Vote of confidence in National Cervical Screening
8 December 2003
Vote of confidence in National Cervical Screening Programme
The Office of the Auditor-General report released today provides a vote of confidence in the country's cervical screening programme says Director-General of Health Dr Karen Poutasi.
The report firmly reinforces the value of our National Cervical Screening Programme (NCSP) and strongly encourages women to have regular smears.
Regular three-yearly smears are a woman's best protection against cervical cancer, and I'm pleased the Audit Office report clearly reinforces this,? says Dr Poutasi.
The Audit Office says within six months it will have checked off as completed two-thirds of the recommendations from the Inquiry; 22 of these 31 are already complete, 12 more than when Dr McGoogan reported six months ago.
"This is the second review by the Audit Office and it is clearly its view that the cervical screening programme continues to improve and make steady progress."
Dr Poutasi says the report provides a balanced view of both the value and the complexity of the issues involved in implementing the Inquiry's key recommendation - the Cervical Cancer Audit.
"Clearly the size of the task was originally underestimated. Delays in the cancer audit have attracted criticism, but the Audit Office says it's confident that these were not caused by lack of either commitment, funding or available resources. They go on to say the audit is progressing as fast as could be expected, given the magnitude of the undertaking."
"There has been some debate about the leadership and location of the National Screening Unit and whilst understandable, the release of this report offers a timely opportunity to put this behind us and move forward, hopefully with as much sector support as possible."
Dr Poutasi says this is being helped by the new National Cervical Screening Programme Advisory Group, which provides independent and external advice and which met for the first time last month.
"I'm confident we?re making good progress here as stakeholder feedback to the NSU is that a culture of cooperation and collaboration is developing where this didn't exist before. The Audit Office identified this as a concern, but acknowledges the efforts made to address this."
The Audit Office sees the need for a period of stability for the National Screening Unit to allow the unit to continue to improve the programme.
"The report also identifies the need for the National Screening Unit to audit health providers to agreed standards. The unit will be working collaboratively and co-operatively with the sector to do this but the reality is that this will take time, particularly as some standards are still bedding in."
The Ministry is committed to continuing to work constructively with external reviewers. The Audit Office recommendation for three further independent audits of the programme by 2011 is a good approach. In particular, it makes good sense to broaden the audits to include the screening programme's wider work plan in addition to focusing on inquiry recommendations.
(information about the
Gisborne Cervical Screening Inquiry)
(previous Audit Office report)
Questions and Answers
This is the Audit Office's second report on the NCSP - when was the first?
In February 2002, the Audit Office reported on progress made to date, and the work remaining to be done to implement the Committee of Inquiry's recommendations. The Audit Office's review was conducted at the same time as the first review by Dr Euphemia McGoogan. Dr McGoogan was appointed by the Minister of Health to provide independent advice on progress being made in implementing the Committee of Inquiry's recommendations. Dr McGoogan's second and final report on progress was released in July 2003.
Why was a second Audit Office report carried out?
Following the release of Dr McGoogan's second report in July 2003, the Minister of Health contacted the Auditor-General requesting a follow-up review. The Minister was concerned about issues raised in Dr McGoogan's report, which were based on her visit in January this year, and wanted to know whether any progress had been made since that date. The Auditor-General's response to such requests is discretionary. The Audit Office had, however, intended to do a follow-up review six months after Dr McGoogan's second report had been issued. The Audit Office decided to bring the timing of this review forward because of the high profile of the programme, and the importance of the programme from a public health perspective.
When did the review begin?
The Audit Office commenced its review in July 2003. This involved meeting with National Screening Unit (NSU) staff and other Ministry of Health officials, and a number of external stakeholders. The NSU supplied extensive documentation for the Audit Office to consider as part of its review.
What was the scope of the Audit Office report?
In its second report, the Audit Office sought to establish:
· What progress the Ministry had made since Dr Euphemia McGoogan's final review (in January 2003) to implement the 46 recommendations of the Committee of Inquiry. · The issues and reasons why the Ministry is not progressing as quickly as recommended with the implementation of some recommendations; and · How and when the Ministry intends to address other issues raised in Dr McGoogan's report.
What are the key findings of the Audit Office's second report?
The Audit Office's second report concludes that good progress is being made in a number of areas, however the Audit Office did find that more work still needs to be done to ensure that appropriate assurance processes exist around the quality aspect of the programme (ref below).
The Audit Office's report provides a summary of progress made in implementing the recommendations of the Inquiry, as follows: · 31 of the 46 recommendations have either been implemented or will be completed by June 2004. · A decision was made not to implement two recommendations relating to the leadership of the NSU and the reconsideration of the Kaitiaki Regulations. · A decision still has to be made regarding the recommendation to offer women two smear tests 12 months apart dependent upon the cancer audit outcome. · Work has begun on eight recommendations but they are unlikely to be completed by June 2004, including the audit of invasive cervical cancer · Work has begun on a further four recommendations relating to ethics committees but it is unclear whether they will be implemented. It is noted by the Audit Office that 'the most significant progress has been made on the recommendations requiring legislative changes, progressing the recommendations on which work was well advanced at the time of the Committee of Inquiry, and the recommendations that were relatively straightforward to address.?
Both Dr McGoogan and the Audit Office identify that there is still much to be done on recommendations related to the Audit of Invasive Cervical Cancer, screening workforce development and information technology developments. In relation to the Audit of Invasive Cervical Cancer, however, the Audit Office finds that it is progressing as fast as could be expected given its magnitude. The Audit Office has noted that more work needs to be done to ensure appropriate quality assurance processes are in place. The Audit Office refers particularly to the need to complete the review of all National Cervical Screening Programme (NCSP) policy and quality standards and carry out audits of provider compliance with those standards. The Audit Office has identified areas that it believes are key to ?completing the puzzle? referred to in Dr McGoogan's final report and is concerned that recommendations related to these areas have been slow to progress. These areas include: · Ensuring that the NSU is more willing to listen and be more open and collaborative with stakeholders and draw more on the knowledge and resources of the professional colleges in particular. · Completing the Cancer Audit. · Providing electronic access to information on the NCSP-Register for service providers with the aim of improving data quality. · Developing a population register utilising the National Health Index. · Implementing quality standards for smear-takers and private colposcopists. · Ensuring that all policy and quality standards introduced in 2001 are reviewed and updated, and provider compliance is audited. · Ensuring that there is a sufficiently trained and skilled workforce for cervical screening, and that the proficiency of staff involved is measured at an individual level. · Maintaining ongoing independent monitoring of the programme. · Completing the work of the National Ethics Committee. · Ensuring systems are in place to identify and assess new technologies such as liquid based cytology. · Establishing a specific quality manager role within the NSU. In its detailed commentary, the Audit Office acknowledges that work is progressing on all of the areas identified as key to completing the puzzle. Why have only some Standards been reviewed? The Audit Office states that the National Screening Unit needs to regularly review all 51 National Cervical Screening Programme Interim Operational Policy and Quality Standards (IOPQS). The NSU has already identified this as a priority and work has already been undertaken in this area and further work is planned for 2003/04 and 2004/05. Experience has shown that once policy and quality standards have been developed they need to be adopted and implemented by providers. This can take at least 6 ? 12 months and requires sector cooperation and support. Following the implementation period, the review of standards would usually be carried out every 2 - 3 years. This timeframe allows the sector a sufficient ?bedding in? period for these standards. Given that the IOPQS only really became effective for contracted providers in July 2001, the NSU believes that realistic progress has been made regarding the ongoing review of the Interim Operational Policy and Quality Standards. Why have the provider audits not commenced? The Audit Office acknowledges that implementing quality standards is an important first step, however it notes that an equally critical step is the checking that providers meet the standards. The Audit Office states that the National Screening Unit needs to audit providers to establish that they are complying with standards and that not doing so reduces the value of the standards substantially. The NSU had already identified provider audits as a priority and work has been ongoing in this area in anticipation of the contractual changes as outlined below. This work has included the development of a National Cervical Screening Programme Audit Framework, which has incorporated consultation feedback from the sector - a process which took 15 months. It should be noted that until recently, the NSU has not been in a position to audit laboratories due to the laboratories being contracted under the (general) Community Laboratory Agreement which made no provision for the separate auditing of NCSP services. The audit provision in the Community Laboratory Agreements related to financial audits only. These agreements were devolved under an Order in Council to district health boards in 2001. Currently, nine laboratories have signed direct NCSP Laboratory Agreements that allow NCSP specific laboratory audits, and negotiations are underway with the remaining three laboratories. Despite the contractual limitations faced by the NSU, the Audit Office states that the NSU should have investigated other interim arrangements with either International Accreditation New Zealand (IANZ) or another accreditation agency. In September 2003 an agreement was reached between IANZ and the NSU to work collaboratively to ensure that the NCSP provider compliance audits and IANZ accreditation of laboratories is closely aligned. With the recent introduction of new colposcopy standards the NSU is now in a position to audit the 21 DHB colposcopy service providers. However, the NSU is not in a position to audit the 5,300 smear takers as there is no contractual relationship between the smear takers and the NCSP. The NSU and the College of General Practitioners are however, working together to review smear taker standards and how they might be implemented. The College's practice review tool entitled ?Information Practice Review Activity to Aid in the Provision of Quality Cervical Screening in General Practice? is based on the NCSP standards. These standards are seen as a benchmark for best practice by the College and have also been used by the Health and Disability Commissioner. The NSU, along with the College of General Practitioners, and the College of Practice Nurses (both of which are represented on the NCSP Advisory Group) will need to work together to consider the implementation of standards in this area. Also, a number of workforce intitiatives are underway to develop and support the screening workforce, including the training of practice nurses to become smear takers and the support required to supervise these trainees.