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in their area, are also potentially a very useful means of aiding recruitment. TheLead Provider, (BSS), with the greatest success in recruitment, reaching 76% of itsestimated population by November 2001, has a contract with a very large IPA whichcovers a high proportion of its GPs, and the Lead Provider itself employs a worker tovisit and recruit the remaining GPs in its catchment area. Each GP's list of eligiblewomen is sent to the Lead Provider. Letters of invitation to each woman, togetherwith a provisional appointment date, are sent out from the Screening Centreaccompanied by a supporting letter from the GP.One might wonder why the same system of recruitment by GPs is not more widelyused by the Lead Providers with lower recruitment rates, and the NSU has recentlystarted a project to examine this in more detail. But it is clear that there aredifferences in the organisation of primary care across the country, as well as in GPs'perceptions of the programme, which may act as barriers. For example, not all GPshave age-sex registers or have contracts with IPAs. There is one large IPA inAuckland which actively promotes breast screening outside the BSA parameters, byrecommending clinical examination and reduced price private mammographyroutinely for all women over the age of 40 on its GP’s lists. This has led some GPs toinsist that they will only refer a woman to BSA after they have clinically examinedher (for which she must pay).Although the Quality Standards require each Lead Provider to have an identifiablestaff member who contacts each GP or Primary Care Provider at least once every sixmonths, this contact is not necessarily face-to-face but could be merely a newsletter.There is also a requirement to inform the GP about the result of every screen, so thatover time GP awareness of the programme is bound to increase. It is clear that thereis a need for more education of general practitioners and IPA’s about the evidence onwhich BSA is based, including the age groups in which trials have shown thatmortality can be reduced by screening, and the relative sensitivities of mammographyand clinical examination in detecting early cancers. One possible means of increasingGPs knowledge of breast screening could be the use of health promotion staff, whoare already well-informed about all the relevant issues, to extend their role fromeducating the public to educating primary care staff at all levels. However educationsessions for primary care staff are a feature of BSC, but this Lead Provider had onlyachieved 57% coverage by November 2001Contracts between the NSU and the Lead Providers include a fee, specifically forrecruitment, of $8 for each woman screened for the first time and $5 for each routinerepeat. But there is no check on whether these fees are actually used for recruitment.The system of payment of GPS in New Zealand, depending as it does largely onprivate fees, means that GPs require adequate financial recompense for all they do,including administrative matters such as compiling age-sex registers and identifyingeligible women. I got the impression that BSS, which has achieved the highestcoverage has spent considerably more money on recruitment through its GPs than anyother Provider, but I learned of no estimate of the true cost involved. In other areas afew GPs have demanded payments which at least superficially seemed excessive inrelation to the cost of their staff time in recruiting women. Support of GP’s for BSA isvery important, and it is essential that they understand their role and receiveappropriate compensation for it.12
5.3.4 Routine Rescreens. The second Lead Provider to reach the 70% target, BSHC,is one of those which took part in the pilot study when 75% coverage resulted from acombined approach using both general practitioners and the Electoral Roll (discussedfurther below) to recruit women. This Lead Provider's catchment population did notincrease between the pilot phase and the start of BSA, with the result that its screeningactivity now comprises mainly routine rescreens, except for the youngest age-group.Invitations for rescreening are sent directly to women, and coverage is steady ataround 72%.5.4 Development of a national age-sex register for health purposes. The successof BSS, in reaching nearly 80% coverage, confirms a wealth of evidence thatindividual invitation, combined with a provisional appointment, and a letter of supportfrom a known health worker, is more successful than even the very best package ofhealth promotion, (which aims to educate not to recruit). But invitation implies thatan accurate register, containing each woman’s name, date of birth, and current addressmust be available. Clearly GPs’ age-sex registers are a good model but, within thepresent primary care system in New Zealand, are not ideal for the BSA programme asa whole for a number of reasons. They are not universally available. Taken as a wholethey may contain duplicates because a woman may consult as many differentpractices as she chooses and thus appear on more than one register. When a womanleaves a practice, for example when she moves to a different part of the country, herrecord does not go with her. And. many different computer systems may be used byGPs and IPAs to store their registers.One single national computerised age-sex register would provide the answer. It wouldbe of benefit to the whole population for many different public health services,ensuring equal access for all. It would also enable eligible groups to be invited toparticipate in programmes such as immunisation or screening, which is particularlyimportant among those who might not otherwise be aware of their entitlement. Asfar as BSA and cervical screening are concerned it would have many advantages.Firstly it would provide a means of individually inviting every eligible woman whenher screen was due. Secondly the date of each invitation and, for those who accepted,date of screening and summarised information of the outcome in terms of routinerecall, referral for assessment, diagnosis of breast cancer, or other reason for exitingthe programme, could be added, thus building a national database of every eligiblewoman’s screening history. For women who moved to a new area this would give hernew Lead Provider the date on which she was next due to be invited, as well asproviding information on the true population coverage of BSA. Thirdly, someknowledge of reasons why women did not wish to participate (e.g. because they werehaving private mammography, or because they were already being followed up afteran earlier diagnosis of breast cancer) could be investigated. Fourthly, it would assistthe Lead Providers in scheduling their screening sessions, which would be ofparticular value for their mobile units which at present often have to guess at thenumber of “new” women who may attend either by dropping in or by calling theFreephone number.5.5 There are a number of different possibilities for compiling such a nationalpopulation register.13
Page 1 and 2: BREASTSCREEN AOTEAROAAN INDEPENDENT
Page 3 and 4: I SUMMARYSUMMARY AND RECOMMENDATION
Page 5 and 6: Independent Monitoring Group10. The
Page 7 and 8: patient when she might not otherwis
Page 9 and 10: Waikato area and the Bay of Plenty,
Page 11: 5. POPULATION COVERAGE5.1 Estimates
Page 15 and 16: Although the register is held withi
Page 17 and 18: of enabling women to reach the scre
Page 19: testing system set up by the Royal
Page 22 and 23: again all Lead Providers have has m
Page 24 and 25: eferral to a surgeon can only be do
Page 26 and 27: 7.6.2 Recommendation The Lead Patho
Page 28 and 29: in any case calculated routinely by
Page 30 and 31: BSA. (A minor easily correctable fa
Page 32: 10. INFORMATION SYSTEMS IN BSA10.6.
Page 37 and 38: 14. RELEVANCE OF THE GISBORNE INQUI
Page 39 and 40: a radiologist working in isolation.

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