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 1                        WEDNESDAY 12 APRIL 2000
 2                    THE HEARING RESUMED AT 9.00 A.M.
 3
 4              DR GEORGE ROBERT BOYD                  (On Former oath)
 5
 6   PROFESSOR DUGGAN [resumes questioning]:
 7   If we could continue from yesterday, the query I put to you was with regard
 8   to the enrolment of the witnesses in the screening programme. And I asked
 9   you if you could comment on those within the context of the 1991 policy for
10   the National Cervical Screening as detailed in volume 5 of Judy Glackin‟s
11   exhibits, no.15, p2. ..... Yes, in the standards for routine cervical smear,
12   women should have a second smear within one year if they have never had a
13   smear before or if more than 5 years have passed since their last smear. I
14   understand that is still the guidelines today. However, in one of the cases, I
15   think we were expecting that the women would have had a second smear
16   within one year of enrolling, even though the laboratory had records that she
17   had had a normal smear within the 5 years before then, and so it is the
18   laboratory which selects the recall time, not the cervical screening register,
19   computer or staff. So if that was the recommendation of the pathologist, I
20   believe that would be the advice that would go out from the pathologist
21   Is that indicated in the document that the smears registered in a laboratory
22   prior to the National Screening Programme establishment would be taken
23   into account in terms of enrolling the women ..... I don't believe it says that,
24   but the way I looked at another pamphlet dated 1999, again it set it out in a
25   diagrammatic form, referring to no previous smears on enrolment. You
26   always have a second smear within one year. If there have been the smears
27   within the 5 years, and I think it says normal, then it would be the routine
28   recall period.
29   CHAIR: Dr Boyd can you identify that document for the Committee.
30   MS SHOLTENS:         Judy Glackin‟s exhibit 50 there is a leaflet inside that
31   booklet with the diagram.
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 1   PROFESSOR DUGGAN:              if I could refer to witness no. 6, who is the
 2   youngest witness ..... yes.
 3   Do you have it ..... yes, I will look for that. Could I make a statement ma'am
 4   before we come to talk about individual women and their evidence, because
 5   you did ask me to read all the evidence, some of which I hadn‟t seen before,
 6   that the inquiry had about the individual women and their cases. And I have
 7   some misgivings about talking about individual women and their care
 8   without knowing whether they are in the room and knowing this is an open
 9   forum. Can I ask that I be allowed to reply to each question as it comes
10   along?
11   CHAIR: perhaps if you just answer the questions for the moment. If there
12   is any matter your counsel can raise it in re-examination. ..... I may not be
13   prepared to give my clinical opinion on someone‟s care when I have only
14   seen part of the document relating to their care, and if they're not here, it is
15   not fair on them.
16   CHAIR:       questions of fairness are for the committee to decide. Each
17   question will be asked and if there is a difficulty with answering it we can
18   deal with it at that time.
19   MR CORKILL:            we have some concerns also that possibly the women
20   whose cases are being discussed are not here. We would ask that this part of
21   the evidence be regarded as being in private at this stage, for the purposes of
22   reporting, and that could be reviewed at the end of the process.
23   CHAIR:      would you like me to clear the room or are you happy for the
24   evidence to be given with persons in the back?
25   MR CORKILL: if it could be a suppression order at this stage until it can
26   be reviewed at the end of this part of the evidence.
27   MR HINDLE:          that seems a reasonable course of action otherwise the
28   debate will be stilted and unproductive.
29   MS SHOLTENS: I would just like Dr Boyd to feel free to raise concerns at
30   the particular time.
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 1   CHAIR: any concerns you have about the women not being here or hearing
 2   it from second hand sources should be met. I make an order that the
 3   answers Dr Boyd gives to the committee‟s questions are not to be published.
 4   MR HINDLE: the questions themselves should be part of that suppression
 5   order as well – all the evidence until further notice.
 6   CHAIR: all evidence, until further notice, is not to be published.
 7   PROFESSOR DUGGAN: my questions are in regard to process. So if we
 8   take witness no. 6 as an example, she had a smear in 1991, the registry
 9   printout does not have any record of that smear. She had another smear -
10   ..... you said witness no?
11   6 ..... who you also said was the youngest. My witness 6 was not the
12   youngest.
13   CHAIR:      as this evidence is not being published we will refer to the
14   witnesses by name – it is witness 8. ..... sorry, it is down as witness 8 in
15   mine. Yes, 1991 a smear taken as normal, read here in Gisborne, re-read as
16   high grade, yes.
17   PROFESSOR DUGGAN: she has the printout of her registry file ..... yes,
18   which has 93 and 98 on it
19   My question to you is, 91 and 92 the screening programme was established
20   and I understand there was an opt on programme ..... March 91 would have
21   been opt on if it was running in Gisborne at that time, and I think it was.
22   So this is a young woman who had 2 smears and they are not registered. Do
23   you have any comment why they are not ..... yes, this was to be in my
24   general comments I was prepared to make about the histories given in this
25   room, that the 91 was, as you say, an opt on and quite probably there was no
26   reason for that to have got to the register. 1992 again was in the opt on
27   period, but this was a hospital admission, not for gynaecological purposes,
28   and we haven't got the hospital records that went with it. I would have to
29   ask whether the hospitals now have an appropriate process for using the
30   same system for their general examinations of patients when they are being
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 1   clerked into the hospital as you would use in the cervical screening
 2   programme in the community. I suspect here somebody had a smear while
 3   having an internal examination while being admitted for a non
 4   gynaecological purpose, and my suspicion is that that information was kept
 5   within the hospital records. What would need explaining to me is why the
 6   patient did not hear that they were expected to have a repeat smear 6 months
 7   later. The hospital system appears to have been unsatisfactory.
 8   Were the smear-takers in the hospitals not governed by the same rules of
 9   conduct as smear-takers in the community ..... I'm not sure how it is today. I
10   would say at that time house surgeons were probably instructed by their
11   seniors, or they learnt at medical school that a full examination for someone
12   coming into the hospital would include a cervical smear routinely and that
13   had been done for a long time as part of the hospital procedures.          And I
14   think the systems here appear at the outside to be quite inadequate.
15   Because in 91 and 92 there was an opt on option, so if somebody had
16   discussed these smears with this woman she would have had a chance to opt
17   on at that point ..... she would have had the option – we don't know whether
18   she did or not get offered the option. I'm highly suspicious she wouldn't
19   have been because this would have been seen as just part of the medical pre-
20   examination when coming into the ward. I don't defend it but I suspect that
21   was the case.
22   If I can take the time to walk you through her chronology of smears. If you
23   can go to p7 of her evidence. ..... yes.
24   In 1991 she had a smear interpreted in Dr Bottrill‟s laboratory. ..... yes.
25   Not registered ..... not as part of the programme, correct
26   In 92 she had a smear in Gisborne Hospital, not registered ..... not registered
27   And the Gisborne Hospital would not be aware that she had a smear in
28   Bottrill‟s laboratory ..... unless that had been part of the routine clerking of a
29   patient into the ward: “have you had a smear recently, what was the result”.
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 1   Would that be likely ..... 50/50 probably. It does depend, I suppose, how
 2   thorough the house surgeon, the junior doctor clerking her into the ward had
 3   been.
 4   It would be in her medical chart ..... if that question had been asked you
 5   would expect to see it in the medical chart.
 6   In 1993 she had another smear in Gisborne Hospital. ..... she had a smear
 7   reported at Gisborne Hospital. It was a postnatal.
 8   This was the first smear that was registered ..... yes
 9   If you are saying that the smears prior to registration in the same laboratory
10   in which the previous smear that was unregistered was read was factored
11   into her enrolment criteria, she was not enrolled properly because the smear
12   in 92 was not within normal limits, it was an inflammatory smear ..... true,
13   but the smear in the – yes, you are quite right.
14   My other concern about the 1993 smear is this is an unsatisfactory smear.
15   The management recommendation at that time, according to your
16   documents, which again is volume 5, 22, p12. On p12 on the left hand
17   column are unsatisfactory smears ..... yes
18   And as you go to the right column it says “the laboratory will describe the
19   reason for the unsatisfactory sample, another smear should be performed at
20   mid cycle within the next 3 months” ..... right. And somewhere I've noted
21   that the report from Gisborne Hospital laboratory said “repeat when
22   convenient”, which is within the coding – whether it‟s the appropriate
23   coding to use for here you are a better judge than me. It is wording usable
24   from the Bethesda coding.
25   If you were the clinician receiving the report when would be a convenient
26   time to repeat the smear ..... yes, to me that would be as soon as convenient,
27   but convenient could mean different things to different people
28   Is 5 years later convenient ..... absolutely not.
29   But that‟s exactly what happened ..... yes, and I noted that as to who actually
30   got that report, because we don't truly know who the other smear-taker was
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 1   and who that report would have been sent to. We assume that is in the
 2   programme data, but we in the Ministry aren't able to access data from the
 3   computer without the woman‟s permission. So that is a note I made that that
 4   needs following up: who did that report go to, why wasn‟t it actioned, and
 5   why in fact wasn‟t there a system to pick up that nothing had happened.
 6   In 1993, did the National Screening Programme have a recall letter system
 7   in place ..... if I could look to others to answer the point, I can't tell you
 8   exactly what there was at that time
 9   By that I mean women with abnormal smears who were scheduled to return
10   for a repeat smear or go elsewhere for further assessment did not attend for
11   those appointments or were overdue, a recall letter will be sent to the
12   general practitioner ..... my understanding is that that system was built in
13   right at the beginning, that‟s what the programme is for
14   Did that system include women with unsatisfactory smears ..... I can't be as
15   specific, and I'm not sure how to get that answer for you immediately
16   because I can't answer at what point it cut in.
17   Again, as a clinician, would you have expected the programme to send you a
18   recall or reminder letter on unsatisfactory smears from women ..... when
19   there was a recommendation to do something, yes I would expect to have
20   received a reminder if I hadn‟t actioned it.          And in this case my
21   understanding is it is a recommendation to do something, that the
22   programme should have been waiting to see the next smear and cancel out
23   the advisory letter.
24   So, a prompt should have been sent ..... I would have expected so.
25   And the prompt not only goes to the primary care provider but also to the
26   women ..... it goes to the primary care provider first and normally it‟s the
27   role of the local co-ordinator to cut in at that point and try and chase up the
28   provider before then contacting the woman
29   As a clinician, when you receive a report from a laboratory that says
30   “unsatisfactory smear”, how do you interpret that report viz a viz the state of
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 1   health of the cervix ..... I interpret it that there‟s some uncertainty and I then
 2   interpret that the next thing to do is make sure that a smear that can be read
 3   clearly is made available to the laboratory.
 4   In some laboratories when the adequacy of the specimen. is interpreted as
 5   unsatisfactory a diagnostic category of a diagnosis is not possible is
 6   rendered which doesn't ..... in some laboratories, I'm sure that happened.
 7   Whether it does in New Zealand laboratories I would have gone on to say I
 8   don't know.
 9   This approach doesn't allow for any equivocation with regard to the final
10   diagnosis ..... correct.
11   Because another disturbing element in this particular witness‟s history is a
12   letter in her exhibit from Dr Jones to Dr Kitchen ..... I have the letter.
13   The last line in the first paragraph says “she subsequently had normal
14   smears in 93 and 98”. The smear in 93 was unsatisfactory ..... yes, I agree.
15   So my concern is about the interpretation of unsatisfactory smears as normal
16   ..... yes, I would agree.
17   I'm glad you have clarified the enrolment criteria on the registry for me
18   because out of the 8 women who gave evidence, 4 of them did actually have
19   their registry printout as part of their exhibits, and if none of these women
20   prior to 91 had had a PAP smear they would all have been unsatisfactorily
21   enrolled – that is they wouldn't have met the enrolment criteria ..... yes, if
22   they hadn‟t had, and in some cases there is evidence that the women had had
23   smears.
24   Witness no. 4: if you can go to the last page of her evidence ..... which is
25   the summary of slides.
26   Yes, p13. The first smear registered was in 1992 ..... that‟s what we learnt
27   yesterday.
28   So with this new information you gave me, because she had a smear in 89,
29   the assumption was made that she was properly enrolled ..... the assumption
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 1   would have been made that the pathologist had picked the correct recall time
 2   in his report, I understand.
 3   But the only smear that would qualify her for enrolment in 92 would have
 4   been a smear performed in 92, not a smear performed in 1989 .....it was
 5   within 3 –
 6   She needs 2 smears satisfactory and within normal limits within enrolment,
 7   factoring in her smear history prior to the registry, she wasn‟t enrolled
 8   properly ..... yes, I'm not sure that what you've said is what are here in the
 9   guidelines. My understanding of what's written on here, and this is just
10   from reading it in the last day, that if this is the first smear, or it‟s more than
11   5 years since the last smear, then a smear in one year is required and the
12   pathologist would be wrong to put anything else on. If it‟s not the first
13   smear and if the pathologist has evidence of normal smears within the last 5
14   years, I could read that as saying that a 3 year follow-up is perfectly
15   satisfactory.
16   So if you can walk back through this – 92 was her first registered smear .....
17   yes
18   You are saying if she had a smear anytime in the previous 5 years which
19   was normal, that would have satisfied the requirement for 2 normal
20   satisfactory smears to go on the 3 year screening interval ..... again it‟s my
21   understanding, and I can't find any documents to show it, but my
22   understanding is the one followed by one a year later is for naive, totally
23   new enrolments into cervical screening and even in clinical practice a
24   woman who‟d come regularly and was having cervical smears right up until
25   enrolling on the programme I wouldn't have thought I would have to recall
26   her one year later when the same laboratory was doing the testing, and may I
27   say I would have been causing her a bill of some $40 or so for what she
28   would probably see as unnecessary.
29   That actually wasn‟t clear from the documents ..... it certainly isn‟t clear
30   from the documents and somebody else may shoot my understanding down.
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 1   I can‟t say that is a statement from the cervical screening programme, it‟s
 2   only my interpretation.
 3   CHAIR: this was a screening programme introduced to protect women‟s
 4   health. What comment do you make on reading policy documents from 91
 5   and 93 it is not clear to you as a clinician what the position was in respect of
 6   women who had had smears before they went on to the programme as to
 7   how they would be recorded on the programme and treated by the
 8   programme ..... I find this unsatisfactory. I am uncertain whether it‟s my
 9   failing or the programme‟s failing to have understood clearly.                My
10   assumption is that that could be read two ways.
11   CHAIR:      Dr Boyd you have been employed firstly, by the Department of
12   Health and by the Ministry of Health;            you have held various senior
13   positions within the Ministry and practised as a locum medical practitioner
14   during your vacations. If you are confused, what impact would this state of
15   affairs have on general practitioners generally ..... I feel that most of them,
16   and also the pathology laboratories, would probably follow my reading of
17   what's there because it is what's written down.
18   PROFESSOR DUGGAN: can we go to witness no. 5. ..... Again, a name?
19   P10 is her PAP smear screening history, and there's also a page on her
20   registry file. Have you found that ..... yes.
21   According to the registry printout, her first registered smear was in 1995 .....
22   yes.
23   And she has no further smear until 1998, which is 3 years later ..... that‟s
24   correct, and if I read this correctly, it says “at the normal screening interval”.
25   So based on what you clarify for us, one can make the assumption that prior
26   to 1995 this woman had a PAP smear not registered, which was normal, and
27   if we go to her summary on p10 we note that in 1991 she had a normal
28   smear in Dr Bottrill‟s laboratory. ..... that's correct, yes.
29   I'm unclear here. Does the primary care provider receive a printout from the
30   registry of the individual woman‟s screening history when that woman
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 1   comes to attend for PAP smear screening ..... no, I don't think so, no. If
 2   she‟s attending within – the programme is – I've used the word
 3   “superimposed” upon the clinical care that‟s given by the woman‟s own Dr
 4   or smear-taker, if she turns up within the time expected, if she's already on
 5   the programme, then the programme would have done nothing. It will be
 6   keeping a watching eye to see that somebody‟s report has come in at the
 7   right time.
 8   If I could re-ask my last question. The question was, when a woman who is
 9   registered on the screening programme and has had smears prior to the
10   establishment of the screening programme, does the primary care provider at
11   the time he is taking a smear have a printout of that woman‟s previous PAP
12   smear screening history ..... I believe the answer is no. No. If the woman is
13   returning within the recommended time-frame on the pathologist‟s report,
14   then there wouldn't have been any reason for the register to write to the
15   practitioner, or to the woman herself.
16   Let‟s stay with the same woman who has registered, has some smears on the
17   registry and prior to the registry, these smears may be read in one or many
18   laboratories. Is that correct ..... yes.
19   As we've seen with some of these smears, they‟ve had smears in Hamilton
20   and Dr Bottrill‟s laboratory and in Gisborne Hospital ..... yes.
21   When the pathologist is providing the management recommendation, does
22   the pathologist have a printout from the registry of her previous PAP smear
23   encounters ..... I think I'm getting out of my depth of experience in that I
24   haven't worked in a laboratory and I haven't run the cervical screening
25   register. We do later on from the Health Funding Authority have Dr Peters,
26   who is the director of the registry. I honestly can't answer your question
27   unless I could look to her and get the question over and done with. I'm not
28   able to answer it.
29   CHAIR:        up until the time you were involved with the cervical screening
30   programme with the Department of Health and the Ministry of Health, in
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 1   that role what was your expectation as to how the programme would work
 2   ..... honestly, I believe that – I'm not able to answer what I expected to go
 3   from the programme to the individual pathologist or how the information
 4   got there, I honestly can't give you an answer
 5   How were you going to evaluate how effective the programme was if you
 6   didn't have in mind how this information would be disclosed and what use
 7   could be made of it ..... I have to admit to a mere failure of memory - I just
 8   cannot remember 9 years ago.
 9   As a clinician, let's say its 1993 and you have a patient in your office and
10   you look in her chart and she has a PAP smear report from Gisborne
11   Hospital from 1992 and a PAP smear report from Dr Bottrill‟s laboratory
12   from 89/90/91, so she has 4 PAP smear reports ..... hmm.
13   And the Gisborne Hospital 92 PAP smear report says “within normal limits,
14   continue” ..... normal screening intervals.
15   Do you wonder how they came up with that recommendation when they
16   didn't have access to all her previous smears, and let's say the smear in 1991,
17   which is the one in the previous year, was from Dr Bottrill‟s laboratory that
18   said “atypical, repeat in 6 months” ..... right. I‟d have expected that to have
19   been based on the history at least of the smear before. Yes, I would have
20   expected the pathologist to have had all the information necessary to give
21   me that advice
22   You would expect each pathologist in each laboratory would know all the
23   PAP smears on this one woman ..... no I wouldn't because there would be
24   results that weren‟t in the register, so therefore they would have been unable
25   to have obtained those results. In the period where the register is being
26   introduced and these records are getting on there, there would be slides
27   unobtainable without going to each and every laboratory in the country.
28   Who is co-ordinating this woman‟s care ..... the primary care provider co-
29   ordinates care on advice given by the pathologist following routines set out
30   by the programme. There has to be an inception date of the programme, and
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 1   my answer was there are some slides from prior to the programme‟s
 2   inception which will not be in the hands of the pathologist or obtainable.
 3   It seems to me that the pathologists are making management
 4   recommendations based on the smear they see at that time without
 5   knowledge of the previous smears interpreted in other laboratories, and I
 6   don't know how religiously the primary care provider is looking at all of
 7   these PAP smear report and management recommendations and deciding in
 8   the context of the patient what is the appropriate management
 9   recommendation ..... that‟s making an assumption on something that I can't
10   remember the detail of, and I have offered a way to find the answer to that.
11   You were a clinician in such a situation when you practised primary care .....
12   yes.   I would have expected the pathologist to have had some prior
13   information about previous slides. I would have expected that there would
14   be some slides before the programme was introduced which they may not
15   have had access to, and my assumption would be that was to be one of the
16   benefits of the programme and it would incrementally develop the longer the
17   programme was in place.
18   You think the primary health care provider should have a copy of the
19   previous PAP smear encounters, a registry printout ..... I know it‟s available
20   on request, but I'm not – I wouldn't expect to routinely receive it.
21   Are you comfortable with pathologists making recommendations on a smear
22   when they haven't seen the patient and they may not know the entire PAP
23   smear history of the patient ..... I'm sure that what you're suggesting has
24   degrees more safety than I've been comfortable with. Yeah, that would have
25   to be my answer
26   CHAIR:      is that a yes or a no Dr Boyd ..... I have in the past been
27   comfortable with a belief that a pathologist would have got the appropriate
28   information to make their recommendations.
29   Do I take that as a yes ..... yes, I have been comfortable with what's
30   described
                                            134


 1   And are you still comfortable with it ..... I can definitely the point, and I still
 2   do not know whether in fact what has been asked is in fact operative within
 3   the programme at the moment or not.
 4   PROFESSOR DUGGAN:               if I can say this again, I'm still not clear as to
 5   whether the pathologists have all of the PAP smear history available to
 6   them, nor am I clear if the primary care provider, or whoever is taking the
 7   smear, smear-taker, has that PAP smear history available to them ..... for that
 8   I apologise because it would be silly for me to say exactly I've offered a
 9   route the information.
10   Because you still practise as a primary health care provider for a short
11   period each year you would know if you had received printouts when
12   women came for PAP smear screening ..... that‟s correct and I certainly
13   haven‟t seen them in practice.
14   OK. Can we go to witness no. 5. In her exhibits there is a registry printout,
15   and according to the printout her first registered smear is in 1994.. ..... yes,
16   that is what I've noted, yes.
17   Then if we go to her evidence, p12, she's had no smears prior to 1994 ..... on
18   that history as we‟re given, that appears so.
19   So she would be a new screen, an initiator into the programme ..... that
20   would appear so, yes.
21   So she would have had a smear in 1995, she should have had one ..... if it‟s
22   correct that she was a patient who had not had smears before, I have to ask
23   the question when I looked at this, is it correct that 1994 was her first smear,
24   did this woman have smears in all the investigations for miscarriages, care
25   under the gynaecologist, where else may she have been – I don't know.
26   Those are questions I would have to have answered before I could answer
27   properly.
28   CHAIR: it would seem from Patient 5‟s brief of evidence she did not have
29   a smear until 1994. ..... I don't actually see that. It says she was under the
30   care of a gynaecologist and at that time I assume “he was testing me for
                                            135


 1   everything” is what it says. To me that could mean anything at all. so I just
 2   positively don't know the answer
 3   Do you have any comment to make on a circumstance on a women
 4   receiving treatment from a gynaecologist from 91 to 94 who isn‟t sure as to
 5   whether or not she‟s had a smear during that time ..... regrettably, both in
 6   disciplinary cases I've sat on and in my own talking to patients, this isn‟t
 7   uncommon what care you've had and what‟s been done for you. And we
 8   discussed yesterday informed consent and full information and partnership
 9   and care
10   When the cervical screening programme was first put in place I would have
11   thought by 1994 those responsible for the programme would have at least
12   assumed by that time women would know whether or not they were having
13   smears ..... I think that would be a dangerous assumption to make.
14   PROFESSOR DUGGAN: so you agree that in regard to witness no. 8 she
15   wasn‟t enrolled properly ..... if that was in fact the first registration, I would
16   suggest that under the criteria we've given she wasn‟t enrolled properly,
17   however I don't know whether the pathologist or specialist or somebody
18   knew there had been abnormal smears in another laboratory during the opt
19   off period. It was a question I had about the previous care. My questions
20   also, someone of that age being totally naive to cervical smears – i.e. not
21   ever had cervical smears at the age of 30 is unusual in this country. Unusual
22   also because of where she lived and the practice she went to, which was in
23   fact a non-fee paying practice where I understand they even prided
24   themselves on enrolling their patients for cervical smears at the time the
25   programme was instituted. But those are questions that I have no answers
26   to.
27   In summary, therefore, with regard to these 4 women who have registry
28   printouts, with clarification, some were enrolled properly but some were not
29   ..... that‟s what it would seem
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 1   And the issue of unsatisfactory smears and management and clarity with
 2   reference to how the management recommendation is decided is unclear, or
 3   clarity is needed ..... clarity is needed and I feel people who would run the
 4   programme would be able to answer. I'm not saying they will have answers
 5   that will satisfy you, but they will be more satisfactory than I can answer.
 6   You are concerned in how these are done ..... yes, there's a lot to learn from
 7   the general care of these women as well as the programme management.
 8   I've realised how little I know about what you have confidence in.
 9   There's also a very important statement in volume 5 , section 15, p2.
10   MR CORKILL:           I've heard the evidence, and on the topic of the
11   suppression order it appears these are matters of pubic interest and it is not
12   necessary for the suppression order to remain in place for the evidence thus
13   far
14   CHAIR:     all the evidence heard this morning you are happy for it to be
15   made public?
16   MR CORKILL: indeed.
17   MR HINDLE: it did seem there was some sense that individual cases have
18   been talked about in a way which may come as a surprise to the patients.
19   What I was going to suggest after this passage of evidence was over was to
20   allow a period of 3 or 4 days within which Mr Corkill could talk to the
21   women and then lift the suppression order.
22   CHAIR:     one matter that does concern me is at the beginning when this
23   witness was questioned today he answered his questions under the assurance
24   at that time that the evidence would not be made public and at the beginning
25   of his evidence he voiced his own concerns about how he would answer
26   questions. He has done so under the blanket of the suppression order and I
27   don't like to turn the tables on him by changing it.
28   MS SHOLTENS: that‟s my concern too ma'am, and I was going to ask to
29   take my leave from Dr Boyd himself.
                                           137


 1   MR HODSON:         Much material has been given relating not to individual
 2   witnesses but to matters of public importance. I can't think that Dr Boyd
 3   would object to that – I support Ms Sholtens‟ suggestion.
 4   Mr KIRTON:          Given that there are issues of public importance with
 5   relation to the programme itself, that another opportunity will present itself
 6   and we can re-question those areas relating to the public issues.
 7   CHAIR:     I will eave the suppression order in place at this time. Once Dr
 8   Boyd has completed giving his evidence, Ms Sholtens if you will liaise with
 9   him and we will revisit the matter after lunch. The suppression order will
10   remain in place until the committee says it is lifted.
11
12   QD BY MRS BARRETT:
13   Before we launched into this patient‟s evidence (Patient 5) my colleague,
14   Professor Duggan, asked you a question about release of data to pathologists
15   etc. to the National Cervical Screening Programme, do you agree ..... I
16   agree.
17   My understanding for the Maori women‟s data is that a request has to be
18   made to the national Kaitiaki group; is that correct ..... My understanding is
19   there are requirements on Maori women‟s data, yes. So yes.
20   So, that limits accessibility to Maori women‟s data doesn't it ..... it certainly
21   puts strictures on Maori women‟s data, yes.
22   I just wanted to make that specific clear.
23   CHAIR: Does that mean that a pathologist wanting to obtain material on a
24   woman registered on the programme may encounter difficulties in accessing
25   that material if she is a Maori women ..... again, I don't believe I'm the right
26   person to answer that question, ma'am.
27
28   PROFESSOR DUGGAN:
29   I was drawing your attention to the statement in volume 5, Judy Glackin‟s
30   exhibit, section 15, p2, the fourth paragraph, it says “women presenting with
                                            138


 1   symptoms of signs of …. irrespective of the smear results.. the cervical
 2   smear … are present.” ..... that is correct. This is in the standards for routine
 3   cervical screening in the government‟s policy, and if asked about my
 4   opinions about cases there would be more than one case here where
 5   personally I would go further than symptoms or signs suggestive of invasive
 6   cancer, I would go further and say the symptoms and the clinical signs
 7   should “outweigh a normal cervical smear” is the rule that I thought applied
 8   clinically. So, I believe that statement is there. I would have suggested that
 9   for some of these cases there's questions as to why clinical signs weren‟t
10   taken into account.
11   Could you refer to witness no. 6. Witness No. 6 does not have a registry
12   printout. ..... that is correct.
13   But we do have, on p9, a summary of her PAP smear screening history. I
14   hope there was a revised one handed out, I hope you have that ..... yes
15   counsel gave me an amended one – well, it‟s written on “amended”.
16   [Shown to witness]       yes, I didn't have the printed version of what you are
17   referring to. I have now.
18   Could we make the assumption, as the screening programme started in 1991,
19   that her 95 smear would have been registered ..... unless Patient No. 6 had
20   opted off and there was some record of that went to the laboratory, then
21   there should be a register result.
22   I believe from her evidence she hadn‟t opted off or it hadn‟t been discussed
23   with her ..... that was my understanding too. I would expect to see her name
24   there if she gave permission for it to be looked for.
25   And in that event her previous smear was 20 years previously ..... yes.
26   So, I think the correct thing was done; she came back in 1996 for another
27   smear. She would be an initiator to the programme ..... that is correct. The
28   nurse at the Well Women's Clinic at Te Karaka recalled her and said it was
29   because she wasn‟t sure of the previous result. It could have been because
30   there‟d been a reminder to be recalled after a year – I don't know.
                                          139


 1   The management recommendation from Dr Bottrill‟s laboratory for that
 2   1995 smear is the next smear should be taken at a normal screening interval
 3   ..... we have that?
 4   It‟s in the exhibits, the second page after the typed page. ..... that would be
 5   wrong on all we've discussed about enrolment.
 6   You wouldn't agree with the management recommendation ..... no, I
 7   wouldn't, and I don't know if in fact the cervical screening programme over-
 8   rode that so she had a smear a year later or not. As you say, the correct
 9   thing was done. I do not know why.
10   It brings me back to my previous concern about how some of these
11   management recommendations are subject to interpretation and I'm puzzled
12   as to who‟s deciding when is the next screening interval for this woman. Is
13   it the pathologist, is it the primary care provider, is it the screening
14   programme? If this woman is being initiated to the programme she should
15   be coming back next year for a smear.
16   Who actually tells her that ..... that is the same question I asked myself
17   overnight.    Was this an over-riding by the programme of an incorrect
18   recommendation or not, and I hope that it is an over-riding of an incorrect
19   recommendation - I do not know.
20
21   MORNING ADJOURNMENT 11.00 a.m. UNTIL 11.15 A.M.
22
23   MS SHOLTENS:          advised re information the women can obtain from the
24   register regarding the screening programme. If we have written consent
25   from each of the 8 women, and if they are enrolled on the register, we can
26   get not only their screening history but also a record of what letters were
27   sent to them, when and to what address
28   CHAIR: that would be helpful.
29   MR GRIEVE: we are in the process now of getting consent from all those
30   women.
                                           140


 1   CHAIR:      certainly, for the purpose of the committee‟s task, it would be
 2   helpful to have as much information as possible rather than have gaps. Also
 3   my colleague, Mrs Barrett, has asked to me to ask does that include Maori
 4   women, because I believe there are further limitations on access to their
 5   information.
 6   MS SHOLTENS:          if the Maori woman requested information just about
 7   her, there shouldn't be an issue about her getting that.
 8   CHAIR: thank you.
 9   PROFESSOR DUGGAN:               just before the break I was asking you about
10   witness no. 6. It‟s just been brought to my attention in that report of her 95
11   PAP smear from Dr Bottrill‟s laboratory, p2 of her exhibit, the last line says
12   “examined by MBB” ..... that‟s right.
13   And CSP - what is CSP ..... the National Cervical Screening Programme
14   What does it indicate ..... that indicates he was treating this as a slide of
15   somebody on the programme.
16   So although we didn't have a printout of Patient No. 6‟s registry file - ..... we
17   would expect one to be there if that‟s what it says.
18   So this would in all likelihood be her first smear on the registry ..... indeed,
19   that‟s what we agreed before.
20   And we agree that there was some confusion about the management
21   recommendation as to what the normal screening interval was, and it is
22   unclear as to who was deciding whether that was 12 months or 3 years .....
23   yes, we are unclear – I am unclear. It doesn't mean the programme is
24   unclear.
25   So if you could move on to her next smear in 96, over the page, it‟s reported
26   as “blood stained smear but no other abnormality seen, repeat in 3 years” .....
27   yes
28   This smear is from the Gisborne Hospital ..... yes.
29   As a clinician how would you interpret that report ..... I would have been
30   very unhappy to have seen that report come in – I wouldn't have accepted it.
                                          141


 1   What would you do with such an equivocal report ..... I would go ahead with
 2   discussing it with the programme or anybody else, I would go ahead and
 3   talk to the lady concerned and invite her in to have another smear, when it
 4   was convenient, at the time when there was no bleeding, and do it again.
 5   Is there a practice in New Zealand where the primary care provider
 6   communicates with the pathologist ..... yes, quite definitely. In this case, of
 7   course, this was a smear-taker, I think, who took this slide, but she did have
 8   access to the general practitioner and the note system within that practice.
 9   So, if you're asking me, I'm not sure I would ring and talk to the pathologist
10   straight away, I would talk to the woman straight away.
11   In the next page of the exhibit the smear-taker made notes on the condition
12   of the cervix ..... yes. This was some of the areas where I had concerns, but
13   we are under the prohibition order/publicity or whatever.         Yes, that is
14   correct. There are notes in here about it.
15   I would like to read it, if you would allow me. “Second cervical smear
16   taken in 12 months, bled prior to any sampling, no obvious lesions” – I think
17   that means nulliparous – “last smear bled after spatula but normal smear in
18   95, the first in 15 years, complains of … irritation last week, worse at night
19   .. the smear and brush heavily stained. Discuss with Dr Whitten”. How
20   would you interpret the condition of that cervix ..... on what it says there, I
21   would certainly want an explanation for all of that if I was the Dr that was
22   being referred to. In other words, I would want to see what the high vaginal
23   report said, if there was one done at that time, and I think there was, and I
24   would certainly want to advise that woman that I would want to see her after
25   any treatment that the swab said was appropriate and actually examine that
26   patient myself. I believe there is enough evidence in what's written there
27   that this is a clinical condition and a cervical smear is not in itself a
28   diagnostic tool to be depended on with a history like that. I see next the Dr
29   did in fact have a diagnosis from the laboratory, or at least a report from the
30   laboratory on the swab, treated with probably the appropriate medication,
                                           142


 1   didn't follow-up the patient. Again, according to the notes, for 2 more years.
 2   Again we haven't got the full notes but that‟s how it reads to me at the
 3   moment.
 4   So, it would appear this woman was assumed to have cervicitis and the swab
 5   grew gardanella? and she was treated for this ..... yes
 6   It would appear the management recommendation “repeat in 3 years” over-
 7   rode any examination of that cervix ..... that would be my reading, and there
 8   may be some more information, but yes, that‟s my reading and that isn‟t
 9   what I would have done in that situation.
10   She did actually return in 1999, 3 years later, where a smear was attempted,
11   but I think because she was bleeding it wasn‟t successful. ..... yes, that‟s
12   correct, although it does appear she‟d gone through some other
13   investigations before they got to the cervical smear attempt.
14   The concern about the 96 report is that it‟s subject to reinterpretation. .....
15   yes obviously there Dr Whitten and I would have treated this particular case
16   differently.
17   And I note that this particular smear was reviewed by Medlab Central .....
18   yes.
19   I'm not sure if we can accept that. Yes, we can, where it was reported as
20   unsatisfactory. And if that was the correct reporting, and this is a smear
21   from Gisborne Hospital, the management recommendation appended to that
22   would have been “repeat in 3 months for an unsatisfactory smear” ..... oh,
23   I'm not sure that I've seen that written down, but something like that is what
24   I would have expected.
25   It is in the exhibits. Would you confirm that the management
26   recommendation for an unsatisfactory smear is “repeat in 3 months” from
27   the exhibits – volume 5 of Judy Glackin, section 22 ..... yes. This is the
28   national consensus on abnormal smears, on page?
                                          143


 1   12, top right hand column ..... ideally another smear should be performed
 2   ideally at mid-cycle within the next 3 months. Yes, that I would confirm is
 3   in the protocol.
 4   If I could return to your brief, paragraph 15, p6. ..... which is the World
 5   Health Organisation criteria.
 6   There are screening programmes in the world older than the New Zealand
 7   programme, some in the Scandinavian countries have been in effect since
 8   the 60s, is that correct ..... yes. I visited Finland and Sweden. At the time I
 9   had some responsibility for establishing the beginnings of the programme.
10   And these would be considered successful screening programmes, is that
11   correct ..... yes indeed
12   Have they eliminated cervical cancer ..... no, I don't believe so. Certainly I
13   haven't been looking at their record in the last few years, but I don't believe
14   they‟ve eliminated cervical cancer totally.
15   So, an organised screening programme will not eliminate cervical cancer, is
16   that correct ..... that‟s the philosophy I believe programmes are built on.
17   Your objective should be a reduction and a continuing reduction, but you
18   shouldn't offer the population that cervical cancer will be eliminated.
19   Why then is there this belief amongst women that organised screening will
20   prevent cervical cancer ..... yes.   I believe that word is used and used
21   probably inadvisedly.      It prevents some or most cervical cancer but
22   “prevent” is not the correct word. However, I do believe it‟s used and it
23   may be found in some of the publications.
24   On p8, paragraph 18, I was surprised by this number. At the inception of
25   the National Cervical Screening Programme it was postulated between
26   1:100 women will develop cancer of the cervix. If I recall correctly before
27   the introduction of a registry into British Columbia the incidence of cancer
28   was 50 :100,000 women. 1:100 seems very high ..... yes, and I regret I can't
29   give you the reference for that point. It was definitely stated at the time the
                                            144


 1   programme was being developed. It was made as a statement. I haven't
 2   found the actual reference that goes back to.
 3   I'm curious on an academic level. Could you provide that reference ..... I
 4   certainly tried to find where the original came from.             It was just in
 5   background material which wasn‟t attributed to any particular person, but I
 6   will certainly look again.
 7   Because your incidence currently is about 10:100,000 ..... and it could well
 8   be, when trying to push for the beginnings of a cervical screening
 9   programme, the definition was stretched out, for the sake of politicians, to
10   be anybody developing CIN. That may be how it was pushed around to try
11   and build up the importance of the programme.
12   On p12, section 27.2, based on current knowledge are barrier methods such
13   as condoms protective from transmission of the human papilloma virus .....
14   my understanding is they are protective without being totally protective. I
15   could be -
16   In fact there is a recent publication in an Australian journal, a study
17   sponsored by one of the condom makers, and it was determined that
18   condoms are not protective ..... uh huh
19   Condoms do protect against other diseases ..... certainly, I think you'll still
20   find that in literature around the world, it isn‟t just that it is New Zealand
21   specific educational material.
22   You are quite right, I have seen it in other literature ..... thank you.
23
24   QD BY MRS BARRETT:
25   Kia ora Dr Boyd, I have a few questions to ask you. Mainly in your brief.
26   The first one is brief no. 6 – paragraph 6, p2.
27   MR CORKILL:          Is this an appropriate time to address the suppression
28   order?
29   CHAIR:       before I lift the suppression order in respect of evidence to be
30   given from now on, and I'm not yet dealing with what has already been
                                             145


 1   given, I will defer that until after the lunch adjournment. [No submissions
 2   from counsel in respect of this matter] For the benefit of the press, the
 3   evidence you've heard so far remains suppressed, but evidence from now on
 4   may be published.
 5
 6   QD BY MRS BARRETT:
 7   I will go back. Dr Boyd, I just wanted a comment from you. In the third to
 8   last sentence of that paragraph, and I take it that it was previous to 1989
 9   about quality issues, did the system work? Were the quality assurance
10   systems effective ..... absolutely not. I put that there to show that that had
11   been the traditional way that government managed the quality of the
12   services it subsidised, but it was a totally unsatisfactory system and I'm
13   pleased that I've had some part in assisting the change.
14   Thank you. Paragraphs 8 and 9, the World Health Organisation criteria.
15   Does this criteria still stand to date ..... I believe so. It was written initially
16   in the early 1980s and the criteria I've seen reported in World Health
17   Organisation publications, or at meetings since then, I think it‟s important.
18   Whether one can stretch it in New Zealand to talk about the tests being
19   acceptable to the population extending to being totally sensitive of the needs
20   of the people who are going to be users of this service, I believe it can be.
21   They are generic conditions criteria.
22   So I take it that this criteria is privy to general practitioners and medical
23   practitioners and health officials, etc. ..... I can't see how they'd actually have
24   it in front of them, among all the other literature that they have, no. It‟s
25   available and it‟s in so many publications if you were interested in screening
26   programmes anywhere you‟d come up against this criteria. If you were just
27   doing your job in a general practice I don't think there's any reason you
28   would have them in front of you.
29   Do you think it would be a good idea to have them in front of them ..... there
30   are practicalities in the work that‟s done dealing with individual patients that
                                            146


 1   you've got to be very selective about the reference material you keep in front
 2   of you. I suppose I have to give my opinion and say these criteria are very
 3   important for the programme, for government officials, for funders, but the
 4   actual general practitioner or smear-taker shouldn't have this as their
 5   principal document in front of them.
 6   CHAIR:       should it be a document in front of them ..... yes, I believe it
 7   should be there somewhere that they could reference it, they should have
 8   read it once ideally, but I couldn't fault somebody if I walked into their
 9   clinic and said “where are the World Health Organisation criteria”
10   Would most general practitioners have an expectation that a screening
11   programme would follow this criteria ..... I would think yes, I believe it
12   would be in the training of the medical practitioners coming through, it‟s the
13   sort of thing that the departments of public health at medical schools would
14   have a teaching session or two on, and so it would have been introduced to
15   them, yes.
16   MRS BARRETT: it‟s just that when you said it was generic, I mean 8.2 is
17   a generic issue, in terms of the history of the disease, and should be well
18   understood, don't you agree ..... yes, that‟s – again we could get into
19   semantics and you argue even the World Health Organisation should make
20   clear what it means. I suppose from a clinical point of view I took that to
21   mean that those who know about diseases should understand the natural
22   history of this particular disease you are intending to screen. I don't take it
23   to mean that everybody in the population should understand the natural
24   history of the disease being screened, but that could mean something else to
25   somebody else.
26   Can we move on to paragraph 10, Dr Boyd. Paragraph 10 makes some
27   reference to promotion of good health promoters and health promotion
28   campaigns ..... yes
29   Do you think those could be effectively adapted in New Zealand as well .....
30   I believe, in setting up the programme, that a lot of emphasis was put on
                                            147


 1   recruiting women and advising them about the screening programme, and
 2   that included efforts to employ Maori health educators and create material
 3   suitable for Maori women to learn about the programme. It could always
 4   have been done better, but there was quite an emphasis right at the
 5   beginning, in making sure that we were reaching groups of women who
 6   were not using the service as much as expected, and that included Maori
 7   women, it included lower income women as a separate group, and both of
 8   those were targeted.
 9   In view of the answer you just gave me, I know that Maori health promoters
10   were very vibrant in how they did their health promotion in cervical
11   screening ..... yes
12   Who was responsible to make sure they gave the right messages ..... the
13   resources were provided through the Ministry of Health and the Public
14   Health Commission, they are using Maori advisers and workers to help
15   create the material. As for quality control from the centre, I would have
16   thought that was not done to a great extent. What a woman said to the group
17   that she went back to, amongst the iwi, was never monitored as far as I
18   know – not documented. Monitoring, anyway.
19   Do you see in the future that that should happen ..... yes, I wouldn't like to
20   be the person from the centre charged with doing that monitoring, but yes, it
21   should be done and it should be done as an organised way amongst the
22   deliverers of the service themselves. So Maori health workers should
23   monitor themselves in the first instance, set standards for themselves, that
24   should be part of the presentation of the material.
25   I don't think it‟s particular to Maoris either. I think it was earlier this year I
26   attended a hui here in Gisborne and we had health promoters who were
27   actually talking to groups of Maori women, they did a fantastic job, and I
28   know two of those women have passed on. The point is it was quite sad that
29   they encouraged Maori women like ourselves to actually take a smear, but
30   unfortunately the messages were wrong, that‟s why I wondered what was
                                           148


 1   the monitoring evaluation situation that the programme provided ..... so, I
 2   am not able to answer exactly what the monitoring is now, only our
 3   expectations when first establishing it and to add that there was a lot of
 4   effort to see that the information provided was right in the first instance, and
 5   that included having to correct some impressions from the people I met who
 6   were ready to rush out and be health educators who didn't have the right
 7   message and they couldn't wait for the material to be actually printed and
 8   manufactured into kit form to take with them.
 9   I think it is also an issue that Professor Duggan talked about in terms of the
10   right messages going across. I would just mention that some people were
11   told that if you had a smear you wouldn't get cervical cancer and that's the
12   interpretation of the resources that they received. ..... yes.      And I can
13   appreciate that could happen. Certainly, it wouldn't have been the intention
14   of the programme, and if so, then it‟s unfortunate and it shouldn't be allowed
15   to happen – at least the material should be able to be interpreted just one
16   way.
17   Thank you.     If we could go to paragraph 17, Dr Boyd, the screening
18   pathways, and I have looked at your document that you've provided. I just
19   want to pick up on the health promotion and education area and know that a
20   lot of health promotion is governed by the Ottawa Charter. I have a real
21   problem with that because I think inclusive of that should be the Treaty of
22   Waitangi, but in that I know that – I'm not very good at the Ottawa charter,
23   but I would say one of the issues is the support of the environment, and the
24   question I want to ask is one of the issues that I raised with the 8 affected
25   women who gave evidence was the support and awhi that they received
26   from whomever. I know the Ottawa charter does not make provision for
27   that physical supportive role or awhi. What would be your views on that .....
28   when looking overnight at the case histories one of the notes I made was,
29   not just for Maori women but for all women, that there seemed to be very
30   little support noted and for what reason I don't know. There are support
                                          149


 1   groups.   Practices in most cases have practice nurses in their medical
 2   practice who are expected to provide support, I think in one case we heard
 3   a nurse tried to be supportive by actually giving the information before
 4   going in to see the Dr. I think that was an inappropriate attempt to do what
 5   they should be doing in helping a woman through a situation. But that was
 6   inappropriate.      It is very important.   I believe the smear-takers or
 7   practitioners have a role in seeing that their clients/patients have some
 8   support, some way of getting themselves through an emotional experience
 9   that none of us would want to go through. That doesn't come through in the
10   case histories.
11   Thank you. If we could move on to paragraph 27.2, in the last paragraph,
12   “the promotion of safer sex … cervical cancer” as my colleague made
13   mention to earlier, usually this is done in relation to sexually transmitted
14   diseases. Do you think that the health promoters in the cervical screening
15   programme actually talk about cervical cancer being one of those ..... I'm
16   sure some do. I know it was not part of the programme initially when it was
17   being set up and it wouldn't be in the information give. It‟s totally the
18   wrong message to say that cervical cancer or even pre-cancerous conditions
19   are perhaps your own fault from practising some unsafe sex.              The
20   connotation is wrong. In fact it would put people off the programme if that
21   was the emphasis. I don't think that‟s ever been in the material put out. So,
22   I think up to Professor Duggan‟s comments it has been in here around for
23   the people running programmes, but if you're trying to run a campaign of
24   information and trying to attract women or recruit them into the programme
25   and get them to stay, then associating socially unacceptable behaviours with
26   something which does occur de novo by itself is wrong and that would have
27   the wrong effect.
28   Thank you. My last two questions are paragraph 49, and I know that a lot of
29   discussion was had yesterday about the workshops that had been run. My
30   question to you is as an official of the Ministry of Health and I suppose at
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 1   that time of the Health Department. Do you agree ministers are only as
 2   good as the advice that his/hers advisers give them ..... there was a minister
 3   in the room a short while ago. No, ministers get advice from all sorts of
 4   quarters and officials definitely do their best to serve the minister they‟ve
 5   got at that time, but we know their advice comes from many sources and we
 6   also know that ministers do not always take the officials advice. That
 7   doesn't stop you serving the minister to the best of your ability and learning
 8   what way they would like the policy to be framed. But it isn‟t our decision
 9   how the picture finally looks
10   Were you part of the official group in 1989 who went to see this so-called
11   minister ..... yes, I was in attendance, the meeting is one of our – it is one of
12   the documents I believe – yes, the meeting of 15 December, so I was one of
13   the officials in attendance.
14   You would have assisted in the workshop recommendations being
15   administered at that time ..... I signed the letter. My job was the scribe for
16   the meeting. I put clearly what the recommendations of the workshop were
17   then and put them to the minister. As I note there, the minister did not
18   accept the recommendations as they were.
19   Thank you. Then paragraph 51, was it in relation to the recommendations
20   made to the minister in 49 where you established a national screening
21   implementation unit ..... it wasn‟t specifically mentioned in the outcome of
22   that meeting because really I guess that is internal management and
23   organisation of the department as it was. Quite clearly I believe it was done
24   to give greater emphasis to the cervical screening programme and not just
25   have it as part of primary health care which was my management area. So
26   that‟s my belief why it was done. I was no longer directly responsible for it
27   because it was seen to be big enough to have its own management structure
28   and to have that much emphasis.
29   You would agree it would be the next step in the planning stage ..... yes,
30   because there was the emphasis and it gave cervical screening a greater
                                          151


 1   profile, yes I would think it was the right thing to take it just out to the
 2   primary care programme and make it a unit of its own to do whatever
 3   preparatory work was needed to implement the programme.
 4   I just make that comment because I think that in paragraph 49 it was made
 5   mention that was the planning stage of the recommendations of the
 6   workshop and 4 months down the track a screening implementation unit was
 7   set up. I thought they kind of ran together and you were a party to that. .....
 8   well, I certainly saw it was a good way to get the programme up and running
 9   in a successful way was to give it its own management structure, yes, so I
10   was happy to be relieved of that particular role because it was more
11   important than just being part of my programme.
12   Thank you Dr Boyd.
13
14   QD BY CHAIR:
15   Following on from those questions, Dr Boyd, could you turn to the exhibits
16   in your volume 3, leaf 14 ..... this is the document I was referring to 20th
17   December 1988 brief notes of a meeting with the minister and officials.
18   Turning over the page is a document headed National Cervical Screening
19   Workshop recommendations ..... that is correct.
20   The first recommendation is that an executive group with decision making
21   power be formed to control the National Cervical Screening Programme and
22   to allocate funding for the programme to Area Health Boards ..... correct.
23   Can you explain how that recommendation came to have been made ..... that
24   recommendation you find in a previous document which was the previous
25   document under 13, the cervical smear workshop of 6 to 8 December 1988
26   and those were the recommendations of the workshop. As the scribe, I
27   made sure they went to the minister as quickly as possible for him to discuss
28   with the Director-General or the chief Health Adviser, who was present.
29   What was the importance of this workshop ..... it had been planned and the
30   best chronology in these documents is to in fact go through 12, 13 and 14.
                                             152


 1   the report of the so called Azimuth reports which in many things just pulled
 2   together views in the Ministry. The recommendations of that report were
 3   that it be taken to this cervical smear workshop which had already been
 4   planned, bringing together the representatives of stakeholders in cervical
 5   screening. So this had been arranged for some time, so the Azimuth report
 6   was one of the documents to be taken to that group. That group was to be
 7   asked to make recommendations. I did say earlier that it was difficult to get
 8   consensus in that group on all the issues, so the report has some parts that
 9   are just from different workshops of special interest groups, then there are
10   the recommendations at the end on which there was, I believe, some
11   consensus. That then, as soon as possible, was taken to the minister in the
12   way you've seen.
13   Would the workshop recommendations be seen as having been made by a
14   reasonably high powered workshop, persons whose opinions might be
15   valued ..... indeed, that‟s why we arranged to have those people brought
16   together at a meeting. And I guess my expectation was that that would be
17   part of the ongoing planning process
18   And the fact that the first recommendation is for this executive group with
19   control of the programme, that it is in the recommendation that is placed
20   first, can we take it there was consensus on that recommendation ..... yes, I
21   would take it – I was at the meeting.
22   Turning over the page, the notes of the meeting with the minister on 15
23   December 1988 ..... that is correct.
24   Turning over to the second page
25   MS BUNKLE: Could we be told the list of the status of those people who
26   attended the minister
27   CHAIR: that is a question which may be asked by persons in this inquiry
28   as a result of questions the committee is asking. Would you turn to the
29   second page, 4th     para   down “with no executive functions” – is that
                                              153


 1   determined by the minister ..... that is correct, that‟s what was noted, what I
 2   noted down from the meeting to feed back to the minister.
 3   I thought this was the notes of the meeting with the minister ..... that‟s
 4   correct.
 5   And was it – am I reading these notes right or not, it seems it was the
 6   minister decided ..... the minister was there at that meeting and the meeting
 7   was to take these recommendations to the minister, so I would have to say
 8   yes, it‟s the minister‟s ultimate decision
 9   Does that mean it was the minister who decided that the Ministry would
10   have no executive functions ..... yes.
11   Are you able to recall now why the minister took that view ..... no, I'm not.
12   And the one proviso that I have to have on this version of this paper is the
13   only one we could find. If you go to the front page above my signature
14   there's an approved/not approved. Ideally, the Ministry document should
15   have the minister signing that. The filing of memos to ministers and back
16   again at that time, probably even today, leaves something to be desired. So I
17   have no absolute evidence that this note was signed and returned to the
18   Ministry, however equally that was the action that was carried out
19   afterwards
20   Do you think it would have been preferable if the executive group with
21   decision making power had been formed in terms of recommendation 1 .....
22   you are now asking my opinion?
23   Yes, as a clinician, someone dependent on the use of the screening
24   programme ..... having read of the problems in the British cervical screening
25   programme some time around the same time, I would have to say no,
26   management by a committee of the size that was being recommended would
27   be very difficult and probably in today‟s world a board of management with
28   a chief executive would be a much better option – that is my personal
29   opinion, I did not have a chance to air it at that time and it wasn‟t my
30   decision to make.
                                           154


 1   What was the reaction of the working group to the minister‟s decision .....
 2   that – the working group you refer to
 3   Who had made the recommendation to the minister ..... the 100 people who
 4   were at that cervical screening workshop. I don't believe they came together
 5   again as that group but it is quite clear that a lot of people were not satisfied
 6   with that situation, and I appreciate why
 7   Can you say why then ..... firstly it was a recommendation in the Cartwright
 8   Report which I've described as a very important document in setting the
 9   phase and heading to the implementation of the programme, therefore it was
10   very much in the minds of the people who were there, and I believe
11   everybody there had a wish to see a cervical screening programme which
12   took into account everybody‟s views up and running for the good of women.
13   The people who objected felt this would not achieve it.
14   I note your reply that you did not think that an executive group of the size
15   envisaged would have been workable. Can I ask you, in comparison with
16   the advisory group, would a small executive group with decision making
17   control and funding have been preferable to an advisory group ..... yes,
18   indeed, but there would also need to be one other factor again from my
19   reading, the British experience, that is a Chief Executive or somebody who
20   is accountable to the board for the management and doesn't expect an
21   advisory group to make all the decisions and someone who can also give the
22   programme a profile.
23   So to summarise then, is it fair to say you think the ideal delivery for the
24   programme would have been a small executive group similar to a small
25   board of directors with a Chief Executive who had a largely public profile
26   and was seen as the day to day decision maker ..... with plenty of
27   opportunity for input and consultation from stakeholders, affected people,
28   and particularly the women concerned.         None of that I envisaged was
29   achieved in the programme, but, as I say, it was not my decision to make
                                             155


 1   Could you outline to the committee, just to clarify matters, what it was that
 2   you envisaged ..... I think, as I've described, a person to be held accountable
 3   for the success or failure of the programme and who was answerable to a
 4   group of – I‟d call them a board of directors who would be chosen by the
 5   minister for their skills on recommendation of affected groups, but also with
 6   advice and input from organisations, groups, whanau, whoever, to represent
 7   the users of the service as well as the technical people involved.
 8   And on your ideal would the Chief Executive be a medical practitioner or
 9   someone else ..... not necessarily a medical practitioner. When I joined the
10   Ministry all but one of the senior management positions were doctors. I
11   believe I helped to change that by maybe making it more difficult for people
12   to come in and take my job. I changed that by making sure there was a
13   career structure and the best people got into the management positions.
14   The model that you have described, has anything resembling that model
15   ever been put in place in respect to the New Zealand cervical screening
16   programme ..... no it hasn‟t.
17   Would you please go to paragraph 16 of your brief. Just to clarify matters
18   for the committee, you've set out in paragraph 16 the key organisational
19   requirements identified by the World Health Organisation for a successful
20   screening programme. Could we please go through each one and apply it to
21   the New Zealand programme as you know it. Firstly, 16.1, a central office
22   or individual responsible for planning, co-ordinating and evaluating the
23   programme. Has that happened ..... I believe it is nearer now than it ever has
24   been, in that under the Health Funding Authority it has got a named leader
25   with some key responsibilities and there is one central organisation with a
26   leader at present. So, nearer now than it ever has been.
27   On that basis is it fair to say that the requirement in 16.1 has not been
28   reached yet ..... no, it hasn‟t in that there is still some divided responsibilities
29   between the Ministry and the Health Funding Authority, for instance the
30   evaluation.
                                          156


 1   Moving then to 16.2, an agreed policy and set of objectives for the
 2   programme against which to measure the programme, from your knowledge
 3   how does that apply to the New Zealand programme ..... I believe the New
 4   Zealand programme has all along met that requirement in that the policy is
 5   stated, it‟s published, anyone who wishes can see it, and the objectives are
 6   there in numerical format, such as the amount of reduction in disease or
 7   death, and the number of women to be registered on the programme by
 8   certain dates. I believe every effort‟s been made to comply and I believe it
 9   complies
10   16.3 computer based information systems, how does that requirement apply
11   to the New Zealand programme ..... it does apply, remembering this was
12   written in 1984 when maybe computers weren‟t quite as common as they
13   are today. I suppose if I was rewriting this it would have to have something
14   a bit more than just computer in there, it would have to be adequate
15   appropriate and something a bit more than computer based. New Zealand
16   was computer based from the outset. It complies, was it the most effective,
17   is obviously something you‟ll hear more about.
18   Moving then to 16.4, extensive continuing coverage of the eligible
19   population.   How does that requirement apply to the New Zealand
20   programme ..... the numbers of people, women being enrolled and
21   continuing on the register has continued to increase.          The coverage
22   obviously was not good at the beginning but it was the beginning and it was
23   an accumulative process.. it has reached a point where the programme
24   stands up against most programmes like this for the world for the number of
25   eligible women on the register. Where we lack information right from the
26   outset, as I've said before, is who are the women who aren't registered on the
27   programme and why not?       It could have been that that information could
28   have be available by now if the health system was different. It looks like,
29   with the policy care programme just published, if that was put into place this
                                          157


 1   would be more improved. We can stand up against the rest of the world for
 2   the number of the eligible population being identified and registered.
 3   I note your answer that you've said if the health system were different more
 4   information might have been available. In what way has the health system
 5   that has been in place since the inception of the screening programme up
 6   until now worked against information being available ..... some of these
 7   have to be personal views, I would not want you to think these are the views
 8   of the Director-General of Health or the current minister because I just don't
 9   know what their views are on this, so I have to have a personal view that
10   says there was a vision that people would be registering with their Area
11   Health Boards for both primary care and hospital secondary care and the
12   policy was heading down in that direction, Area Health Boards of course
13   became disbanded and the secondary care, the hospitals, took on a business
14   model in which cervical screening was not actually a viable part of the
15   business and equally they had no interest in registering all their potential
16   population. It may have attracted some of them to come to the hospital and
17   cost money. That system has changed again and we‟re again heading to a
18   combination of the primary and secondary care under the same management
19   with some local controls and locally elected representatives on boards. This
20   has great potential for providing a community service from a local facility.
21   Can you just put rough dates on when the business model was put in place
22   and when it was abandoned ..... 1993 was the inception of the Regional
23   Health Authorities at which then the hospitals became CHE‟s, 1993, and
24   Hospital and Health Services were advised about a year ago to not be
25   applying the same business ethic as before. Really that came in longer than
26   a year – that was under the former Coalition government and the Coalition
27   agreement the business ethic was removed – that‟s 3.5 years ago. And now
28   the structure for local management is coming in in the current minister‟s
29   policy
                                          158


 1   Certainly from looking at your brief of evidence in paras 1, 2 and 3 and 4
 2   you are a very experienced medical practitioner whose had many years of
 3   service with the Department of Health and the Ministry of Health and
 4   therefore must have sound experience in these areas.       Could you tell the
 5   committee what impact the business model during the years which it
 6   applied, by your reckoning which I think was 93 until 94, what effect that
 7   model may have had, if anything, on the cervical screening programme .....
 8   the cervical screening programmes had been set up to be run peripherally
 9   with central co-ordination . they moved from an Area Health Board to the
10   CHE, who really their board of directors saw themselves as business units
11   and they bring the business ethic of being able to divest themselves of
12   unprofitable businesses or those which didn't see as their core business and I
13   believe that local co-ordination was definitely reduced by this; they were not
14   seen as one of the core parts of an essentially hospital service.          So,
15   therefore, funding had to be negotiated, contracts had to be let, and I believe
16   the contracts for cervical screening were considered not of major importance
17   and so they tended to roll over instead of requiring quality and
18   accountability, they were just allowed to carry on as before without the
19   improvements that one would have liked to have seen at the beginning of the
20   business model
21   What about at the end of the business model, did it change at all ..... Under
22   the Coalition agreement and when the CHEs changed to Hospital and Health
23   Services there was some greater co-ordination, the contracting was clearer
24   and probably lines of accountability were clearer and I guess towards the
25   end contracts were more meaningful and improvements were able to be put
26   in place. I don't say all of them have been put in place but they were able to
27   be put in place.
28   In view of your reference to the Coalition agreement, I take it those changes
29   would have begun to occur from 1997 onwards, is that correct ..... yes.
                                           159


 1   16.5. that refers to quality control of both the sample taking and the
 2          sample-reading. Can you say how that requirement applies to the
 3          New Zealand programme ..... as I perhaps said in my evidence, this
 4          was seen as very important, essential, when setting up the initial part
 5          of the programme.        It has been considered all along, there are
 6          processes of quality control in sample-taking, there are quality
 7          control measures required now in sample-reading, it has taken much
 8          longer than I would have envisaged to get to where we are, and I
 9          think I've given some of the reasons why in the previous answer.
10   just for clarification, can you please say, you've said it has taken time for
11   sample reading to be put in place, are you able to say when those measures
12   were put in place ..... what was envisaged right at the outset was that quality
13   control would be the responsibility of the laboratory, because we‟re taking
14   about laboratories for sample-reading, and that it would be overseen by third
15   party auditing, i.e. by the organisation known by the acronym TELARC,
16   that had been the view all long, it was the advice of our experts, and it had
17   always been the intention – I will cover it more in my second part of the
18   evidence as to the exact dates when things happened and how the advice
19   was developed; and the inhibiting factors.
20   16.6: measures to ensure that those with abnormal results are followed up
21   and treated.    How does that requirement apply to the New Zealand
22   programme ..... that is one of the basic reasons for having a programme and
23   that is making sure that where there has been an abnormal result steps have
24   been taken, it doesn't mean the programme takes the steps, initially it‟s
25   expected that the woman and her health care provider will take the steps but
26   if they don't happen the programme is meant to cut in to ensure that the
27   follow-up referral is made and treatment is provided by linking to the results
28   of that treatment if it‟s histology, which we cover later on.
29   Moving to another topic, is it difficult to recruit health professionals to
30   isolated regions ..... yes, it is. And Gisborne is an example, pathology is the
                                            160


 1   example, and that‟s the public hospital service.           So, particularly as a
 2   specialist in isolated practice you are not in the company of your peers, you
 3   don't have as much opportunity to go to meetings and to just mix with
 4   people in the same line of work, schooling for your children is not what
 5   many of the people who go into those professions want locally, so they are
 6   faced with sending their children away, or thinking about doing so. And
 7   remuneration. It‟s not very easy for whoever is employing specialists of that
 8   type to actually pay them more to be in a rural area. Obviously a higher
 9   salary would make a job more attractive, but that isn‟t taken into account in
10   any of the funding.
11   Is there no possibility in terms of funding available for hospitals or services
12   generally in isolated regions to pay a higher premium to traditional health
13   professionals ..... there's always a possibility but in doing so with the
14   funding formulae the management would have to decide what they are going
15   to do without.
16   I note in paragraph 5 of your evidence you refer to the clinical services
17   division before 87 and you say one of the services performed was to employ
18   general practitioners to work in special areas ..... that‟s right
19   Does that apply today ..... obviously they'd be funded by the Health Funding
20   Authority probably – so I don't know what the procedure and local people
21   would be able to tell me because the east cape Tairawhiti area had more of
22   these special area doctors than anywhere else but the West Coast.
23   When you ceased to be involved with the programme I looked at your
24   medical expertise and I note in respect of Judy Glackin who will give
25   evidence about the programme that she does not have a medical
26   background. Do you have any comment to make on that ..... that certainly
27   doesn't make her a poor grade manager or spokesperson for the Ministry at
28   all. there probably isn‟t a role for a medical practitioner within the Ministry
29   relating directly to cervical screening because management is in the Health
30   Funding Authority and our role is to monitor the Health Funding Authority
                                            161


 1   and a clinical expert or a pathologist or a cytologist could be wasted in the
 2   Ministry unless they had other interests or skills to offer
 3   Under the current organisation it is unnecessary for a medical practitioner to
 4   hold this position ..... to hold any position directly relating to cervical
 5   screening in the Ministry.
 6   CHAIR:     My colleague has discovered that there was one further witness,
 7   witness 3, who she wishes to question you on. So for the purpose of this,
 8   starting now, the suppression order made earlier will be back in force just
 9   for the part of this evidence. I will tell you when it is lifted.
10
11   LUNCHEON ADJOURNMENT 1.00 – TO RESUME AT 2.15
12
13   MS SHOLTENS:           As far as Dr Boyd‟s evidence goes and the issue of
14   confidentiality, I haven‟t had a chance to discuss that matter with him. I
15   wonder if we could respond to you on that tomorrow morning.
16   MR HINDLE: I have exchanged voice messages with the representative of
17   Tairawhiti Health Care who has expressed some concern about what may or
18   may not have been said which Tairawhiti Health Care may want to say
19   something about as well.
20   CHAIR:       Tairawhiti Health Care wants to make submissions on the
21   question of suppression?
22   MR HINDLE: Tairawhiti Health Care are concerned about things that may
23   have been said that may not be the full picture. They are aware the evidence
24   has been given under the suppressed basis and I will have more to say about
25   that tomorrow.
26   CHAIR I will extend the suppression order until 9.30 tomorrow morning.
27
28   PROFESSOR DUGGAN:
29   Witness no. 3: for this witness we don't have a printout of the doctor‟s
30   registry data, but the witness did say that she was on the registry in her
                                            162


 1   evidence ..... her evidence would lead you to that, she said she followed the
 2   instructions according to the cervical screening programme and she was
 3   written to by the register.
 4   In fact, my question is in regard to that letter from the register. ..... I wonder
 5   if we do in fact have a register printout, it‟s just that it‟s photocopied
 6   without a heading, dated 1/3/2000.
 7   I think that‟s the re-read. So, just to go back over the enrolment. It would
 8   appear that her enrolment method was appropriate in that her first smear was
 9   in 91, she had a smear in 92 and then she would have been put on a 3 year
10   interval and due in 1995 ..... that would appear so. It was late in 1992, it
11   wasn‟t 12 months, it was more like 22 months – 20 months, but that may
12   well have been the programme catching up.             We don't know that was
13   because of a recall by the programme but it probably was.
14   The smear in 1995 which was taken in Dunedin ..... yes
15   Had a report of insufficient cells ..... “return in one year” it says there.
16   I don't think we have a copy of that ..... no. and from what we discussed
17   earlier this morning, one would expect that would be a 3 month return rather
18   than 12 months but her evidence says she got a letter suggesting 1 year to
19   return.
20   That would be the concern in my question to you. Does the registry have a
21   mechanism to ensure that the management recommendations on reports are
22   consistent with the diagnosis being rendered on the report ..... and that's I
23   guess again I can't answer what would have been happening in 1995 or what
24   is happening now specifically. It will be clear from the letters that we gather
25   are going to be obtained to see exactly what was sent out. The local co-
26   ordinators have had that task and they all had the guidelines to work to. I
27   think we should see the letters to see exactly what was said there.
28   What would you expect from either a laboratory or a register with reference
29   to   ensuring   that   there   is   consistency between        the   management
30   recommendation and the diagnosis ..... I would expect there would some
                                           163


 1   leniency for the programme co-ordinator to shorten the recommendation
 2   interval if it didn't comply with the standards for cervical smears as put out
 3   by the programme. So my understanding is that they have an opportunity to
 4   override the recommendation but I‟d like to see the letters to see exactly
 5   what was said in this case.
 6   In fact some laboratory reporting systems can be programmed such that
 7   diagnosis and management recommendations that are inconsistent with each
 8   other will not allow verification of the report ..... yes, I would have thought
 9   that laboratories do run that system in some places, in that the report that
10   goes out from some laboratories to my knowledge is not quite the word
11   that‟s in the Bethesda protocol. They do have some specific wording of
12   their own that they can put in. so they would also have the facility I guess to
13   interfere with the – interfere is not the right word, some laboratories could
14   amend in the way that you are suggesting.
15   Do you think that all laboratories should have such a system ..... we will see
16   later in the minutes of the advisory committee where this was brought up
17   and discussed with the laboratories who wished to keep some of their own
18   system and if it was agreed that it wasn‟t inconsistent with the programme
19   standards then their own wording could be used. If they could do that they
20   could also I believe have something which would refuse to point if there
21   were inconsistencies in the code. But we will return to that under the
22   discussions of the advisory committee.
23   To summarise with regard to witness 3, if there was some form of control
24   system, an unsatisfactory report would not have a management
25   recommendation of repeat in 12 months ..... if that is not the standard at the
26   time, yes you are right.
27   CHAIR: Mr Grieve, can you ensure the screening test results of witness 3
28   and the printout are available for witness 3.
29   MR GRIEVE: we have just got a printout.
                                          164


 1   PROFESSOR DUGGAN:             could I ask you to inform me about in what
 2   service was cervical cancer screening included in the period 92 to 96 – for
 3   example who was responsible for delivering that service ..... this forms part
 4   of the chronology of the witness to come. - and I haven‟t got it at my
 5   fingertips what dates anything changed. Judy Glackin will be presenting
 6   that as a chronology.
 7   You made reference to hospital services as being secondary care ..... yes
 8   And primary care as community service ..... yes, for funding purposes in this
 9   country the primary care services I see what you mean, the primary care
10   services delivered by general practitioners and the tests or pharmaceuticals
11   ordered by general practitioners is classed as primary care for funding
12   purposes and it has always come out of a separate budget than the hospital
13   services do. To answer then your question at a local level, say in Gisborne,
14   the local co-ordinator was always attached to the hospital and health service
15   over that period of time. So it‟s the hospital is the employer of the local co-
16   ordinator in the Gisborne area.
17   What is your opinion of that model of delivery, for a service that's
18   principally a community service ..... they ran CHE‟s at that time, then
19   became Hospital and Health Services, they also run the health services as
20   health protections in most of their regions, so they were given the local
21   services run previously by district health officers of the department. There
22   is no organised primary health care in each of the regions, they are
23   individual private practitioners, whether they are general practitioners,
24   laboratories, radiologists, so terminology-wise it could be called a primary
25   health care service but there is no real primary health care management in
26   the regions in New Zealand. There will be by the end of this year when the
27   new system of district health boards comes in.
28   In the model between 93 and 97, where do the laboratories fall ..... the
29   laboratories themselves were a private contractors who arranged their
30   funding by negotiation with the Regional Health Authorities which then
                                            165


 1   became the one central transitional health authority which became the
 2   Health Funding Authority. These Regional Health Authorities of the Health
 3   Funding Authority were classed as purchasers of service on behalf of central
 4   government and they purchased these primary health care services, so the
 5   general practitioners were paid for their cervical smear taking, the practice
 6   nurse was paid for cervical smear taking from that Regional Health
 7   Authority funding, the hospitals managed their own affairs and for
 8   themselves negotiated one payment out of the Health Funding Authority in a
 9   bulk way. That‟s not the easiest way to describe a diagram, but I think we
10   tried to allude to that in my evidence, that is a problem in saying what has
11   been the cost of the cervical screening programme, some of the payment
12   comes out of one pocket, bucket, fund, and the other service payments, like
13   administration or hospital services for the colposcopies come out of another
14   funding stream.
15   Did that create complexity in the successful delivery of the programme ..... it
16   created contract negotiations being run by different parts of the health
17   authorities, so yes, to some extent it did, I believe.
18   What was the impact ..... there is a strong argument for saying that if all the
19   administration had been put in one place, with good leadership as we
20   discussed before, that you'd have a programme that was more robust and
21   could stand on its feet more and could talk about all the combined services,
22   may even have been able to develop efficiencies and better ways of working
23   by having a sole single management stream.
24   Thank you.
25   CHAIR:      Thank you very much for answering the committee's questions,
26   Dr Boyd.
27
28   MR HODSON:          Dr Boyd, you were asked about the publication which
29   described cervical cancer as preventable and about the statistics. I wonder if
30   you could look at volume 2 under tab 10, you will see there a departmental
                                            166


 1   paper dated December 1998 “Towards a more effective cervical cancer
 2   screening programme for women in New Zealand”. I think that was one of
 3   the papers presented to the department by the working party which evolved
 4   the papers that you presented to the minister ..... yes
 5   Would you turn to p4 of that paper ..... yes, the word preventable is there.
 6   I was going to look first at paragraph 2 in which various statistics are put
 7   forward and at the end there is reference 5. I take it that is some scientific
 8   paper on which those figures were based. It‟s not attached. ..... it‟s not
 9   attached, and it would certainly be a reference and it looks like it‟s a New
10   Zealand reference. That's as much as I can say.
11   Perhaps that could be made available to the committee ..... perhaps this one
12   was found and this is the most complete version that has been found in the
13   file, I think.
14   The preceding paragraph starts “cervical cancer is preventable” it says that
15   cervical cancer carcinoma is one of the most preventable cancers that the
16   smear is a simple .. early detection. That the primary purpose … and
17   treatment of these lesions results in a cure rate of virtually 100% “ ..... that‟s
18   what it says.
19   If one read that reasonably quickly one might suggest it was suggested a
20   programme could have something like 100% effectiveness in preventing the
21   disease ..... yes, you could in reading that you could take that view
22   But in fairness to the author, that is not what it actually says ..... it says
23   virtually and you have to make your own interpretation, and yes with what
24   we‟ve heard I guess it wouldn't have gone out in this form after today or
25   even in the last year or so. This was one analyst‟s paper to put forward
26   fairly quickly to the workshop
27   I am not intending any criticism of that, I would make the observation, that
28   there is nothing in the paper about errors or failures which can/could arise
29   out of the process itself – i.e. the screening and reporting process ..... I will
                                           167


 1   take your word for it. I certainly can't remember any specific reference in
 2   this paper.
 3   On the one hand, you've made it clear that it was the aim of the Ministry that
 4   women should join in as large number as possible the screening programme
 5   for the laudable reason that they are much more safe if they do so. On the
 6   other hand it was known then, as it is known now, that it is not 100%
 7   certain, it is not infallible and some risks remain. Can you comment on how
 8   you can present that balance then, or now ..... I believe it is very hard to do
 9   with the balance being you can't sell something which is seen as ineffective
10   to people, and yet you don't want to raise their hopes too much. I think as a
11   health education , health promotion activity that was very difficult. I do
12   believe that the instructions have gone out more than once to the people
13   preparing material to try and strike that balance, but it isn‟t easy and I
14   believe Ms Barrett is absolutely right, when it gets to the local health
15   promoter level it‟s even harder to sell something which is a complicated
16   concept even for people dealing with it every day.
17   Thank you very much.
18
19   MR CORKILL:
20   Dr Boyd, you were asked by the panel some questions concerning the
21   Porirua workshop. I want you to look at an extract from a subsequent book
22   written y was Sandra Coney, a well known consumer advocate in the area of
23   women‟s health in this country, and heavily involved in the Cartwright
24   Inquiry ..... yes I have obviously read the book and this particular extract.
25   She has a chapter in which you have an extract, and I want to take you p168
26   where she deals with the issue of the Porirua workshop. Would you like to
27   read to yourself halfway down p168, the top of the next page. ..... yes.
28   She makes the point that the two day workshop was seen as a substitute for
29   the “Expert Group” ..... she says that it seems clear that the department saw
30   the workshop as a substitute for the Expert Group. I don't know where she
                                          168


 1   got that impression from. I can see no documents anywhere that would
 2   suggest that that was the case. I have said earlier personally I saw it as part
 3   of the ongoing planning process, this is opinion, I think it‟s incorrect
 4   opinion.
 5   Can you comment, then, on this matter. Judge Cartwright as she then was,
 6   recommended that the Minister of Health establish a group representing a
 7   wide range of women health consumers and appropriate health professionals
 8   from the relevant disciplines of cytology, pathology and colposcopies
 9   nursing personnel which group was to evaluate procedures, advise on
10   resource allocations, and implement within a reasonable period the
11   screening programme. The question is this: did the department at the time
12   see the workshop as the implementation of that recommendation ..... I
13   certainly didn't and I was only a member of the department. I can find no
14   evidence anywhere that that was so. I've already said I believe it was part of
15   the forward planning process.
16   How    do    you    say   the   department    implemented     that   particular
17   recommendation of Judge Cartwright ..... the first thing we did was
18   obviously have it discussed at that group meeting in Porirua. We obtained
19   the recommendations out of it. I've already said it was difficult to achieve
20   consensus at that meeting, and personally was grateful for some of the help
21   of some colleagues in the Ministry of Women's Affairs to gets
22   recommendations from that group. The recommendation is very similar to
23   Judge Cartwright‟s, perhaps a little more direct in that it says it should have
24   executive powers or decision making powers.
25   But the recommendation sent to the Minister of Health did not make
26   reference to the various cats which Judge Cartwright had identified by
27   expert personnel, cytologist, pathologists did it and so on ..... no, it didn't
28   have those words.
29   The recommendation had no reference to those health professionals did it
30   ..... I accept your word that it doesn't, but that was a recommendation put
                                            169


 1   together   by     the   working   group      who   knew    Judge    Cartwright‟s
 2   recommendations extremely well I suggest.
 3   As you rightly say, these are statements of opinion here, but I do ask you
 4   whether you were aware of these frustrations as expressed here at the time
 5   ..... I've already made reference to them in answering previous questions.
 6   Yes, people who were at that meeting were not at all happy with the way it
 7   was run, the way it was managed and, in the end, the outcome. I was asked
 8   what did the group say about this and the answer was the group never came
 9   together again.     Yes, people were concerned and that doesn't mean I
10   personally wasn‟t concerned at the outcome either.
11   Just finally Dr Boyd, do you agree that this somewhat unhappy experience
12   at Porirua became the seeds for later events, seeds of frustration for later
13   events which later resulted in a Ministerial review being appointed in the
14   next year ..... if asked I wouldn't put it exactly like that, but definitely there
15   was concern, definitely concern was put very forcefully, and it was put to a
16   new Minister and yes, a Ministerial inquiry group was set up.
17   Thank you Dr Boyd. I would like to produce this through this witness,
18   madam chair.
19   CHAIR:     this is a book that is publicly available so it doesn't need to be
20   produced in evidence. So I don't see any need formally for you to produce
21   the document. Pragmatically it might make it easier if people have a copy
22   of the excerpt now so they know where it fits with the evidence. I will
23   accept it purely at the moment as a document that this witness has been
24   asked to comment on. That doesn't mean I accept as evidence the opinions
25   contained in the document.
26   Mr KIRTON: you mean on the introduction of this evidence or questioning
27   of Dr Boyd?
28   CHAIR:        in terms of whether or not this document is admissible in
29   evidence, I'm going to admit it, but it is being admitted purely as material
30   that was put to Dr Boyd and which he was XXD on and answered questions
                                          170


 1   upon. That does not mean that I am accepting as evidence anything that Ms
 2   Coney has recorded as saying in the document. [Exhibit 0037]
 3   The suppression order relating to witnesses 3 and 7, the evidence that was
 4   given afterwards is not affected by the suppression order.
 5
 6   XXD Mr KIRTON:
 7   Dr Boyd, before moving away from the Sandra Coney commentary, I
 8   wonder whether you could note on p169 of her book the second paragraph
 9   on that page which reads “The department‟s next omission was to fail to
10   appoint the strong leader Judge Cartwright had recommended”. ..... yes.
11   Can I refer you to Judy Glackin‟s volume 9, tab 47, p44 you will note on
12   p44 the listing of the 6 key recommendations of the Cartwright Report, and
13   you will be aware of key recommendation 6 which Mr Corkill referred to in
14   relation to his questions to you. I refer you to key recommendation 2 “there
15   be strong leadership to develop, coordinate and maintain the programme”.
16   Is it your opinion that the recommendations of the Porirua workshop, their
17   recommendation 1 was in recognition of that key recommendation from the
18   Cartwright Report;    in other words, they saw the executive group as
19   manifesting key recommendation 2 ..... that could be the interpretation you
20   put on it, the other is that that recommendation from the working group
21   really paraphrases the intention of the fact that there should be an advisory
22   group which implements the programme, that would mean it would have to
23   have leadership and ownership, not just be an advisory group.
24   Can I ask you now about the Department of Health‟s actual response to the
25   key recommendation 2, and how the department wanted to ensure
26   compliance with recommendation 2 re leadership, and I refer you to tab 15
27   of your own volume 3 exhibits.      ..... which again is the meeting with the
28   minister.
29   And the second sheet of that lists the recommendations of the workshop .....
30   yes.
                                            171


 1   Which item 1 is the executive group we just talked about, and on the third
 2   page is the meeting with the Minster, is that correct ..... that is correct.
 3   At the top of the page are listed the names of the minister, the names Karen
 4   Poutasi, yourself, Bob Boyd, Fiona Sanders Francis, Ann Warner and Gill
 5   Durham. Could you advise what the respective roles, other than perhaps the
 6   minister, that those persons held within the department ..... Dr Karen Poutasi
 7   was at that time chief health officer of the Department of Health. I was the
 8   programme manager primary health care. Fiona Francis was, I would think
 9   at that time, one of my employees in the primary health care programme.
10   Ann Warner is a nurse who at that time would have been manager of the
11   women Child and Family programme in the Ministry. So someone at the
12   same level as myself. And to be honest, Gillian Durham‟s position at that
13   time, I'm not sure – I believe she was a senior medical officer attached to the
14   Women Child and Family Health programme.
15   The next question is, is it correct that the response following that meeting
16   was to establish the implementation unit of which Gillian Durham was the
17   head of at that point ..... the implementation unit was, as I discussed before,
18   took over responsibility for the Ministry‟s activities on cervical screening
19   from my programme at that time, and both Fiona Francis-Sanders and
20   Gillian Durham were associated leading that small unit and that was when
21   my responsibility stopped.
22   There was a transition at that point, the leadership within the department at
23   that point was handed to the implementation unit of which Gilliam Durham
24   and Fiona Francis-Sanders were the heads ..... I certainly know interim was
25   in the title for Fiona Francis-Sanders..
26   Can I further in Judy Glackin‟s evidence, Gillian Durham is described as the
27   head of the implementation unit ..... whether that happened immediately I'm
28   not sure, it probably is in Judy Glackin‟s evidence better than mine.
29   If I can assist, reading from paragraph 15 of Judy Glackin‟s brief, Gillian is
30   described as project manager, implementation unit ..... has it got a date on it?
                                            172


 1   It says in April 89 the Department of Health established that unit ..... uh huh.
 2   Yes, certainly I think I've given you all the facts that I can muster on who
 3   took responsibility at that time.
 4   Were you aware at which point in the organisation that that unit responded
 5   to ..... I believe it went with the Women Child and Family programme.
 6   Definitely it was a unit on its own whereas cervical screening in primary
 7   care had just been part of my programme with staff assigned to do that very
 8   early preparatory work.
 9   Can I gain from that response that Gillian Durham reported directly to the
10   Director-General of Health ..... no.
11   Would she have reported to a deputy Director-General ..... I honestly can't
12   answer.
13   Perhaps we will discuss that with Judy Glackin later. Can I ask you whether
14   the assignment of that management was in keeping with the Cartwright
15   recommendation ..... at the time the unit was formed to take over some of
16   the responsibilities of my programme, I would have imagined that it was
17   heading towards at least part way meeting the recommendations of either the
18   working group or the Cartwright Report. I have no documents anywhere
19   that said what the intentions were at the time that unit was set up, except –
20   no, I haven't got any terms of reference for that unit.
21   Were you aware that approximately 6 months after the establishment of that
22   implementation unit serious issues were raised about progress on the
23   development of the screening programme and the minister sought a review
24   of progress and instituted such a review ..... naturally, yes, I'm aware of that.
25   Would it be fair to surmise that the leadership throughout that period was
26   insufficient in the eyes at least of the minister to lead him to be confident of
27   delivery of the programme ..... I believe it was a different minister, but I
28   could be wrong. The changeover from David Caygill to Helen Clark was at
29   what date, I wonder?
                                          173


 1   We can check that a little later. Whichever minister was then, given their
 2   concerns in raising a review, would you conclude there were difficulties
 3   with leadership and the programme at that point ..... quite clearly that review
 4   was set up because the minister was not satisfied with the progress. I'm not
 5   sure whether leadership was mentioned but certainly the general
 6   programmes was not to the minister‟s satisfaction and she rightly set up an
 7   advisory group. more than that it has got another title. It‟s more than an
 8   advisory group.
 9   Can I refer you back to the words of Sandra Coney in her book, again on
10   p169, commencing after the item I noted to you earlier, where Sandra says
11   “a position was advertised by the department but despite rumours that a
12   number of people applied no-one ... instead. … was seconded to the post.
13   …. indicated a failure to recognise the formidable task ahead.” Can I ask
14   you whether in fact a junior departmental staff member was seconded to the
15   position of co-ordinator of the programme ..... yes, and I do believe I said to
16   you that interim came into the title as far as I know. I can't confirm the rest
17   of that paragraph.
18   Dr Boyd, you've made comments in your evidence that expertise was
19   important, leadership was important in the programme, there was concern
20   about that expertise residing within the department at the time. Can you
21   offer an explanation as why the department did not seek that important
22   expertise at that time to ensure the success of the programme from day one
23   ..... no, I cannot, I wasn‟t party to the appointment process, but I already
24   believe I've said some fairly strong words about leadership with in the
25   programme up to now.
26   Were you aware of the appointment, the first external appointment to the
27   programme, and if we take what you've said in terms of that interim
28   seconded appointment, the first national co-ordinator appointed was Gillian
29   Grew ..... I've read that in the next brief, and yes, that would be my
                                          174


 1   understanding, but I would have to say this is in the next part of the
 2   chronology, so dates, times and so on I'm not sure about.
 3   It‟s the issue of leadership that I'm wanting to pursue. Are you aware of the
 4   qualifications of Gillian Grew in terms of expertise to run a highly complex
 5   National Cervical Screening Programme ..... I know from personally
 6   knowing Gillian grew that before she came to the Ministry she‟d been the
 7   head of Nelson Polytech school of nursing. So she had staff management
 8   expertise and a clinical nursing background, that‟s as much as I know.
 9   Would you consider expertise, particular expertise in population health to be
10   an absolute pre-requisite for a National Cervical Screening Programme ..... I
11   can't say absolute. If somebody is a very good person manager is a very
12   good leader and can obtain the expertise that‟s needed, such as
13   epidemiology and other forms of population health medicine, I don't
14   subscribe to the view that it has to be one of my colleagues as a public
15   health specialist.
16   Given the knowledge that Gillian Grew remained in the position for
17   approximately 18 months and then resigned, can you advise us whether you
18   saw her leadership as being successful during that time, notwithstanding
19   there may be a large array of problems confronting her entering that position
20   ..... I'm not prepared to answer that as to what my views of a fellow worker
21   were. If I had evidence that she‟d been incompetent I believe I would have
22   said that if it had been proved, my particular view of the person I don't think
23   is warranted in this hearing.
24   I was referring rather to competency, more to the support given to her in her
25   position and the problems she may have encountered during that period .....
26   that wasn‟t what I heard from your question.
27   Ma‟am, can I ask whether it is appropriate to tender “the New Zealand
28   National Cervical Screening Programme” booklet, dated 1991 and authored
29   by Maree Leonard
                                          175


 1   CHAIR: yes, you can introduce it through this witness. Insofar as you get
 2   the witness to comment on portions of the document, it's admissible, but in
 3   terms of any views expressed in the document I would want to hold over
 4   admissibility of that issue at the moment.
 5
 6   Mr KIRTON:
 7   I appreciate that point. Dr Boyd, I wonder if I could refer you to p78 of this
 8   document. As I said, this is a case study towards a diploma of community
 9   health, authored by Maree Leonard ..... you didn't say that, but that‟s what it
10   is, and Maree Leonard is a public health medicine specialist now and has
11   been involved in some of the leadership of cervical screening in this country
12   and I class her as a friend, but I have never been asked to p/review this
13   Do you know whether Gillian Durham has reviewed this case study ..... I
14   couldn't have discussed it with her because I didn't know it existed until 5
15   minutes ago.
16   Given that this is an analysis of the New Zealand‟s National Cervical
17   Screening Programme dated 1991, it is possibly one of the fresher views of
18   that period – in other words, it‟s an analysis close to the time and I just
19   simply make that point. I refer you to p78 of the document. And I want to
20   question you as to the possibilities within the Department of Health at the
21   time decision were being made about implementation of the Cartwright
22   Report and the establishment of the National Cervical Screening
23   Programme. And in that case I refer you to the second paragraph on p78
24   and in it it is said – referring to the programme – “the fact that it was a
25   politically imposed policy rather than something championed by the
26   department is likely to have contributed to the difficulties encountered as no
27   key people owned the policy … despite this the Department of Health had
28   no option but to proceed and immediately moved into an implementary
29   phase. Can you comment on the validity of the view that because this was a
30   politically imposed policy it was not championed in the department .....
                                           176


 1   firstly, the department ever since the 1986 meeting of experts that I had
 2   referred to in my evidence, which recommended a National Cervical
 3   Screening Programme, ever since then the department had been talking
 4   about a National Cervical Screening Programme population based to start in
 5   the year 1989. there were, in retrospect you could doubt we could have
 6   achieved it, but to say this became a policy in a way Judge Cartwright was
 7   reiterating statements that had been there already. So the impression you
 8   get, that it suddenly became a policy to have a National Cervical Screening
 9   Programme is patently incorrect. There was a definite increase in impetus
10   and absolutely a definite broad based support from consumers, providers
11   and experts, which is the effect of having had the Cartwright Inquiry
12   recommendations, so in that it‟s absolutely right. The time was right for
13   doing something. I don't believe one can say suddenly this was foistered on
14   the department, you will find the words National Cervical Screening
15   Programme 1989 being written in several documents in my evidence.
16   Dr Boyd, I put it to you that the response of the department in setting up and
17   managing the Porirua workshop reflects a department uneasy, unhappy and
18   unwilling to allow women, health professionals and others with a vital
19   interest in the cervical screening programme, to participate at the level that
20   the department was comfortable with. Do you regard that as true ..... no, I
21   don't. that workshop had been planned for some time. The Azimuth report
22   that we've referred to was specifically going to be presented to that
23   workshop. We were seeing input into the way forward, and I believe we
24   didn't leave out many people who were real stakeholders. We tried to get
25   them all together at that meeting to help plan the way forward.
26   Is Karen Poutasi a medical Dr ..... yes.
27   Are you a medical Dr ..... yes.
28   And is Gillian Durham a medical Dr ..... yes.
29   These people were in the forefront of heading the implementation of the
30   cervical screening programme at that time. Was there any sense that they
                                          177


 1   resented the prospect of having women, consumers, advocates as a part of
 2   an essential part of operating the National Cervical Screening Programme
 3   ..... I heard my name referred to in the they you referred to, I can speak for
 4   myself and say absolutely not, and I think the work of the others since that
 5   day, in the varying roles they‟ve had in health care in New Zealand,
 6   probably answers the question for itself.
 7   Dr Boyd can I refer you to p82 of the Leonard document.             The first
 8   paragraph states “a critical factor in this part of the process … as a policy
 9   development unit rather than having any role in service delivery”, which
10   was how national co-ordination of how a National Cervical Screening
11   Programme was perceived. Do you recall this as being a prevalent ideology
12   during that period ..... I do remember you asking me before about whether it
13   was appropriate for the cervical screening programme to be in the Ministry
14   at that time because it was a policy unit. It wasn‟t. yes, there was planning
15   when Area Health Board‟s became fully established and took over the
16   management of primary and secondary care in there areas there would be
17   less for the Ministry to do. When that was implemented the Ministry would
18   be a full unit.
19   P82, second paragraph it is stated “the formation of Area Health Boards …
20   of a national co-ordinated cervical screening programme .. Area Health
21   Boards for their region and the department was to monitor them .. rather
22   than means” was that a prevalent view at that time ..... in my evidence
23   there's reference to a meeting between the min, the Director-General and
24   chairs of Area Health Boards and Area Health Boards to be where they all
25   agreed that it was within their resources and capabilities to respond to the
26   Cartwright recommendations and have a cervical screening programme
27   running, so I don't know where the evidence that Area Health Boards were
28   seen as a barrier has come from. I haven't seen that word used. That wasn‟t
29   agreed between my superiors at that meeting.
                                            178


 1   Can I refer you to p84 of the same document, the top of the page, first line,
 2   it says “Many people have been critical of the staff appointed to work on the
 3   cervical screening programme in that their positions were of low status in
 4   the department and they had no experience of organising such as
 5   programme.” Given that the programme was no higher than third tier within
 6   the department, and given that a succession of national co-ordinators had no
 7   or very little population health experience and had no experience of running
 8   a screening programme or even a pilot programme, that criticism was
 9   justified ..... it‟s true many people were critical of the staff appointed, so the
10   statements certainly correct. And I've already said in evidence before that
11   my personal view on the shortcomings of the programme have been , or one
12   of them has n in the are of leadership or perceived leadership.
13
14   CHAIR: I will admit that document GRB/MOH/038 on the limited basis I
15   have given it.
16
17   MS JANES:           Dr Boyd, you will recall this morning Professor Duggan
18   asked you about history of previous smears when a pathologist was reading
19   slides ..... yes.
20   And do you recall that your answer was that previously you were
21   comfortable in the knowledge of the information that was available ..... yes.
22   Certainly with my understanding the pathologist would have the material
23   needed to make the right judgement call on that smear.
24   Would it surprise you, and this may be outside your knowledge because it‟s
25   in the Glackin exhibits, but there are no less than 8 references between 90
26   and 96 indicating the importance of previous smear histories being available
27   to pathologists in order for readings to be able to take them into account .....
28   I'm sure the references would be to discussions at the advisory committee
29   and part of my problem is having read those and I'm not sure what's reality
30   and what's recommendation, so I think that has compounded my problem,
                                          179


 1   that yes I've read about the importance, yes I know of proposed standards
 2   proposed which said that would be a requirement, I just don't know if those
 3   are in place right now.
 4   If we can proceed on the assumption that those references that it wasn‟t
 5   available is correct ..... I don't think I can. The material is available if
 6   requested by the laboratory and from my quick skimming that is expected of
 7   the laboratories whether its actually in place and tested fore by TELARC
 8   I'm not sure. I can't assume they have no past histories in front of them.
 9   Who would be responsible then for disseminating that as a protocol ..... it‟s
10   now the responsibility of the Health Funding Authority and TELARC
11   working together on their laboratory standards, which they‟ve been doing
12   for some time, so I would say it‟s a Health Funding Authority to make sure
13   that gets out.
14   What about the early 90s when it was the Minister of Health responsibility
15   ..... it certainly was the cervical screening programme‟s role which they took
16   on to publish and send around the recommendations of their cytology liaison
17   advisory committee, and also to provide those to TELARC, which we will
18   discuss more later, for use when auditing laboratories as a standard of good
19   practice.
20   Obviously we will discuss TELARC in greater detail in the second parent of
21   your evidence, but if I may comment that their whole procedure falls down
22   unless all laboratories are accredited and those issues are being assessed by
23   TELARC or some other accreditation body, is that not correct ..... the
24   information would have been out there in the laboratories, that it‟s expected
25   of them. It‟s true to say that without external monitoring you would not
26   know whether it‟s happening or not, but certainly the information about
27   what‟s expected and what their professional advisory committee has been
28   advising the programme was circulated to all laboratories.
29   Be that as it may, you also responded to a question this morning that the
30   primary caregiver has the major responsibility towards a woman on the
                                           180


 1   cervical screening programme ..... the question was whose managing that
 2   woman‟s care for her and I have to stick by that, that‟s the person she relates
 3   to, that‟s where the partnership is in my thinking.
 4   It‟s logical regardless of what information a pathologist has available, they
 5   have never seen the woman face to face ..... yes, and another point brought
 6   up this morning, the clinical appearance and symptoms as related to the
 7   caregiver actually should take precedence over a cervical smear report,
 8   particularly if it‟s a normal one, so more care should be sought from
 9   specimens.
10   Could you confirm that there is a protocol which is well known and
11   understood that a vaginal examination by a primary caregiver or smear-taker
12   should always take precedence over a screening result ..... I believe that is a
13   golden rule.    If I have some difficulty with the idea that there are
14   smeartakers who‟s role is only smear-taking because they happen to be
15   women or women of the community, I haven't seen the evidence of people
16   falling through the cracks, but it is possible if their examination isn‟t backed
17   up with sufficient clinical knowledge to assist them in whether to refer on to
18   somebody with more expertise.        It is possible that somebody could be
19   harmed. I certainly looked at the cases we've dealt with today to see if you
20   could draw the conclusion. Because the case notes were part pages you cant
21   draw a conclusion yes or no, but while subscribing to people‟s right to have
22   their smear I think there is a potential risk if the primary care Dr did not talk
23   to or examine a woman and she felt all her gynaecological problems could
24   be solved by going to a smear-taker and just having a cervical smear,
25   What I don't like to see is case notes which have sore throat, cough, smear
26   result, cough, sore throat in chronological order. You ask where‟s the
27   history that went with that cervical smear.
28   Just turning to the evidence of the 8 women that we've heard, there were
29   repeated references to what certainly I would take to be clinical symptoms,
                                              181


 1   for instance prolonged repeated heavy bleeding ..... yes, there's definite
 2   evidence of heavy bleeding and we‟re talking individual cases again are we.
 3   Just in a generic ..... anyone who heard the evidence, I‟d have to say yes
 4   there was heavy bleeding in more than one patient, but at least in one of
 5   them the heavy bleeding from my reading of the notes had nothing to do
 6   with the cervical problem at all, although I don't have all the case notes and I
 7   can't say that for sure, but 12 months of hormone treatment I would have to
 8   wonder about that as a treatment. And I feel the witness believed that that
 9   was related to cervical intraepithelial neoplasia and I don't know that it was.
10   In fact, I would be certain it wasn‟t.
11   The concern that I want to focus the question on is an apparent abdication
12   from the protocol, or the golden rule as you've described it, where symptoms
13   like that or a vaginal examination should have alerted a primary caregiver to
14   the fact that they should not place reliance on the results of a National
15   Cervical Screening Programme which is not diagnostic by objective, would
16   you agree with that ..... I‟d agree that symptoms that are symptoms which
17   are related in the textbooks to cervical problems shouldn't be overlooked
18   just because there‟s a normal smear, nor should the examination of the
19   cervix if it looks abnormal that shouldn't be ignored even though there is a
20   normal cervical smear. The one particular case of the prolonged bleeding I
21   suppose in my mind that wasn‟t due to the cervix and if we had the
22   opportunity of a non blood stained smear and it was normal perhaps you
23   would have thought this is fibroid, this is coming from within the uterus, but
24   it would be referred to a specialist at a fairly early stage.
25   Wearing both your clinician‟s hat and your Ministry of Health hat, given the
26   evidence that you've heard from the women, put against the background of
27   the golden rule and the symptoms, was it reasonable, clinical treatment to
28   not follow up the symptoms that have been described to the inquiry ..... there
29   are 8 cases and I don't know I can give one answer to all of them. There is
30   evidence in what I saw in complete as it is, that there were symptoms there
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 1   that should have been investigated and vigilant practitioner probably should
 2   have sent those women off to a specialist earlier than they did in several
 3   cases. Despite the normal smears. But that‟s council of perfection which I
 4   can't relate to one particular case or another one.
 5   In your practice and also your understanding of the programme, are you able
 6   to comment on whether there is unreasonable reliance being placed on
 7   results from the cervical screening programme in treatment by primary
 8   caregivers ..... I don't think I've got enough experience of what goes on in
 9   general practitioner or specialist rooms to answer that.       I know what
10   happened in the practice I worked in, or have worked in. I know from the
11   programme‟s point of view that the programme doesn't see clinical histories.
12   I would suspect there is overdue reliance but I have no evidence to back that
13   up, and these cases would in part confirm my suspicions and it would rely
14   be peer review amongst the general practitioners as part of their re-
15   certification programme that will help pick that up.       I certainly would
16   suggest to the Royal College of General Practitioners that this become part
17   of the subject of their p/4rvw exercise for re-certification under the Medical
18   Practitioners Act.
19   [GRB/MOH/036 – letter to Dr Boyd December 1997]
20
21   RE-EXAMINED MS SHOLTENS:
22   Dr Boyd you were asked a number of questions about the recommendations
23   from the Porirua workshop. Can I just ask you to turn to that document in
24   your volume 3, exhibit 13.        page 29 of that document, those are the
25   recommendations aren't they ..... yes, as I understand it, those were never
26   modified after having come out of that workshop.
27   And then at tab 14 that‟s where you have recorded those recommendations
28   in your memo to the Minister ..... correct.
                                          183


 1   And under tab 14, the third page, the notes of the meeting with the Minister,
 2   you've been asked questions about the fact that a number of those
 3   recommendations were decided not to be implemented. ..... yes.
 4   Can you see at the top of the last page a note that the Minister asked that any
 5   further announcement concerning the outcomes of the workshop and the
 6   proposed implementation of the screening programme await the decision
 7   regarding the method of funding ..... yes.
 8   Did that occur. Was there any further announcement prior to decisions on
 9   funding ..... I don't believe there was, and of course that is part of the
10   criticism and the part we read out of the “Unfinished Business” book that
11   the draft report of that workshop and its recommendations was delayed to
12   the chagrin of the people who'd been at the workshop.
13   So effectively there were no further announcements for some time ..... I
14   couldn't find any, except I'm not sure when the advertising – well, that one
15   did go ahead, the co-ordinator, but maybe that wasn‟t one of the
16   recommendations anyway.         So further announcements concerning the
17   outcome of the workshop, no I don't believe there were any until the budget
18   had been agreed with the Minister‟s Cabinet colleagues.
19   And we‟ll know from the record and the evidence to be given in July 1989
20   the budget announcements were made by the now Minister of Finance, the
21   Hon David Caygill ..... yes. I think he would still have been the minister at
22   that time.
23   So between December 88 and some time the next year the Minister changed
24   ..... yes.
25   I turn to another subject, the azimuth report which you asked a number of
26   questions about at tab 12 of the same volume. I think counsel assisting
27   asked you a number of questions about a matter on page (iii) ..... yes.
28   The statement two-thirds down, “that the proposed system”, that‟s the
29   register system, “does not recall follow up … of histology information “ .....
                                          184


 1   that‟s correct. That was their statement in their proposal which they
 2   recommended be taken to the workshop.
 3   „can you turn to p42. are those the recommendations you are referring to
 4   ..... yes, that's correct. This was a report written by two consultants who
 5   were already working in the primary health care programme, they made
 6   those recommendations which included providing the document to those
 7   attending the 6th December cervical screening workshop. The issue of the
 8   linkage between cytology, register and the histology results was in fact
 9   discussed at that workshop and is in fact the very last page of the report of
10   that cervical smear workshop. It‟s a diagram.
11   Turning to tab 13 there now, are you, the last page ..... yes. The last page
12   before it headed appendix 6, that shows that the cytology register is in fact
13   separate from histology in their flowchart they are linked but the register
14   does not itself include histology data. So I take it from that that it was
15   accepted during the discussions of the workshop, whoever discussed that
16   issue, saw them as linked but not included in the register and –
17   CHAIR:       this diagram you've referred to, being appendix 6, is that
18   something created by Azimuth or a workshop ..... I believe it‟s created,
19   looking at the type – I thought from the typeface it was actually co-produced
20   by the Ministry of Women's Affairs but it is in the documents that came out
21   of that workshop.
22   Was it implemented in this form ..... that will come out I guess in the
23   chronology later. This was an early recommendation.
24   MS SHOLTENS: is that consistent with the passage in the w/;shop report
25   which Mr Corkill took you to at p27 ..... that refers to appendix 6, so that‟s
26   the cross reference.
27   I'm talking about on p27 under the heading “Smear Reading” ..... yes, the
28   wording is “cytology results should be linked with cytology reports and the
29   cancer register … laboratory reporting”. Very similar words to the 1986
30   workshop we held and the wording to really take note of is “linked” in both
                                          185


 1   cases, not “included in the register” which was really the question I was
 2   being asked yesterday.
 3   Do you know what decisions were in fact made about linking cytology and
 4   histology in the register ..... whether they're linked in the register I'm not
 5   sure, but the approach has been that they should be linked and the data
 6   should be available between the two. I believe the histology is collated by
 7   the staff of the cervical screening register, the difficulty here is they are
 8   called the register, although they are the staff. The register is also the
 9   computer data base.
10   Do you know what decisions were made immediately after this period of
11   time about linking histology and cytology ..... the next reference to it that I
12   have seen is when it comes to the Ministerial review committee where they
13   look at the issue and if memory serves me, that committee states that it
14   would be impossible at this time, or extremely difficult at this time to put
15   histology results into the cervical screening register and the register should
16   be set up as an entity of its own.
17   CHAIR: when was that .....
18   MS SHOLTENS:          Glackin, Volume. One, exhibit 1, November 1999, the
19   report of the review committee.
20   Have a look at p7 of that exhibit. Paragraph 2.10 a reference to the fact that
21   the review committee would have liked the opportunity to date further
22   whether it should be a cytology register or the entire population at risk.
23   Next page, there is a discussion on p8 about the benefits of different
24   approaches and on p9, 2.21, two further reservations about the register
25   noted. The second being whether it would be possible to link cytology and
26   histology, and I think if you would read to yourself paragraphs 2.23 and
27   2.24 which seem to record the decision. ..... I read that as being that the
28   minister‟s review committee agreed that requiring histology results to be
29   incorporated onto the cytology register from the outset would delay the
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 1   implementation of the overall screening programme and I believe that
 2   coincides with the view of the Azimuth people a year before.
 3   Then if you turn to p55, paragraph 8.14, and on to 8.15 on p56, does that
 4   express a similar view ..... yes, they certainly consider that linking the two
 5   results should be mechanisms of how to do it should be investigated and I
 6   would hope they suggest this should be done as soon as practicable, but they
 7   say the programme shouldn't be held up while these issues are resolved.
 8   CHAIR: do you know if they‟ve been resolved at the present time ..... yes,
 9   they have. And that will certainly be made clear later on in the evidence.
10   Do you know when they were resolved ..... it had to await reconfiguration
11   and the submitting of the data – I believe 1996/97, there is still some
12   manual element in putting the data into the computer base but it is being
13   done.
14   MS SHOLTENS: turning to a different matter, just briefly. At paragraph
15   44 of your evidence, and my friend Mr Hodson asked you about a document
16   that you produce in paragraph 44, so if you have paragraph 44 open –
17   referring to Exhibit 10, which is in volume 2. I just want to clarify one point
18   about this. This is Boyd Volume 2, Exhibit 10. this is the document which
19   refers to cervical cancer as preventable ..... correct.
20   In response to Mr Hodson‟s question you agreed this was a paper that had
21   been prepared for the Porirua workshop. Can I just ask you to look again at
22   paragraph 44 of your evidence. And just clarify the purpose for this paper.
23   ..... right.   Things were rushing on at the same time I guess at that
24   September/October 1988. I say there that a background for the meeting of
25   the Director-General and minister and Chairs of the Area Health Boards this
26   paper was prepared for. I know it was presented at both the meeting with
27   the minister and the Chairs came first, so I know who wrote it and yes it
28   went to both meetings I'm convinced of that.
29   One final matter, madam chair, the reference in Dr Boyd‟s evidence to
30   1:100 women, perhaps if I could just give a reference to the study that is
                                        187


1   cited in support. The earlier reference that my friend Mr Hodson referred to,
2   because it is published in the New Zealand Medical Journal, I can produce if
3   you require. [Paper to be made available later.]
4   CHAIR:     thank you very much Dr Boyd, your evidence has been of great
5   assistance to the committee.
6
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 1   MS SHOLTENS CALLED –
 2                 JUDITH MARGARET GLACKIN                 (Affirmed)
 3   I have prepared a brief of my evidence for this inquiry. I have a copy with
 4   me. I turn to the first page of the table of contents. That begins with Part I
 5   Qualifications and Experience; Part II Chronology Background of the
 6   National Cervical Screening Programme, and then over the page there is
 7   another Part II 2/3rds of the way down the page, the programme in
 8   Tairawhiti.   I amend the Part II Qualifications and Experience to read
 9   “Introduction : Qualifications and Experience”.      I amend the part that
10   currently reads part II chronology background to read Part I. On p2 of the
11   table of contents under 1999 that should read the “misreading of cervical
12   pathology in Gisborne”.     Turning to paragraph 1, under what is now
13   Introduction, Qualifications and Experience, I now start reading my brief
14   from the second sentence.
15
16   CHAIR: Suppression issue to be dealt with after Dr Bottrill has appeared
17   on Wednesday.
18
19
20
21
22   THE HEARING ADJOURNED AT 6.00P.M., TO RESUME ON
23   THURSDAY 13 APRIL 2000 AT 9.30 A.M.

				
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