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
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.
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.
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.
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.
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.
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.
AFTERNOON ADJOURNMENT 4.00 – 4.15 P.M.
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.
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.
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.
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.
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 .....
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
MS KAPUA: if the incidence data is taken from the
Maori women’s statistics ..... the statistical
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