breastscreen aotearoa an independent review - Ministry of Health

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Gisborne Recommendation 11.33. The need for a population register is emphasisedvery strongly and is recognised by the providers of BSA screening as much as by theIMG and the NSU.Gisborne Recommendation 11.37. Liaison with the Royal Australasian MedicalColleges. Within BSA the link with the RACR is strong, all participating radiologistshaving to pass its requirements for mammography reading. Liaison with the RACSand the RACP could be stronger. Many of the Lead Provider staff have spent sometime in the Australian Breast Screening Programme, the UK Breast screeningProgramme, or both.Gisborne Recommendation 11.38. The information provided to women registering inBSA is honest about the strengths and weaknesses of breast screening, and isreinforced by the MRTs and other staff they meet.Gisborne Recommendation 11.45. A sample of users of BSA is questioned abouttheir views as part of the 2-yearly audit of each Lead Provider.15. CONCLUSIONS15.1 There are a number of factors in New Zealand that militate against theorganisation and administration of efficient public health screening programmes.Some of these are in the population as a whole, like the wide cultural differencesbetween Maori and Pakeha perceptions of health services, the excessive concernabout privacy in the public at large, and the level of media interest in women'sscreening which emphasises the failures and ignores the achievements. Others arestructural within the health care system, such as the mix of public and private care, thelack of a single national health register, and repeated re-organisations of the HealthAuthorities and Ministry of Health.15.2 The way in which Breast Screen Aotearoa was planned and introduced reflectssome of these constraints, but it is to its credit, and particularly that of the NSU (andbefore it the HFA), that it has developed into a coherent service across the wholecountry. The screening process itself is organised in a well controlled way, consistentacross all Lead Providers, that is likely to maximise the benefit and minimise theharm.15.3 Its major constraint remains its apparent difficulty in recruiting a high proportionof eligible women, compounded by the fact that the exact proportion remainsunknown due to the lack of a population register. The development of a populationregister for health purposes, to include a cumulative record of each woman's screeninghistory, is essential.15.4 The training of Medical Radiation Technicians is adequate, and that ofradiologists working in BSA is excellent, thanks to the accreditation process of theRoyal Australasian College of Radiologists, and the Quality Standard that insists thatBSA radiologists read a minimum of 2000 screening mammograms each year. Thesystem of cranio-caudal as well as lateral oblique mammographic views being takenat every screen, coupled with the independent double reading of every screening film,ensures a high standard of radiological performance and guards against the danger of38
a radiologist working in isolation. Although the system of internal quality control ofradiological performance could be made more transparent, particularly with regard tosub-contracted units in some Lead Providers, there is no evidence that it is inadequate.The Lead Providers' computerised record systems have built in mechanisms forguarding against mistakes, and in particular the direct entry of results by radiologistsprevents the sort of clerical errors that occurred in the early stages of BSHC, and morerecently in the UK. In these respects the Lead Providers are at least as good as thelonger standing programmes with which I am familiar in northern Europe.15.5 The current incompleteness of information on final pathology and treatment ofwomen with breast cancer diagnosed by BSA prevents an assessment of how wellBSA is doing in moving towards its goal of reducing breast cancer mortality. Thisresults from a weakness in the arrangements for following the treatment pathway ofwomen with breast cancer. This could and should be resolved by the Surgeons andPathologists in each Lead Provider taking responsibility for finding out details ofthese women's diagnosis and treatment. In most Lead Providers this work is beingdone, on a voluntary basis, by the Breast Care Nurses in addition to their nursing rolewhich they perform with skill and dedication.15.6 The Independent Monitoring Group has set up an extremely comprehensivesystem for routine monitoring and is designed to give early warning of any falling-offof performance. It is vital to the maintenance of a high quality screening programmebut is expensive in time and resources, and could be made both more efficient andmore acceptable to Lead Providers by some minor changes. The National ScreeningUnit works with Lead Providers to remedy any problems highlighted by the work ofthe IMG.The routine monitoring coupled with 2-yearly audits of each Lead Provider makes thepossibility of a sustained failure, such as occurred at Gisborne, extremely remote. But,as in any human system, these measures cannot entirely guarantee that adverseincidents will not occur; they should however ensure that any failure is rapidlyrecognised and corrected.15.7 There needs to be more communication between the numerous professionalpeople in the Lead Providers, and between the Lead Providers, the IndependentMonitoring Group, and the National Screening Unit.15.8 The National Screening Unit needs a period of stability without any morereorganisations, Inquiries or Reviews!15.9 Most of the recommendations of the Gisborne Inquiry Report which apply inmodified form to BSA have already been implemented. But the role of EthicsCommittees in monitoring and auditing public health services still needs to beclarified.15.10 The adverse effects on women screened are within acceptable limits, and arecarefully monitored, but the most worrying disadvantage of BSA in my view is itscost to the health service. Although economic aspects were not included in thisreview, BSA appears to be very expensive in its use of health service resources, notleast because of the numerous safeguards to ensure its excellence. The number of39
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 and 12: 5. POPULATION COVERAGE5.1 Estimates
Page 13 and 14: 5.3.4 Routine Rescreens. The second
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: 14. RELEVANCE OF THE GISBORNE INQUI

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