Speech To The Challenge Of Screening
Speech To The Challenge Of Screening - The Progress And Challenges Of The National Screening Unit
The Progress and Challenges of the National Screening Unit
Speech to "The Challenge of Screening" Conference
Dr Julia Peters, Clinical Director, National Screening Unit 11:30am, Tuesday 29 May 2001
Greetings and Acknowledgements
I would like to acknowledge Women's Health Action for holding this conference today, and the women of New Zealand who support our cancer screening programmes in so many ways. They have a right to expect that these programmes will deliver the best outcomes possible and many may rightly feel let down at this time. I also want to acknowledge my colleagues who work in both the breast and cervical screening programmes at national and provider levels to make them a reality for New Zealand women. Dr Muir Gray, a British screening expert has described screening as "at best a zero gratitude business." I hope it is not that bad here but I do think we also need to be aware of just what a challenge it is for those who work in these Programmes.
My brief for today is to talk to you about what will be in place in the future to ensure New Zealand's two cancer screening Programmes are successful, what progress has been made over the past two and a half years and what challenges face the Programmes for the future.
First, I want to talk about where we have come from.
When I became Manager of the Health Funding Authority's (HFA's) newly established National Screening Team in November 1998, I had a team of four and a half permanent staff, excluding the National Cervical Screening Register staff who at that time were located in another team within the HFA. In those days we were known as the Public Health Change Management Team which did cause concern in some quarters because of the implication that our mission was constant change! ? it wasn't, but it feels as though by default that has been our mandate. We were a new team in a new organisation and it was probably fairly obvious to the outside world that we had little experience in the co-ordination of an organised screening programme at a national level. Let alone two! What we did have though, was a lot of commitment and a lot of energy.
Like the National Screening Team, the Health Funding Authority (HFA) was itself a recent invention. Co-ordination of the National Cervical Screening Programme (NCSP) had recently been transferred to the HFA and we were about to launch the national breast screening programme - BreastScreen Aotearoa ? the following month. During the two years of the HFA's existence the national screening team, for want of a better term, grew a bit like a yeast growth, there was so much to do that we had to get more people and we did. By late last year, there were 11 permanent team members. In that first year, we were committed to completing the establishment of the breast screening programme, when we were also confronted by the Gisborne misreading problem. While we had been preparing to review the cervical screening programme, we were not really prepared for the extent of the task that confronted us, which included of course appearing at the Gisborne Inquiry hearings. It has been, as Karen Mitchell, our new Group Manager would say, "all hands to the pump" with no room for anyone to stand on ceremony.
It was therefore gratifying to us that one recommendation in particular from the Gisborne Inquiry Report acknowledged some of the hard work and commitment that the national screening team had shown over the past two and a half years.In acknowledging the merger between the Ministry of Health and the HFA, the report called for the preservation of the culture, which was developing in the HFA regarding the management of the NCSP
Obviously things are very different now than they were towards the end of 1998, and what I want to do now is briefly describe some of the key achievements of both Programmes over the past two and a half years which should contribute to their success. I would then like to talk about some of the challenges ahead.
After a difficult establishment phase, BreastScreen Aoteoroa was launched in December 1998. Over the past two and a half years the national team and providers have worked extremely hard to complete the establishment of the programme and work towards its consolidation. For four out of the six providers, this was completely new. For the two providers from the pilot years there were major changes working towards a national programme. That they have achieved what they have, is a credit to their hard work and dedication. Five new mobile screening units have been designed, built and are on the road making the Programme accessible to women in all parts of the country. Rigorous quality standards, routine on-going monitoring and audit have been features of the programme from its inception. A national recruitment campaign was launched in October 1999 and was the recipient of a media award in 2000. The next monitoring report will show that in the first two years of operation more than 153,000 women were screened - 54.5% of the eligible population. There are undoubtedly challenges ahead for the breast-screening programme, and I will discuss these later but I think we can look back at where we have come from with some satisfaction.
The National Cervical Screening Programme (NCSP) was of course established well before it was transferred to the HFA. However, it was really shaken to the core by the events in Gisborne which showed the need for all essential components to be in place together. Accordingly our work at a national level has focussed on the quite lengthy process of developing and implementing the essential quality assurance processes and broadening and strengthening national co-ordination activities. Strengthening national co-ordination was extremely important but not without its problems in a Programme that had evolved with a very strong regional focus. It had to be done however, because it is not possible to have a national programme without strong national co-ordination and leadership. It was positive to hear Dr Euphemia McGoogan emphasise the importance of strong national co-ordination in an interview she had with Kim Hill last week.
We have also conducted a major review of health promotion activities and health education resources. At present we are re-developing the resources which will include a detailed brochure for women which we hope will be useful to health professionals as well. Significant resource and effort has also been committed to health promotion training. At a national level, there has also been a need to focus on building wider relationships with the many professionals who provide services to the cervical screening programme, in particular pathologists and gynaecologists, smear-takers and their representative bodies.
These have been some of our key operational achievements. However, there have been other changes at a national level which are, I believe, critical to placing both programmes on a firmer footing for the future. Some of these are less visible but are also important in ensuring the future success of both programmes.
The first has been ensuring that with the current health changes, almost all the funding for both programmes was not only retained centrally but was transferred to the National Screening Unit from the locality teams of the old structure. This means that from 1 July 2001 the NSU will directly, fund and contract for all publicly funded components of both programmes, an achievement endorsed by the Ministerial Inquiry report and a first in the history of either screening programme.
The second was obtaining approval to establish a screening unit within the Public Health Directorate of the Ministry of Health with 33 full-time equivalent positions, a move fully supported by the Director-General of Health. Importantly, this enables us to have dedicated staff in operational management, quality and monitoring, information systems, contracts and finance and Maori and Pacific co-ordination. We will soon welcome to our unit the first Pacific screening worker at a national level. We are also looking to appoint a dedicated Maori Screening Manager to the unit, in addition to the senior analyst position we already have. As I said earlier, the establishment of such a unit was also endorsed by the Inquiry report. The National Screening Unit has achieved what it has today as a result of the hard work and dedication of a small team of people. This is not a sustainable approach long-term and to manage, fund and co-ordinate these programmes effectively at a national level an adequate, well trained, workforce is required.
The third has been maintaining our commitment to quality and openness. We have developed and maintained a firm commitment to quality at each stage of the screening pathway. We know that neither of these programmes can prevent every case of cervical cancer or detect every very small breast cancer. However, the higher the quality, the more cases they will prevent or detect and the smaller the number of women who will have false negative results or be recalled unnecessarily for further investigation. We have also endeavoured to be open. We could have done a number of things better, but I think we have maintained a culture of being prepared to admit this and to work with the sector to move forward. The Gisborne Inquiry report explicitly encourages the National Screening Unit to develop collaborative relationships with the College of Pathologists. We have worked towards collaborative relationships with all stakeholders in both programmes but we take the message that there is always room for improvement.
What are the challenges for the future?
Workforce issues Workforce issues are a substantial issue for the health sector as a whole both in New Zealand and internationally. Reaping the benefits of effective, high-quality screening programmes is highly dependent on the availability of a motivated, skilled workforce at every level of the screening pathway and at a national level. It's time to pay attention to those issues. We are doing this with a twelve-month workforce development and planning project. Those working on this project will provide their report to the National Screening Unit in December this year. This report will outline practical strategies to maintain and improve the workforces of both screening programmes. During the year, some of you may be contacted by the project team for your views. Specific technical skills are required at all stages of the screening pathway and at a national level. An understanding and commitment to public health is also needed ? such an approach needs to pervade our approach to screening.
Quality Quality and quality assurance needs to continue to be a major focus of our work. There is much more work to be done over the next two to three years. The ethics of screening demand that we work towards the highest quality possible and that lapses in quality are identified and remedied quickly and effectively.
Public and professional understanding of what organised screening programmes can and cannot achieve. As I said previously, and this is not an excuse for not striving for the highest quality possible, but screening programmes cannot guarantee individual benefits. Screening programmes are public health risk reduction programmes and high quality screening programmes should be able to deliver substantial population benefits. Not all cases of cervical cancer will be prevented and some breast cancers will not be detected. Some individuals will be harmed by screening programmes at an individual level, either as a result of a false negative result or a false positive result that leads to unnecessary anxiety. It is important that this information is conveyed accurately to all because unrealistic expectations are potentially very damaging.
Public and professional understanding and acceptance of the value of monitoring and audit The National Cervical Screening Programme has been rightly criticised for the fact that for the first decade of its existence no quality standards were developed or implemented and no routine, on going monitoring and evaluation processes were established. However, the fact that these have been a feature of the breast screening programme from its inception does not seem to be a cause for celebration but appears to some of us to provide a quarterly opportunity to put the programme down. Monitoring will find problems ? that is one of the key reasons why we do it ? to monitor progress and also to detect issues which need to be further investigated or remedied. I think it was Dr Terri Green from Christchurch who said to me that we should regard every problem detected by monitoring as a little nugget of gold. How can we improve our programmes if we don't know where the deficiencies are? A clinical audit conducted in Leicester as a routine quality assurance activity has been greeted by the British media as further evidence that the cervical screening programme there is "failing". This issue was also raised by Dr McGoogan in her interview with Kim Hill last week where she noted that some newspapers had referred to the results of the audit as "Leiscester Scandal" Inevitably the audit found that some women had had false negative results and may have developed cervical cancer as a consequence. However, this does not mean the screening programme is failing in England. Far from it: there is good evidence that it is succeeding and such audits enable all those in the Programme to determine what areas require improvement and thus where efforts and resources must be directed. It is essential for the sake of quality in all areas of the health service that we develop a mature attitude to routine monitoring, audit and evaluation in New Zealand. If we don't, there is a risk that health workers will resist openness about these activities and, as regards screening programmes, it may become increasingly difficult to find people to work in them. Again, Dr Muir Gray has noted that, in screening, if your quality assurance processes are not generating at least one major investigation every three years, they are probably not effective.
Relationships with primary care providers Both Programmes appear to have some way to go to build positive and effective relationships with primary care providers. They are the people, with practice nurses, who take most of the cervical smears in this country and who can work with us to inform women about screening and recruit them to participate in both Programmes. Huge demands are placed on primary care providers and a majority of them are not trained in public health. They are therefore not necessarily going to be aware of the technical intricacies of organised screening programmes. They may view the negative attention given to the breast screening monitoring reports as evidence that the programme is of low quality and it would be surprising if they were not concerned at the events which have occurred in the NCSP. One of our challenges at national and provider levels is to continue to build collaborative relationships with the College of General Practitioners and to extend that to other primary care and nursing organisations and individual practitioners where possible.
BreastScreen Aoteoroa For the programmes individually, there are some challenges ahead. It is possibly a little early to be sure but it looks as though recruitment and coverage is going to be a major challenge for the breast-screening programme in general and more particularly for Maori and Pacific women. If this is not addressed, it will affect the potential effectiveness of the programme. We do not currently have access to a population database from which we can invite women directly to participate in the Programme. The challenge for the national unit and providers in the second screening round of the national programme is to go to work on this area. In the absence of a population database, we need to investigate all other avenues to ensure eligible women hear about the breast-screening programme and have the opportunity to participate.
The National Cervical Screening Programme (NCSP) For the NCSP, coverage is also a challenge. Enrolments are high - at around 90% of women aged 20-69 years - but three-year coverage stands at approximately 70% and is lower for Maori and Pacific women. We also need to continue to develop our quality assurance processes for the Programme and to give urgent attention to some of the more fundamental recommendations of the Gisborne Inquiry report on which future success of the NCSP is dependent. I refer to the need for audit, implementation of the operational policy and quality standards and the monitoring plan and legislative change, not only to ensure that essential monitoring and audit can occur, but also to ensure that the legislation supports the Programme in an effective way.
Rebuilding women's confidence in the screening programmes Finally, and perhaps this is an appropriate note on which to conclude, we need to rebuild women's confidence in screening programmes. While there have been suggestions of the need for a media campaign to do this, I believe it is by working away at the fundamentals of screening and communicating this to the public, that we will rebuild women's confidence. If women know that the National Screening Unit and Programme providers are committed to delivering them the very best we can, and they see tangible evidence of our efforts. This includes the implementation of the Gisborne Inquiry report recommendations, the development and implementation of quality practices and standards, high-quality health education material and on-going monitoring and evaluation activities, then slowly but surely confidence will return.