Colette Kelleher (Independent) | Oireachtas source

I have great empathy with the women concerned about and affected by the recent issues relating to CervicalCheck. I know the emotion associated with not being told something. I fully believe in the principle and practice of open disclosure. My brother died unexpectedly at the age of 19 after a routine appendix operation and my family never got answers. That still hurts and bothers us as a family. Regarding cervical screening in Ireland, we need to focus on the future. I agree with Dr. Scally. I am not in favour of a commission of investigation. That would not be the best way to proceed. We need to put our energy into the implementation of the 50 recommendations.

Let us remember that cervical screening is screening. It is not diagnosis. It is about population health rather than about individuals per se. There will be false negatives in screening programmes. For women's health it is important to have both cervical screening and breast screening. The move to the new approach of also screening for HPV will significantly improve the accuracy of the screening process, increasing the chances of more cancers being prevented due to the detection of early changes. From a review of every 1,000 women screened, of the 20 women identified with pre-cancerous changes, the HPV test will correctly identify 18 but will still miss two. The current pap test will identify 15 women, but will still miss five. There will always be false negatives in any screening process. We need to remember that as we make the changes we need.

Dr. Scally speaks of a realistic prospect of the virtual elimination of cervical cancer in Ireland in the coming decades. That is a prize worth fighting for and worth keeping to the fore in our deliberations this evening rather than establishing a commission of inquiry. Cervical cancer is the fourth most common cancer in women. Cervical screening has saved lives. According the Scally report, in 2015 the lifetime risk of getting cervical cancer was one in 135 as against one in 96 in 2007. As a result of screening, the odds of developing cervical cancer have drastically reduced. The NHS screening service states that it is estimated that cervical screening prevents 75% of invasive cervical cancers. Dr. Scally states unequivocally that, in the case of cervical cancer, there is clear and undisputed evidence that properly run screening programmes are of substantial benefit to the female population of the State. Dr. Scally also states that he is satisfied with the quality management in the current laboratory sites. That is very reassuring.

While there are issues to be addressed in order to ensure that we have in place a properly run cervical screening programme in which women as a population and women as individuals can have confidence, there is much on which we can build. Public understanding of what screening is and what it is not is critical. Understanding the concept of sensitivity, that is, the ability to correctly detect the condition in people who have it, and the concept of specificity, that is, the ability to correctly identify people who do not have the condition, is really important. The Minister of State said that in his statement and we need to get that message out. There is no screening test yet developed that can deliver 100% sensitivity. It is important that is understood by those of us participating in screening programmes.

I have some observations. What we need for the reform of cervical cancer screening in Ireland is clarity about the task, as well as the governance and management of screening. Chapter 5 of the Scally report goes into this issue in some detail. The governance and management of the cervical screening programme looked a bit of a mess. I ask the Minister of State to look at the organogram I am holding up. He need look no further to know that a recipe for disaster was contained in this organogram. One does not even have to have a degree or an MBA, as I have, to know that was a recipe for disaster. There was chopping and changing in the cervical screening programme. It was subject to the vagaries of political and departmental expediencies and decisions. There was no HSE board and then there was. There were abolitions, amalgamations, absorptions and financial constraints. I give all credit to the staff who kept CervicalCheck going in the middle of all of this. If one looks at the organisational chart on page 26, as I said, it is a recipe for disaster. There is no single line of accountability and no clear answer as to who is in charge, as Senator Colm Burke said. There is no way for people to know who their boss is or what their role is. There are no job descriptions. It is no wonder recruitment and retention issues exist for CervicalCheck, an issue which is not helped in any way by the fetid atmosphere of public outcry and media heat.

In order to succeed, any organisation has to be clear about its primary task and its governance, management, and division of labour. This is especially true of health organisations and it is often sadly lacking with catastrophic consequences. As the Minister moves to put in place properly run cervical screening systems and, indeed, systems for Sláintecare, I recommend he take stock of the John Carver policy governance model, Brian Dive's model for decision making accountability and Henry Mintzberg's reflections on health systems and their organisations. All of these need to be taken on board as we move forward.

There are many people involved in the cervical screening process, including the woman herself, the clinician doing the smear test, the people in the laboratory reading the slides, those involved in any audit and those who care for the person in the long run, that is, the nurses, consultants and GP. All of these need to be clear about their roles and responsibilities, particularly in respect of open disclosure. Each person involved needs to be very clear about open disclosure in the context of a screening, as opposed to a diagnostic process, and in the context of the chill factor and the threat of being sued for large payouts as a result of medical negligence. Any reform of cervical screening must have these clarifications at its heart. There also needs to be clarity about process, including about audits and their purpose. There are blind audits and biased audits and there are consequences arising from each. Dr. Scally's report, while commending the intention to audit, was critical of how aspects of how previous audits were undertaken. The Minister must ensure that audits or reviews are properly designed with clinicians having input in the design, though obviously not in the audit or review processes themselves. That also needs to feature in the reform of cervical screening. Above all the person, in this case women, must be front and centre.I ask the Minister of State to take my observations on board to achieve the prize of which Dr. Scally spoke, namely, a properly run cervical screening service in which women have trust and confidence, one with engaged and motivated - not scapegoated - clinicians, scientists and managers, all working towards the virtual elimination of cervical cancer in Ireland in the coming decades. That is the priority, as highlighted in this most useful report by Dr. Scally.