Philosophy of the Department63. It was clear that the Department favoured devolution of the cervical screening programme to AHBs. While the Department had held meetings to plan for a programme in 1986/87, by 1988 and after, it had moved away from the nationally organised aspects of a programme. I believe the reasons for this were:
63.1 An ideology of devolution that was widely held in the Department of Health at that time.
63.2 Unhappiness that the decision for the programme had come from the Minister of Health, following the Cartwright Inquiry, rather than emerging from the normal process of departmental recommendation and development.
63.3 Apprehension about successfully implementing such a programme, which was a first for New Zealand, especially within the unrealistic time-frames that had been set.
64. The philosophy of the Department showed through in many aspects of our work and a number of these are detailed in other parts of this brief. Here I want to draw attention to some particular documents which illustrate the philosophy of devolution within the Department hierarchy and the fact that this persisted over the period of our work. One of the ways this was expressed was in resistance to signing the register contract.
65. On 23 May 1990 an Expert Group member, Ruth Bonita, sent a memo to me and Betsy Marshall outlining a conversation she had had that morning with Sandra Davies. This is produced at SC/4/0230. Sandra Davies had wished to canvas with selected members of the Expert Group, (Ruth Bonita, Sandra Coney, Betsy Marshall and Peggy Koopman-Boyden) the overall direction of the programme. The contract for the hardware for the register was about to be signed and Mrs Davies wanted to explore some options and ensure that the Expert Group was satisfied with the direction in which the programme was going. The option she presented was to move towards a regionally run cervical screening programme. Sandra Davies reported that she and possibly Dr Salmond felt the programme was enjoying privileges not accorded to other services and that decisions were being made nationally that were usually being made by AHBs. She suggested putting the contract for the register hardware on hold until the end of June to ensure that it not become a 'monster' that will 'run us'. She suggested devolving funding to AHBs so that they could establish their own registers. This would provide more flexibility. The Department would set guidelines for minimum standards and performance indicators.
66. In July, as a result of our concern about the lack of commitment within the Department to a national programme, I was asked by the Expert Group to write a brief paper on 'The case for a National Cervical Screening Programme'. This was presented to the Expert Group in May and is produced at SC/3/0110. The paper set out the requirements of a successful programme and the disadvantages of a regionalised system. It reported the very small reduction in death rates achieved in Denmark with a regionalised system and the failure of the British system due to a lack of central organisation. While it might seem strange that such a defence of a national programme was necessary at this stage, it reflected the degree of uncertainty among the Expert Group resulting from the lack of commitment within the Department.
67. It was because of the position of the Department that I was asked at the meeting of 1 August 1990 to provide a 'stronger argument for a national cervical screening programme' in the Expert Group Policy for the programme that I was co-writing with Robin McKinlay.
68. During July, while working on the policy for the programme, I became very aware of the climate in the Department in favour of devolving the national programme. This view on devolution was not shared by members of the NCSP Implementation Unit. In a memo to members of the Expert Group on 27 July 1990, which I produce at SC/4/0237, I discussed the climate in the Department.
'In the course of working on the policy we have spent several weeks in at the Health Department. I am extremely disturbed at attitudes held at a high level in the department to the programme and therefore the fate of the policy.
There are considerable reservations being expressed about the need for a centralised system with a centrally monitored register. The idea of scrapping the register and devolving responsibility for screening to boards is still strongly supported in some quarters.'
69. I recommended that the Expert Group seek affirmation of the government's commitment to a national programme. I noted that there was 'a considerable feeling of futility amongst members of the NCSP staff'.
70. On 2 August 1990 Peggy Koopman-Boyden wrote a letter to Helen Clark seeking reassurance about the government's commitment to the NCSP. She also raised the continuing communication difficulties with the Department of Health. The writing of this letter had being agreed to at the meeting of the Expert Group on 1 August 1990. This letter is produced at SC/3/0134.
'The Expert Group has recently become aware that reservations are being expressed within the Department of Health about the need for a nationally co-ordinated cervical screening programme. The stance being taken by the department appears to be the complete devolution of responsibility for cervical screening to all AHBs while discontinuing the centralised national computer register. The Expert Group strongly believes that the National Cervical Screening Programme should proceed along the lines recommended in the Report of the Ministerial Review Committee on Implementation of a National Cervical Screening Programme November 1989. A policy statement supporting this view will be sent to you within three weeks.'
71. As a result of this letter Heather Simpson from the Minister of Health's office attended the next meeting of the Expert Group held on 30 September 1990. She confirmed the government's support for a nationally co-ordinated cervical screening programme.
72. At the same meeting it was agreed to ask Dr Salmond to the Expert Group's next meeting to find out his position on the introduction of a national programme. At the meeting of 1 November 1990 the chair reported that he had declined the invitation as there was no new development to report to the Expert Group.
73. I summarised the situation of the Expert Group in a report to the Auckland Women's Health Council dated 25 August 1990 which is produced at SC/4/0243. I had been nominated by the AWHC to be the consumer representative on the Expert Group and regularly reported back the progress that was being made. In this report I said
'One problem for the programme is the lack of universal commitment to a national screening programme. Although the NCSP unit is working towards this goal and Helen Clark has said she is committed to it, there are some senior executives in the HD who would prefer to see the programme totally devolved to boards with no national register. The EG does not believe this would work as no country in the world has succeeded to reduce its cervical cancer death rate by carrying out screening in this way.
This conflict in goals means that the programme is being pushed in two directions simultaneously. It also means the lines of communication and responsibility are very difficult.'
74. In October I made comments on the report made by Judith Straton for the Expert Group. I understand the Straton Report has already been produced by the Ministry of Health, but I produce my comments on it at SC/4/0233. While I agreed with much of the report, I had some disagreement with her analysis on pages 55-61 about the relationship between the Expert Group and the Department of Health. In my comments, I outlined the difficulties we had experienced and said there had been a deliberate tactic of keeping apart the people in the NCSP Implementation Unit and the Expert Group, so that there was suspicion and ignorance about each other. I noted that in terms of the NCSP Unit and the Expert Group these problems had been largely resolved. But the problems with the hierarchy of the Department might well remain. These comments were endorsed by the Expert Group at its meeting of 1 November 1990.
75. While I was working on the policy with Robin McKinlay, we became aware that the plans for the register had resulted in limitations in what the register could do. It was unable to carry out some of the functions that were considered necessary for a management tool for a national programme.
76. I drew up a table showing what the register should do, whether the New Zealand register could fulfil this function, and suggested remedies. (This table is produced at SC/4/0242.) I planned to present this to the Expert Group meeting of 1 August 1990. Sandra Davies became aware of this work and asked for a meeting with me, Robin and Gill Grew. The table was shown to her and she took a copy. Mrs Davies later told me she had reworked this material to show to the Director-General of Health. My table was redrawn by Mrs Davies and presented in a report to Dr Salmond, on 24 July 1990. This memo was privately given to me by departmental staff member and is produced at SC/5/0325. Mrs Davies' version of my table is produced at SC/5/0330. I was furious to discover the use to which Mrs Davies had put my work.
77. The purpose of her report was to identify 'deficiencies in the register'. She presented three options; the first was to proceed as planned; the second was to delay signing and installing the computer hardware until the results of the pilots were in.
78. The third was to 'abandon programme in current form and reconstitute eg. Maintain policy promulgation and service statement preparation at Head Office and devolve operational responsibility and financial resources to AHBs, instigate massive education programme aimed at women and general practitioners. Survey/research results (above) could / would justify change in policy).'
79. She recommended delaying the signing of the contract while a pilot was run in an urban area to see whether the register was so limited that this would provide 'sufficient reasons not to proceed with the proposed nation-wide implementation'.
80. The Department continued to try to delay the signing of the register contract. One of the successes of the Expert Group was to finally achieve this on the evening before the General Election. In the minutes of 1 November 1990 Peggy Koopman-Boyden thanked the NCSP Implementation staff for their assistance in the previous month in arguing the case for signing the register contract.
81. The change in government provided an opportunity for the Department to attempt to gain a change in direction in the programme. However the Expert Group moved speedily to enlist the support of the incoming Minister of Health for the programme.
82. Peggy Koopman-Boyden wrote to the new Minister of Health, Simon Upton, and the Associate-Minister, Katherine O'Regan. She worked through the letter with Dr George Salmond. In a letter to me dated 25 November 1990, Peggy Koopman-Boyden stated that we needed 'to keep the pressure on him [Dr Salmond], he is still quivering'. This letter is produced SC/4/0247.
83. Robin McKinlay told the Expert Group that at a meeting of the Ministry of Women's Affairs, Katherine O'Regan had stated a commitment to a national policy, but had voiced doubtful questions about the register. It was agreed that Peggy Koopman-Boyden, Ruth Bonita and Clint Teague would meet with Katherine O'Regan to brief her about the programme. A Maori group and a Pacific group would also arrange to meet her. Strategies for doing this were discussed at the Expert Group meeting of 4 December 1990 which is produced at SC/4/0176..
84. On 13 December 1990 Ruth Bonita, Clint Teague and Peggy Koopman-Boyden met with Katherine O'Regan, and the following day Peggy Koopman-Boyden met with the her along with the Dr George Salmond and Ian Johns, Policy Manager.
85. In a memo to Ruth Bonita dated 18 December 1990, which I produce at SC/4/0248, Peggy Koopman-Boyden reported on the meeting. She described the meeting as a great success in that the Minister 'quite clearly instructed the Department' that national co-ordination with a system of national register, national co-ordinator, national evaluation and a nation-wide education programme were to be government policy. Peggy wrote: 'It was as though the long fought battle was over'.
86. The Expert Group was disbanded by Katherine O'Regan and replaced by a technical advisory group as advised by the Department. I was not a member of this group. I understand evidence about this group will be given by Dr Brian Cox and Betsy Marshall.
87. Women's Health Action stayed vitally interested in the NCSP and I was a member of the Auckland AHB Cervical Screening Advisory Committee until 1995. The problem of a lack of commitment to a nationally organised programme did not disappear. It continued to be illustrated in the failure to adequately resource the programme, the lack of expertise provided within the Implementation Unit (specifically epidemiological and medical), and the periodic attempts to restructure the programme. The review of accountabilities in 1996 is an example of the persistence of the ideology of devolution.