Health issues - more smears ......

OK, a few stories about screening.

The biggest story to hit the UK was when screening errors at Kent and Canterbury Hospital led to the deaths of eight women and 90,000 women were recalled for further tests. BBC News link about results

Not surprisingly, after that, screening procedures were tightened up somewhat. 'Quality' crept into screening bigtime. Actually it didn't creep, it jumped in and screamed across the stage. When I first took over responsibility for cancer services, I was told screening was included. Big difference in health authority terms, none to the public. But basically, screening is regarded as a public health function, ie something to keep people healthy. Cancer services are about treating people who are sick.

'You'll be chair of the quality assurance group,' said one colleague. Knowingly, and sniggered. I didn't even get to the first meeting of 'MY' group. I was busy writing the Millennium Plan for Year 2000 and couldn't spare the time. I had, however, recently acquired a seconded assistant - a medic gaining public health experience - so I cheerfully sent him to cover for me. It was only afterwards that he told me what an interesting experience it had been for him because he had never chaired a meeting before in his life.

I finally made the next meeting. I guess the group wasn't too happy that I had skipped the first one. They also weren't too happy that for more than 12 months my authority had been promising them a newsletter that had never materialised. Ah! a gift horse. Newsletter? Get that one whacked out in no time. Even if one director, a secretary and a public health consultant had failed to do it. See, journalists do have some advantages.

At the end of that first meeting, one of the consultant surgeons said to me, and I still remember his words to this day: 'I am right, aren't I? You aren't a clinician.' Well, so what. Two clinicans hadn't produced the frigging newsletter that they were all clamouring for so they weren't much use. And secondly, there were so many clinicians around the table that there were more points of view than you could poke a speculum into.

I think I gave the polite and restrained (for me) response of: 'No, I'm not. We are lucky to have plenty of intelligent clinicians around the table with a lot of knowledge and experience. It's my job as a manager to pull that together and use it in the interests of improving the service.' Or some such similar crap.

This guy was no walkover. He had more than one of my female colleagues in tears and was rude and insulting to them. He was well known for being sexist and arrogant, and old-fashioned. He didn't try it on with me any more. In fact, when he moaned about the preponderance of vegetarian food available for our lunches - which people had said they preferred - I arranged a carnivorous banquet for him but he didn't turn up. I received grovelling apologies however and no further complaints about the food.

I should say that I also represented our organisation at his leaving do. He wasn't a bad guy, in fact I would say he was good if you stood up to him. He also took the time to show me around his clinic one afternoon so that I had a better understanding of the work he did. I liked him.

Bit of background. My district included two hospitals with laboratories where the smears were tested, and the same hospitals also had colposcopy clinics where women went for an even nastier procedure than a smear. We had a totally separate admin department that organised the invitations and result letters. Then there were all the hundreds of GPs, and community clinics, the GUM clinic, blah blah. Oh, and health promotion, I always forget that one. All this lot were on my cheerful little group.

To add spice to the mix, one lab was also used by another authority, and that authority had different procedures to ours. Gah!! The minor first disaster was learning that in spite of all our new quality assurance procedures, the shared lab had discovered some poor reporting of smears and hadn't bothered to tell either me, or my colleague in the other authority about this.

Whose neck is on the block? Theirs - and - OURS, as guardians of the screening programme. So much for joint working together. But when the other lab had a problem - they did tell me. I probably wished they hadn't. I had to call a serious incident procedure. The lab had totally missed a smear that wasn't just borderline, or abnormal. It showed cancerous cells on the slide.

This is probably the point at which to say, that screening slides of cervical smears was a hellish boring job that was badly paid. Invariably as local technicians qualified, they were poached for a few more quid by a local lab. I would never dream of blaming the technician for missing something. Or even the cytopathologist that double checked it. It was just not an easy job.

For me though, the very worst experience was one that didn't happen - hopefully. A colleague was in charge of registering local homes, some of which included people who had disabilities. There was a problem in a home with someone who didn't want a smear. Did my colleague come and ask me what the local policy was? Of course not. ( A few personal power political games possibly in play here).

She went happily off to ask a MALE public health doctor who knew jack shit nada about the work of our group. 'Sedate her,' he said authoritatively and arrogantly. 'She needs a smear.' Well, Mr Arrogant Public Health Consultant, it is basically not your decision. Simple as that. It wasn't then and it isn't now. Do not force a woman with disabilities to undergo an invasive test that she clearly doesn't want. Sedating her? Hey date rape doctors here we go.

Finally I'll finish with a comment dear to my heart. It's hardly surprising that patient information has always been one of my priorities. I could never understand why medics, nurses (usually left to nurses of course) and every other clinican in the health service, always thought they could write well, because they couldn't, it wasn't their job to write - theirs to diagnose and treat.

When I discovered that GPs were sending out info and letters, as well as our computerised admin centre sending out similar-but-not-quite-the-same info to our resident female population, I asked a colleague to conduct an audit. By which I mean, asking all the local surgeries to send in their patient info stuff so that we could share best practice, aka tell the ones who are writing rubbish to STOP DOING THAT. Because that was what I wanted at the end of the day.

And what was worrying about the results? GPs were writing out to the women on their list and telling them, basically, that if they didn't attend for a smear they would get cancer. Now that was not only misleading, it was a downright lie, and only served to perpetuate disinformation. I wonder why women are ill-informed about cervical smears? What next? Patient consent perhaps?