Ronald Jones: Still ignoring what could be achieved

COMMENT

Thirteen years have elapsed since the national cervical screening programme rose out of the shadow of our worst medical disaster, the National Women's Hospital cervical cancer inquiry. Yet hardly a week goes by without media reports of harmful results from cervical smears or criticisms of the programme.

The Ministry of Health is unlikely to have greeted with enthusiasm the comments of the independent expert adviser, Dr Euphemia McGoogan, relating to poor understanding of public health screening programmes and concerns with leadership and management within the ministry.

It is worrying that Dr Karen Poutasi, the Director-General of Health, believes all pieces of the screening programme are present but still have to come together to create a cohesive picture. After 13 years and with all of the problems with cervical cytology screening, is it reasonable for the public to wait and hope a cohesive picture will emerge?

Importantly, Dr Poutasi has failed to identify the central defect in the programme - a lack of visionary scientific leadership. Since its inception, the programme has constantly been reactive to the multitude of criticisms rather than demonstrating proactive leadership.

This was illustrated in the television debate comparing conventional with liquid-based cytology. While knowledgeable professionals argued for the liquid-based approach, the ministry had no professional spokesman, and the Minister of Health was left to defend programme policy.

At the outset, the screening programme set standards for auditing. After the Gisborne inquiry, neither Dr Poutasi nor any member of the programme accepted responsibility for their shortcomings. By contrast, the Government was quick to pillory Dr Michael Bottrill, a man whose performance should have been identified by the programme, a man unaware of his deficiencies.

It should be no surprise that the Health Screening Programme Amendment Bill now before Parliament includes detailed powers for screening programme evaluators but none for (external) evaluation of the programme itself. Given previous difficulties and the need to achieve public confidence, continued external monitoring is essential.

What sort of screening programme do most people want? Do they want the best programme, or do they want a politically and culturally correct one lacking scientific leadership and vision?

Dr Colin Tukuitonga, the Director of Public Health, used the New Zealand culture as a reason for the shortcomings in the cervical cancer audit. He said that Dr McGoogan did not understand the "New Zealand context", and "our laws are different and we are much more consultative than other people".

The thousands of women I have met with abnormal smears over the past 30 years have all said they want the best screening programme - they are not interested in the "New Zealand context".

In recent years, health policy has been to reduce or eliminate medical leadership, replacing doctors with itinerant generic "managers". For some time a British-trained generic health manager has led the programme, someone who could not be expected to have any special understanding of cervical cytology or public health screening or the New Zealand context.

Questions need to be asked why Dr Julia Peters, the only physician directly involved in the programme and one who had gained considerable respect, elected to leave. The programme needs to be directed by a professional with scientific knowledge and experience in the field of public health cervical screening and/or cervical cytology, not by a generic manager.

A significant proportion of programme resources is devoted to monitoring the multitude of privately (and sometimes overseas) owned and publicly funded laboratories. Is it reasonable to ask whether it would be more appropriate to have a publicly funded national laboratory?

The establishment of uniform standards, education, research and leadership would be so much easier and should be more cost-effective. Such a service would be directed by an experienced cytopathologist and epidemiologist. These leaders would provide scientific analysis and research benefiting the local and wider communities.

After 13 years, I am unaware of a single scientific paper to have emerged from the screening programme.

Would it be possible for the system suggested above to function within the bureaucratic framework and culture of the Ministry of Health? The answer is almost certainly no. A national laboratory and associated screening unit would need some independence similar to that of other countries.

A number of unresolved items in the field of cervical cancer prevention remains. There must be increased community awareness of the role of the sexually transmitted human papilloma ("wart") virus as a primary cause.

Audit of all cases of cervical cancer should be a non-litigious continuing education process.

The highly publicised and expensive retrospective audit will largely tell us what we already know; it will give us no information on what is happening today.

It is another example of the ministry's reactive, as opposed to proactive, philosophy.

The vast amount of data which women have provided to the programme needs careful analysis so that management strategies for women with abnormal smears can be refined.

Clearly defined standards for colposcopy are in the public sector, but none for the private sector.

While there is no reason to believe that the screening programme is not functioning satisfactorily at a basic level, the continuing harmful publicity, and the ministry's reactive rather than proactive philosophy, demands visionary leadership and results that give confidence to the public.

Sadly, my guess is the screening programme will continue to muddle along within the insular world of the ministry. Thus it will continue in relative ignorance of what it could and should achieve, will be reluctant to accept criticism and be propped up by health bureaucrats who see New Zealand as peculiarly "different".

* Professor Ronald Jones is the director of the colposcopy clinic at the National Women's Hospital.