Phelan case: The days of doctor knows best are behind us

The case of Vicky Phelan, and subsequent news that more than 200 women diagnosed with cervical cancer should have received earlier interventions, have put a serious dent in public and ministerial confidence in the national cervical cancer screening programme.

There is now a strong argument that the promised external review of CervicalCheck be extended to all health-screening programmes. The National Screening Service oversees BreastCheck, BowelScreen, CervicalCheck and the diabetic-retinopathy screening programme, which tests for early signs of eye damage associated with diabetes mellitus.

Strangely, the National Screening Service came under the remit of the National Cancer Control Programme only relatively recently. It previously reported to a different section of the HSE. That the screening programme and the control programme were separate entities – a possible governance deficit – may have contributed to the events leading up to Ms Phelan's High Court case and the dramatic revelations about CervicalCheck's communication failures that followed it.

Loopholes

There is no question mark about the clinical excellence of individual programmes, but CervicalCheck’s former practice of not ensuring open disclosure for the women it invited for cancer screening means the public must be reassured that screening programmes for other diseases do not have similar loopholes.

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Modern healthcare must operate in an environment of full candour. The days of doctor knows best are firmly behind us. And previous thinking around ownership of medical notes has been replaced by a clear understanding that information about our health belongs, in the first instance, to each of us individually.

This means healthcare professionals informing patients, as soon as is practicable while in their care, of problems with test results, changes in diagnosis and any errors associated with their management.

The principle of open disclosure was introduced almost two decades ago and is now accepted as a global norm. In practice it means doctors, nurses and hospitals must inform a patient of any untoward event.

Most of these will not involve error but, rather, reflect the uncertain nature of healthcare and the known side effects of investigations and treatment. But patients must be informed promptly, as the adverse event is likely to influence a person’s future choice of treatment.

So for CervicalCheck not to have a robust policy in place to manage events such as a look-back at previous smear results was a significant failure of governance. Such a policy would clearly identify how to ensure the patient and her doctor would receive simultaneous notification from the screening programme of a potential error.

In order to limit any collateral damage to screening programmes for breast and bowel cancer, the promised review must examine their open-disclosure protocols as well. And although some observers have said a voluntary approach to open disclosure must be maintained, cold analysis suggests that particular horse has bolted.

Irish healthcare, despite numerous scandals and promises to improve, is systemically incapable of making this important cultural change. Unlike some of his predecessors, Minister for Health Simon Harris must not shy away from his commitment to enshrine open disclosure in law.