District health boards have accused the Ministry of Health of failing women as rates of life-saving cancer screening go backwards.
A Weekend Herald investigation has revealed tension between two of the country's biggest DHBs and Wellington officials over the thousands of women not screened.
Only three of 20 DHBs are meeting a target for cervical cancer screening. Coverage has worsened in 15 DHBs and is stagnant in three.
Dr Debbie Holdsworth, director of funding for Auckland and Waitemata DHBs, emailed a ministry official in November. She called the ministry's reaction to a bowel cancer screening issue "over the top" when compared to serious problems with cervical and breast cancer screening.
"Women are being diagnosed with cancer who have not been screened," Holdsworth wrote in the email, released under the Official Information Act.
"You hold contracts with independent service providers which we believe are failing these women and we can't reconcile your response to the [bowel screening pilot] issue relative to these programmes and our understanding of the role of the ISPs."
DHBs have a responsibility to reach target coverage of 80 per cent of eligible women screened for cervical cancer, and 70 per cent for breast screening.
Auckland DHB screening coverage for both cancers is the worst in the country and has been dropping since 2016. Just 66 per cent of women aged 25-69 had a cervical smear in the three years to March 31 – meaning 51,365 women were missed.
Nationally, cervical coverage is 74 per cent. Three of 20 DHBs - Nelson Marlborough, Taranaki and Bay of Plenty – are over the 80 per cent target.
Cervical coverage is just 55 per cent for Māori women in Auckland. Screening for Māori has worsened in 17 of 20 health boards.
"The falling or static cervical screening and breast screening coverage, particularly for Māori women, has been a concern for some time," Holdsworth told the Weekend Herald.
"The current contract organisation and level of DHB resourcing limits the DHBs' ability to meet the needs of women to improve coverage."
The national cervical screening programme is largely provided through GP and family planning and sexual health services. It's not fully funded and women make a co-payment, the cost varying by practice and whether a GP or nurse performs the test.
Screening can be free for some eligible women. Auckland and Waitemata DHBs estimate it would cost about $3.2 million annually to provide all women across both DHBs free screening.
"Significant further funding to remove cost barriers would be needed to support achievement of national coverage targets, particularly regarding equity in the Auckland region," Holdsworth said.
Independent service providers (ISPs) – now called screening support services – are contracted by the ministry to provide individualised support for women, including Māori, who may face barriers to getting screened.
There was frustration amongst DHB staff when the ministry re-tendered contracts in 2016. After delays, the Well Woman and Family Trust was eventually selected as the screening support provider for breast and cervical screening in Auckland and Waitemata, from November 1, 2016.
"This change from the previous four or so providers resulted in very limited support to service provision over the process of re-tendering for a period of approximately 18 months which was a source of frustration," Holdsworth said.
Auckland is one of three DHBs below the 70 per cent target for breast cancer screening, with 64 per cent screened in the past two years. The others are Waikato (69 per cent) and Waitemata (66 per cent).
Holdsworth said giving both screening programmes access to national population-based registers would help identify unscreened women, and the DHBs understood there were plans for that to happen.
Astrid Koornneef, group manager of the ministry's National Screening Unit (NSU), said support services worked hard to improve coverage and "all DHBs have a responsibility for the health of its populations".
"We know priority group women face more barriers to healthcare, such as accessing primary care and associated costs, cultural differences and, specifically in relation to cervical screening, the uncomfortable nature of the test."
Koornneef said provision was continuous throughout the 2016 re-tendering process, and there was no evidence access decreased.
Cancer Society Auckland chief executive John Loof said screening rates in the metropolitan area were concerning and difficult to understand, given people in cities typically enjoyed better access to services.
"What is also worrying is that these DHBs are some of the largest in New Zealand, and therefore the number not being screened is significant."
Emails released to the Herald show health professionals have been alarmed by the lack of screening.
In October last year Dr Karen Bartholomew, from Waitemata DHB, was contacted by a clinical adviser at ADHB, who had seen two women diagnosed after cancer was at an invasive stage.
"Apart from the fact that there were missed opportunities in the care provided to both women, the most important primary cause of the delayed diagnosis was a lack of Pap smears in over a decade in both cases," the clinician wrote.
Cervical cancer tests will this year change to screening for the human papillomavirus (HPV). That will mean screening will be required once every five years, and enable some women to take their own sample.
Auckland and Waitemata DHBs are leading research projects on how this could apply to priority groups including Māori, Pacific and Asian women.
Free HPV immunisation, which prevents up to 90 per cent of cervical cancers, was extended to include boys last year.
'There was nothing out there that spoke to her'
Talei Morrison has been told her cervical cancer is terminal – but the 42-year-old is still fighting to protect other women from the disease.
Morrison is a driving force behind the Smear Your Mea ("smear your thing") campaign that has helped thousands of women, many Māori, get tested.
After being diagnosed with stage four cancer in August 2017 she identified her beloved kapa haka as a way to bring attention to the importance of testing.
At least 35,000 will attend the national competitions, Te Matatini, next February. At each of the regional champs before then there will be a #smearyourmea table, with nurses ready to carry out smears.
Talei's mother Sandy Morrison spoke to the Weekend Herald as her daughter was too ill for an interview.
"She campaigns because she doesn't want anyone experiencing what she is currently experiencing," Morrison said. "There was nothing out there that spoke to her as a Māori woman, that had her values, her world view and interests at heart."
In April, Talei learnt her cancer had spread around her body. Her mother said the family remained hopeful.
"We are very strong in our cultural faith and belief. We keep up a strong network of support that has all the elements of Māori culture infused through it. So we still walk forward in hope."