Metropolitan Auckland Cervical Screening Strategic Plan 2015 - 2017
Metro Auckland Cervical Screening Coordination Service Strategic Plan 2015 - 2017
Introduction
The National Cervical Screening Programme (NCSP) was established as a national programme over twenty years ago in 1990. The aim of the programme is to reduce the number of women who develop cervical cancer and to reduce the number of women who die from cervical cancer. A cervical smear test is a screening test to look for abnormal cell changes to the cervix. Some cells with abnormal changes can develop into cancer if they are not treated. Treatment of abnormal cells is very effective at preventing cancer. (www.nsu.govt.nz) Cervical smear tests help identify those women at higher risk of developing cervical cancer and its precursors so that treatment can be provided at the earliest possible stage of disease to minimize complications from treatment and risks of progression of disease.
There has been a significant improvement in the key outcomes for the NCSP nationally with rates of cancer and deaths decreasing between 1996 and 2009.
– Nationally, rates of cervical cancer (incidence) nearly halved from 10.5 to 6.6 per 100,000 for women of all ethnicities, and more than halved, from 25.0 to 10.4 per 100,000, for Māori women.
– Mortality also declined significantly from 3.8 to 1.7 per 100,000 for women of all ethnicities, and from 13.0 to 5.4 per 100,000 for Māori women
The updated NSCP Guidelines to best practice for clinicians in 2008 and the Quality Assurance and Monitoring recommendations within the NCSP Review 2011 provide a framework for further improvement. The Policies and Standards were revised and updated in 2014.
Active engagement with eligible women and their initial and ongoing participation in the Cervical Screening Programme remain important. Issues in the Auckland area include equity of coverage for Māori, Pacific and Asian women and coordination of activities across service providers along the screening pathway.
Data from the NCSP for September 2015 shows:
– Only half of the eligible Māori women are screened on time (57.4% ADHB, 62.0% in CMDHB, 56.8 % WDHB)
– Nearly two thirds of Asian women are screened on time (65.4% ADHB, 63.6% in CMDHB, 63.5 % WDHB)
– Coverage rates for Pacific are markedly better in Auckland than in Waitemata or Counties Manukau (80.6% ADHB, 74.7 % in CMDHB, 71.7% WDHB). The high rate in Auckland is thought to be associated with effective Pacific leadership and the strong Parish nursing network (a component of the Auckland DHB funded Healthy Village Action Zone (HVAZ) Pacific education and engagement programme) which prioritises cervical screening.
– The national 3 year coverage rate is now 76.6% (a decrease since October 2012 when it was 77.3%). Total coverage rates in Auckland are above the national rate at 79.3%). Counties Manukau and Waitemata DHBs are slightly below the national rate. (72.6% CMDHB, 76.5% WDHB) however they have improved since 2012. The chart below shows changes in the Cervical Screening 3 year Coverage Rate from 2011 to 2015.
In relation to programme organisation, there is a multiplicity of funding streams, management lines and providers in the Auckland region. Both nationally and locally managed services contribute to cervical screening programme outcomes. Services include:
– National Screening Unit funding, national coordination, policy, quality assurance and audit
– Health Promotion and social marketing
– National Cervical Screening Programme (NCSP) register administration
– Free smears for priority group women
– Low cost smears
– Evening and weekend clinics
– Laboratory services
– Colposcopy services.
– Training for Smear Takers
A range of providers deliver services including:
– General practices
– Family Planning
– Independent Service Providers (ISPs)
– Auckland Regional Public Health Service (ARPHS)
– Community/Hospital laboratories
– DHB provider arms.
Primary Healthcare Organisations (PHOs), District Health Boards (DHBs) and the National Screening Unit (NSU) purchase services to meet programme objectives. DHBs use baseline funding as well as revenue funding from the NSU to purchase services including free smears for priority group women. The National Screening Unit (NSU) contracts with four Independent Provider Organisations to provide health promotion and free smears for women in metropolitan Auckland, of note this service is currently under a national review by the NSU.
In 2014 cervical screening became a Primary care Integrated Performance and Incentive Framework (IPIF) target. This enable increased focus and attention on strategies to increase coverage. The target was set at 80% coverage but unfortunately did not identify priority group population targets.
Guiding Principles
This Strategic Plan is aligned with the legislative framework within which the programme operates, including regional governance, and reflects the following principles.
– The Treaty of Waitangi principles of partnership, participation and protection.
– Equity of outcome for priority groups[1] within the programme.
– Women making an informed decision about enrolment and screening
– Population health perspectives and the principles of screening programmes including coherence with the cervical screening pathway and the cancer screening intervention logic model (appended).
– Evidence underpins activity and new activity is undertaken within an evaluative framework, recognizing the importance of quality and safety.
– Collaborative ways of working towards improving cervical screening uptake and regular screening.
– Responsive to clients’ needs and the socio-cultural diversity among them.
– Acknowledging the important role and accountability of PHOs and General Practices (working with the regional coordination service) as both providers and coordinators of service provision within the framework of the National Cervical Screening Programme.
Cervical Screening Goals for Metropolitan Auckland
– We will increase the Total cervical screening coverage rate to 80%.
– We will significantly reduce inequities in cervical screening coverage and participation along the screening pathway, particularly for Māori, Pacific and Asian women.
– We will work with the NSU and other key stakeholders to ensure the screening programme is line with current evidence and best practice
Key performance areas
Key performance area 1: Governance, leadership and monitoring
1. An effective regional governance body will provide strategic leadership and monitor progress against goals.
– In 2014 the Metro Auckland cervical screening governance body was moved to sit with the Metro Auckland Planning and Funding managers group which also includes the Waitemata DHB Public Health Physician
– The governance group will support development of regionally consistent approaches to strategy and service delivery
– The governance group will monitor coverage as well as other data along the screening pathway and use available evidence to inform their recommendations for service activity along the screening pathway
– The governance group will ensure timely effective communication occurs between the metro Auckland region and the NSU.
– The governance group sets the budget and reviews expenditure
2. A high functioning coordination service to drive activity and change processes with primary care.
– A project manager leads the coordination service with the support of cervical screening nurse
– Operationally, the project manager convenes a monthly cervical screening operations group inclusive of primary care, DHB representatives and ISPs and smear taker training providers. The purpose of this group is to identify opportunities for systematic improvement and to function as a coordinated team with shared goals to achieve more than the sum of the parts. Any blockages to effective functioning of this operations group should be escalated to the governance group to address.
Key performance area 2: Quality information and data
Quality data underpins effective programme management as well as the effectiveness and efficiency of practice level activities including invitation and recall of women enrolled in primary care. The quality and timeliness of the data available to primary care from the NCSP register has been improved and from the December 2015 the data lists/reports will be updated to provide the screening status of all women enrolled in the PHO, and will not be limited to the current quarter. Ongoing issues still need review and resolution including the quality of the hysterectomy information and ensuring all result are recorded accurately on the NCSP register.
3. Improve the quality of information on the NCSP – Register for women who live in the Auckland area, particularly with respect to ethnicity and hysterectomy
– A working group has been established in collaboration with Primary care to focus on correct hysterectomy management
– Complete an exclusions audit from Dr Info to ensure women are not put at clinical risk due to being excluded from routine screening
4. Ongoing monitoring and review of the data (including coverage reports) to ensure quality information is available to support best practice.
Key performance area 3: Improved access and reduced barriers
5. We will improve access to cervical screening for all women by:
– Encouraging compliance with Policy and Quality Standards
Providing targeted free smears
– Free smears will be made available through PHOs for priority group women within available DHB resources
– Ongoing monitoring will occur to ensure the funded free smears are targeted to priority women including free smears funded by the NSU through the ISPs.
Messaging to improve women’s knowledge of the importance of having regular cervical screening
– We will use a range of resources to increase women’s understanding of the importance of regular cervical screening, with a particular focus on priority women.
– We will develop a training programme which supports improved engagement, participation and provision of informed consent. This programme will be made available for all service providers (both clinical and non-clinical staff) to use.
– We will supplement the NSU national social marketing campaign to target Asian and Maori women in the Metro Auckland region and will also target Pacific women.
– We will support primary care practices to display available print resources in multiple languages (brochures and posters).
– We will work with NSU to ensure resources are translated in to key languages
Removing other barriers to access along the screening pathway, such as cost, access at times that are convenient, transport and cultural barriers
– We will ensure that primary care providers know what support ISPs can provide including transporting women and supporting them through cervical screening and treatment appointments.
– We will ensure that there is an alternative provider of cervical screening for women who cannot or do not wish to access this service from their primary care practice or choose to go elsewhere.
– We will develop and monitor ongoing a referral pathway between PHOs and ISPs.
Explore opportunities to implement HPV primary screening in the metro Auckland region. Investigate if self-sampling would be an initiative to increase coverage for priority women whilst maintaining a quality best practice service.
Culturally Specific strategies for Māori, Pacific and Asian Women
Based on increased awareness of barriers and strategies to reduce those barriers
Strategies common to each of the three groups:
Ë Improve the health literacy of women in relation to the importance of having regular cervical smears to age 69 years.
Ë Ensure that information about community health workers who can help women attend appointments and support them through screening is available to women and to general practices in communities with a high proportion of Māori, Pacific and/or Asian women.
Ë Support general practices in areas with larger Māori, Pacific and Asian populations to provide respectful screening services; to optimise opportunistic screening, and; to make smears freely available to women either within the practice or nearby in an appropriate setting.
Ë Support primary care practice in areas with larger Māori, Pacific and Asian populations to provide the best recall and reminder services to women including text to remind to minimise DNAs at screening and along the screening pathway.
Ë Gather more qualitative information to learn from and share successes from primary care.
Strategies specific to each group:
Strategies specifically to improve cervical screening coverage and outcomes for wahine. We will …. / Strategies specifically to improve cervical screening coverage and outcomes for Pasifika women. We will … / Strategies specifically to improve cervical screening coverage and outcomes for Asian women. We will …Ë Gather evidence from successful initiatives for Māori women from other regions. / Ë Ensure that Pacific leadership is engaged in cervical screening governance and that key Pacific people are engaged in the development of resources from the beginning. / Ë Acknowledge language, culture, religion, awareness of the screening programme and perception, cost and transportation are potential barriers for Asians.
Ë Link with the National Kaitiaki Group to access more timely coverage information. / Ë Disseminate Pacific Best Practice through primary care and in colposcopy to improve main-stream responsiveness to Pacific women. / Ë Ensure that Asian leadership is engaged in cervical screening governance and that key Asian people are engaged in the development of resources from the beginning.
Ë Improve the quality of ethnicity and other information recorded on the NCSP – R for Māori women. / Ë Build on and extend established Pacific relationships in the community through the HVAZ model of parish community nurses. / Ë Promote CALD cultural competencies, and encourage the uptake of CALD cultural competency training among primary care providers and colposcopy health providers to improve cross-cultural interactions and cultural responsiveness to Asian women.
Ë Take a whanau ora approach so men and other family members encourage and support their wahine to access screening and other services along the screening pathway. / Ë Work towards extending the parish community nurse network throughout WDHB and further inside CMDHB. / Ë Build on and extend established Asian networks in the community for information sharing and awareness raising (e.g. The Asian Network Inc., Chinese New Settlers Service Trust, Chinese community groups, Korean Society, Indian Association).
Ë Promote regular screening in Māori settings and ensure local messaging talks to wahine. / Ë Ensure that both the message and the messenger is appropriate for Pacific women. / Ë Ensure that messages about the importance of cervical smears and how to access them are communicated effectively, easy to understand, culturally and linguistically appropriate so that Asian women can make informed decisions and take appropriate actions
Ë Ensure additional providers who are appropriate for Pacific women are readily accessible for Pacific women who do not want to access cervical screening from their usual general practice. / Ë Ensure that cervical screening providers (funded or not funded) are gender appropriate for Asian women and that alternative providers are readily accessible for Asian women who do not want to access cervical screening from their usual general practice.
Ë Explore options for engaging Pacific families around supporting women to access cervical screening. / Ë Target younger age groups, religious groups, and those from high deprivation groups (NZDep Quintile 5).
Ë Identify practices with low Asian coverage rates and explore the effectiveness of telephone reminders in patient’s languages coupled with provision of translated information.
Ë / Ë / Ë Engage Asian community groups and their settings to promote healthy messages which includes preventive screening behaviours
Ë / Ë / Ë Provide access to interpreters where language is a barrier
Key performance area 4: Primary care delivery
6. We will enhance primary care’s responsiveness by: