New Criticisms in Ireland About Cervical Screening

Physicians report how CervicalCheck’s restrictions reduce women’s access to Pap testing

CEO SUMMARY: Pathologists worldwide are witnessing how a government health service can erode its nation’s pathology capabilities in cytology. Ireland’s experiment in off-shoring all its Pap testing even as it requires women to register in a national database in order to get free cervical cancer screening is not turning out well. A growing number of credible critics is turning up the heat on government health officials in the Emerald Isle.

IN IRELAND, CRITICS ARE HAVING A FIELD DAY after news reports indicated that the Irish Health Service Executive’s national program to expand coverage of cervical cancer screening—called CervicalCheck— has actually reduced the number of women getting access to screening services and Pap testing less than one year after its full implementation.

Ireland’s CervicalCheck is a free national cervical cancer screening program that began to roll out in 2008. It is the latest example and reminder of how a government’s helping hand often has unintended consequences for the very people it was designed to help.

Ireland’s problem is that its mortality rate for cervical cancer, at 4.2 deaths per 100,000, is nearly twice the average of the European Union (EU), where the average is 2.7 deaths from cervical cancer per 100,000. Ireland is the last EU nation to implement a universal Pap smear program. CervicalCheck was an effort to improve this situation.

Part one of the government’s plan to reform cervical cancer screening sent all the nation’s Pap testing overseas to Quest Diagnostics Incorporated. That contract became effective on July 1, 2008, and took literally 100% of the nation’s Pap tests away from Irish laboratories. (See TDR, August 31, 2009.)

Phase two was the deployment of CervicalCheck, which was introduced on September 1, 2008, and took full effect on September 1, 2009. The CervicalCheck program limits free Pap testing to women between the ages of 25 and 60. A woman is required to register with CervicalCheck to qualify for free cervical cancer screening services as part of Ireland’s health insurance.

After registration, CervicalCheck sends out an invitation for cervical cancer screening. A woman must have the invitation and make an appointment with her physician in order to get the free cervical screening service. Critics point out that newly-registered women must wait up to six months for CervicalCheck to send them the invitation that allows them to schedule an appointment to have the test.

Published statistics provide evidence that CervicalCheck is failing in its goal to increase the number of women getting annual cervical cancer screens.

First, once on the list, the CervicalCheck call/re-call system automatically sends women an annual invitation. But more than 53,000 invitations or reminders mailed to women between September 2009 and May 2010 were returned unopened. Further, if a woman is not on the CervicalCheck registration list or has not had a screening in more than three years, she must call a national helpline or go on-line to register with the program in order to receive an invitation.

Fewer Women Get Screens

Second, Irish physicians are speaking up about the remarkable drop-off in the number of women undergoing cervical cancer screening this year—under CervicalCheck—compared to previous years before the program’s introduction.

The Dublin Well Woman Centre reported in June that, since last September 2009, its three clinics have experienced a dramatic drop in Pap tests performed, from an average of 830 to just 340 per month. That’s 59% fewer women.

Alison Begas, the centre’s chief executive, blamed the decline on changes “from a free and accessible model to a much more restrictive one.” She noted that last year, the centre experienced a 15% increase in Pap screenings overall, due in part to the “Jade Goody factor.”

More Woman Wanted Tests

The 27-year-old British reality TV star and mother of two, died in August 2008 of cervical cancer. She had allowed filming of her own battle with cervical cancer, which raised public awareness of the screening program across the British Isles. Begas also noted that, in the wake of publicity over Goody’s death, the center experienced a record number of abnormal results, with more than 650 women referred for colposcopies.

Ronan Boland, M.D., a general practitioner who heads the Irish Medical Organisation (IMO) has declared that, since the policy change became effective in September 2009, cervical screening at his own practice has “effectively ground to a halt.”

Critics charge that these policies—put in place as part of the CervicalCheck pro- gram—are putting the lives of Irish women at risk. James Reilly, M.D., health spokesperson for the nation’s largest opposition political party Fine Gael (United Ireland Party), described the policy as “a cynical attempt to limit the demand for the smear test.”

Pamela Morton, former president of the European Cervical Cancer Association and founder of the Irish Women Against Cervical Cancer Association, called these policy changes unacceptable. “It is worrying because there are a lot of women out there not in the system and so do not know they are entitled to a free smear.”

Turning Away Patients

Primary care physicians complain that when unregistered patients show up in their office for an annual Pap smear, they now must turn them away.

Following announcement of the new registry policy, Marian O’Reilly, M.D., head of the CervicalCheck program, sent a letter to GPs to inform them that CervicalCheck would no longer pay them for performing this service! The program, however, would continue to facilitate testing by paying for clinical materials and test processing at the designated laboratory.

This action came as a surprise to Boland. In a story published by the Irish Medical Times, he said that, regrettably, what was supposed to be a free national program is “being rapidly dismantled.” Boland pointed out that by not paying GPs for performing cervical screening services, the National Cancer Screening Service (NCSS) “effectively reintroduced charging to vulnerable groups.”

He also criticized O’Reilly for the unprofessional handling of notification of physicians about policy changes. Boland pointed out that letters were sent directly to physicians without the courtesy of prior notification of the IMO, which has become the sounding board for physician anger over government policy changes.

Boland noted that CervicalCheck’s change to a call/re-call policy was not part of the extensive negotiations with the Irish Medical Organization last year, and physi- cians are very unhappy with this sudden and unexpected change. “I have had a lot of contact from people who are not normally in contact with the IMO, who are not militant in any way, who do not usu- ally complain,” said Boland.

The medical community also continues to be critical of Health Minister Mary Harney’s decision to outsource all Pap test processing to overseas laboratories. During the BioMedica 2010 conference in Dublin this May, keynote speaker Marie Culliton, President of the Irish Academy of Medical Laboratory Science (AMLS), who is an outspoken critic of NCSS’ decision to offshore laboratory jobs, pointed out that it was “short-sightedness” that led the outsourcing of all cervical cytology to America. She suggested that as a result of new CervicalCheck policies, the waiting has not been shortened, but rather the “bottleneck” had simply moved from waiting for a Pap test result to waiting for a smear to be taken.

Dismantling Lab Capabilities

“In addition, the competence to provide the service has been decimated within this country,” she charged. “The intellectual capital that took 40 years to build up in this country was written off at the stroke of a pen. This decision has led to the exporting of high worth, skilled jobs. This is not smart for a knowledge economy,” Culliton said, noting that 70% of all clinical decisions are based on results of a diagnostic test, which accounts for less than 5% of healthcare budgets.

These developments in Ireland presage the types of decisions about how to restrict use of pathology and clinical laboratory tests that other government health programs will make when faced with inadequate budgets. Outsourcing Irish Pap testing to an overseas laboratory evidently cut the Irish health service’s cost by as much as one third. Not paying GPs for cervical cancer screening services is another blunt cost-cutting tactic.

Unfortunately, it is Irish women who will pay the true price. To date, the CervicalCheck program has not demonstrated that it will improve access to cervical cancer screening services.

Irish Doc Calls CervicalCheck a “Dog’s Breakfast” Disaster

SOME IRISH PHYSICIANS ARE BLUNT in their criticism of CervicalCheck. In a letter to the editor of the Irish Medical Times, John O’Keeffe, M.D., a practitioner at Morehampton Clinic in Donnybrook, Dublin, summed up physician frustration, calling CervicalCheck “a monstrosity of a breakfast that any respectable dog would refuse.”

He blasted the program for both ignoring sexually-active women under 25 and the bureaucratic registry requirement. “Since September first [2009], any woman who plucks up the courage to have a smear and goes to her doctor to request this is now turned away because she has not registered with CervicalCheck. Of course, she has not registered; she has never heard of CervicalCheck.

“A conspiracy theory is probably too far-fetched, but if the HSE (Health Service Executive) wanted to find another way to save money by cutting down the number of smears being performed by GPs (general practitioners) then they, for once, have succeeded beyond their dreams,” he sarcastically wrote. “I cannot think of any possible objection to this, except that whatever ‘experts’ set up this ridiculous scheme do not want women to have smears. It’s as simple as that, and that is what my colleagues also feel.”

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