Roy Heather: Health (Screening Programmes) Amendment Bill — First Reading 
Roy Heather: Health (Screening Programmes) Amendment Bill — First Reading 
[Volume:606;Page:3501] 
HEATHER ROY (ACT NZ) 
: 
 The Government tells us that the aim of the bill is to assist the operation and evaluation of the national cervical-screening programme. The bill also addresses the extension of these provisions to other screening programmes. The aim of screening programmes is of course to detect abnormalities early so that they can be referred for treatment early. It is informative therefore to look at the number of cases of cervical cancer diagnosed over time and also at the mortality rate. International comparisons are also useful. In 1995 New Zealand had the second highest rate of death due to cervical cancer of the OECD countries—a rate of 4.2 deaths per 100000 of population. From 1989 to 1998 the mortality rate for cervical cancer decreased within New Zealand by 27.5 percent. There may be many reasons for that—among them perhaps the introduction of the Cancer Registry Act of 1993 under the then National Government. The World Health Organization has the following to say about cervical screening: “Screening with adequate follow-up therapy can achieve major reductions in both incidence and mortality rates.” ACT New Zealand will therefore support this bill at its first reading but we have grave reservations about many of its provisions. I will go on to point those out.  
Much concern has been expressed recently about the quality of health screening programmes in New Zealand—cervical screening in particular. This bill addresses the political concerns but not the issues behind the failure of the current screening programme. The current programme was set up because of a need to be seen doing something about cervical cancer but international guidelines were ignored experts within New Zealand were not consulted and most important there was no adequate system of quality control. Those failings were brought to attention with the report from the Gisborne cervical-screening inquiry and the recent inquiry. The current bill is a response to the Gisborne inquiry but it risks creating another political response to a medical problem. Once again the desire to be seen to be doing something overtakes more practical considerations.  
The first point to make is that there is a moral hazard in having one organisation both provide and evaluate a service. Under the provisions of this bill the Ministry of Health could be charged with producing a New Zealand cervical cancer register running the register itself and being responsible for evaluating the process. There would appear to me to be a conflict of interest. It would be better to have a contract with an independent organisation to provide a screening programme and a separate contract with a separate organisation to audit the programme.  
I appreciate that the Government might find it unpalatable to deal with a profit-making organisation even if it were to provide an excellent service. We in ACT do not have that philosophical handicap and believe firmly that such a contract should go to those able to provide the best quality service for the best price. However there are organisations that this Government could well do business with—for example university departments with the relevant expertise. My point is that the Ministry of Health does have a conflict of interest. Human nature being what it is people have a high opinion of their own work. For a national screening programme to be successful that matter must be addressed.  
There is little doubt that the present screening programme has been inadequate. Quality control was of major concern in the Gisborne inquiry. One could well ask where was the quality control? Why was Dr Bottrill’s under-reporting not picked up earlier? He was after all participating in the national cervical-screening programme. Was the current screening programme working effectively anywhere in the country? I know from my own experience as a participant in the programme that it has been woefully inadequate. I recently received my recall notice—2 years late.  
Although this Government has released a series of statements describing action on the recommendations of the Gisborne inquiry it has ignored the criticisms made of the Ministry of Health by that inquiry. Many of those criticisms were very sharp. Let me quote: “During the first session of the committee’s public hearings it was advised that Professor David Skegg from the University of Otago was attempting to carry out a cancer audit of all the cases of cervical cancer from the Gisborne region. At that time Professor Skegg thought that was the best way to determine whether there had been an unacceptable level of under-reporting in the region. A cancer audit would also have revealed any errors in the reporting of other laboratories. However the cancer audit could not proceed as Professor Skegg was unable to gain access to the information he needed to carry out the audit.”  
The ministerial inquiry into the under-reporting of cervical-smear abnormalities in the Gisborne region concluded that an audit of cases of cervical cancer was the best way of measuring the effectiveness of a cervical-screening programme. In fact I would go so far as to say that there is no point in having a screening programme if the results cannot be evaluated. That would mean having all the cost with none of the benefit.  
However within the community there are widely ranging opinions about the process of audit—in particular with the issue of consent. In the 25 January 2002 edition of the New Zealand Medical Association journal Associate Professor Charlotte Paul of the University of Otago Medical School made the following comments: “It is disturbing to see now that the Government has ignored both the letter and the spirit of the advice of the Gisborne ministerial inquiry. Indeed it has made a decision which flies in the face of that advice—that ready access to medical files for audit must be permitted. The Cabinet decision released on 3 October 2001 now requires that consent must be sought from women with cervical cancer to assess their medical files for audit and the consent of their next of kin must be sought if they have died.” She goes on to say: “Cervical screening will now become the most difficult service to audit.”  
However the Federation of Women’s Health Councils has criticised the new bill for leaving the way open for auditors and evaluators to access hospital records without women’s consent. The bill addresses enrolment on the national register by having an opt-off policy as opposed to the current opt-on policy. That emphasis has wide-ranging implications for women’s rights. The legislation must ensure that each individual has the necessary information to allow her to participate in the programme or if she so wishes not participate.  
I hasten to add that there is reason to be cautiously optimistic about cancer of the cervix. The rate of new cancers has fallen during the last 10 years for which full figures are available. The rate has fallen by about one-third which is extremely encouraging and suggests that the current process of screening intervention may be producing results. The question we have to ask is will that process be aided or retarded by a national register run by the ministry? It is quite possible to leave individual doctors to take action on their own account and it would be better to do that than to have a poorly run national screening programme. A badly run programme would generate conflict and create uncertainty as to where responsibilities lie.  
ACT New Zealand supports the passage of this bill to the select committee stage but we will be pushing for independent audit and scientifically based evaluation. We remain unconvinced that the Ministry of Health is the appropriate organisation to run this programme. We also want to see a complete resolution of the issues regarding privacy. To embark without a clear understanding on privacy issues risks the creation of a programme that generates cost but cannot progress because nobody is allowed to talk to anyone else.