done this
recently in a number of areas, or alternatively will follow
up through its chief advisers what is occurring. It would
depend whether our approach would be to ask the Regional
Health Authority.
In terms of asking the Regional Health
Authority to investigate the performance of a health
professional, if you are delegating the issue of
investigation to an Regional Health Authority what quality
assurance checks do you have on the performance of the
Regional Health Authority in assessing whether or not it is
doing its job in carrying out an investigation for the
Minister of Health competently ..... the Ministry would ask
the Regional Health Authority to report informally and then
in writing and depending on the type of complaint for
example our chief advisor medical or if it were an issue
with disability a chief advisor disability would be asked to
comment on what had been done. If the issue under some
other circumstances the Ministry will itself contract with
an outside expert and ask them to report. We would then
provide that information to the Minister of Health along
with our recommendations as to what action should be taken
and the Regional Health Authority would be involved in that
as well and it may be that a report would simply detail how
the Regional Health Authority was dealing with the issue and
give the Ministry’s view as to whether that was appropriate
or not.
And so in preparing the Ministry’s report on what
the Regional Health Authority or the independent contractor
advised there would be critiquing of the Regional Health
Authority of the independent contractors approach and the
report written on it ..... that is so, it may be we may
consider the correct approach has been taken.
MR CORKILL:
if I can go back to the document, this appears to be a
document prepared by Fiona Sander Francs and peter miller
following their visit to Tairawhiti ..... correct
And
they were Ministry staff from the implementation unit .....
yes I believe so.
And as your exhibit 84 tells us, that’s
the diagram that you produced yesterday, Dr Gillian Durham
was the project leader of the implementation unit at that
time ..... I believe that’s so although I note I've since
preparing this over the weekend become aware that at some
time I was not able to identify precisely when Dr Durham
left the Ministry for the Area Health Board and Fiona SF was
manager of the cervical smear implementation unit and I
believe this continued until Gillian Grew was appointed in
1990.
Until Dr Durham went to the Wellington Area Health
Board she was the project leader ..... yes that’s what the
Ministry’s records show
And Ms Sanders F and Mr Miler
reported to her ..... yes, it would seem so.
The comment
we were discussing on p5 “laid back to the position of
almost falling over” you would accept is a criticism ..... I
would believe so, yes.
Carrying on in that bundle, I want
to take you to a document of 1 July 1981, just before half
way in the bundle, a memo to Janet Takarangi, do you see
that ..... I do.
It’s got “memo” on the top of it .....
yes.
That is the source in the comment in your brief that
the Tairawhiti … for cervical cancer in New Zealand” .....
yes, although that is referred to elsewhere as well.
And
just staying in the bundle for a moment, if you go through
to minutes of Programme Managers meeting September 93, about
2/3 of the way through the bundle, ..... yes.
If you go
to paragraph 5.17 of that document the Tairawhiti entry, at
that stage the Programme Manager was noting that she was the
only person employed on the programme spending 80 to 85% of
her time operating the register, no replacement for the
educator position, many things had not been done as she did
not have the resources ..... yes, that’s what’s
recorded.
That’s an example of a Programme Manager making
a report or comment at a Programme Manager’s meeting which,
as we see from the previous page, had a number of Ministry
attendees ..... yes.
What would the Ministry do in the
face of a comment like that ..... this is September 1993,
which means that Regional Health Authorities would have been
in operation. I cannot comment on what was done in relation
to this issue. As I pointed out in my brief all the
Ministry’s references to Tairawhiti that were held in our
files are included in this bundle of documents, so in
relation to the specific incident I am not aware what
follow-up there was.
Do you agree there does seem to have
been a worrying theme through some of her reports as to the
adequacy of staff cvrge, for instance in your paragraph 200
you note that the staff or that she said that the staff were
covering reception duties – this is coming onto 95 .....
yes, I think my brief does say that
Do you agree that was
a bit of worrying theme from her reports, that for a time
there was only one person, because the educator was not
replaced, and they were having to deal with basic matters
such as reception matters ..... that issue was consistently
raised in her reports although it was resolved later. I am
not aware of what action if any was taken to follow it
up.
If you go on to the second to last document in this
bundle, which is a verbal report to a June 1997 meeting of
managers, the second to last document in the bundle, and go
to the second page of it, this is a report from the
Programme Manager it would seem, it‘s on Tairawhiti health
care letterhead and on the second page “seems to be getting
… especially from own clinics”. Again, would you agree that
an observation of that kind more high grades is a flag for
something that needs to be attended to promptly ..... yes it
is, and I did discuss this with Dr Best who was the
co-ordinator at this time in relation to what follow-up
there had been on this issue. She said they found it very
concerning but apart from keeping the issue under review
there was nothing they could directly do about it. In
retrospect it is quite clear this result is to be expected
if there were problems with under-reporting in
Gisborne.
Firstly, can you say what the extent of the
“more high grades” was at that stage ..... no, as I
mentioned in my brief, these are the records kept in the
Ministry’s files. I wasn’t present at the meeting.
Do
the Ministry’s records not disclose the extent of the high
grades ..... not in relation to Gisborne, no.
Surely that
information was obtnble from the register ..... yes. this
is high grade smears so the histology would have been
recorded on the register.
The information was on the
register and available to the Ministry ..... yes, I believe
it was.
You mentioned that it was a matter of concern to
the co-ordinator and it was decided to keep the matter
under review, how was that done and what happened ..... I
think apart from discussing the issue as an issue of concern
there was not a great deal that could be done. I'm not
aware because our discussions didn't go that far, whether or
not it was raised with the Regional Health Authority in the
area. I think the reality is this was an issue raised with
the programme it was an observation they were seeing more
high grade smears made at one time. What I would have
expected was to observe the trend, she comments that she
hasn’t had the time to evaluate it yet at that point
But
it was an alarm bell wasn’t it ..... certainly it would seem
to be an alarm bell under present circumstances yes
And
that is precisely the sort of situation where one would
expect the Ministry to be maintaing a very close eye on this
trend ..... if the trend continued yes, that’s true.
And
you don't know at this point in time whether it did ..... no
I don't.
PROFESSOR DUGGAN: in this period of time, 97,
where were those smears being processed and interpreted
..... the smears were being read by Medlab Waikato, that
took over the smear-reading from the Gisborne Laboratories
after Dr Bottrill’s retiremt
All the smears from this
area were being referred out to another laboratory .....
they were being read from 1986 when Dr Bottrill retired at
another laboratory.
Is there data on the registry that
would compare the reporting frqncy of the previous years
95/96 and allowed to be compared to the reporting of 97 of
the smears from this area ..... I believe so, yes.
And
where would that data be ..... the data is held on the
register. For the Gisborne area histology is now almost
complete back to June 1993. I think the other point was
that the histology was not complete until it was entered, I
believe early this year
So the com could see the data
on the smears ..... I believe so
For the same population
group ..... I believe so though I would need to check that
with somebody who manages the register to ensure that
information could be produced, but certainly histology
information from the area is held on the
register.
Actually, that’s a good point from this comment
is Ms Read referring to the smear results or the histology
..... the smear results. She is referring to it in the
context of smear results from the clinics.
So the data on
the smear reporting over several years could produced .....
it is on the register an assuming it is technically possible
I assume so.
MR HODSON: my instructions are vital to an
assessment of some of the issues and I would ask the
committee to direct that every effort be made to obtain
it.
CHAIR: certainly. Who can tell the committee
whether or not this data is readily available ..... the
Ministry would be able to verify that to you and respond
hopefully today.
MR MURRAY: a lot of this data is being
worked on now for the study that is to be brought back to
the committee in July. It is now being loaded on to the
register.
CHAIR: the committee would be interested.
to know whether during the years 95/96 this data was readily
achievable to make an assessment possible.
PROFESSOR
DUGGAN: the data is the frequency of abnormal smears
reporting from the population in Gisborne, not from the
laboratory files of the new laboratory in 1997,
Hamilton.
MR MURRAY: I believe the most accurate
reading will come from the Sydney re-reading. I believe the
focus is on the period 91-96 – so will have to see what the
position is from 96 onwards
PROFESSOR DUGGAN: my query
is from 97, Ms Reid, re her perception there is an abnormal
number of smears after taking over Dr Bottrill’s practice.
the 1997 data should pertain to the Gisborne
population.
MR HODSON: there is still an area of
misunderstanding. Dr Bottrill retired in 1996. nobody has
reviewed any of the material from march 1996 onwards, and it
is that material which I suggest is vital.
MR MURRAY:
If that information is not available we will work on it – I
have noted that and follow it up to see who would cover that
sort of evidence.
MR CORKILL: just to complete the
paper trail, in my researches there was another Tairawhiti
document which we will place before the committee for the
sake of completeness. This is another document which I
think came from the Ministry records – it discloses a visit
by Penny Geddes to Tairawhiti in late 1993. [Produced as
JMG/MOH/ 092]
On a different matter, you will be aware of
the Medical Practitioners Disciplinary Committee hearing in
relation to Patient One ..... yes, I have heard about
it.
It is a fact that the decision of that committee
emerged on 5 June 97 following a hearing in February of that
year. Were you aware of telephone comnctn of the result of
that committee hearing from Betsy Marshall of the Cancer
Society to Mrs Best, the then programme co-ordinator in June
1997 ..... no, this is the first I've heard of it.
Thank
you. At that stage, under the legislation which this
particular complaint was being dealt with – i.e. the old
Medical Practitioners Act, at that stage the
Director-General was a member of the Medical Council was he
not ..... I believe that a representative of the
Director-General sat on the Medical Council. I would
comment as well that Dr Boyd is better placed to comment on
these issues than I am, the Ministry’s safety and register
branch is respble for the administration of regulation and
has dealt with these issues whereas I have not.
That’s
helpful and we will, but I just want to establish when the
case of Patient One went on appeal from the Medical
Practitioners Disciplinary Committee to the Medical Council,
the Medical Council heard the appeal in November 1997 and
delivered its decision on 10 December 1997. to your
personal knowledge, was the Ministry then provided with a
copy of this decision of the appeal of the Medical Council
to its member, the Director-General ..... I have no personal
knowledge of this and I wouldn't expect that I would have
had.
CHAIR: can you say fm your knowledge of the
Ministry’s practices whether an appeal decision of this
nature would be brought to the Ministry’s attention ..... I
think that needs to be referred to Dr Boyd
MR CORKILL:
In your considerable researches for this hearing have you
seen records showing the provision of the decision to the
Ministry ..... no I have not.
Have you made enquiries
about this topic ..... Dr Boyd was following this issue – we
had separate responsibilities between us
Have you not
concerned yourself about this particular issue ..... I have
not dealt with that and am not able to speak on that on
behalf of the Ministry, Dr Boyd is an appropriate
person.
As madam chair mentioned a moment ago there is
another restrucint later this year, what is the Ministry’s
view as to the appropriate location of the programme upon
the dis-establishment of the Health Funding Authority .....
the provisional, structured consulted on with the Ministry
places this programme in the public health
directorate.
And who is in charge of that directorate
..... the person who will eventually appointed as Deputy
Director-General public health.
Who is that at present
..... there is no exactly equiv position at present.
And
physically where will the register be located upon that
happening under the Ministry’s scenario ..... I'm not able
to comment on that. I understand that the intention
certainly is to keep the register functions together, I've
also heard discussed in the Ministry the intention to
consider the outcome of this inquiry before making that
decision.
Who in the Ministry is charged with the
responsibility of considering the future of the programme
..... The Deputy Director-General Dr Karen Poutasi
XXD MR
HODSON:
You have referred in exhibit 62 to the visit
of the implementation to Tairawhiti area on 19 July 1989 and
yoyuve been invited to read, and you have read, the comments
made about Dr Bottrill, do you remember that .....
yes.
If you look through that document, I suggest you
will see comments similar in tone and about as equally
offensive, not in every case, in relation to the Tairawhiti
Area Health Board staff, the EDP committee represents and
the general practitioners – fair comment ..... yes that is
fair comment.
Had that document ever been circulated
pretty well everyone mentioned in it would have been furious
..... I believe so, and I note that the document is headed
“rough notes” on the visit.
What must have been clear to
the implementation unit at the conclusion of the visit was
that the concept of the programme and its basic principles
had not been sold effectively in that district, correct
..... I think it would be true to say that they had quite
some way to go before being ready.
And a little lower
down in that bundle, I find a letter dated as late as 9
April 1991, and that's 20 odd pages later, from the Ethics
Committee of the Tairawhiti Area Health Board, which says in
effect, that they don't want the programme, they want the
money spent on problems which were seen in that area as much
more pressing than cervical cancer ..... yes, that is
correct, and in fact was included in my brief.
And the
response was that cervical cancer was at that time a major
problem in Gisborne ..... that’s correct. I can confirm
this from my knowledge of the documents.
What Dr Bottrill
told the implementation unit was that he had a capacity in
his laboratory of about 20 smears to be read/day and he
didn't want to exceed that, and there were a number of
practical difficulties about hiring additional staff,
correct ..... you might deduce that, it says he has not
tried to hire additional staff.
If you look down, about 8
pages, you foind a minute sheet from Rosemary Jones I think
it is to Jill Grear, with Tairawhiti’s actuals and targets
attached on the next page ..... yes.
What that indicates
is that 5,360 smears were read in 1990/91 and the target for
the next year was 6,300. the 5,360 is about the 20/day that
Dr Bottrill was talking about isn’t it ..... you might be
better at mathematics than me but I’ll take your word for
it
Nobody appears to have given any consideration to the
possibility of practical problems in processing the sort of
information that you wanted to get from Tairawhiti .....
there are references to concerns about capacity given the
expected increase in slide numbers to be read that I think
run throughout the documents, but I've never seen anything
specific about Tairawhiti.
No. the other topic I wanted
to ask you about, I take it you heard of the concern about
Tairawhiti in common with the Health Funding Authority and
others some time around about March of last year ..... yes,
that’s recorded in my brief.
And previously there was no
particular concern, either within the Health Funding
Authority or the Ministry about Dr Bottrill or his
laboratory ..... I'm not aware of any, and the information
the Ministry has produced covers all the written material
available in our files.
Yes. and the reason that
Tairawhiti hadn’t come to notice, as it were, was because
the figures which had been obtained from Dr Bottrill’s
readings indicated that his practice was within the normal
parameters of all the laboratories that had been reporting
to the register ..... I think as my evidence makes clear,
prior to the reconfigrtn of the register there was only one
report which enabled national comparisons to be made, and
that was information assembled for the preparation of the
second statistical report
Would you please go to volume 5
of Dr Boyd’s exhibits, tab 29. is that a letter dated 7
August 1996 which you sent to all the laboratories reporting
cervical smears ..... yes, it is.
And attached to that
letter is a copy of the particular analysis relating to Dr
Bottrill’s laboratory ..... yes, it is.
And although you
wrote the letter in August 1996, the information which it
contained was for the period ending 30 June 1994 .....
that’s correct.
I just want to isolate four of those
statistics. The first one, under the B codes, that is the
category under which the % of reporting within normal limits
or for referral or repeats is set out, correct .....
yes.
Dr Bottrill was reporting 86% of his smears as
normal, correct ..... yes.
The national mean of community
laboratories was 80.9% ..... yes
But the range of
community laboratories was a low of 68.7 and a high of 94.7
..... yes.
So some laboratories were reporting more
normal smears than Dr Bottrill ..... that is true.
In the
third heading, under the B codes, you have the %s relating
to request for repeats within 3 months. Dr Bottrill was the
highest requester of repeats within 3 months, correct .....
yes. according to the range shown here.
The vital ones
with which were concerning about is under C, the diagnosis.
And the fourth heading is the % of low grades reported by
this laboratory, correct ..... yes.
Dr Bottrill reported
1.4% ..... yes.
The mean was 3.2% ..... yes.
But the
range was 0.9% to 6.6% ..... yes.
So there were
laboratories reporting few low grades than Dr Bottrill,
correct ..... yes.
And in the high grades Dr Bottrill
reported .6y% but the national mean is .8% .....
yes.
Very close ..... a .2% difference.
But the
national mean was 0.4 – 2%. Now, within those figures there
is no cause for alarm, is there ..... I'm not – it wouldn't
appear to me, but in relation to this issue I am very much a
lay person, Dr Boyd is better qualified to comment on this
than I am.
The concern in 1999 that came to you was that
he had been missing high grades and low grades ..... the
concern that came to us in 1999 was that when it intialy
came, that there were issues of concern in Gisborne. I
think that concern emerged or became more specific as the
situation became more clearer.
Did you look at those
statistics ..... the Health Funding Authority
No, did
you look at those statistics ..... no I did not.
CHAIR:
did anyone at the Ministry look at the statistics ..... I
don't believe that we looked at the statistics until we
received – no, I would like to correct myself – once the
Ministry as I've recorded in my brief, received official
into or requests for into related to Gisborne Laboratories
and Dr Bottrill, then this information was among that pulld
from our files I believe, at which point the Ministry would
have looked at those.
MR HODSON: it is apparent, then,
that there is a laboratory/laboratories which were known to
be reporting at a lower rate or possibly the same rate as Dr
Bottrill. My first question is have any steps been taken to
identify which laboratories are in that position ..... as my
covering letter to this information suggested, that this
data provided here is historical and limited and it was
provided for quality assurance
I'm not talking about when
you wrote the letter, I'm talking about last year in 1999
..... you would need to raise this issue with the Health
Funding Authority, responbile for this
Were you satisfied
in your own mind that the data or any other source at that
time that there was no question of risk to any other women
..... the purpose of the Health Funding Authority’s
investigatns
No, were you satisfied in your own mind that
there was no possibility of risk, you were the person
reporting to the Minister ..... I was not reporting to the
Minister on the Health Funding Authority’s follow-up in
relation to the concerns raised iin Gisborne. As is clear
from my evidence that issue was being dealt with by the
ministrys health performing branch and quarterly reports are
included here.
What was your title last year ..... in
respect of the programme last year I was a director of
policy and the Ministry[‘s policy respbty for this programme
was part of the population health and social policy
portfolio. That p/folio manager reported to me, the
Ministry’s policy branch was not dealing with the hfas
follow-up with the issues of concern as they arose in
Gisborne and I think that is clear from the memoranda which
I have produced. It’s clear that the Ministry divided
respbty for this issue.
I will ask you for the third
time, did it ever cross your mind as an ofcial in the
Ministry, a private person, a woman that there might be
other women at risk ..... if you are asking me for a
personal opinion and an official I was extremely concerned
about the potential for harm to other women as soon as this
issue came to light.
CHAIR: who in the Ministry was
responsible for following it up ..... once the issue came to
light the Director-General health called a meeting in the
Ministry at which I as present, Dr Boyd also who was acting
Deputy Director-General safety and regltn. We discussed the
pfmcne management was present as well. And we discussed the
action that the Ministry would take. At that point it was
agreed that policy branch would asisst where it was able,
that the lead in relation to reporting on the issues to do
with medical practrns rspbties would sit with the safety and
regltn branch which had responsibility for reglts and the
performance branch WOULD WORK closely with the Health
Funding Authority. In addition to that the policy analyst
in my section, who is our desk officer in relation to these
issues, participated in the team in the Ministry that looked
at these issues and provided comment.
Of the various
people you've mentioned formg this team, was anyone
appointed as a team leader ..... the Director-General asked
who should take the lead in resonding to the issues. At
that time it was decided that the safety and regltn branch
were to take the lead.
So, who in the safety and regltn
branch became the team leader ..... Dr Boy was the Acting
Director-General at that time, later replaced by Ron
Paterson appointed as deputy Deputy Director-General
I am
trying to fnd out the name of the person – was it Dr Boyd
..... it depends which periods you are talking about. A
project leader was later appointed.
You have described an
arrangement when the problem at Gisborne was drawn to their
attention … took on -
What I would like to know is who
was in charge of this team ..... ultimtly the
Director-General and it’s my understanding that these issues
were frqntly discussed at the m tg of the general management
team – I was not a member then.
Usaly where there are a
team of persons, each with separate responsibilities,
someone is appointed team leader to ensure that each person
in the team is properly performing their responsibilities,
is that correct ..... certainly that is something that the
Ministry does on many occasions. I don't recall that that
was specifically done
Was this team leaderless ..... it
is no unusual in the Ministry for a group of staff working
on an issue to as this group did regularly keep in contact
with each other. The responsibility for reporting to the
Minister was identified and that person was respble for
those issues. I think this reflects the Ministry[‘s
structure, ultimately the Deputy Director-General of policy
who was my manager at that time had responsibility for any
policy input. The Deputy Director-General performance
monitoring was responsible for following the action the
Health Funding Authority was taking and the Deputy
Director-General safety and regltn was dealing with the
issues as they affected the regltn particularly of health
professionals.
MR HODSON: at any rate, as it was not
your official respbty to be concerned about the possible
effects on other populations, that is why there is nothing
referring to that subject in any of the Ministerial papers
that you have produced ..... that is correct.
When Dr
Farnsworth’s results started coming in from Sydney it must
have become apparent fairly early on that Dr F was not only
saying that Dr Bottrill had reported about ¼ or the number
of slides that she has reported as high grade but that her
rate of reporting is at least double that of any other
laboratory in New Zealand . did that thought occur to
anyone in the Ministry to your knowledge as a possibility
that other areas than Gisborne might need to be ld at .....
that was certainly discussed, however, the Ministry[‘s view
was to follow closely the outcome of work being undertaken
by the Health Funding Authority in relation to laboratories
which went broader than Gisborne
Would you tell us the
name of the person and the job title of that person whose
responsibility it is to reassure the women of this country
that the problem is not limited to Gisborne or that steps
are being taken to find out whether it is ..... at present
that would be the Chief Executive of the Health Funding
Authority, which is Peter Hughes. As has been
discussed.
I just asked that. Is that person going to be
witness ..... he doesn't work for the same organistn as I do
- I can't comment on that.
Is anyone in the Ministry,
able to give the reassurance I've asked for, that this is in
fact a Gisborne alone problem ..... that is the issue that
is being investigated by the Health Funding
Authority.
CHAIR: but is the Ministry not concerned
itself to have an answer to this question ..... yes and the
mechanism for doing that is to follow very closely the work
being undertaken by the Health Funding Authority. There
have been a number of meetings with the Director-General of
Health to discuss exactly the Health Funding Authority’s
progress on this issue
Who attends those meetings with
the Director-General of Health ..... I have attended some of
those. The pfmance management attends as well. We are in
close contact with the Health Funding Authority on this
issue.
Is there anyone person who has single
responsibility for finding out what the Health Funding
Authority is doing and reporting on its progress to the
Minister ..... ultimtly that is the Deputy Director-General
performance monitoring in the ministry and the
Director-General of Health.
Can I take it that the Deputy
Director-General is carrying out this task personally .....
no the staff of the Ministry are carrying out this
task
Who are the staff ..... you want their names
What
I am try8ing to discover who are the individual person
charged with carrying out this task ..... I'm not exactly
sure how the responsibilities are allocated within that
branch, it’s not the branch I work in.
Would there be
one person with overall responsibility for the outcomes of
this team ..... ultimtly that is Dr Poutasi
I know that
is the case ultimtly, but when Dr P wants to make an
asesment on whether the task is carried out or not I thought
she would look at someone within the Ministry responsible on
the day to day basis for ensuring that the task is carried
out ..... ultimately she would request that information from
the performance monitoring branch the Deputy
Director-General responsible. I'm sorry it’s difficulty to
answer your question because I'm not aware precisely who has
what responsibilities on a day to day basis.
MR HODSON:
the figures that I've given to you are not new and I put
them on the record to the open meeting of this committee in
Auckland in August last year and I said in my submission
then if the figures revealed by the Sydney review had any
validity at all the whole performance of every laboratory in
New Zealand was under question and that it was necessary
that a control group be established. Was that submission
referred to you or any group or meeting of which you were
part ..... not to my personally. However that action is
being taken by the Health Funding Authority.
You mean
that a control group is being set up ..... I believe they
have an advisory group working with them, I'm not aware of
the details – this is the pfmance monitoring group of the
Ministry which is in touch with what the Ministry are
doing.
I'm talking about the pfmance monitoring of every
laboratory in New Zealand and as to how that should be done
in light of the Sydney information – can you not answer
..... no, I am not directly involved in this issue.
MR
MURRAY: there is a practical problem in that we have
briefed up the matters for Gisborne – it’s the background
evidence – the inquiry is leaping into the Gisborne
investigatn and we have evidence to come on all of that, and
Ms Glackin is not in charge of that.
CHAIR: it would be
helpful if it became clear to the committee who is managing
the task, who is responsible, but on a day to day basis I
would like to know who is responsible. At the moment there
is so much uncertainty.
MR MURRAY: most of the work is
being done w8ithin the Health Funding Authority but the
Ministry has a role as well.
CHAIR: Mr Hodson it
would seem this witness doesn't know.
MR HODSON: the
briefs we have been given by the Health Funding Authority do
not cover this topic at all. one would like to know what
is being done to identify and deal with the laboratories
that reported fewer incidences of cancer than he
did.
CHAIR: is there any one person in the Ministry who
has knowledge of these matters
MR MURRAY: I think Ms
Glackin could tell us the head of the Performance Monitoring
branch.
CHAIR: can you tell the committee who is in
control of the branch of the Ministry responsible for
looking into what is happening in Gisborne at present .....
The acting Deputy Director-General is Joan Merkin.
XXD
MR KIRTON: My questions were going to commence in this
precise area of accountability and responsibilities, can I
take you to paragraph 4 of your evidence and we could
possibly conclude the line of questioning from the panel and
from Mr Hodson. It says in paragraph 4 that “in October 1998
following the establishment … Both portfolio managers have
reported to me … 2000”. Can you please explain to the panel
why it is that given those very senior roles in the
programme you are unable to identify the persons responsible
for liaising with the Health Funding Authority and leading
the team in terms of a response to the Gisborne situation
..... what I have been asked to do is identify those
specific individuals dealing with the Health Funding
Authority. On this issue. I am simply not aware of who
those people are.
Would you forgive us for believing that
is a somewhat incredible response ..... I can't be
responsible for your response to what I've said, but the
fact of the mtr is my respbtys relate to policy advice. I
have made it clear the policy branch of the Ministry was not
dealing with the Ministry’s oversight of the Health Funding
Authority’s response on this issue.; I have stayed in touch
with it as a point of general information but I'm not
personally directly involvd. There is a policy analyst who
works within the population health and social policy p/folio
part of the Ministry’s overall network dealing with this
issue – she would be better able to deal with that. I would
not expect to have day to day knowledge of what was being
done with the Health Funding Authority.
Can I take you
back to paragraph 3 of your evidence. And it says that in
Jan 1996 you were appointed manager prevention policy in the
Ministry’s public health group and you were responsible for
the Ministry’s policy and operational roles in relation to
the programme ..... that’s correct. I was in that
position.
So you were in that position from Jan 996
through to October 98, is that correct ..... at April 1998
the Ministry’s functions apart from those which are still
retained in relation to the cervical screening programme
transferred to the Health Funding Authority. That was
national cordntn and the oversight of the register.
So
your rspbts finished in April ..... my direct operational
responsibilities finished in April when they were transferd
to the Regional Health Authority
For over 2 years you
have direct responsibility for the programme including
policy and oprntnl roles ..... except for those carried out
by the Health Funding Authority and as we discussed
yesterday those consisted of responsibility for the services
provided by the programme.
You have presented 387
paragraphs of evidence and 80 exhibits, a marathon effort.
Were you asked to do this role or did you volunteers ..... I
did not volunteer. The Ministry’s management team decided
that Dr Boyd and I would be the primary witnesses for the
Ministry.
I think you need a medal. Can I just take you
back to paragraph 1 of your brief, paragraph 2 in fact, you
joined the Department of Health in 78 ..... that is
correct.
And was that your first job ..... no it was
not.
Were you involved in any health care delivery or
programme management roles prior to that ..... no I was
not.
So you have training and qualifications in training
and development and took on the role in the department as a
staff training officer ..... I did
You took on various
executive roles and had a prod from 84 to 88 out of the
department ..... yes, when I was providing child care
And
you returned to the department in march 98 ..... yes
And
held various executive and advisory positions ..... yes, I
did
From march 93 until you took up your role having
managerial responsibility for the cervical screening
programme holding senior analyst positions ..... I worked in
senior analyst positions from march 93 until Jan 96 when I
took up that position.
Can you confirm you had no formal
training in population health and that you had not held any
position in any form of population health programme in fact
had not worked in any area of health service delivery .....
I have not worked in any area of health care delivery as I
said, my career in the Ministry has been in policy
development – in 93/94 I worked in the population health
services in the Ministry in child health.
You've been
asked you did not volunteer to provide this evidence to the
committee ..... I said I did not volunteer to be a Ministry
witness.]
Presumably your skills were sought because you
traversed a decade when the cervical screening programme
issues were most at point of issue here ..... I believe my
services were sought because as has doubtless become clear
to the inquiry it is difficulty to identify anyone with
continuous experience with this programme.
The continuity
which is important in terms of your brief ..... the point
about my brief, as is made clear in the introductn, is that
I am presenting information from the Ministry[‘s files and
providing an overview and my sources for that also include
my own knowledge where I have it and also conversations with
past and present Ministry staff who have worked on the
programme.
For that period from 90 to 96 you had very
limited as the questions have evolved, an inability to
answer a number of questions fore that period ..... that is
correct, I have only been able to work from the Ministry’s
files or what I have been done
Is there anyone in the
department or Ministry that had a similar continuity of
knowledge and experience in the cervical screening programme
..... I am not aware of that, no. there are very few
individuals in the Ministry
Other than you and
Dr
Boyd ..... that have had indeed been in the Ministry over
that time and have also been involved with the cervical
screening programme.
Can you assist the panel perhaps by
taking the document 084, i.e. a description of the people
involved in the programme within the department/Ministry,
can you confirm that in 1988 at the early days in ters of
workshop and implementation of the cervical screening
programme that Dr Karen Poutasi and Dr Gillian Durham were
closely involved in that process ..... I have spoken to
Karen Poutasi about her involvement – she told me that she
had general oversight of the Cartwright projects at that
period of which the National Cervical Screening
Implementation Unit was one. However she left and I'm not
aware of the exact dates to become Chief Executive of the
Wellington Area Health Board at that time.
You are
unable to tell us the date – can you confirm that it may
have been in 1991 or 92 ..... I don't know – I would prefer
to ask Dr Poutasi that – I can do that.
Can we finally
turn to Dr Durham, who had responsibilities as in charge of
the initial implementation unit. Can you confirm that Dr
Durham took on management responsibilities for the
Cartwright projects after the Ministerial review in 1989
..... I'm not aware of the exact dates.
Can you tell us
when Dr Durham left the department ..... I do not know. I
could attempt to – when she left the department?
Yes
..... oh, in 19 –
Can you confirm that Dr Durham also
went to the Wellington Area Health Board ..... she did, I'm
not aware of the exact date although I could attempt to find
out from the Ministry.
Could you now confirm that Dr
Poutasi returned in 1995 to be the Director-General health
..... yes.
Can you confirm that Dr Durham returned or
took up her position as Chief Executive of the public health
commission in 1993 ..... yes, the commission was established
in July 1993 and she was Chief Executive
And that was
later reabsorbed back into the Minister of Health ..... yes
and that’s why she was Deputy Director-General of public
health from July.
Thank you.
MID-MORNING ADJOURNMETN – 11.10 A.M. TO 11.25 A.M.
MR KIRTON: Can I suggest we
pull together volumes 1, 2 and 5 and exhibit 087, a letter
dated 16 August 1993, and if they could be top to bottom in
that arrangement, it may assist. If I could take you to
paragraph 17 of your evidence Ms Glackin, this is to do with
the Ministerial review in 1989, which recommended a wide
range of issues and there were some key recommendations
arriving from it – I refer you to 17.6 on p7 of your
evidence. You will note there a recommendation which
essentially is in two halves, it says a set of guidelines
…should be developed . And the second half: “… could occur
in 1990”. Can I deal firstly with the second half of that
now, and refer you to volume 1, tab 1, p56, under the
heading “cytology training”. Paragraph 8.17. it reads “the
reading of smears is a skilled task … (reads) … as soon as
possible”, and referring to p58, the bottom, recommendation
4, “it is essential that decisions be taken in the near
future … at the beginning of 1990.” Can I now refer you to
volume 1, tab 4, p49. On p49 is the Straton Report, there
is a recommendation 5.2 “that the Department of Health
carry out a study … follow-up of a woman’s abnormalities.”
Can I now refer you to volume 2, tab 5, p204, item 12.2.5,
where it reads “the Department of Health, Cytology Advisory
Liaison Committee … requirements for the programme.” That
was the Expert Group report. I now proceed to volume 5, tab
15, the 1991 government policy document for cervical
screening, and if we turn to p5 of tab 15 ..... tab 15 isn’t
in volume 5.
Your exhibits. If you refer to 4.1.5, , p6
“the Department of Health …. Laboratory assistants” that’s
the policy in terms of you had a recommendation from the
Expert Group that the Ministry take responsibility for
cytology training and the policy is as we’ve just read.
Can you tell us what was actually done by way of training
for cytology ..... I'm afraid I can't help you with this
issue at all – Dr Boyd is covering it in his
evidence.
Can I then refer you to Exhibit 087, just by
way of background to that, this document arises because a
training programme was set up at Central Institute of
Technology and it says in the summary to that 087 document
that the 1999 “…. Was applied for the training course
…
criticism of Dr Teague … his criticisms was that there was
no longer going to be funded a programme for training of
cytology” and this document – p3 of the report – backgrounds
that issue, and on the last paragraph of p3 “both the
Ministry and Cytology Advisory Liaison Committee …. Smear
reading is integral to the success of the cervical screening
programme – the department was approached by Central
Institute of Technology in 1992 … education responsibility.”
Can you – you've said you've referred these issues to Dr
Boyd, but in general with your understanding of the cervical
screening programme and your later responsibilities for it,
can you indicate whether the department/Ministry took any
responsibility for cytology screening ..... cytology
training, from my knowledge from my direct knowledge in 1996
this issue did not arise. In relation to 1993 Dr Boyd, I
believe covers this at some length in his evidence to be
delivered.
During your period of responsibility for the
cervical screening programme, Jan 1996 to 98, did you regard
the cytology training as an important part of your
responsibility in terms of oversight ..... I do not recall
this issue ever being raised with me.
The rub is in 1993
the training programme stopped and no-one thought about it
again ..... I think it would inaccurate for me to comment on
that at all without the evidence of Dr Boyd being heard.
What I am actually saying is that to my knowledge the
Ministry had no direct involvement in this issue during the
time I was responsible for the programme in 1996. I
wouldn't draw nay conclusion from that without having heard
Dr Boyd’s evidence which tas about the action and the
situation as it existed in 1993.
So in 1996 when you took
responsibility for the operation and policy of the cervical
screening programme you did not at any stage turn your mind
to the issue of training, is that correct ..... I suspect
that in 1993 the ongoing responsibility for this issue was
clarified, however I can't usefully comment on that as it is
Dr Boyd’s evidence that is key here
CHAIR: I thought
the question was 1996 ..... the issue was never raised with
me during the period I was responsible for the programme in
96l, however I couldn't agree with the statement made about
the Ministry’s lack of concern as I would assume that the
issue had been resolved earlier, and that was the reason it
didn't arise.
Mr Kirton’s question was in 96 did you turn
your mind to the training of cytologist ..... it didn't
arse.
97 and 98 ..... the answer is the same.
MR
KIRTON: could it be concluded that this issue of training
was no longer current and that the Ministry did not take any
responsibility from that point forward for it ..... from
19896 the Ministry had no direct involvement.
Can we now
move to another block of enquiry. And if we could assemble
again volume 1, volume 5 and volume 14. I will refer you
back to 17.6 of your evidence again, and particularly to the
first half of that particular paragraph which says “a set of
guidelines for min … should be developed” I don't want to
repeat the wide ranging issues raised by Mr Corkill over
this issue, but I'm sure you will be aware of the importance
of the laboratory standards and their crucial role and place
in this inquiry, and if I could refer you to volume 1, tab
1, p52, this is the Ministerial review document, 8.1, midway
through that “as with all parts of the programme …
competency”. Those sentiments were repeated in the strategy
report and the Expert Group report ..... yes I believe
so
Can I now refer you to the 1991 government policy
document, volume 5, tab 15, p5. and there it reads at 4.12:
“all cytology … take up to 2 years” and we covered
significant ground on this yesterday, two years from then
would be 1993 would it not ..... yes. I can't remember
which exact month that was published in.
You may recall
from your evidence yesterday the significant concern about
the issue of TELARC registration and the department’s role
and responsibilities in that, and it would be quite proper
and reasonable of the committee to ask why the
department/Ministry did not proceed to undertake its
responsibilities with this regard ..... I believe that that
question was asked in one form or another yesterday.
Can
I refer you to volume 14, tab 75, it’s very difficult to
follow here, it’s about the middle of that exhibit and it’s
the minutes of the cervical screening programme managers
meeting December 4/5th 1991. can I refer you to the fourth
page in from that front page of that, the second heading
down is “Responsibility, Laboratories and general
practitioners”. In the minutes of the Programme Manager’s
meeting of December 4 and 5 is reported “Heather reports on
an inquiry into problems in the Bay of Plenty … Jill said a
recommendation .. TELARC registered … Heather wanted advice
as to how to communicate with general practitioners.” Can I
now refer you, about 10 pages further on, to the Programme
Manager’s meeting of 23/24 July 1992.
PROFESSOR
DUGGAN: did the smear providers have a choice in what
laboratory they sent their smears to ..... I understand they
did.
MR KIRTON: Have you got that page open .....
yes.
Under the heading of “laboratories” it is stated:
“Reliability was dubious … TELARC also concerned about
quality of reporting … Gillian Grew the Programme Manager …
in Brian Cox’s study … not initially agreed to this. ..
however as the market increasingly becomes competitive with
the implication of Regional Health Authorities and ches ….
For smear-reading”. This is the record of Gillian Grew is
it not ..... yes.
Would you say, being the programme
co-ordinator for the cervical screening programme, she would
be in touch with her colleagues in the dept at the time
..... I would have expected so
What do you make of her
statement that the market will incrsngly become .. with the
establishment of Regional Health Authorities and CHEs and
the managers will options as a result “ ..... I think it is
important to note this statement was made in July 92, a full
year before the estabt of Regional Health Authorities and
CHEs. While I was not involved in this area at this time I
aware am it was unclear at this point how the new
arrangements would operate.
I put it to you that the
government’s new policy direction under the Hon Simon Upton
was very well known at that point in the commercial model
that he proposed in the Green and White paper was the
currency within that time in the department ..... I'm not
aware that the words commercial words appear in the green
and white paper
Had you heard the words purchaser
provider split ..... yes, certainly.
At that time can you
recall ..... yes certainly, the purchsr provider split was a
fundamentl principle of reforms
Is that not a commercial
model of competive service provision ..... it’s a
contractual model, whether a cml model is appropriate or not
as a descrtiptn.
Paragraph where it says Regional Health
Authoritys and CHEs is mentioned. What is a CHE ..... a
Crown Health enterprise.
So it’s an enterprise, a
commercial enterprise ..... no. enterprise just refers to –
I can't technically say what it is, it is a technical term
used for various crown bodies.
I put it to you that the
prospect of competition in the laboratory sector would have
been prominent in the minds of the department staff at that
time and that Ms Grew’s comments were most relevant at that
point ..... as I said when you first asked me about this, in
1992 exactly how the model would operate was unclear,
therefore Gillian Grew’s comments were based on her
understanding how it might operate in 1992 and it shouldn't
necessarily be taken as reflectg the situation as it did
exist in 1993.
Where she says there will be options would
she be referring to competition between laboratories .....
the concern I have with what she says is that Programme
Manager s will have some joptns of contracting with
laboratories. I'm not aware Programme Managers contracted
with laboratories.
The point I am making is that
regulation was not taking place within the department, the
department didn to attend to any regltn because a notion was
about that competition would do the job for them. .....
certainly a fundmentl expectation was there would be choice
of providers as a general pricnipcle underlying the
reforms.
Can I refer you to your evidence going forward
to your paragraph 291.
CHAIR: the minutes of 23 / 24
July “Programme Managers will have some l… for smear
reading” does suggest that Programme Manager’s were
contracting with laboratories for smear-reading does it not
..... it does, that is my concern with the sentence, I do
not believe that ever occurred
It suggests at the time
before the estabmt of Regional Health Authorities and CHEs
that Programme Managers had no options as to which
laboratories they sent smears to for reading ..... Programme
Managers were not smear-takers and did not send smears to
laboratories.
Would Dr Boyd be able to clarify whether or
not Programme Managers were contracting with laboratories
for smear-reading ..... Dr Boyd would certainly be able to
clarify that.
PROFESSOR DUGGAN: the last sentence
Gillian Grew agreed … should be monitored”. Did that
actually happen ..... I have not seen that from the
documentation that we found. Therefore I can't verify
whether it did or didn't. there is no evidence that I have
seen.
Could somebody clarify that ..... unless Gillian
Grew has some personal memory of that, I don't believe
anyone could clarify it
CHAIR: would it be fair for the
committee to conclude, given your lack of evidence, that it
didn't happen ..... while our researches were exhaustive the
files were full of gaps, therefore I couldn't categorically
say that. We often found that something for example a
response to correspondence would appear on the files without
the initial letter being there
Do you not agree that this
point about Programme Managers being given averages against
which laboratory smear results should be monitored was an
important part of the programme ..... it certainly was
important at.
If it were taking place on any regular
basis would you not expect to find now at least one example
of it occurring on the files ..... yes I would have expected
that and possibly something in the Cytology Advisory Liaison
Committee files as well – I'm not sure what her source of
information was at this period. Dr B might have more
information than I do
And you found nothing ..... we
found nothing
You think Dr B could better inform the
committee ..... if there is information Dr B would be more
likely to have it.
Does it concern for something like the
cervical screening programme the records are not complete in
respect of important matters such as this information we are
talkg about ..... the – while ideally we would like Ministry
files to be complete in terms of important issues, the
reality is that human nature being what it is, there are
quite a number of things that can happen to papers in
between somebody handlg them and them being on a file some 8
years later.
Would the incomplete records have something
to do with the various restructurings that have occurred
within the department and Ministry ..... no I would not draw
that conclusion, it is simply to do with the practice that
individuals had in terms of identifying papers for
filing.
Would it have anything to do with the programme
management being split between various bodies rather than
under the control of one single entity ..... no, not at all.
it’s up to the individual staff member dealing with the
paper to take responsibility for ensuring that it is
appropriately filed, or it is appropriately sent for filing,
then there is the issue of ensuring it gets on the
file.
MR KIRTON: if I could refer you again to your
evidence at paragraphs 290/291, at 4.1.3 it reads “the
Minister of Health … in 4.1.4” this is an extract from the
93 policy document ..... it is.
Which Is a rewording, if
you like, or a contnuation of the 91 policy , that is
correct.
With the only admission there being the 2 year
reference ..... yes, we established that yesterday
So we
are 2 years down the track and at 291 you say paragraph
4.1.3 could be read … be responsible … criteria required for
TELARC registration. Could you tell me what part of 4.13
does not say the Ministry was responsible ..... I think I
was referring to the words “and the difference between b=the
words and practicality” which I explain in the next
sentence
Have you seen the TV programme Yes Minister
..... of course I have
Could that sentence remind you of
that situation ..... is that a serious question?
This is
a very serious matter ..... this is a very serious matter –
I'm not sure what my experience of TV programmes has to do
with it.
You say it wasn’t possible for the Ministry
because they didn't have a direct relationship or influence
over laboratories over the Regional Health Authority – there
were no Regional Health Authorities prior to July of 93 –
what are you referring to having no influence or no direct
relationshp with laboratories ..... this policy was
established AFTER THE ESTABLISHMENT OF Regional Health
Authorities.
Would it be possible for the department
between 91 and 93 to have amended the Social Security act so
that you did have a direct relationship and you could tag
the $s going to laboratories on performance ..... firstly
the department does not put up legislation, our ministers
do. Secondly, I'm not aware prsnly as to whether the
provisions of the Social Security Act would allow that and I
believe Dr B would be better able to comment on that given
his experience in the area.
You have significant
experience as a senior Ministry official over a long period
of time. I rfer you to the amendment act 1993 which
introducd the legislation for the register. Was that not an
intervention on behalf of the cervical screening programme
to meet an important objectv of the programme ..... it was
a change to the legsltn to do something that was important
to the programme, yes of crse
Someone promulagated that
piece of leglstn to ensure the programme could succeed .....
as my record indicates and indeed as previous counsel has
demonstrated that was important and recommended by many
committees. My evidence also includes an exhibit where the
Minister agrees to pursue that.
CHAIR: was it the
Ministry initially the catalyst for change in legislation
..... this was the health Amendment Act 1993 – no, it was
the government, the health Amendment Act as I recall arose
as a result of the coalitn agreement that was established by
that government
MR KIRTON: in terms of the screening
programme,..... the register, there was an amendment in 1993
which allowed the opt off arrangements to occur ..... yes,
I'm sorry. That was included as part of the Amendment Act,
the Amendment Act arose out of the coalitn agreement
.
CHAIR: the recommendation to change from opt on to
opt off register, was that recommendation initiated within
the Ministry ..... there was a point at which the Ministry
put up a paper recommending that. I believe although I
would need check my evidence that was approved in
1q991
Is it fair to conclude there are times when changes
to legislation are generated as a result of reforms within
the Ministry ..... as a result of policy advice on issues
which the Ministry is dealing with, yes.
So the Ministry
could therefore given the necessary researches and policy
papers have put forward to the Minister recommendations to
change legislation ..... certainly.
MR KIRTON: my point
was that, that had there been significant concern about
delivering the department’s responsibilities would you agree
the opportunity was there for the department to advise the
Minister that a change in legislation was needed .....
certainly that was the case. My caution related to the
fact I'm not aware of whether the Social Security Act would
have enabled that to occur – Dr B is more familiar with
that
CHAIR: why do you say you don't think the Social
Security Act ..... I said I don't know.
MR KIRTON: was
there an opportunity within the regltns and the authority of
the Director-General at that time to in fact impact in
payments to laboratories ..... Dr B would be able to answer
that. The payment of health benefits was not an issue I
have had personal involvement with.
Can you confirm that
there are a range of health protection units or such similar
amenities within the former CHEs, the Area Health Boards and
now Health and Hospital Services entities, health protection
units which are responsible for administering a range of
different legislation and issues – for example food
regultns, - ..... some CHEs and a private provider have
officers with statutory powers under various health
legislation, including the health act in relation to issues
like food.
They were in fact in existence in the early
90s, the time of the Area Health Board ..... the health
protection units were originally part of the Department of
Health and then passed to Area Health Boards or hospital
boards towards the end of the 1980s
And those units today
for example in the food regltn area have quite sophisticated
communication means, computer cnctn with the Minister of
Health on a 24 hour bass and a weekly basis, is that correct
..... I think that is quite possible – it maybe you have
more direct knowledge of that than I do.
I assure you
they are. ..... I have no role in relation to food.
Food
and other environmentl issues ..... I have had no direct
role in relation to food issues.
If I were to tell you
that the health protection units throughout the country
monitor fish and chip shops on a very regular basis, they
know what the temperature of the chillers are, a great deal
of information is relayed back to the Ministry and the
h/protection officers have been in existence for a long time
– would you take my word on that ..... certainly
Going to
your – but I'm assuming that you have checked your sources –
I personally don't know. I suppose I know that some health
protection officers are also employed y local authorities
and it may be them that inspect fish and chips shops
The
Minister of Health oversees a range of legislation including
food regltns would you agree that those arrangements have
continued throughout the health reform era unhindered and
that those regltns are put in place successfully throughout
that period ..... yes, I can confirm that that function has
continued. It has been challenging in terms of acntblty
arrangements.
Can I ask you whether the women of Gisborne
would be comforted to know when they have their fish and
chips the Minister of Health has a close eye on that
production but when it comes to the laboratory smears they
had no such protection ..... the point was made yesterday,
it is the Regional Health Authority which is directly
responsible for the provision of laboratory services. In
relation to statutory functions under leglstn such as the
food act the Ministry designates delegated officers directly
and that is the reason for the link. I would not assume
that the fact the Ministry is not involved directly in
asesing laboratory quality meant that the Regional Health
Authority did not have responsibility for that.
I put it
to you once again that the Minister of Health had
responsibility for TELARC registration and that if it had
upheld its responsibility live up to its responsibility in
93 we would not be here today ..... that is your view. I
can't comment. You are specultg on the possibility of a
regltn being passed which would have permitted that. The
Social Security Act was replaced when the regional health
authorities were established.
CHAIR: earlier on Mr
Kirton asked you a question – he referred you to 4.1.3
“Minister of Health …. And histology for the programme meet
the requirements set out in 4.1.4 and he then referred to
your paragraph 291 in your brief where you say this could be
read … responsible and he asked you what part of 4.1.3 could
you read which suggested otherwise. ..... I believe that my
answer is that while the words themselves are clear enough I
go on to explain this was clearly not possible.
This is
the policy document and the policy document says the
Minister of Health will be responsible and is it fair to say
on reading 4.1.3 there is nothing ambiguous about that
responsibility ..... there is nothing unambiguous about the
wording, the problem was there was no apparent way in which
that responsibility could have been carried out.
And
looking at volume 13 of your exhibits which has the Health
Funding Authority contracts, interlever 72, I haven't had a
chance to look through the full contracts, but the contract
94/95 – p74 – the bottom of p73, next page it says p73 at
the bottom National Cervical Screening Programme. If you
turn over p74, 10.3 it refers to the Regional Health
Authority in conjunction with other health authorities to
purchase … this programme … consistent with s74A the Health
Act … for National Cervical Screening ..... yes.
It seems
that the 1991 policy was actually incorporated into the
funding agreements for 94/95 ..... yes that is how it
reads.
And if you would turn to the next funding
agreements 95/96 and go to p112, the bottom of the right
hand cornr of the page, S4 !!4, there is reference to the
programme and again it says that the programme screening
services … the cervical screening Regltns and the government
91 policy for National Cervical Screening ..... yes.
Once
again the 91 policy document is made a term of the funding
agreement is it not ..... it is
Anyone reading the
funding agreements seeing that the 91 policy was part of the
funding agreements and going to the 91 policy, paragraph
4.1.3, would conclude that the Minister of Health was to be
responsible for confirming that the laboratories met the
requirements set out in 4l.1.4 ..... yes.
And I
understand your evidence is that practically speaking,
because the Ministry had no directly influence over
laboratories, it couldn't discharge its responsibility which
it had under 4.1.3 of the policy ..... the mechanism
available to the Ministry was through the Regional Health
Authority funding agreements and that referred to the 91
policy. So yes, it would appear that was the case.
So it
seems then that the Ministry either knowingly allowed itself
to be placed in a situation where it could no longer
responsibly carry out its rspbltys under 4.1.3 ..... I
believe that’s the case and I think the problem associated
with this is the one I refer to later in my brief, which is
the delay in the review of the policy at the time the policy
was reviewed in 93 it was envisagd that review would be
completed in 94 in fact it was not completed until 96 which
meant that the policy stood as it had been originally
worded.
Thank you.
MR KIRTON: For the next stanza,
can we take volumes 6, 8 and 13 and document 084 the
department Minister of Health hierarchy document. Can I
refer you to paragraph 59 of your evidence, where it says
“the health reforms announced by the Hon Simon Upton … from
the provision of those services”. ..... yes.
Can I now
refer you to the departmental hierarchy document 084 and on
the right hand column of the front page is Director-General
Dr George Salmond, is that correct ..... yes
And Dr
Salmons was the Director-General from October 1986 to
April 1991 ..... yes.
And in your evidence you've
said the Hon Simon Upton announced the forms in June 91,
prior to the announcement of the reforms Dr Salmond left, is
that so ..... yes I believe so
Can you recall whether
there was any publicity around Dr almond’s departure and
some of the reasons for that ..... yes, there was publicity.
I can't be exactly sure what it was for. It’s difficult for
me to distinguish between my own experience of this and what
in fact publicity might have been about
Would it be fair
to say Dr S was of the old school and not perceived as
fitting into the new health purchasing environment ..... I
can't comment on that as a motive for Dr S’s resignation or
in relation to the opinion of anyone.
You have experience
of Dr S as the Director-General when you worked in the
department but you would not suggest he was old school or
was not the driving force of the h/reform ..... the
department itself was not the driving force of the
h/reforms, the proposals were developed first by a task
force and then the health reforms directorate.
Can I
refer you to document 084 the next Director-General
appointed was Chris Lovelace ..... after a period of Ian
Miller as Actin Director-General
Can you recall whether
chris lovelace was a New Zealander or from overseas ..... he
was a Canadian.
Can you recall whether he had a medical
qualification ..... no he did not, which is why it is not
included on the sheet
Did he have business qualifications
..... I wasn’t able to identify those in the Ministry in the
information the Ministry was able to provide on
Friday.
Is it not correct to say that an international
search was made in order to obtain a new Director-General
with expertise in commerce and who would better fit the new
govt health reform programme ..... I was not aware of that
at the time or indeed since. I know there was a lengthy gap
before a Director-General was appointed.
Can you tell us
what processes were involved in the appointment of chris
Lovelace or other directors general ..... no the
Director-General is employed by the State Services
Commission.
So the State Services Commission has a
significant role in that ..... the State Services Commission
is the employer responsible for recruitment under the State
Sector act.
I now refer you to the last Director-General
named on that page, Dr Karen Poutasi. Can you confirm your
earlier comment that Dr Poutasi had been the Chief Executive
at the Wellington Area Health Board ..... yes that’s
correct.
And she was appointed in July 95 when the
reforms were well underway ..... yes.
Can you confirm
that her appointment was most likely to have been made with
the sanction of the State Services Commission and the crown
company monitoring unit and you can conclude from her
appointment that she had skills that were relevant and
appropriate for the new h/reform cervical cancer environment
..... I can't comment on that. The selection is made by the
State Services Commissionr. I'm not aware what criteria
were used by the State Services Commissionr.
Can you
confirm it is likely that the State Services Commission
would want to select an appointee with those types of skills
and that those skills were compatible with the government’s
direction ad policy ..... I can confirm the State Services
Commissionr no doubt considered what government’s
expectations would be of the person in the position. I can
make no further comment
Would you confirm that Dr Poutasi
would be a reliable person to advance the h/reform agenda
..... I am not wiling to answer that, you are asking me to
comment on the qualifications of my employer.
CHAIR: I
think that is a fair answer.
MR KIRTON: paragraph 85 of
your evidence, bottom of the page it says Dr Gillian D ….
The Public Health Commission” is that correct ..... it says
later Chief Executive, yes.
Would that appointment have
been or have had the imprimatur of the State Services
Commission and the crown company monitoring unit ..... I did
not comment before when you mentioned this in relation to Dr
Poutasi, I have no reason to believe the State Services
Commissionr sought the advice of the crown company
monitoring unit on the employment of chief executives.
Secondly in relation to Dr Giliam D I do know whether her
position was dealt with by the State Services Commissionr in
the same way. The Public Health Commission was not a core
government agency, it had a board and I believe it is likely
that the board made the appointment.
Can you offer an
opinion as to whether Dr D would be very reliable in terms
of implementing the government’s policy around the h/reform
agenda ..... I cannot comment on that at all.
MR MURRAY:
objectn as to where this is going to.
CHAIR: I think
this question is one which is really outside the realms of
this witness’s expertise
MR KIRTON: Volume 6, at 28,
page 4. this is a memo dated 18 march 93 in relation to a
letter written by Dr d for the relocation of the cervical
screening programme into the Public Health Commission .....
yes. it is from Sonia Easterbrook-Smith who was the
population health services manager to Chris Lovelace the
Director-General.
Can I refer you to p4 of that memo,
second to last paragraph “while the … cervical screening
programme … primary role”. Finally, “the programme …of the
reforms”.` is that not the advice given to the
Director-General regarding the citing of the cervical
screening programme ..... that was the opinion of Sonia ES,
as we discussed yesterday the Ministry of Health comsnd a
review of the sighting of the programme by KPMG.
But that
advice was accepted by the Director-General and the
screening programme remained within the Ministry ..... the
advice of KPMG
This was November 93 – this is advice on
18 March 93 in respone to Dr Durham’s request for t45ransfer
of the programme ..... I believe – my exhibit 29 which
follows this is a letter from David Smythe the acting
Director-General to Dr Gillian Durham, which refers to the
review originally being intended to be undertaken in June
1993 but deferred at the request of the Public Health
Commission so I think it would be probably unlikely to
conclude that the Director-General took the advice of Sonia
Easterbrook-Smith and I would see the decision to carry out
the KPMG review of been the ultimate resolutn of the
issue.
The Director-General did not move at that time
..... this is march, he is talking about a review in June.
I would see those as probably being related, but as I'm not
aware of the detail I can't verify that.
You will e aware
that the Public Health Commission came into being in July 93
..... that is correct
This was in advance of the Public
Health Commission coming into being ..... yes
And no
decision was made at that point to include the screening
programme in the Public Health Commission responsibilities
as at July 93 ..... that is correct, although as other
evidence discussed yesterday has shown there was a great
deal of discussion about the location and responsibilities
for the cervical screening period before/after this
period.
Can we go now to –
CHAIR: was Sonia
Easterbrook-Smith a Department of Health employee ..... she
was, she appears in exhibit 84 as manager population health
services from December 92 to some date unknown in 95.
So
at the time she wrote this internal memo she would have been
manager population health services ..... that is
correct.
How senior is this position ..... if you look at
exhibit 84 you will see that she - that that position was on
the same level as I had in 1996, ? who reported to a
Director-General.
MR KIRTON: turning to volume 6, tab
30, p39, we have the KPMG location review and the
recommendation a little over 2/3 down the page, “the
Ministry provides the best possible … funding agent” that
was the recommendation ..... yes, it was.
Can we now go
to volume 8, tab 38, this is the Ministry’s report of March
96 ..... 28 March 1996.
It’s a memo to the Associate
Minister of Health from the Ministry in the performance of
the programme ..... that is correct.
And if we turn to
the third page at the report highlights the quarterly
Regional Health Authority quartly reports from
October/December 95 is that correct ..... yes, the report is
provided in response to concerns that the Minister
highlighted in the quartly report of Regional Health
Authority performance.
It highlights a concern that the
minister had ..... the Minister had requested a report on
the issues the report covered.
In the first page under
quartly reports of Regional Health Authorities December 95
is summarised the issues of backlog and enrolments
Canterbury, backlog of enrolment Auckland and what had been
done about the problem ..... that is correct.
And these
were directly from the quarterly report ..... no. the
issues had been identified by the Minister when the q/report
of Regional Health Authority performance was provided to
her. This was to advise her on what action had been taken
on those issues.
So that is not a summary of the Regional
Health Authority report ..... that is correct.
On the 2nd
page of that report under B accountability arrangements,
reltg to the programme, the Ministry makes a recommendation
does it not “quoted” so that’s a recommendation made by the
Ministry ..... yes that’s quite correct. That is why the
different issues covered by the reports are indicated by a)
which relates to the q/performance report b) which relates
to accountability arrangements, and c) relates to the
Ministry reporting back on cervical screening programme and
the accountability review.
So can we conclude that the
issues of backlog of enrolment in Auckland and Canterbury
weren’t to the stimulus for the Ministry’s commentary on
accountabilities on that point ..... they were not.
Can
we now go to volume – ..... however, they were related, if
I could finish.
Can we go to volume 13, tab 74
CHAIR:
this document at tab 38 or volume 8, the memo to the
minister is noted urgent, it is signed out by you, as
manager, note at item 5 the Ministry considers …. Delivery.
Now this was in 1996. would it be fair to the committee to
read this as an admission by the Ministry in 1986 that the
accountability arrangements in place at that time were
contributing to problems that in respect of the programme’s
delivery ..... yes the reference is to the review of
accountabilities carried out at that time. Without checking
here it was up to, it was going through processes in the
Ministry.
MR HODSON: it is clear two pages over and
over the next.
CHAIR: so it’s clear that the Ministry
in 1996 recognised that there were problems with delivery of
the programme ..... that the acntbty arrangements were
causing problems with delivery
That means there were
problems with delivery yes or not ..... yes there
were
And it was the accountability that was contributing
to the problems ..... that was the recommendation as a
result of the accountability review.
Does that mean the
Ministry considered there were problems relating to
accountability ..... yes
What were those accountability
arrangements ..... that is dealt with in the report we went
through yesterday. Explicitly the split of responsibilities
between the Regional Health Authority and the
Ministry.
Turning over the page under B accountability
arrangements that’s a broader explanation of the summary
that's ended up in the memo to the Minister ..... yes, I
believe so.
So it would be fair to conclude, as at
November 96, the Ministry was well aware that there were
difficulties with the programme because of the way in which
it was structured, split between the Ministry the Regional
Health Authority and the CHEs, yes or no ..... that’s my
understanding of why the accountability review was
undertaken.
And is it fair to conclude that the only
reaction the Ministry could have to this recognition that
the programme was facing problems was to initiate a review
of it ..... the review was initiated by Dr Durham I assume
that and she had discussed it with the general management
team so I can presume that was the issue that the Ministry
saw as most urgent.
How much urgency would there need to
be before the Ministry stepped in and did something ..... I
find it difficult to answer that question.
Given that the
Ministry could see that there were difficulties which were
affecting programmes delivery and it had described it in a
memo to the Minister of Health as being urgent, could all it
do is initiate a review ..... to clarify the fact that the
memo is urgent I believe that related to the principal issue
covered in the memo, to respond to comments highlighted by
the Minister in relation to the quarterly report. The
Ministry’s review I believe dealt with some long standing
concerns about whether the fit was best rather than an
urgent issue at that time.
If the Ministry had wanted to
could it have done anything more than initiate a review
..... I think there is a difference between urgent problems
with service delivery and broader concerns about whether the
fit of the cervical screening programme was appropriate.
And I suppose that the Ministry’s view was that taking a
considered look at accountability arrangements was the
appropriate response to this particular issue.
I'm not
questioning whether the response was appropriate or not but
given the structure of health at the time whether it was the
only response the Ministry could make or whether it could
have taken a more interventionist response if it had chosen
to do so ..... I t would have n difficult under the
accountability arrangements at that time to have been more
interventionist.
LUNCHEON ADJOURNMENT – 1.05 P.M. TO
2.15 P.M.
MS GLACKIN (On former oath)
XXD MR
KIRTON (continues)
Before the break, we were considerg
the issues around accountabilities for the programme and the
possibility of moving the programme to the Regional Health
Authorities. Can we go to tab 38, volume 8, and refer to
the Minister of Health – Nrs Shipley at the time .....
yes.
This is a memo from the Minister, Mrs Shipley’s
office, asking that a briefing be provided on the issues
highlighted on p12 “of this report”. Please also refer to
p15 including an agenda for the Monday morning meeting. Is
that from the Minister’s office ..... yes, it is.
Can we
also refer to volume 13, tab 74, and that is the quarterly
report that the minister’s office is referring to ..... yes,
it is.
And the reference to cervical screening is at the
bottom of that first page, the Ministry has a number of
concerns centred around the operation of cervical screening
registers ..... yes.
That is p13 of that report is it not
..... yes.
Can you tell us what the context of p12 was
..... I'm afraid I can't without referring to the original
document. However, I can say that as it wasn’t included in
the Ministry’s exhibits it wouldn't have referred to
cervical screening.
However, it is important to note that
the ? did highlight the issue on p12 and can I speculate
what p12 said given the wording at the top of p13. in the
absence of that report it reads “the country of New Zealand
general practitioners … expenditure growth” that’s the
conclusion of p12 is it ..... yes, it’s carried over from
p12.
The response to the request from the Minister for an
update for a report on that is the tab 38 is it not, memo to
the Associate Minister of Health from the ministry on the
performance of the programme 28 march 96 ..... I presume
so.
So the response was there and that response as we
referred to earlier considered the problems with the
concerns about the backlog in Canterbury and Auckland and
what has been done with the problems ..... yes.
However,
would it be fair to point out that the problems referred to
had been somewhat long standing in their development, in
terms of the Auckland register in particular ..... yes and I
referred to that yesterday in my evidence.
Yes, you did.
And the issue was about essentially increasing funding for
the Auckland register was it not ..... eventually that was
the conclusion, but prior to that various things had been
done around the capacity of the Auckland computer.
In
that report around what has been done nth health reported
that significant gains in reducing delays of the backlog had
been achieved over the last few weeks – is that correct
..... yes.
So in reading the q/report could you conclude
that the issues referred to by way of enrolment backlog
problems in effect had been attended to and seemed to have
met the under measure of control ..... under a measure of
control although I believe at that time as the Ministry’s
report says that nth health would be continuing negotiations
with Auckland health care about this issue.
But the tenor
of the report to the Minister was that there were endemic
problems to do with location of the cervical screening
programme and its distance from the Regional Health
Authorities and delivery that caused major problems ..... I
think as I attempted to point out before, that this report
covered the specific information sought by the minister and
also identified the work that the Ministry was doing in
relation to acntblty relationship arrangements.
So that
report sought the approval of the Minister to undertake a
review of acntbltys ..... no I don't believe it did. It
asked the Minister to note as recommendation 5 that the
Ministry considered that current anctblty arrangements were
contributing to the problem with the delivery of the
cervical screening programme and they were currently
reviewing those argnmts. And it noted that the Ministry
would report to the Minister on the performance on the
programme and acntblty arrangements by 30 April 1996.
Was
that not a note to the minister that a review was about to
take place ..... yes, but it wasn’t seeking the Minister’s
approval – if it had it would have read agree.
Moving to
tab 39
PROFESSOR DUGGAN: in these quarterly reports how
many of the TELARC were recorded ..... no.
CHAIR: why
not if there were reasonable endeavours to ensuring the
laboratories were TELARC registered ..... that was not
identified as a p/indicate and presumably for that reason
was not something the Regional Health Authorities were Asked
to report on
But it was a term of the funding agreements
as it not ..... yes in that Regional Health Authorities were
to purchase the programme which specified the need to move
towards TELARC accreditation
Was the Ministry not
interested in receiving a report in that the Regional Health
Authority … the Ministry did not explicitly seek a report on
that issue.
Can you say why not ..... no
Who In the
Ministry could say why the Ministry did not seek a report on
that matter ..... there were many issues they didn't seek a
report on – it would be difficult for anyone to deal
explicitly with this issue.
MR KIRTON: moving to tab 39
and referring at the same time to your own evidence,
regarding that review of accountabilities at paragraph 118,
the review team considered there were 3 key problem areas –
118.1 to 118.3 ..... yes and they are also listed in my
exhibit 39.
So the report came back and recommended that
the programme be moved ..... no, the report recommended that
responsibility for the national coordination move to the
Regional Health Authorities in the 1996 97 year I believe.
Sorry, the 97/98n financial year after an assessment of
whether cordntn and consulting and liaison were needed at
the national level and the register was proposed for
retention in the ministry.
So responsibilities in terms
of cordntn were to be devolvd to the Regional Health
Authorities ..... that was the Ministry’s
recommendation.
One of the reasons that you sought that
move was that the current accountability arrangements
limited the ability of the Regional Health Authorities to
develop flexible arrangements best suited to local needs …
principles of purchasing. Is that one of the 3 key problem
areas in aid or in response of which a response was to move
the programme ..... that is correct.
Can I refer you to
p6 of that review document. And the middle of the page
“provider held registers”. The wording is while a national
register could conceivably be replaced … realistic option”
can you tell us what provider held registers are ..... these
are age sex registers held by general practitioners
And
was it considered a part of the principles of purchasing
that such registers be held at that general practitioner
level ..... those registers had been in existence in various
forms for a very long time. My material on Tairawhiti
records that in the specialist area for example early in
this period that general practitioners had those running on
computers.
Could we conclude from the earlier assessment
of the Regional Health Authority quarterly report in
relation to p12, the page we haven't got, that the Minister
Mrs Shipley was interested. to know about budget holding
argntmts and the holding of registers by general
practitioners and that is part of the motivation for shiftg
the programme cordntn to the general practitioner level
..... no I would be very uncomfortable with concluding that.
I don't know what was on the other page, although the
Ministry could produce that.
CHAIR: perhaps if that
happened – if p12 were produced. ..... secondly, if you look
at p6 of the report, it actually explores comments on 3
options of which the one you have described as one and two
of those are rejected including the provider held
registers.
MR KIRTON: can you tell me if the national
co-ordinator of the programme was consulted prior to the
compilation of that report ..... as I made clear yesterday,
she was not.
Can you tell me whether the co-ordinator
responded in any way and expressed her concern about that to
you ..... she certainly did.
Madam chair I wonder whether
I could introduce at this point a critique by the national
co-ordinator Tina Handiside dated 17 April giving her
analysis of the review of accountabilities.
CHAIR: is
Ms H being called as a witness
MR KIRTON: that is the
intention at this point.
CHAIR: if she is called as a
witness I have no objection to accepting it now subject to
her being questioned on it. I will admit the document
provisionally at this stage
MR KIRTON: if you are able
to turn to the first page of that document, T Handisides
says that “the recommendations are predicated … fallout.”
She then considers the review team said the policy review
and the development … hindered … accountabilities.” “The
review team was concerned … considerable fallout in the
Ministry” would you agree that that response from the
national co-ordinator was one of great concern across a
number of issues that arose out of that review document
..... yes, she had considerable concerns and expressed them
on a number of occasions, including in this letter.
Madam
Chair I would like to enter another document dated 14 May
1996, a letter to T Handiside, the co-ordinator from Dr
Gillian Durham – JMG/MOH/ 093
CHAIR: My view is to
accept this document provisionally on the basis that it will
be put to TH when she gives evidence.
MR KIRTON: the
first paragraph of this letter says “at our meeting on
Thursday 9 May I indicated to you … implementation process”.
Is that are those words correct ..... yes, and the paragraph
goes on to say “I know you have assured me that this is your
intention.
would you describe that as a somewhat direct
approach to the national co-ordinator in response to her
concerns ..... the co-ordinates letter is dated 17 April,
this is dated 14 May. As the letter points out, this was to
follow up from a meeting with the national co-ordinator
which I also attended I believe on 9 May. There had been
quite a number of discussions in the intervening period.
[Exhibit JMG/MOH/ 094]
Can I now move on to paragraph 121
of your evidence. Without going into too much detail of
your evidence of yesterday under examination of Mr Corkill,
on the 13 June the meeting of Programme Managers and the
Minister resulted in overturning the decision on the
programme location did it not ..... it did.
I'm looking
at your paragraph 121. ..... yes, it did
So the
Associate Minister withdrew her consent and confirmed no
change would be made to the acntbtys to the Ministry and
Regional Health Authorities during the next financial.year
that was the finding of the Minister ..... that was the
Minister withdrawing her earlier consent.
After that
discussion a number of concerns raised, the minister changed
her mind ..... that is correct.
Did you hold a series of
meetings with Thandiside the dfcordr subsequent to that
meeting ..... yes, I did, and I believe Dr Durham did and I
also met with the staff. Clearly they were responsible to
me.
Would it be fair to say you were disaprtd and even
furious at the nminster changing her mind after the
decisions made by you and your colleagues ..... no, it would
be fair to say it was difficult for me, hovwr I would point
out this was not myh decision, this review had been approved
by the Deputy Director-General public health and by the
Ministry’s general management team and indeed by Catherine
O’Regan as associate Minister. Clearly it was difficult to
reverse that process.
You said yesterday in your evidence
that soon thereafter you took direct respbty for the
analysts involved in the cervical screening programme, can
you confirm that today ..... that is true. Of course I did
have responsibility for them but through Tina
So you
moved the responsibilities from co-ordinator Tina and took
direct responsibility for those analysts ..... the line
management responsibilities yes.
Did you consult the
co-ordinator about those moves ..... yes and in fact as the
psa became involved a very careful process was followed in
relation to what was done.
You say the psa was involved
..... as this was a staffing issue the psa became involved
at the request of one of the staff who was a member.
Can
you tell us which staff member invited the psa to become
involved ..... I don't suppose there is any harm in doing
that.
MS SCHOLTENS: Relevance. ..... it was Warwick
Taylor who was a psa delegate.
MR KIRTON: was it the
concerns of Tiny H around which you had taken responsibility
for the analysts that had the psa person involved or
resulted in the psa being involved ..... no I'm afraid I
can't recall precisely what the issue was but I think it was
more the general concern of the staff as to the process used
for the review and indeed what implications it might have
for them.
Can you confirm that the physical location of
the register was moved at this time as well ..... no, it
wasn’t moved, I can't confirm that.
So the co-ordinator
Tina H was in close location with the register and the
analysts ..... the policy analysts were moved into the
prevention policy
section with the remainder of the
policy analysts who worked in the section.
At paragraph
124 of your evidence you record that the co-ordinator Tina H
resigned ..... yes.
And in fact she was paid redundancy
is that right ..... as I explained yesterday she was offered
the option of voluntary redundancy because of change in her
j/description.
Madam chair may I enter a newspaper
clipping from the Sunday Star Times June 30 written by
Sandra Coney.
CHAIR: it seemed that the criticism
expressed in the article can't be accepted at this stage –
if Ms Coney decides to give evidence she is free to repeat
these criticisms if she wishes to do so. So far as the
criticisms which are issues to be put to this witness and
she be asked to comment on those criticism I don't see
anything objectionable to that.
MS SCHOLTENS: If you
consider it helpfl, no objection.
CHAIR: at the moment
I am inclined to accept it, but only on the basis it is a
document put to this witness on the basis of various
criticisms of the programme which Ms Coney made. I do not
accept that any of the criticisms contained in the article
at this stage can themselves be accepted as evidence.
MR
KIRTON: I understand Ms Coney is to give evidence
later.
JMG/MOH/ 095.
Rather than go through the entire
column by Ms Coney could I direct you to a few paragraphs in
it. The first one is the second to last paragraph on the
first column and it reads “what the government intends to do
is hand over the cervical screening programme … unit in the
Ministry” is that accurate as to what was to happen ..... I
think an accurate dscrptn of what was to happen is included
in the original recommendation and it is set out in more
detail in there.
Can I take you back to that paragraph,
it says that the government intends to hand over the
cervical screening programme to the 4 Regional Health
Authorities was that true ..... the 4 Regional Health
Authorities as I've explained before were already
responsible for all service delivery in relation to the
programme.
Can you tell the committee whether the cordntn
role handing over the 4 Regional Health Authorities was
accurate or not ..... the intention was that was to be done
from the beginning of the following financial year
So
it’s true ..... yes.
And that the national co-ordinator
component was to be disbanded ..... no, that is not true.
It was indicated that there would be discussion with the
Regional Health Authorities as to what was required in the
way of national cordination.
However, the review document
that had developed indicated that the co-ordinator positions
would no longer be held within the Ministry ..... it
indicated that the co-ordinator position would not exist in
the Ministry after the beginning of the 1997 98 financial
year.
So the co-ordinator after that time was not going
to be in the Ministry ..... that is clear.
CHAIR: was
there going to be a national co-ordinator from somewhere
..... the intention was to take the next year to decide what
form that would take.
So at that stage whether there
would be a single national co-ordinator or whether the role
would e split amongst the Regional Health Authorities was
still open ..... it was still open but there was more than a
year to work that through
What was going to happen during
the 12 month period while it was being worked through .....
if you look at my exhibit 39 on the second page, under 3, it
provides clarity in relation to the fnctn moving from the
Ministry.
It reads “agree that the Minister of Health …
coordinatn and continues on ..... yes. and then under 4 the
fourth dot point, identifies as a key task for the Ministry
in relation to the programme for 1996/97 included work with
the Regional Health Authorities to assess whether cordntn,
consultation, provider support and liaison Is needed at a
national level and to implment a process … from the
beginning of the 1997 98 financial year.”
this report is
dated 11 April 96 ..... yes
And the intention was in the
97 98 year the national co-ordinator function if it then
existed would be handed over the Regional Health Authorities
..... that is correct, in July 97
And at the time the
report was written in 96 it was an open question whether or
not by the time the 97/98 year arrived there would be such a
position as national co-ordinator ..... that right.
As at
April 96 was there someone occupying the position of
national co-ordinator ..... there was.
And that was tina
H ..... that is correct
How long did she stay in that
position ..... she took voluntary redundancy in June
96
So from June 96 until 97/98 there was no national
co-ordinator ..... no. if you refer to exhibit 84 she
resigned in June 1996. Di Best was appointed in December
1996 and in the interim period Di Best agreed to assist the
Ministry in relation to duties that would have previously
belonged to the national co-ordinator.
And in 1998 this
position transferred to the Health Funding Authority .....
that is correct.
And whose the national co-ordinator now
..... I'm afraid I couldn't tell you, I'm not that closely
alignd to the Regional Health Authorities management of the
programme, however Dr Julia Peters is the manager
responsible for the programme
But presumably Minister of
Health officials dealing with the programme would be aware
who the national co-ordinator was ..... I believed those
roles are not carried out precisly the same way within the
Health Funding Authority.
And is the role in its current
form described in any of your exhibits ..... no it’s not,
the Ministry had considered that those issues would be dealt
with in the Health Funding Authority evidence.
MRS
BARRETT: also in that period I see that there was a
national Maori co-ordinator ..... not actually in this
precise – oh yes, you mean Raina Meha, that is
correct
What role did she play in the cervical screening
programme ..... Raina’s title if you look at exhibit 48 was
in fact national co-ordinator Maori cervical screening and
sexual and reproductive health. From my knowledge most of
her role was associated with assisting the Kaitiaki group
and workg directly with Maori stakeholders around the
programme.
On those particular issues pertaing to – that
a national Maori cordntr would be involved with sexual Maori
health ..... I believe Ria Earp will discs that. My
understanding is that was a recommendation from a hui of
Maori women associated with the programme.
MR KIRTON:
the Sandra Coney article – mid column second to last
paragraph “At first sight it seems curious that the Minister
of Health … resentmt. Added to that … some things that need
national oversight”. Can you confirm that was a common
criticism around that time, particularly of those
commentators who had an interest in the cervical screening
programme ..... you mean in relation to the Ministry’s
prposal that national cordntn should go to the Regional
Health Authorities
No I mean the view that the Minister
of Health did not want to do screening, it wasn’t their idea
and they resented it – can you confirm that was a common
criticism around the cervical screening programme ..... I
have heard that criticism but mostly from Ms Coney.
Can
we move now to the last column, the second to last paragraph
– the line commencing Katherine O’Regan’s decision … no
consultation with the national co-ordinator … beginning”
can you confirm that is an accurate description of how the
decision came out ..... the parameters of the Ministry
review included there would no outside consultation,
however, I pointed out yesterday as well that in terms of
the announcement of that decision K O’r had intended to take
that directly to the stakeholders associated with the
programme, and that is why she met the advisory committee
and the programme managers.
Continuing through that
document, the second to last paragraph, a victory for common
sense ? not yet, and moving to the last paragraph “I have no
doubt … setback” ..... that is what Ms Coney has
written.
Can we finally turn to
CHAIR: the date of
this article is 30 June 1996
MR KIRTON: that’s as I
understand it. Can we now finally turn to paragraph 143 of
your evidence. It says at 143 “the Minister the Hon Bill
English … to the Health Funding Authority” is that what
you've stated in your evidence ..... that’s what I have
stated, and that is correct, and the matter is covered in my
exhibit 46.
Can we now turn to volume 8 tab 46. this is
a report from the Ministry dated 24 June 1997 ..... that’s
correct.
Can you turn to the very last page of that
exhibit, item 5. these are your recommendations, agree that
consultation on the future location of the programme be
linked to the consultation on the steering group. can you
read what the response was on that to that recommendation
..... no this needs to go to consultation, after the s/group
report. There must be a framework developed for
consultation. I note however that was from the Associate
Minister at the time and the report the second paragraph on
the first page points out that the report was forwarded to
both the Minister and Associate Minister pursuant to a
cabinet min 97/m22/10 which indicates Hon bil
Has the
lead role in this matter.
Who had delgated authority for
the cervical screening programme ..... I believe it was Neil
Kirton who was Associate Minister at the time.
So I had
delegated responsibility did I not ..... yes but as the
miny’s report indicates this was considered part of an issue
to do with the reforms on which the with the s/group report
which cabinet had decided Hon Bill English had the lead
role
You sent the report to me, I told you that
consultation should happen after the s/group met, you didn't
like that answer so you went to Mr English ..... that is not
true. If you look at the front of the report it was
forwarded for both your attention and the attention of Hon
Bill English which reflected two delegatns, and is practice
in the ministry.
So when Katherine O’Regan the associate
Minister was assigned documents revoking her decision in May
1996 you accepted that as an appropriate response to you and
acted on it ..... that is correct and indeed we acted on the
advice on the Associate Minister on this matter, hovr when
the s/group report was produced, as my evidence later
records, in fact the decision was made the operational
coordntn would be a function of the Health Funding
Authority.
I put it to you that the advice I gave you in
that 24 June document was sage advice and should have been
followed ..... that may have been so but in effect it was
overtken by events because of the recommendation that came
from the s/group report.
Thank you.
MR RENNIE:
I am representing the Royal College of Pathologists of
Australasia. I wish to ask some questions about the expert
com, could you turn to p129 of your brief, the appendix. You
there set out the terms of reference of the expert committee
..... the cytology advisory liaison committee
I have the
expert group December 1991 ..... yes, I believe there was
some discussion when this exhibit was first produced which
identified the fact that the terms of reference were
incorrectly written here.
If you turn to the last page,
thumb tab 5, do you find another statement of the terms of
reference for the expert group ..... yes
Are you able to
say whether those were the terms of reference adopted for
the expert group ..... not without comparing them, they
would seem to be longer.
Do you wish to make that
comparison ..... I am a little confused as to where the
correct terms of reference are.
MR CORKILL: the back
of the 1994 evaluation report reltg to Cervical Screening
Advisory Committee. ..... which would mean the terms of
reference in my appendix are correct
MR RENNIE: on what
basis do you say those terms of reference are correct .....
I was confused, I was aware that the terms of reference for
one committee had been questioned but it’s been pointed out
that was not the expert group.
If you look at the
proposed terms at the back of tab 5 are you
accepting/rejecting those became the actual terms of the
expert group ..... I need to compare those with the actual
terms of reference. If I assume that the terms of reference
in my appendix are correct, they are not exactly the
same\
The first feature is that the document at the back
of tab 5 is explicit that the expert committee’s role is to
advise the Minister ..... yes. althoo in fact the expert
group also advised the Minister I believe.
We are talking
about the same group aren't we ..... I think so. No, while
it is not referred to in its terms of reference it was
advisory to the Minister
That’s what you say in your
brief ..... yes.
How do you say that the statement at the
back of your brief of evidence is authoratv whereas tis
contemporary document at the back of the expert committee’s
report is not authorativ ..... the statement at the back of
the expert group document says proposed terms of reference I
thought the issue I was being asked to comment on was
whether the terms of reference for the exprt group were the
same as those prposed and it would not appear to be so
unless there has been some error with the material provided
in my appendix which I understood to have been taken
correctly from Ministry documents. However as there was a
problem with later material in this panedix I don't have the
condfidence I usually would.
I can assure you the
document you have produced is the only reference document
that I've been able to trace setting out the terms of
reference for the expert group. does your evidence indicate
you think there must be another one ut you don't know where
it is ..... no, my ustandg was that the terms of reference
for the expert group were as set out in the appendix to my
brief on p127. the only alteratn I would make to that is
that there was a problem with some later material in this
appendix – I can't be 100% rock sure that this is
accurate
If you look at the document at tab 5, you will
see that terms of reference 2 is explicit as to the expert
committee overseeing the impln of the programme as to
oversseing ttmt protocols and the susqnt adherence to those
protocols and in 7 to reviewing the overall efetgvcns of the
programme and interaction with treatment services .....
yes
Going back from there item 7 does not appear in the
annexure to your brief at all does it ..... no it does
not.
And yet that specifically refers to an ongoing
review of effectiveness interaction with treatment services
and advice on resource allocation does it not ..... it
does
Can you account for the disappearance of that terms
of reference from the statement which appears in your brief
..... no I can't I can only say that the terms of reference
for the Expert Group I would assume were approved by the
minister at the time
CHAIR: where are the actual terms
of reference of this expert group ..... they were taken from
the Ministry’s files
So the terms of reference themselves
could be produced, because we have your second hand account
in the appendix to the brief and a copy of prposed terms of
reference
MS SCHOLTENS: if I could make enquiries as
to the source document this was taken from.
MR RENNIE:
the document that I'm drawing to your attention forms part
of the expert com’s August 90 advice to the Minister does it
not ..... yes, it does.
And by that stage on your
evidence the committee had been in existence for some 9
mthhs ..... yes the committee was set up in December
89
And in fact it had but another 6 months to live .....
yes, based on my evidence that is so, it was disbanded in
Jan 91.
In our appendix you list persons as being the
mbrsw of this committee but you also state in your brief you
have not been able to locate the minutes or other documents
of this committee ..... yes
If the Minister of Health has
lost the papers could it be the Ministry of Women's Affairs
has the papers since they were clearly on the committee
..... that is possible, we can enquire whether them
do
Are you aware Dr Teague a member of the committee has
retained 8 of the 11 sets of minutes and made them available
to thep arties ..... no I wasn’t aware of that, I have not
seen those
In your evidence as to the mint’s frustration
that the committee did not make decisions, pp201 and 202 of
your evidence yesterday, you hadn’t inspected the decisions
of the committee ..... that was not my conclusion, that
ocnolusn was made the time, included in advice to the
Minister.
You told MR CORKILL: that there was tension
between the expert group and the minty ..... that was based
on an ammeo which the ministry prodcifgvided to the
Associate Minister on this issue. I have no personal
knowledge of any tension, I was not involved in this area at
this time
This expert group was set up following the
review report of 89 to provide expert input into the
implementation of this programme was it not ..... yes, that
is correct.
And looking at the terms of reference as
shown in tab 5, it was explicit that
expert group was
to be involved in the course of the hearing
Implement and
the ongoing review of the programme ..... as in expert 5
proposed terms of reference
I think that the exact role
of the expert’ would depend on the wording of the actual
terms of reference.
The question I put was on the baiss
of that document it is clear it was to have an ongoing role
..... it’s clear that was proposed.
In terms of the
evidence you've gifen as to the work of the group in 1990 do
I take it all your evidence is dervid from looking at
redfcords or talking to person then in the department .....
I can clarify inrt the espert group all my evidence was
defvied from information found on the Ministry files.
The
minutes show that the Minister of Health member of the
committee wasoinitly Dr Durham and then Gillian Grew .....
no, and Ms Grew has notmentnd that to me.
Have you asked
Ms grew of her knowledge of the expert group ..... not
explicitly of the expert committee, I was not aware she had
been a member, although clearly there was a working
relationship between her and the expert group once she was
apointd as coordtr
The minutes from 1 August show her
attending as the departmental representative, would there
have been anyone else within the depet who had the expertise
or responsibility in this area of work ..... what date was
that
1 August 1990 ..... 1 august 1990 I wouldn't have
thought so, no.
was the Ministry dependent on external
expertise in rtltn to both advice and implementation at this
time ..... it was dependent oan expertise in relation to
advice crtnlyu. In relation to implementation there were
staff within the Ministry.
WaS the implementation unit
which had been critiicsd in early 1989 for failing to make
progress still in existing – as at 1 August 1990 ..... my
understanding, although I may not be totally correct in
this, was that the implementation unit as such went out of
existance when Gillian Grew was appointed in June 90. the
easiest way to confirm this would be to discuss it with her.
The effect was that the unit’s failure had led to it
being displaced by this expert committee structure correct
..... I am not sure that I know enough about this issue to
make this conclusion, I know that the Ministerial review
referred to the need to set up an expert group. and as you
have pointed out there was some notion that they would
oversee the Ministry[‘s work.
Would that account in part
for the tension between the expert group and the Ministry
..... I would prefer to refer to the exhibit, which is my
only source of information.
CHAIR: what exhibit is that
..... I think it is probably exhibit 6, 7 or possibly 8 – I
would need to check to see which one it is. I find it
difficult to answer this question without referring to the
exhibit. It is in fact exhibit 8.
MR RENNIE: Exhibit
8 is the memo of 28 Jan 1991 to the incoming Associate
Minister is it not ..... yes, it is.
And who was Ms
Davies who originated this document ..... exhibit 84 shows
her to be manager health for women and younger people
policy.
If you turn to the last page of that document you
will see a draft press statement announcing the end of the
Expert Group and a new advisory group to advise the
Director-General of Health ..... yes.
Can you tell me
where in the preceding pages the discussion is set out for
the Minister indicating the basis upon which that
recommendation is put by the department ..... I'm not able
to identify that.
But this was produced by you as being
the recommendation to the minster for the dis-establishment
for the group was it not ..... no I'm afraid I still have
the wrong reference. I will need to check it during the
break.
Are you sugsting there is some other document than
this making that recommendation to the ninster ..... I am
expressing my confusion as to the source of my information
at this present moment.
There is nothing in document 8 to
advise the Minister that the expert group had an ongoing
terms of reference for implementation or for the monitoring
and reviewing is there ..... not as far as I can see,
no.
The effect of discontinuing the expert group was to
discontinue the expertise provided externally to the impn
which you've said was ng carried on internally ..... the
expert group was replaced by a cervical smear advisory group
which provided advice to the ministry.
The expert
committee had some 15 members of whom some 3 survived as
members of the new committee is that correct ..... I think
that is correct.
And the terms of reference of the new
committee did not involve the same level of implementation
or review did it ..... it did not involve the same degree of
oversight of implementation I believe
So the management
of the programme moved from the experdt committee to the
Ministry correct ..... yes, although the management of
implementation had always been in the Ministry. The
question is to what degree the expert group had an overview
role of that.
Other than the use of the expert group what
further expertise was obtained by the Ministry in early 1991
internally or externally ..... I am unable to comment on
that as I said before my information about this period is
based on the material in the Ministry’s files, apart from
reports from c/consultants and other rthings which I have
produced there is no evidence of other expertise being used.
There was of course a laboratory the cytology liaison
committee.
And in reference to that committee Dr Teague
was a member until 96 when it too was abolished ..... yes I
believe so
You indicated in your evidence yesterday that
the ministry made an arrangement with him to provide
laboratory advice as required and in your view the nminy’s
need for laboratory advice was blved to be met by that
arrangement ..... I discussed that issue both with him and
the national co-ordinator and came to the conclusion that
that arrangement was sufficient as opposed to having a
standing committee at that time.
Are you aware of the
level of use that the Ministry has made since July 1996 of
that argt ..... I'm not aware precisely of that level, I
know that the national co-ordinator during the time the
programme was still the Ministry’s direct responsibility did
frequently discuss laboratory issues with Dr Teague.
Dr
Teague will advise in his evidence that there have been two
formal meetings and some phone calls over that period of
time ..... I'm sure that Dr Teague;’s reclctn would be
correct, I have no personal knowledge how often he was
used.
Dr Teague’s evidence will also be that the Ministry
over that period of almost 4 years has paid him just under
$2,500 in fees and advice ..... if Dr Teague has record how
much he was paid I'm sure that is correct, I couldn't verify
that myself
That’s about $12/week for external advice on
laboratories over the last 4 years, does that indicate that
the Ministry has been confident that it otherwise has the
interal expertise ..... as was discussed yesterday, the
Regional Health Authoritys had direct responsibility for
laboratories by this period. The Ministry’s role in
relation to this were on specific issues in relation to the
use the co-ordinator made of advice from Dr Teague.
The
Ministry’s responsibility continued inn terms of policy
oversight in tis area did it not ..... that is
correct.
The Ministry dealing with policy the Regional
Health Authority’s dealing with operational contracting
..... the Ministry dealing with stdrategic policy and
specific operational issues which came to the attention of
the co-ordinator.
In the Ministry’s policy response from
996 onwards what external advice did it take in relation to
quality control and laboratory issues ..... I take it that
you're referring tgo the cervical screening programme
Correct ..... it is the qadvice that you have recorded,
the use of Dr Teague’s time and the meetings that were
called.
Would the low level of use of his time indicate
conficnce on the part of the Ministry that there was no
issue ..... the level of use of his time would indicate that
in relation to the specific issues related to the cervical
screening programme which the co-ordinator was dealing with
the Ministry rq rd that level of advice. Of course as I said
yesterday, the contracts with laboratories were managed by
Regional Health Authorities.
What policy changes has the
Ministry so far initiated in response to the 99 Gisborne
situation ..... as I indicated this morning, the Ministry I
do not believe has as yet indicated any policy change with
the exceptn of those set out in my brief which relate to
medical practitioners advice on medical practitioners. The
minsty is following the action of the Health Funding
Authority. And at the point where it is clear what the
outcome of that is, and the o0utcome of the inquiry, I would
expect policy changes to be considered.
In the cervical
screening programme the availability of expertise over its
history has depended on the goodwill semi volunry contribtn
of people in the health sector in New Zealand hasn’t it
..... the advisory groups to the Ministry were paid and
their expenses met
Dr Teague’s evidence will be over
about 11 years that amounted to almost $19,000 in total
..... the Ministry pays fees to committee members in line
with shedule of fees set out by the State Services
Commission
Is the Ministry satisfied this is am
appropriate way to obtain policy advice for health
programmes ..... this is the use of expert committees, you
are referring to?
That I'm referring to that as being the
way in which expertise is obtained ..... that in general is
the way the Ministry obtains expert advice except where it
has experts of its own on the staff
Is there an
established Ministry policy to decide when you have staff
experts, when you have contract experts and when you have
expert committees ..... that would be a dcwsn made depending
on the cirdfcs at the time and the demands of the
issue.
CHAIR: is that a yes/no. the committee, in
writing its report, does have to draw conclusions from the
answers you are given ..... I think I would need the
question repeated. ..... there is no standard practice which
is why I went on to explain it would depend on the
circumstances that related to each issue. The answer would
be there is no standard practice
Does that mean there is
no policy ..... there is no explicit policy as such that I
as a manager could turn to say under these circumstances we
would employ someone with expertise.
MR RENNIE: when
you engage external expertise on a fee basis do you define
those arrangements in writing ..... yes, through the terms
of reference and appointment letters sent to committee
members.
You've referred to the 1996 arrangement with Dr
Teague, is there such a letter ..... I recall signing a
letter at the time after discussion with Dr Teague including
the rate he was seeking
Would you be able to produce
that in due course ..... we have not located it
Neither
has Dr Teague ..... I'm not sure where it would be, I recall
it, I would have required this in order for Dr Teague to be
paid.
You've referred in your evidence to the ongoing
evaluation being done by Dr Cox ..... yes
That's a
project which the Ministry administers and which is
currently in progress ..... yes, the Ministry is – Dr Cox is
the lead researcher on this contract to the Ministry for the
evaluation
Does that represent another form of the
external contracting of expertise ..... yes it does
As a
policy response to the 99 Gisborne events has that programme
been reevaluated or modified in any way ..... no. when the
Ministry became aware of the events at Gisborne the contact
was very close to signing and I believe was signed not long
after that
Would you accept some external legal advice
that contracts can be changed ..... of course they can be
changed
Has it been seen to be necessary ..... no the
Ministry had prior to that comsnd a scopg report for the
evaluation which is part of my exhibits. The contract
proceeded on the basis of that. We did not consider that it
needed to be changed on the basis of the events at Gisborne.
At that time we had less knowledge of those than at
present.
Referring to legal advice in your research for
your brief did you locate any instance in 1992 or 93 of the
Ministry obtaining internal or external legal advice as to
its powers to impose TELARC registration on laboratories
..... no I have personally not see that and it wsassnt
brought to my attention by the team of people who searched
the files.
In using the expression that are you thinking
of the same document as I am ..... I'm not aware that there
is any document in existence.
And in particular you are
not aware of any internal Ministry legal opinion on that
issue ..... I have never seen one and wasn’t aware one
existined if indeed it does
In your research for your
brief did you encounter any suggestion that the ministry
believed it lacked the legal power to enforce TELARC
registration ..... I did not see any such document.
I was
referring more to other material where decisions were made
or options discussed on the basis of a belief that the
Ministry could not enforce it ..... I have not seen anything
like that.
In the list of persons who are shown as
members of the expert committee at the back of your brief
the chairperson is given as Peggy Koopman Boyden .....
yes
Were you aware that the first 2 meetings of the
expert committee were chaired by Heather Simpson ..... no I
was not. I think that illustrates the issue that the
Ministry did not have access to minutes or agendas for this
group
Can you identify who Heather simpson was ..... I
believe she was the executive assistant to the Prime
Minister, Helen Clark
Does that indicate the committee
began as … rather than a departl initiative ..... that may
seem so in particle as H Simpson had been involved in the
Ministerial review committee which proceeded this
She
chaired the review committee ..... I believe so.
Did the
review committee and the expert committee represent a
Minister’s imposed solution on a Ministry with which she was
dissatisfied ..... that may well have been the case – I have
no personal knowledge of this issue
Clearly that
situation had the potential to impair the establishment of
the programme, can you see who would be able to say whether
that happened ..... if we are referring to the period 90
Essentially yes ..... Gillian Grew was appointed as
co-ordinator in June 90, she would have the best
knowledge
Does it follow she has not had an input into
the evidence the Ministry is presenting to this inquiry
..... in fact Gillian Grew is providing project management
for the Ministry’s involvement with the inquiry.
Thank
you.
AFTERNOON ADJOURNMENT 4.00 – 4.15 P.M.
MS
KAPUA
You would accept that one of the priorities of the
programme was screening for Maori women ..... yes, Maori
women were one of three priority groups.
You'd accept
that that priority was based on the incidence numbers that
were available for Maori women ..... yes, that’s correct,
there was a very high incidence and I believe from a survey
done low uptake of cervical screening.
You would accept
that Tairawhiti is an area as a health district has a high
Maori population ..... that is in my evidence
So you
would accept it ..... yes.
Do you acknowledge and accept
that in establishing the screening programme there were
specific issues identified that related to encourgmt of
Maori women to participate in the programme ..... yes, that
theme is consistent in the reports around the
programme.
Would you accept that the Ministry devised
policy aimed at meeting those consistent themes and concerns
..... yes.
Who in the Ministry of Health of in the
Department of Health was responsible for formulating the
policy relating to Maori women's aprticiptn in the programme
..... that would vary over different times. Policy on Maori
women was included in the general policy statements for the
programme, I believe, and in addition to that there were at
two periods in the programmes history Maori co-ordinators.
I'm aware as well that there is a Kaimahi group which met
and held regular hui which provided advice in relatn to the
programme.
In the beginning stages of establishing the
programme who had responsibility for formulating Maori
policy in relation to delivery of this programme ..... I'm
not aware that there was one individual with that
respbty.
Who in the Ministry now is responsible for
formulating or monitoring Maori policy that relates to
provision of service in this area to Maori ..... the respbty
for operational policy which relates to service provision
sits with the Health Funding Authority. The Ministry does
not have any responsibility for operational policy and as
I've explained 3erlier I believe, in terms of strategic
policy and not a great deal of work is being done around
this programme at all at present.
Does the Ministry
currently take any action at all to ensure that its policy
relating to Maori is carried out by the Health Funding
Authority ..... yes, theminy does.
What does it do .....
the Ministry monitors the Health Funding Authority in
relation to Maori policy as in relation to other issues,
hovrwvr my colleague Ria Earp is best palced to deal with
this as she has specfic policy within the Maori policy
within the Ministry.
But Ms Earp does not have specific
responsibility for moinitoring the policy does she .....
which policy
In respect of this programme and the Maori
policies and objectives and strategies set out by the
Ministry ..... the implementation of those strategies sits
with the Health Funding Authority. I think we have already
discussed the nature of the Ministry’s monitoring.
CHAIR:
I am confused here. Who is responsible for that programme
..... in respect of operational policy, the Health Funding
Authority
No, I mean in respect of the strategic policy
work ..... issues specifically related to Maori would tend
to be dealt with between where they arose generally would
tend to be dealt withi either by Tekiti Haorua, which Ria
Earp heads, in conjuctn with the appropriate policy area or
by ether of those, depending on what the issue was
When
you say the Ministry monitors, are you are referring to the
evidence you gave yesterday about the funding agreements’
and the performance indicators that is correct
There is
no other form of monitoring ..... apart from the programme
monitoring
What is the operational ..... that is the
evidence in my brief about the other route for informal
monitoring which was information from Programme Manager
passed to the national co-ordinator or indeed information
from through Ministerial or other sources which came to the
Ministry’s attention.
What paragraphs of your brief is
that .....
MS SCHOLTENS: p97.
CHAIR: this goes
from 97 to 98 does it ..... it refers to the time when the –
it refers to the time when the Ministry had the national
co-ordinator as a staff member, that kind of monitoring is
now the responsibility of the hfas
It is descrtfibed on
pp97 and 98 of your brief of evidence ..... yes. that’s
correct, although it also relates to the succeeding
paragraphs as well, to 101, which refers to the role of the
co-ordinator
So at present the monitoring that the
Ministry does would be coinfined to the funding’agreements
..... apart from areas of concern such as correspondence
with the Minister or issues raised in the media.
So in
those circumstances the Ministry is reacting to issues that
come to it rather than taking a proactive role ..... that is
correct.
MS KAPUA So there is nobody wihin the Minister
of Health who is checking or ensuring outside of funding
agreements already entered into as to the delivery of this
programme and whether it’s meeting the objectives and
policies that the Ministry has developed, is that correct
..... there is no-one with that explicit task, that is
correct.
And if there is no-one with that explicit task
can we take it no-one is in fact undertaking that task .....
as I think the point was made, no-one is undertaking that
task proactively. The assumption is that the Health Funding
Authority provides services as required by its funding
agreements which includes its special obligations in
relation to Maori.
I would point out that I am not well
placed to comment on any special work which te kiti Haura is
carrying out and Ria Earp would be able to advise on
that
CHAIR: is there someone in the Ministry who
evaluates how well the Health Funding Authority is carrying
out its obligations under the funding agreements ..... that
is almost the entire rolf to he minstrys health performing
branch.
Is there anyone within the performance monirtg
branch who deals specificly with Maori policy transferred
into the funding agreement ..... the post-mortem branch
works on policy in colaboratn with the policy areas. I
cannot answer that question, I am not explicitly involved
with Maori policy Ria Earp would be able to answer it for
you.
CHAIR: if the p/monitoring branch works with other
policy branches within the Ministry would the best evidence
for how the monitoring and evaluation is carried out come
from some one in charge to the p/monitoring branch .....
that is correct
CAn you name that person ..... that is
joan merkin, acting Director-General. And having said that
I just wonder whether someone else might be holding that
role at present.
MS KAPUA : in terms of the Ministry’s
obligations in respect of the Treaty of Waitangi how does it
meet those obligations if it has nobody checking the policy
in terms of delivery for programmes such as this ..... I did
not say that the Ministry had no-one checking the policy, I
said there was no specific individual with respbty for
checking the policy in relation to the cervical screening
programme. In relation to the Ministry’s obligations under
the treaty I think Ria Earp would be better postnd to answer
that than I would given that I'm speaking for the Ministry
Is there someone within the Ministry who deals with the
Ministry’s obligations under the Treaty of Waitangi .....
the primary responsibility for that sits with Ria Earp,
that is of course the obligations under the treaty are a
shared responsibility and primarily more correctly sit with
the Director-General. But in a practical sense the person
with the lead responsibility is Ria Earp.
In the divided
responsibilities within the Ministry is there knowledge and
cross checking between the arms in relation to provisions of
services in relation to Maori policy from the area you are
responsible for would you have an involvement with those who
are involved in Maori policy is there a cross check .....
yes there is. If I could use a specific example. In
relation to immunisatn for example, that is a responsibility
under one the portfolios I am responsible for. There is a
cross Ministry group which includes technical advice on
communicable disease, policy, performance monitoring and
staff from te kete hauora and often a Pacific adviser.
In
relation to the cervical screening programme is there such a
group that has ever been set up within the Ministry or
exists today ..... when I was responsible for the cervical
screening programme there was for almost all that period a
national co-ordinator Maori sexual and reproductive health
and the cervical screening co-ordinator and other staff
worked closely with her.
In paragraph 76 of your evidence
you refer to the Ministry’s recognition of the special
status of Maori women and you talk about formally welcoming
a kuia to the Ministry and the National Cervical Screening
Programme. Who was that kuia ..... Mere Hoani, I think. I
believe that may be covered in Ria Earp’s evidence.
Do
you in including it in your evidence recall what particular
position she had in relation to the programme ..... this
part of my evidence is a chronology so it is recorded as an
event, a milestone for the programme. I understand from
meeting her myself when I did attend programme managers
meeting she was there in a general role representing Maori
women specifically.
MRS BARRETT:
You've actually got
n76 where this kui advises the national co-ordinator .....
yes.
Which national co-ordinator did she advise ..... at
the time the position was established, which is 1993, that
was before there was a separate Maori co-ordinator so I t
would have referred to the national co-ordinator.
So I
take it that the kuia actually advised Sue Dahl ..... yes I
believe sue was co-ordinator when she was appointed
Tina
H ..... yes I believe so.
So in fact paragraph 76 is
really to do with the role of the Ministry of Health in
terms of your national co-ordinator who was a non Maori
..... that is correct.
How did you select a national kuia
– how did the Minister of Health select a national kuia that
would cover the whole of Aotearoa .....I believe this
process was problematic and I have seen discussion about it
in terms of the issues you have raised. I'm not aware how
she was selected.
Thank you.
MS KAPUA: was the kuia
an employee of the Ministry of Health ..... no she was not.
I believe the Ministry paid her expenses, I'm not whether
she was paid directly.
So there was limited fiscal
implications in respect of welcoming this kui into the
Ministry of Health would that be fair ..... certainly a lot
less than there would have been for a staff member,
yes.
How long did this kui fulfil that role ..... as far
as I am aware she continued to be involved particularly
with Programme Managers meeting for the time that national
cordntn was in the Ministry. I'm not completely certain of
that, though.
Would that be until 1998 .....
yes.
Reference was made earlier to the position of
national co-ordinator Maori and that position was first
filled in November 94 is that correct ..... the file record
in the Ministry showed December 1994 – Exhibit 84
I
paragraph 99 of your evidence you referred to November, that
should read December ..... I suspect that is an issue of how
that was recorded, the information in exhibit 84 was
provided to me from a different source than the information
in my evidence. I couldn't be exactly certain when she
started although – I couldn't be certain exactly when.
At
the time some time towards the end of 1994 when she was
appointed was her responsibility purely in respect of the
cervical screening programme ..... I understand that that
was so although I don't believe I have ever seen her job
description.
When she resigned at the end of 1995 she
wasn’t replaced until 1997 is that correct ..... she was
replaced in June 1996 as far as I am aware. That is the
information in exhibit 84.
In your evidence at paragraph
137 ..... you are quite correct, it shows 1997. sorry, I
can't account for why that’s happened. The information in
exhibit 84 was provided by our human resources section who
actually looked at the employment record. I also believe
it to be true from my own memory, I think the 97 is an
error.
So your paragraph 137 is in the wrong place is
that correct ..... yes, it’s under the wrong year.
It
would be fair to say on the appoint of Raina Meha the role
that she was to undertake had been extended and a number of
other tasks added to her role as co-ordinator in relation
to the screening programme ..... yes that is correct. I
understand that was done on the recommendation of the
hui.
On what do you base that comment ..... that’s what I
have been told. This position did not report to me. I
wasn’t closely involved with it and wasn’t in fact involved
with the appointment.
In essence, by incorporating among
her tasks in 1996, sexual and reproductive health and
support for the national Kaitiaki group, her ability to
fully put time into the cordntn role for the cervical
screening programme was severely restricted, would that be
fair ..... I believe that would be the case. As I said I
understand that was done quite deliberately. I believe
these
issues will be covered in the evidence of Ria
Earp.
MRS BARRETT:
I find it so unrealistic that the
kui was kept to 1998 when we had national Maori
co-ordinators in place until at least 1996 we say. Was that
not a conflict with the national Maori co-ordinators
concerned? ..... I am not able to comment on that, I'm
sorry. I think you should put that question to Ria Earp.
I've never had discussion.
I'm of the understanding the
kui was there for the national co-ordinator non Maori .....
that may be so, I'm not sure how that arrangement
worked
Going back to the question Ms Kapua asked, to add
other jobs to Reina Meha’s position don't you agree that was
a massive task for that person to do ..... I believe it
would have been . as I say I wasn’t involved in
establishing the j/description.
Who was responsible to do
that – I take it you are in charge of the policy that would
b3e a policy issues ..... if you look at exhibit 84 that
position was not established in prevention policy which I
managed, I t was established in the Maori health group and
John Whanga was the manager.
MS KAPUA would it be fair
in incorporating a number of tasks for one person to
undertake it would have cost the Ministry less money in
terms of salary for one person than to have 2 or 3 people
undertaking those tasks ..... yes but I've never heard that
used as the reason for having the scope of the position so
broad.
If we look at what happened in Tairawhiti in your
evidence you refer to the reports from this area from about
paragraph 194. Sharon Reid who you quote from her reports
in your evidence was originally employed as a systems
administrator for the programme wasn’t she ..... I believe
so yes.
There was a Programme Manager employed at the
time that Ms Reid was taken on as systems administrator is
that correct ..... yes that is correct, its set out in
paragraph 189.
And when the programme manager left Sharon
Reid was asked to take on both – well, may not have been
asked, Sharon Reid was tasked with the responsibility of
systems administrator and Programme Manager ..... yes,.....
that is in paragraph 195.
And in paragraph 195 the health
educator position at the same time was reduced to a .5
position ..... that is correct.
CHAIR: what is a 0.5
position ..... it means somebody working half time.
MS
KAPUA So we have a region with one of the highest
incidence of cervical cancer you accept that .....
yes.
We have issues that relate to provision to a large
Maori population ..... yes.
And we have a down scaling of
personnel undertkg the programme in that region in 1992
..... yes.
At a time when the Ministry was responsible
for the delivery and the co-ordination of this programme
..... the Ministry was responsible for co-ordination, the
Tairawhiti Area Health Board was responsible for these
positions.
Did the Ministry ever express to Tairawhiti
health board their concerns about this downgrading ..... I
was not able to find any reference to that but I believe
there was actually an exhibit produced this morning which
relates to this exhibit 92 which was not found on the
Ministry’s files.
The Ministry took no formal action
though in respect of any concerns about services here in
Tairawhiti ..... the reference in the second paragraph to
sue Dahl expressing concerns I think relates to an issue
raised with Midland regional Health authority as I am aware
penny Geddes worked for the health authority.
CHAIR: at
the time, what could the Ministry actually do about these
concerns ..... it could raise it through its performance
monitoring arrangements, I haven't said so because I've been
clear the performance monitoring branch is established to
talk about this.
There were relationship managers with
each Regional Health Authority and a way of raising the
issues was using the relationship mgrs. I'm not sure
whether this relates to an issue which Sue Dahl raised
initially or with one of those managers which was then
passed on to the Regional Health Authority.
If the
concerns which the Ministry raised fell on deaf ears what
else could the Ministry do next ..... I would have expected
they would be raised in a formal way in relation to the
quartly reports – this does not seem to have happened in
relation to staffing Tairawhiti.
And if the concerns were
raised in a formal way in the quarterly reports and still
nothing was done, what steps then could the Ministry of
Health take in respect of the performance by the deliverer
..... I think there is an escalation path which runs all the
way to the possible direction from the Minister. There are
a lot of steps before that related to formal a.. they have
changed at different times.
Are these steps set out in
any document ..... there have been many various documents at
different times which have set out these protocols. We did
not specifically identify these as part of our
evidence.
Could they be made available to the committee
..... yes I could undertake to ask the Ministry to find
those where they are able.
MS KAPUA: there are a couple
of matters of clarification. In paragraph 98 of your
evidence you refer to the hui for Maori cervical screening
co-ordinators. There were no such positions were there, no
such positions as Maori cervical screening co-ordinators
..... I believe fm my reading of the documents that when the
issue of regional co-ordinators was proposed by I believe
the Ministerial review or possibly the Expert Group that
that was rejected by the minister but I have seen something
which said that Area Health Boards should decide how they
discharged that responsibility and whether they appointed
co-ordinators. I can't point to my source.
You
misunderstand my question. There were no positions created
of Maori cervical smear co-ordinators. There were no
positions , there was a national co-ordinator Maori created
= first appointed in November/December 94 but no positions
of Maori co-ordinates ..... I believe there may have been
some regional positions. I haven’t explicitly looked at
that issue – question should be addressed to Ria Earp.
In
terms of your reference to that hui though in paragraph 98,
are you referring to a hui for Maori for kaimahi working in
this area ..... I think that is quite possible as I
explained when you were not here before the Ministry divided
the preparation of its evidence up and I did not look at
mao0ri issues involved with the programme. That evidence
was prepared separately this is included here as it was an
item in the chronology. I don't know anything more about
that hui than is here. Ria Earp deals with these issues in
her evidence.
In your role when you were responsible and
had responsibilities in respect of this programme with the
Ministry did you have knowledge of or were you privy to
information regarding concerns of Maori in relation to this
programme ..... not explicitly although I'm aware there were
concerns. My direct involvement was in relation to the
accountability review in 1996 when I was asked to attend a
meeting of the kaimahi in order to explain what had happened
with the review. At that time I attended as the guest
almost of john Whanga and the national co-ordinator.
It
would be fair to say wouldn't it that Ria Earp hasn’t had
direct involvement with this particular programme either has
she ..... that is correct as far as I know.
So who during
the Ministry’s period of responsibility was tasked with
having some knowledge and involvement with the programme
specifically in relation to Maori issues ..... I cannot say
who explicitly had that responsibility beyond the national
co-ordinator for the period before I was directly involved.
For the period I was involved as I've explained the Maori
side of the programme was managed separately and the maori
public health section and I don't believe I've said so but
after Reina departed Pauline Kingi took on this
responsibility. She also worked in that section.
From
which time is this ..... this is after the departure of
Reina.
Would that have been while she was undertaking her
role with te Puni Kokiri ..... no, that when she was in the
Ministry first with the Maori public health section and then
that section was absorbed into a different section in the
Ministry of which the name escapes me at the moment, still
in the public health group.
MRS BARRETT: I was not
aware that Pauline Kingi worked for the Minister of Health
..... I must have the wrong name.
You have.
MS KAPUA
she doesn't appear on your exhibit ..... she doesn't. she
wasn’t a Maori co-ordinator. It’s a memory loss.
In terms
of the Ministry’s role would it be fair to say there is not
an integrated approach to dealing with Maori policy and
delivery of programmes ..... the Ministry is not directly
associated with programme delivery. In relation to policy
as I have explained before, the issues may be dealt with
separately or through a collaborative approach, depending on
what they are.
Do I understand from your evidence though
that the issues relating to Maori policy are on the whole
dealt with separately or in a separate area within the
Ministry ..... certainly issues relating to strategic policy
are dealt with in that area, but issues where it makes sense
as I said for example immunisation or child health or indeed
almost anything that directly affects where it is possible
to directly identify a Maori population interest are dealt
with collaboratively.
I understand that the Pauline we
are looking for is Pauline Hill ..... yes.
In the example
you've given of collaboration within the Ministry for
example on immunisation do I take it from that that was an
informal decision among Ministry officials as to how to deal
with that particular issue ..... that is correct, although
it is quite recognised as a means of working. I should add
if we are talking general policy issues I would expect any
of the people working in policy branch to seek from Te Kiti
Hauora.
In relation to allocating resources for the
programme, the allocation of resources was population based
wasn’t it ..... for the cervical screening programme. There
was specific tagged funding initially when the programme was
established and that went to Area Health Boards when
population based funding was introduced I understand that
the costs funding fot he cervical screening programme was
contracted for in the normal way with Regional Health
Authorities so there was no specific allocation. The
funding to any particular organisation, if we are talking
about CHEs who were providers of the programme, was by
agreement between them and the appropriate Regional Health
Authority or later the Health Funding Authority.
In the
allocation of resources and funding from the Ministry’s
point of view, for the programme, was any consideration
given to incidents rates, locality, socio-economic status of
people in the area and so on ..... in relation to the Area
Health Board funding it is my understanding that there were
some specifically allocated in relation to priority groups
for the programme of which Maori women were one, the others
were older women and Pacific Island women.
Was funding to
Tairawhiti, did that take account of those issues as far as
you were aware ..... without checking this issue any
knowledge is not detailed, I believe certainly at one time
part of Tairawhiti’s funding was related to priority
groups.
And yet in 1992 we have a situation in Tairawhiti
where the staffing levels for the programme sit at 1.5
people, is that correct ..... yes.
Would it be fair to
say that the programme suffered from a lack of resources
allocated to it ..... that seems likely, and it seems that
that problem continued in 1993.
CHAIR: did the
situation improve at all ..... yes I believe my evidence,
which is based on Sharon Reid comments to Programme Managers
does identify that
When did the situation improve .....
I would need to check my evidence. I think in paragraph 198
Sharon Reid reports that the sight was now once again …
quarterly reports and was focusing on education and
information. There wasn’t a specific reference to staffing
levels here but I think there is elsewhere. I think the
problem within this information is this was based on
material on the Ministry’s files which was by no means
complete.
MS KAPUA: There's no indictn from Sharon Reid’s reports that either the funding situation has changed or the allocation of resources has changed over the period of time that you've included in your evidence ..... I think there is in te Programme Managers report, I recall specifically circumstances in which they were able to provide training for a systems person who was not Sharon Reid so I would take from that that the situation did improve.
CHAIR: I note
at paragraph 200 you say “in December 1995 … doing just
their own work by Jan 1996” ..... yes
Once again it would
be fair to say as at December 95 the programme was suffering
from a lack of resources ..... certainly in terms of
dedicated resources, yes.
MS KAPUA : you refer in your
evidence to the national Kaitiaki group and I anticipate
that will be a matter you will refer to Ms Earp .....
yes
Are you aware of the basis on which the protection of
information relating to Maori women was that provision was
asked or was requested for its protection – are you aware of
the basis ..... I understand it was as a result of concern
expressed by Maori women within the programme for the
protection of their data within the programme.
Are you aware of the basis on which that request was made ..... I am not aware of the specific basis apart from the fact that information on this issue was considered particularly important by Maori women and they considered it appropriate that the use of this information should be treated which led to the proposal for the Kaitiaki regulation.
The Ministry would regard the establishment of the national Kaitiaki group as meeting its objectives in respect of Maori policy wouldn't it ..... I believe it related to a specific concern expressed by Maori women about the use of their data. I wouldn't want to take it further than that.
Would it be fair to describe the national Kaitiaki group as a body that can determine whether certain statistical evidence that is held about Maori women should be released to particular parties ..... the Kaitiaki group has quite extensive power in relation to approving the use and release of information of aggregated information in relation to Maori women. These are explicitly set out in the regltn.
The national Kaitiaki group has no input into the data collection or what information is to be collected does it ..... I am not aware that it has, I would have thought though that it might be good practice to refer changes to the Kaitiaki group. I believe the regltn as drafted refers to the release of aggregated data.
In evidence given at some time during the last few days you referred to reliance on the competency or accuracy of health professionals do you recall that ..... I referred to the programme depending on health professionals being competent I believe.
Now in the statistical data that’s collected is it fair to say that part of the evaluation of the programme is based on those statistics and what they reveal ..... yes.
In paragraph 374 to 378 of your evidence you are referring to target for the reduction of mortality and incidence in paragraph 374 and in 378 you set out specific targets including those for Maori mortality and Maori incidence and make comment about where those targets currently sit ..... that is correct.
Is it the Ministry that sets the targets that are sought to be achieved by the implementation of this programme ..... yes, there are 3 sets of targets listed in the section of my evidence, one which comes from the Expert Group in paragraph 374, one set by the Public Health Commission in 377, and then a final set identified in the 1996 policy document in paragraph 378. the Ministry takes technical advice on those targets and I believe it was probably Dr Brian Cox who was responsible for most of those.
If we look at paragraph 378.4 where we talk about Maori incidence, and you set out the target and at the end of that paragraph state that “this had reduced to an average of 23/100,000 Maori women by 1994” ..... yes.
That figure relies on the accuracy of the information that’s contained in the register doesn't it ..... that figure is taken from the Maori statistical report which was felt to be the best source of data for Maori.
Well, the Maori statistical data does not in any way question or it relies on the accuracy of the readings that have occurred during the period of tme ..... the smear readings
Yes ..... this is about incidence. The incidence data – this is cervical cancer – no the data I believe the best source of this data is now the Cancer Register.
What was the basis for the data in 1994 ..... I'm afraid I can't comment on that beyond saying I have been told it was the Maori statistical report and Ria Earp is covering that in her evidence.
PROFESSOR DUGGAN: the Cancer Register data is separate from the screening programme data ..... that is correct.
Is the Maori data in the Cancer Register separate from everybody else ..... no I don't believe so. That’s – the Maori – perhaps if you could clarify by separate. Data is sorted by ethnicity just as it is sorted by gender.
So when I see figures that say the
incidence of cervical cancer for New Zealand is X this
applies to the entire population ..... yes
When I see a
figure of Y for the Maori population ..... this is specific
for the Maori population
And this is extracted from the Cancer Register ..... the best source of data is now the Cancer Register which we believe to be quite acure in relation to cervical cancer.
What year was the Cancer Register robust ..... from the beginning of this year it is very robust, there were problems prior to that
All this incident data may be inacurate prior to 2000 ..... I believe that the data on the register has been checked. The – I am rather out of my field here. If you wouldn't mind I would very much prefer to talk this through with someone
That’s fine.
MS KAPUA: if the incidence data is taken from the
Maori women’s statistics ..... the statistical
report
That’s the report that was released last year and
was an analysis of data to 31 December 95 is that correct
..... was it 95 or 94?
Well, is this the one, 1995 (shown
to witness) ..... I am told that was the source of the data,
yes, I'm not quite sure why 94 is used here though.
So if
the data on the register which is the source of the
information the statistical analysis that’s in Ms Earp’s
evidence, if the data in there is wrong in respect of the
readings that relate to the smears, if the data is wrong
then the figure of incidence will be wrong, do you accept
that ..... the incidence data is based on histology reports.
So yes, I believe that that would probably follow. I hope
I'm not getting out of my depth here.
Perhaps if I just go to the general question which is that the targets that you have set without independent and proper checking of the data such as we've heard in relation to the laboratories and so on, we can't be sure that those targets are being met can we ..... the effect of under-reporting would be to under state the incidence, yes.
So if we understate the incidence the Ministry’s targets to reduce the incidence within the Maori population for example will show a decrease when in fact if we have under-reporting there may be more incidence than are shown in y9o0ur figures ..... I don't believe so. Ultimately cancer will show itself. I think this is to do with the timing.
In terms of your figures and your target figures is it fair to say that the register and the figures and the statistical data that comes from that is the basis for assessing incidence ..... the cancer register is the ultimate basis for assessing incidence.
As of now .....
the Cancer Register has always been the ultimate basis, the
problem is the completeness of data on the Cancer
Register and as discussed earlier there have been problems
with that over the years.
So your references in 378.4 is to data from where ..... I understand that that was taken from the statistical report. I am becoming confusing, I would like the opportunity to check this.
CHAIR: the statistical report is not the cancer registry ..... no, the cancer registry is a registry established under legislation to which doctors are required to notify cancer
PROFESSOR DUGGAN: in nearly every country that I'm familiar with the incident data is derived from the cancer registry not from a cytology registry.
MS KAPUA : If I understand Ms Glackin these figures are taken from the maori statistical data ..... that is what I've been told. I believe I may be able to provide some provisional statistics from the cancer registry which may deal with this issue.
MS SCHOLTENS: I
wonder whether we could conclude now – the witness has been
in the chair since 9.30 this morning.
CHAIR: that being
the case we will adjourn until 9.30 tomorrow
morning.
THE HEARING ADJOURNED AT 5.50, TO RESUME AT
9.30 A.M.
WEDNESDAY 19 APRIL
2000