A well-researched investigation and subsequent report will always raise as many questions as answers. This is true of Dr Gabriel Scally’s scoping report into the CervicalCheck controversy, published this week.
Among the answers provided by the report is a clear outline of how cancer screening, based on human examination of slides of cervical cells, is a less than robust process. Of 1,000 women screened using Pap smears, 20 will have pre-cancerous changes. However, only 15 of these 20 will ever be picked up by a national screening programme. Regardless of the quality of cytologists looking down microscopes and the perfection of smear takers, this is as good as it gets. Some five out of 20 pre-cancerous smears will be labelled normal when they are not, representing a relatively high rate of false negative tests.
This significant reality of cervical cancer screening was quickly lost in the political and media furore that arose following the Vicky Phelan case.
Scally's message is clear: CervicalCheck must continue, but with significant restructuring
The organisational mess that is CervicalCheck is also clearly laid bare by Scally. He concluded there were many indications that the system in place “was doomed to fail at some point”.
He found a demonstrable deficit of clear governance and reporting lines between CervicalCheck, the National Screening Service and the higher management structures of the Health Service Executive. And he could have added to that the Department of Health, which did not set up clear parameters for a quality service in the first place.
This is why an audit cycle, a fundamental requirement, was not included in the programme from the outset but was “tacked on” at a later date. This semi-detached approach led to the subsequent communication failures that have so infuriated women.
“This major crisis emerged into the public domain because of a failed attempt to disclose the results of a retrospective audit to a large group of women who had, unfortunately, developed cervical cancer,” Scally noted.
Benefit and harm
Scally also pointed out that, “Screening services are sometimes finely balanced in terms of benefit and harm and can act as an early-warning sign of wider systemic problems [in the health system].”
Many of these wider systemic problems are well-known: understaffing; not enough hospital beds; a failure to support and develop general practice; a deeply dysfunctional culture in the HSE; and for the public, a curate’s egg of a health system that, at best, partly functions but with no guarantee of consistency.
Ongoing emigration of young medical and nursing staff is a telling sign of how poorly the health service functions: their career decisions are more about how unsupported they feel in a system whose reflex reaction to problems is to hang them out to dry than they are to do with personal financial gain.
Bad as the systemic issues are, Scally’s description of how women were informed of the audit results is horrific. Paternalistic, misogynistic comments when doctors are breaking bad news are utterly unacceptable. It means there are questions to answer about the quality and quantity of communication skills training at undergraduate and postgraduate level.
Among the communication questions to emerge from the handling of the CervicalCheck controversy are: were the consultants tasked with breaking the news about the audit result provided with a standard form of words to ensure a consistent and sensitive experience for the women affected? We know it took five hours for Dr Scally to explain his findings to three people on Tuesday – were consultants given sufficient protected time away from their regular duties to ensure these difficult conversations could take place in an empathetic manner?
‘Contradictory and unsatisfactory’
The report describes the current policy and practice in relation to open disclosure as “deeply contradictory and unsatisfactory”.
But again we must ask why was this allowed to develop. Open disclosure is accepted as a sine qua non internationally. So why the last-minute decision by politicians to withdraw a section making duty of candour compulsory from patient safety legislation here?
We live in an era where patients rightly feel they should have full ownership of all personal medical data. To have it held back from them, as was the case in the CervicalCheck audit, makes people angry and understandably causes them to question their trust in the health system. The Medical Council has signalled its intention to strengthen the ethical guide for medical practitioners in the area of promoting and practising open disclosure.
The data issue points to another deficit in our health services. Why aren’t patients front and centre at all levels of the health system? Lay people must be appointed to local, regional and national bodies as a matter of course and not as a gratuitous afterthought.
It is reassuring when Scally says the laboratories used for the reading of smears are satisfactory. “They are meeting regulatory requirements in their own country,” he notes. But do we not need laboratories that meet standards and classification laid down by CervicalCheck that are specific to Ireland, even if the labs are not located here?
There are a number of other findings in the report that should ring alarm bells. As a screening programme matures, there is an expectation that the percentage of late-stage cancers detected in those screened will decline. This has not happened with CervicalCheck: in Scally’s view this “should have instigated questions as to why a significant stage shift towards earlier-stage cancers being diagnosed in the screening age group was not being observed”.
And he also raised concerns that significant numbers of women in the screening age group were still being diagnosed with cervical cancer who appear not to have been screened. This raises the question: were there inequalities in the coverage and uptake of cervical screening in Ireland?
Dr Scally has produced an excellent report in difficult circumstances. His sensitivity to the women affected stands out. His message is clear: CervicalCheck must continue, but with significant restructuring. Uncertainties surrounding the current method of cervical screening, which is not a diagnostic test, are unavoidable.
Meanwhile, the fundamental reasons behind systemic deficits across the wider health system remain.
Dr Muiris Houston is The Irish Times health analyst