Friday 24 May 2019

Dan O'Brien: 'Screening saves many lives, it needs protecting'

Concerns about the future of cancer screening are genuine and certainly not 'hysterical'. Public health is at stake, writes Dan O'Brien

Ruth Morrissey and her husband Paul speak to the media on leaving the Four Courts after the High Court judgment that her incorrect cervical smear tests were the result of negligence. Photo: Collins Courts
Ruth Morrissey and her husband Paul speak to the media on leaving the Four Courts after the High Court judgment that her incorrect cervical smear tests were the result of negligence. Photo: Collins Courts

Over the past nine days, a wave of alarm has gone through the Irish medical profession about the future of public health in Ireland.

On an issue which has little or nothing to do with the self-interest of doctors, some have spoken out because they have profound concerns for the future of screening services of all kinds. In a worst-case scenario they fear people could die unnecessarily in the future if what happened in the High Court last Friday week is not reversed on appeal.

Before getting into the detail of that judgment, consider what some of the people who know what they are talking about have said over the past week.

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"Cervical screening is now in jeopardy," said Dr Ciara Kelly, a former GP who is a presenter on Newstalk radio.

Dr Ray Walley, a past president of the Irish Medical Organisation, widened the concern beyond that disease, saying: "General opinion among medics in discussion nationwide is that we are seeing the death knell of public health screening."

Dr Ailin Rogers, chair of the Irish Surgical Training Group, called for her profession to show more leadership in the discussion. "The onus is on us to protect the screening programme we have, rather than cripple it and render it completely ineffective. It is more important now to ensure the public know that screening is just that - not ideal, but better than nothing," she said.

Last Wednesday, the HSE held an emergency meeting. The suspension of the screening programme was suggested, although not agreed. This reflects the extent of the alarm among those in healthcare.

The extreme concern of the medical profession was triggered by a ruling in the High Court last Friday week in relation to cervical screening which has potentially profound implications for the screening of all diseases and other medical tests as well.

This is a highly sensitive issue for many people - as someone whose father died of cancer I am but one of many, if not a majority, of people who know at first hand the anguish this disease can cause to entire families. But clarity is needed on the facts where there is clarity, and what the implications are of those facts.

There has been insufficient articulation of what is known and what is not known going all the way to the Minister of Health, Simon Harris, and the Taoiseach, Leo Varadkar, who is a medical doctor by profession.

Screening for various diseases, including cancers, can result in early signs being picked up before they become harmful and/or life-threatening. These tests have been rolled out across the world in recent decades. Hundreds of thousands of people, perhaps even millions, are alive today who would otherwise be dead if screening had not been put in place.

Nobody disputes that fact. That there is unanimity in the medical profession on this is the very reason screening has become so ubiquitous internationally.

There is also unanimity that screening is not fool-proof. On some occasions, screening professionals will judge that something is concerning, but which turns out to be nothing. Following up with such patients involves further checks. It may require invasive testing or even surgery. This brings its own worry and disruption and can mean that someone with no illness gets unnecessary or even harmful treatment when someone in need of treatment doesn't get it.

On other occasions, screeners will miss early signs that something is awry because many tests do not give simple negative and positive results. Some of those people whose early signs are missed will go on to fall ill. In the worst-case scenario people die.

Ruth Morrissey is terminally ill with cervical cancer despite having two smear tests in 2009 and 2012. Last Friday week a High Court judge, Mr Justice Kevin Cross, found her tragic case was the result of negligence. He said medics reading smear tests must have "absolute confidence" in their decisions when saying an individual smear test does not warrant further investigation of any kind. It is this high bar that has the medical profession so concerned. Seeking absolutes in any area where medical judgment is not clear-cut is wrong and dangerous, they believe.

Contrary to some claims last week, Mr Justice Cross did not invent the "absolute confidence" test himself. He relied on a case in the British courts two decades ago as a precedent for his judgment in which the "absolute confidence" bar was introduced for cervical screening (the women involved were found to have been victims of negligence by a British healthcare provider).

Where there has been little discussion over the course of the week is what happened in the neighbouring jurisdiction once the "absolute confidence" bar was introduced. This was harder to establish than one might imagine. However, numerous contacts with doctors, agencies and charities in the UK involved in healthcare, cancer and cervical cancer screening pointed to no major changes to screening after the "absolute confidence" bar was introduced there almost two decades ago.

This offers some reassurance - but not nearly enough. Ireland is different from the UK in a number of respects.

From speaking to multiple people in healthcare over the past week, it is clear those involved in screening services are at a low ebb.

The controversies around the Irish cervical screening programme in recent times have led to a widely held misperception of wholesale wrong-doing despite there being no evidence Irish rates of misread smears are different from peer countries. They feel they are being accused of being culpable in people's deaths when they have not been.

Professionals are talking about moving out of the screening field for fear that they may end up vilified in court cases. This is not happening in the British system.

There is also the issue of resources. As always with issues of health, appearing to put a monetary value on life can be viewed as insensitive or worse. But allocating available resources efficiently is about saving as many lives as possible.

Currently the cervical screening programme costs €32m annually. If the awards that have been made recently were to multiply, awards and legal fees would exceed the cost of the programme. Some fear they could end up costing multiples of the programme itself.

If medical litigation were to widen out to other areas and judges were to interpret the "absolute confidence" bar liberally, much more of the healthcare budget could be spent on awards and legal fees than is already the case.

In terms of the rate of litigation, the amounts often awarded in compensation cases and high legal fees, this jurisdiction is different from our neighbour. It is for these reasons there is such concern in the medical profession.

The State Claims Agency, which manages cases taken against all branches of the State, was dealing with almost 10,000 claims as of the end of 2017 (the latest figures available and long before the Cross judgment loomed into view). The estimated liability, which comprises mostly medical cases, stood at €2.7bn, a figure similar to the cost of the Government's broadband plan which caused so much controversy.

Last Friday, at the beginning of a process to appeal the judgment, the judge in the case accused doctors and others of reacting "hysterically" to his ruling a week earlier. The medical profession is a formidable lobby group which is validly blamed for resisting reforms that would address failings in the wider system, but to accuse its members of being "hysterical" on this issue was more than unwise.

If medics stand accused of anything it is a failure to communicate clearly and repeatedly how screening works, its weaknesses and how it has saved many lives.

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