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Three independent external reviews showed that between 2013 and 2018 the Southern District Health Board (SDHB) colonoscopy service delayed or denied colonoscopies to numerous symptomatic patients, with adverse clinical outcomes for some.[[1–3]] The SDHB Board has subsequently accepted responsibility for these unacceptably poor outcomes and has apologised to all those affected.[[4]]

During this same period, the SDHB wished to join the National Bowel Screening Programme (NBSP). As a result, in April 2017, following a request from the Ministry of Health (MoH) in December 2016, the SDHB submitted a draft business case for inclusion in the NBSP Business Case for 2017/2018 to Treasury for Budget 2017. Funding was subsequently approved, and in April 2017 the SDHB began preparing for an April 2018 ‘go-live’ for the screening programme.

The NBSP Business Case 2017/2018[[5]] identified six evaluation areas to be used to assess district health board (DHB) readiness for delivery of the bowel screening programme (Table 1).

Table 1: NBSP Readiness Assessment Evaluation Areas.

To assess the SDHB’s readiness to begin offering bowel screening to their population, the MoH’s NBSP team monitored progress and achievement against these criteria, via a series of self-assessment reports, document reviews and site visit-based assessments by NBSP personnel. After going through this process, permission for the SDHB to commence delivery of the NBSP to its eligible population was granted by the NBSP Leadership and Governance Groups on 18 April 2018. The service went live in the SDHB region on 24 April 2018. Given the state of the SDHB colonoscopy service and some related colorectal cancer (CRC) clinical management services, the authors of this article feel it is their professional responsibility to ask how permission was granted under the circumstances that prevailed at the time.

Requesting information under the Official Information Act

In order to systematically investigate the adequacy of the assessment process, a series of requests for information under the Official Information Act 1982[[6]] (OIA) were lodged with the MoH (Appendix Table 1). These were refused on the grounds that the requests, as worded, were for “a very large volume of information and may be refused under section 18(f) of the Official Information Act 1982, because the information requested could not be made available without substantial collation or research.” It was suggested by the MoH that by narrowing the scope of the requests, either by selecting a shorter time frame and/or specifying a topic, the information may be provided. However, even with the requests narrowed, the MoH may still have required them to be narrowed further, extend the amount of time necessary to respond or even refuse the requests.

Accordingly, a series of refined requests was then made. This second series focussed on two main areas of interest: (i) the introduction and operationalisation of the Colonoscopy Waiting Times Indicator (CWTI), as the only metric of colonoscopy performance management information on which DHB readiness to assume bowel screening would be assessed; and (ii) the National Bowel Screening Programme at the SDHB, with particular emphasis on the identification, awareness and mitigation of risk to colonoscopy access for symptomatic patients arising from either of these, as evidenced by reports, meeting minutes, emails or discussions. The timeframe covered by the OIA requests was reduced by half as a result of re-scoping and refining. Individual questions were assigned an indicative priority to allow the MoH to stratify the timing of their responses according to their resources (Appendix Table 2).

The second series of refined requests was also declined under section 18(f) of the OIA 1982 because the information requested could not be made available without substantial collation or research. However, following intercession by the Office of the Ombudsman, and after an understandable slowing of the process due to the necessity of dealing with the COVID-19 pandemic, 3,516 pages of documents (in hard copy only) were received from the MoH in August 2020, relating to the OIA requests made to the MoH. The lengthy process to obtain any information under the OIA is detailed elsewhere (Appendix Table 3).

The 3,516 pages received constitute a partial response to the information requested of the MoH. For example, no information was provided on the recollections of ministers of health, directors-general of health or MoH staff of discussions relating to colonoscopy access for symptomatic patients within SDHB, as had been requested. It is worth noting that in the time period covered by these requests (2016 through 2019) there were, within the SDHB, ongoing concerns regarding access to colonoscopy raised on multiple occasions with the SDHB Chief Executive Officer (CEO) and Chief Medical Officer.[[1]] Given the ‘no surprises’ expectations in the CEO–MoH relationship, it seems unlikely that no such discussions occurred. A question as to whether monitoring of referral trends for symptomatic patients requiring colonoscopy was undertaken as preparation for SDHB implementation went unanswered. A number of other questions were apparently ignored, with no rationale for a non-response provided.

The documents obtained

Despite earlier communication with the MoH representative handling these requests regarding the file size of the aggregated documents and the possibility of providing them electronically, the entire document set was subsequently printed and then couriered. There are a number of remedies to the issue of email file size limitations, any of which would have preserved the electronic format. Instead, the format in which the documents were received defied meaningful analysis. This required the entire document set to be scanned to portable document format (.pdf), then converted to optical character reader (OCR) format, in order to become fully searchable documents. Trial and error revealed the best resolution settings in the OCR conversion process to overcome the issue of pages being watermarked with ‘Released under the Official Information Act 1982’. It is clear that receiving documents of this volume and in hard-copy format precludes any useful analysis for most people most of the time.

The documents were then searched for key words and phrases. The context in which the word or phrase occurred could then be assessed and the containing document identified for further analysis as required. After further analysis, a ‘once over’ read of documents assessed as low relevance was undertaken to ensure all relevant information had been seen. Much of the information provided was irrelevant to the question of the identification and management of risks to provision of clinically appropriate levels of diagnostic colonoscopy to symptomatic patients, in either a pre- or post-bowel screening SDHB environment. Unsurprisingly, copious pages of National Bowel Screening communications/promotional material, which were included, failed to shine any light on risk awareness or risk management strategy in this regard.

Deficiencies in the plan for the SDHB to join the NBSP

The ‘onboarding’ process driven by the MoH included a requirement for the SDHB to provide a colonoscopy production plan with a six-month horizon. The only production plan included in the document set is populated out to the end of June 2018, just two months after go-live. The template beyond that date is empty, yet it is precisely at this time that the first increase in demand for colonoscopy arising from bowel screening participants with positive results would be experienced. There is no modelling of the increased volumes required by radiology, surgery or oncology arising from additional cancers detected through the screening programme. The information obtained under the OIA was devoid of evidence of capacity to support additional volumes in diagnostic and treatment services. This is a concern, as a formal review by the University of Otago of the SDHB Department of Surgical Sciences in June 2017 was informed by staff that access to both elective and acute operating theatres on the Dunedin site resulted in patient delays and suboptimal treatment experiences.[[7]]

The specific risk of reduced access to colonoscopy for symptomatic patients as a result of the introduction of bowel screening was not obviously mitigated through the SDHB NBSP implementation process. Instead, there appears to be reliance solely on the CWTI target performance. It is now understood that the CWTI can easily be manipulated by a number of means, including applying direct access referral criteria inappropriately to specialist referrals, applying the criteria inconsistently and even choosing to decline referrals using tone and language that discourages referrers from future referrals to the service. Pre-implementation referral management practices were not assessed, and the impact of these on the apparent performance of the endoscopy service was therefore never considered nor associated risks identified.

Referral management practice was not audited or otherwise reviewed, though a document provided suggests that a national change to data collection by the MoH meant that the rate of declined colonoscopy referrals would have been known. It would also have been known that the SDHB declined referral rate was high compared to other DHBs.[[3]] From 2016 there were repeated formal written complaints to the SDHB CEO from senior surgeons concerned at the difficulty they were experiencing getting patients they referred accepted for colonoscopy. Also, in 2017 the SDHB surveyed the views of their endoscopy services users. Here 32.4% of respondents were aware of patients they thought came to harm because of declined endoscopies. None of these concerns are evident in any of the documentation provided under the OIA. That the SDHB was already failing to fully assess symptomatic patients in a clinically timely manner, before the bowel screening programme was introduced, was not revealed.

Concerns about the DHB capacity to join the NBSP

From the emails provided it is apparent that there were significant concerns among the MoH NBSP team in the week immediately prior to NBSP granting permission for the SDHB to go live with screening in their region. These concerns related to the ability of the SDHB to provide sufficient capacity for both NBSP participants and symptomatic patients, in terms of colonoscopy, radiology, surgery, medical oncology treatment and radiation oncology treatment. These concerns arose after months of preparation and site-readiness assessments undertaken by the MoH NBSP team. In an email from 11 April 2018, the Clinical Lead for NBSP asked NBSP staff to obtain some reassurance from SDHB that “symptomatic patients will not be disadvantaged in any way.” The documents provided did not include a response to that request.

Several MoH staff emails to SDHB personnel stressed the need for a letter of assurance on these matters from the SDHB CEO, prior to seeking approval five days later for SDHB to go live with bowel screening. A letter was received by the MoH NBSP team from the CEO of SDHB (dated 10 April 2018) in which he advised that surgery, medical oncology and radiation oncology staff were committed to making the programme work and he was satisfied they will be able to provide the additional volumes that the programme will generate. No CEO assurance was provided for colonoscopy or radiology capacity. Subsequent to receiving this letter, the Clinical Lead for NBSP at the MoH expressed her concerns (in an email dated 12 April 2018 to the MoH NBSP Programme Director and the Implementation Manager – Bowel Screening at the National Screening Unit) that the SDHB CEO letter did not say “without compromising the waiting times for symptomatic patients—that is the ethical concern we have.”

The decision to join the NBSP

In a memo requesting permission from NBSP Governance and Leadership Groups for SDHB to go live with screening, NBSP personnel note having received a letter from the SDHB CEO giving assurance that there will be sufficient colonoscopy capacity. The letter obtained under OIA offers no such assurance of sufficient colonoscopy capacity. Despite this, permission was granted on 17 April 2018—in our opinion inappropriately—and screening commenced in the SDHB region on 24 April 2018.

The MoH was asked to confirm if the CEO letter of assurance provided under OIA was the only written assurance as to capacity availability obtained from the SDHB in the process to commence bowel screening in that region. A letter of reply from the MoH (Population Health and Prevention) in October 2020 (Appendix Figure 1) confirmed that: (i) there is no additional written correspondence the MoH received from SDHB beyond what was sent to us in August 2020; (ii) “the decisions relating to SDHB were taken by an earlier leadership team so [they were] unable to provide further context”; and (iii) “the delivery by SDHB of a consistently high-performing bowel screening programme, exceeding national targets would suggest the confirmation of readiness was sound.”

Problems encountered with the OIA

The authors have confidence in their analysis of the material provided under the OIA, and in the conclusions drawn. They are experienced in analysis of complex information and had access to the technology and skills required to ‘drill-down’ through what was provided, even though the format was not analysis-friendly. The unduly long process required to obtain the requested information fails to diminish the value of analysis in this instance—in fact, it emphasises necessity of the analysis. The authors are aware that the intent of the OIA 1982 is sometimes undermined by the obfuscation, delay and deliberate barriers used by some entities and agencies subject to the OIA. For many people wishing to use the OIA mechanism to make enquiries of public institutions, the net confounding effect of these tactics would be insurmountable. The authors conclude, along with others, including its principal sponsor, that the OIA 1982 is no longer fit-for-purpose and needs to be revised.[[8–10]]

We, the authors, stress that the evidence for this investigation was obtained from the MoH under the conditions of the OIA. We assume that their answers were correct and complete. On the evidence, we conclude the process to assess SDHB capacity to assume NBSP did not ask critical questions. Further, the SDHB was not required by the assessment process to disclose relevant issues, and apparently did not choose to disclose voluntarily.

Analysis of the process to join the NBSP

It has become clear that the MoH process for assessing the readiness of a DHB to join the NBSP was flawed and should be made more open and transparent. There is a need for specific targets, and their method of calculation, to be identified and consistently met before screening is implemented. Any additional clinical load on a DHB must be considered in the context of its current ability to meet the needs of its population. In the case of the SDHB, uncovering the true level of unmet need in symptomatic patients would have allowed an opportunity to ensure safeguarded access for these patients to colonoscopy as clinically indicated. Instead, reviews have found that their access and clinical outcomes were jeopardised.[[3,4]]

Further, the authors believe that significant value and safety would be added to the NBSP-onboarding assessment process by ensuring that it includes benchmarking (i) the rate of declined colonoscopy referrals with other DHBs, and considering this rate against the known CRC incidence rate for the DHB population, and (ii) the proportion of new CRCs diagnosed via emergency department presentation. Additionally, DHBs should be required to disclose complaints and issues raised with DHB management pertaining to endoscopy service provision in the years preceding NBSP-onboarding assessment.

There should be recognition, at the level of government, of the potential for health targets to incentivise perverse behaviours by organisations and individuals. The reliance on the CWTI as the sole metric of performance of colonoscopy services should cease, or at least be coupled with a more transparent evaluation of performance, which looks for and reports on unmet need. This is particularly important given that some other DHBs are yet to commence bowel screening, and the same failings of readiness assessment may produce similar adverse outcomes to those seen within the symptomatic population of the SDHB. Concerns about these possible failings have been recently aired in the public media.[[11]]

Need for better planning before DHBs join the NBSP

There should be greater planning capability within both the MoH and DHBs when introducing new services. It is noted that the preliminary groundwork for bowel screening in New Zealand began over twenty years ago, and workforce development was considered a critical pre-requisite at that time. Despite this early awareness, successive governments have failed to prioritise workforce development in any meaningful way.[[1]] The opportunity to use the intervening years to build a specialist workforce sufficient for the task of bowel screening was wasted. The introduction of a national bowel screening programme has not been effectively planned for in this regard. It is hoped that current plans to mitigate the resourcing deficiencies will be successful. It is a serious concern, however, that the final letter from the MoH (Appendix Figure 1) expresses the view that the high level of performance of the SDHB’s bowel screening programme suggests that the MoH’s permission for screening to begin there was correct. That opinion ignored or ascribed no importance to any possible adverse clinical consequence that the concomitant restrictions on colonoscopy access had for numerous symptomatic patients in the SDHB region. The deficiencies clearly revealed in subsequent reviews[[1–3]] outline the serious consequences of the poor decision-making process.

The introduction of new health policy and services must be accompanied by well-defined lines of responsibility and accountability, particularly in environments of constrained resource. Where new policy or service provision creates inequities in access, as this innovation has, clear leadership and accountability for remediation is essential.

The potential for harm to symptomatic patients resulting from the additional demand on already limited resources occasioned by the introduction of the National Bowel Screening Programme warrants further research.

Good bowel screening programmes and timely colonoscopy for symptomatic patients are equally important in the battle against CRC. This is particularly so in a country such as New Zealand where CRC is so common. Indeed, screening should have started here many years earlier, should have a lower positive test threshold, and should provide coverage starting at a younger age, particularly for Māori. Both screening and symptomatic colonoscopy services must be adequately resourced (probably the main underlying problem) and run separately so they are never allowed to compete for resources—as they did in the SDHB.[[1]]

Appendix

Appendix Table 1: Original OIA requests to Ministry of Health, early September 2019.

Appendix Table 2: Re-scoped OIA requests to Ministry of Health, late September 2019.

Appendix Table 3: P Bagshaw OIA requests—progress timeline, September 2019 to August 2020.

Appendix Figure 1: Letter from Ministry of Health, Population Health and Prevention, to P Bagshaw 30 October 2020.

Summary

Abstract

We examined the documentation underlying the decision to permit the Southern District Health Board (SDHB) to join the National Bowel Screening Programme (NBSP) at a time when it was not providing an adequate colonoscopy service for symptomatic patients. A coordinated sequence of relevant Official Information Act 1982 (OIA) requests was lodged with the New Zealand Ministry of Health (MoH), which is responsible for determining the readiness of district health boards (DHBs) to join the NBSP. However, the MoH OIA process was obfuscating, unduly long and responded only after they anticipated imminent intervention by the Office of the Ombudsman. The amount of information provided was massive, partly irrelevant and presented in an inconvenient format. It revealed that the MoH readiness process was incomplete, and permission for the SDHB to join the NBSP was given prematurely without following due process and despite concerns expressed by some MoH staff. Subsequently, the MoH has failed to admit that they made errors in this case or have any weaknesses in their readiness assessment process. The MoH readiness process failed to determine that the SDHB was not ready to join the NBSP in 2018. Concerns have been expressed in the public media that such failures have occurred with the assessment of other DHBs. The process needs to be overhauled or replaced before further permissions are granted to DHBs. Requests for information under the OIA from the MoH, and similar public entities and agencies subject to the OIA, are too easily deferred, derailed or declined. The OIA is in need of revision.

Aim

Method

Results

Conclusion

Author Information

Philip Bagshaw: Chair, Canterbury Charity Hospital Trust. Paula Goodman: Independent. Brian Cox: Hugh Adam Cancer Epidemiology Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine.

Acknowledgements

Correspondence

Philip Bagshaw, Chair, Canterbury Charity Hospital Trust

Correspondence Email

philipfbagshaw@gmail.com

Competing Interests

Nil.

1. Bagshaw P, Cox B. Adequacy of publicly funded colonoscopy services in New Zealand. NZ Med J 2020;133(1526):7-11.

2. Agenda Southern District Health Board Meeting 3[[rd]] November 2020. https://www.southernhealth.nz/sites/default/files/2020-10/2020-11-03%20SDHB%20Board%20Agenda_Public.pdf

3. Bissett I, Broome K. Colonoscopy Patient Review Report for Southern District Health Board September 2020 https://www.southernhealth.nz/sites/default/files/2020-10/2020-10-06%20SDHB%20Board%20Agenda_public.pdf

4. Statement from Dave Cull, Chair, SDHB - Colonoscopy Services. Issue: Tue 6[[th]] October 2020. https://www.southernhealth.nz/publications/statement-dave-cull-chair-sdhb-colonoscopy-services

5. National Bowel Screening Programme Business Case 2017/2018. https://www.health.govt.nz/system/files/documents/pages/nbsp_business_case_2017_18_v2_redacted-optimised.pdf

6. Official Information Act 1982. https://www.legislation.govt.nz/act/public/1982/0156/latest/whole.html

7. University of Otago Review. Department of Surgical Sciences. University of Otago; June, 2017.

8. Amnesty International. Joint call for overhaul of Official Information Act. 9[[th]] October 2020. https://www.amnesty.org.nz/joint-calls-overhaul-oia

9. Palmer G. A hard look at the New Zealand experience with the Official Information Act after 25 years. Address to International Conference of Information Commissioners, Wellington 27[[th]] November 2007. https://www.lawcom.govt.nz/sites/default/files/audioFiles/Palmer%20Speech%20on%20Official%20Information%20Act.pdf

10. Ecclestone A. An updated Official Information Act must strengthen our right to know. 14[[th]] July 2020. https://www.stuff.co.nz/national/politics/opinion/122114366/an-updated-official-information-act-must-strengthen-our-right-to-know

11. Broughton C. Screening despite demand failings. The Press, Christchurch 23[[rd]] January 2021.

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Three independent external reviews showed that between 2013 and 2018 the Southern District Health Board (SDHB) colonoscopy service delayed or denied colonoscopies to numerous symptomatic patients, with adverse clinical outcomes for some.[[1–3]] The SDHB Board has subsequently accepted responsibility for these unacceptably poor outcomes and has apologised to all those affected.[[4]]

During this same period, the SDHB wished to join the National Bowel Screening Programme (NBSP). As a result, in April 2017, following a request from the Ministry of Health (MoH) in December 2016, the SDHB submitted a draft business case for inclusion in the NBSP Business Case for 2017/2018 to Treasury for Budget 2017. Funding was subsequently approved, and in April 2017 the SDHB began preparing for an April 2018 ‘go-live’ for the screening programme.

The NBSP Business Case 2017/2018[[5]] identified six evaluation areas to be used to assess district health board (DHB) readiness for delivery of the bowel screening programme (Table 1).

Table 1: NBSP Readiness Assessment Evaluation Areas.

To assess the SDHB’s readiness to begin offering bowel screening to their population, the MoH’s NBSP team monitored progress and achievement against these criteria, via a series of self-assessment reports, document reviews and site visit-based assessments by NBSP personnel. After going through this process, permission for the SDHB to commence delivery of the NBSP to its eligible population was granted by the NBSP Leadership and Governance Groups on 18 April 2018. The service went live in the SDHB region on 24 April 2018. Given the state of the SDHB colonoscopy service and some related colorectal cancer (CRC) clinical management services, the authors of this article feel it is their professional responsibility to ask how permission was granted under the circumstances that prevailed at the time.

Requesting information under the Official Information Act

In order to systematically investigate the adequacy of the assessment process, a series of requests for information under the Official Information Act 1982[[6]] (OIA) were lodged with the MoH (Appendix Table 1). These were refused on the grounds that the requests, as worded, were for “a very large volume of information and may be refused under section 18(f) of the Official Information Act 1982, because the information requested could not be made available without substantial collation or research.” It was suggested by the MoH that by narrowing the scope of the requests, either by selecting a shorter time frame and/or specifying a topic, the information may be provided. However, even with the requests narrowed, the MoH may still have required them to be narrowed further, extend the amount of time necessary to respond or even refuse the requests.

Accordingly, a series of refined requests was then made. This second series focussed on two main areas of interest: (i) the introduction and operationalisation of the Colonoscopy Waiting Times Indicator (CWTI), as the only metric of colonoscopy performance management information on which DHB readiness to assume bowel screening would be assessed; and (ii) the National Bowel Screening Programme at the SDHB, with particular emphasis on the identification, awareness and mitigation of risk to colonoscopy access for symptomatic patients arising from either of these, as evidenced by reports, meeting minutes, emails or discussions. The timeframe covered by the OIA requests was reduced by half as a result of re-scoping and refining. Individual questions were assigned an indicative priority to allow the MoH to stratify the timing of their responses according to their resources (Appendix Table 2).

The second series of refined requests was also declined under section 18(f) of the OIA 1982 because the information requested could not be made available without substantial collation or research. However, following intercession by the Office of the Ombudsman, and after an understandable slowing of the process due to the necessity of dealing with the COVID-19 pandemic, 3,516 pages of documents (in hard copy only) were received from the MoH in August 2020, relating to the OIA requests made to the MoH. The lengthy process to obtain any information under the OIA is detailed elsewhere (Appendix Table 3).

The 3,516 pages received constitute a partial response to the information requested of the MoH. For example, no information was provided on the recollections of ministers of health, directors-general of health or MoH staff of discussions relating to colonoscopy access for symptomatic patients within SDHB, as had been requested. It is worth noting that in the time period covered by these requests (2016 through 2019) there were, within the SDHB, ongoing concerns regarding access to colonoscopy raised on multiple occasions with the SDHB Chief Executive Officer (CEO) and Chief Medical Officer.[[1]] Given the ‘no surprises’ expectations in the CEO–MoH relationship, it seems unlikely that no such discussions occurred. A question as to whether monitoring of referral trends for symptomatic patients requiring colonoscopy was undertaken as preparation for SDHB implementation went unanswered. A number of other questions were apparently ignored, with no rationale for a non-response provided.

The documents obtained

Despite earlier communication with the MoH representative handling these requests regarding the file size of the aggregated documents and the possibility of providing them electronically, the entire document set was subsequently printed and then couriered. There are a number of remedies to the issue of email file size limitations, any of which would have preserved the electronic format. Instead, the format in which the documents were received defied meaningful analysis. This required the entire document set to be scanned to portable document format (.pdf), then converted to optical character reader (OCR) format, in order to become fully searchable documents. Trial and error revealed the best resolution settings in the OCR conversion process to overcome the issue of pages being watermarked with ‘Released under the Official Information Act 1982’. It is clear that receiving documents of this volume and in hard-copy format precludes any useful analysis for most people most of the time.

The documents were then searched for key words and phrases. The context in which the word or phrase occurred could then be assessed and the containing document identified for further analysis as required. After further analysis, a ‘once over’ read of documents assessed as low relevance was undertaken to ensure all relevant information had been seen. Much of the information provided was irrelevant to the question of the identification and management of risks to provision of clinically appropriate levels of diagnostic colonoscopy to symptomatic patients, in either a pre- or post-bowel screening SDHB environment. Unsurprisingly, copious pages of National Bowel Screening communications/promotional material, which were included, failed to shine any light on risk awareness or risk management strategy in this regard.

Deficiencies in the plan for the SDHB to join the NBSP

The ‘onboarding’ process driven by the MoH included a requirement for the SDHB to provide a colonoscopy production plan with a six-month horizon. The only production plan included in the document set is populated out to the end of June 2018, just two months after go-live. The template beyond that date is empty, yet it is precisely at this time that the first increase in demand for colonoscopy arising from bowel screening participants with positive results would be experienced. There is no modelling of the increased volumes required by radiology, surgery or oncology arising from additional cancers detected through the screening programme. The information obtained under the OIA was devoid of evidence of capacity to support additional volumes in diagnostic and treatment services. This is a concern, as a formal review by the University of Otago of the SDHB Department of Surgical Sciences in June 2017 was informed by staff that access to both elective and acute operating theatres on the Dunedin site resulted in patient delays and suboptimal treatment experiences.[[7]]

The specific risk of reduced access to colonoscopy for symptomatic patients as a result of the introduction of bowel screening was not obviously mitigated through the SDHB NBSP implementation process. Instead, there appears to be reliance solely on the CWTI target performance. It is now understood that the CWTI can easily be manipulated by a number of means, including applying direct access referral criteria inappropriately to specialist referrals, applying the criteria inconsistently and even choosing to decline referrals using tone and language that discourages referrers from future referrals to the service. Pre-implementation referral management practices were not assessed, and the impact of these on the apparent performance of the endoscopy service was therefore never considered nor associated risks identified.

Referral management practice was not audited or otherwise reviewed, though a document provided suggests that a national change to data collection by the MoH meant that the rate of declined colonoscopy referrals would have been known. It would also have been known that the SDHB declined referral rate was high compared to other DHBs.[[3]] From 2016 there were repeated formal written complaints to the SDHB CEO from senior surgeons concerned at the difficulty they were experiencing getting patients they referred accepted for colonoscopy. Also, in 2017 the SDHB surveyed the views of their endoscopy services users. Here 32.4% of respondents were aware of patients they thought came to harm because of declined endoscopies. None of these concerns are evident in any of the documentation provided under the OIA. That the SDHB was already failing to fully assess symptomatic patients in a clinically timely manner, before the bowel screening programme was introduced, was not revealed.

Concerns about the DHB capacity to join the NBSP

From the emails provided it is apparent that there were significant concerns among the MoH NBSP team in the week immediately prior to NBSP granting permission for the SDHB to go live with screening in their region. These concerns related to the ability of the SDHB to provide sufficient capacity for both NBSP participants and symptomatic patients, in terms of colonoscopy, radiology, surgery, medical oncology treatment and radiation oncology treatment. These concerns arose after months of preparation and site-readiness assessments undertaken by the MoH NBSP team. In an email from 11 April 2018, the Clinical Lead for NBSP asked NBSP staff to obtain some reassurance from SDHB that “symptomatic patients will not be disadvantaged in any way.” The documents provided did not include a response to that request.

Several MoH staff emails to SDHB personnel stressed the need for a letter of assurance on these matters from the SDHB CEO, prior to seeking approval five days later for SDHB to go live with bowel screening. A letter was received by the MoH NBSP team from the CEO of SDHB (dated 10 April 2018) in which he advised that surgery, medical oncology and radiation oncology staff were committed to making the programme work and he was satisfied they will be able to provide the additional volumes that the programme will generate. No CEO assurance was provided for colonoscopy or radiology capacity. Subsequent to receiving this letter, the Clinical Lead for NBSP at the MoH expressed her concerns (in an email dated 12 April 2018 to the MoH NBSP Programme Director and the Implementation Manager – Bowel Screening at the National Screening Unit) that the SDHB CEO letter did not say “without compromising the waiting times for symptomatic patients—that is the ethical concern we have.”

The decision to join the NBSP

In a memo requesting permission from NBSP Governance and Leadership Groups for SDHB to go live with screening, NBSP personnel note having received a letter from the SDHB CEO giving assurance that there will be sufficient colonoscopy capacity. The letter obtained under OIA offers no such assurance of sufficient colonoscopy capacity. Despite this, permission was granted on 17 April 2018—in our opinion inappropriately—and screening commenced in the SDHB region on 24 April 2018.

The MoH was asked to confirm if the CEO letter of assurance provided under OIA was the only written assurance as to capacity availability obtained from the SDHB in the process to commence bowel screening in that region. A letter of reply from the MoH (Population Health and Prevention) in October 2020 (Appendix Figure 1) confirmed that: (i) there is no additional written correspondence the MoH received from SDHB beyond what was sent to us in August 2020; (ii) “the decisions relating to SDHB were taken by an earlier leadership team so [they were] unable to provide further context”; and (iii) “the delivery by SDHB of a consistently high-performing bowel screening programme, exceeding national targets would suggest the confirmation of readiness was sound.”

Problems encountered with the OIA

The authors have confidence in their analysis of the material provided under the OIA, and in the conclusions drawn. They are experienced in analysis of complex information and had access to the technology and skills required to ‘drill-down’ through what was provided, even though the format was not analysis-friendly. The unduly long process required to obtain the requested information fails to diminish the value of analysis in this instance—in fact, it emphasises necessity of the analysis. The authors are aware that the intent of the OIA 1982 is sometimes undermined by the obfuscation, delay and deliberate barriers used by some entities and agencies subject to the OIA. For many people wishing to use the OIA mechanism to make enquiries of public institutions, the net confounding effect of these tactics would be insurmountable. The authors conclude, along with others, including its principal sponsor, that the OIA 1982 is no longer fit-for-purpose and needs to be revised.[[8–10]]

We, the authors, stress that the evidence for this investigation was obtained from the MoH under the conditions of the OIA. We assume that their answers were correct and complete. On the evidence, we conclude the process to assess SDHB capacity to assume NBSP did not ask critical questions. Further, the SDHB was not required by the assessment process to disclose relevant issues, and apparently did not choose to disclose voluntarily.

Analysis of the process to join the NBSP

It has become clear that the MoH process for assessing the readiness of a DHB to join the NBSP was flawed and should be made more open and transparent. There is a need for specific targets, and their method of calculation, to be identified and consistently met before screening is implemented. Any additional clinical load on a DHB must be considered in the context of its current ability to meet the needs of its population. In the case of the SDHB, uncovering the true level of unmet need in symptomatic patients would have allowed an opportunity to ensure safeguarded access for these patients to colonoscopy as clinically indicated. Instead, reviews have found that their access and clinical outcomes were jeopardised.[[3,4]]

Further, the authors believe that significant value and safety would be added to the NBSP-onboarding assessment process by ensuring that it includes benchmarking (i) the rate of declined colonoscopy referrals with other DHBs, and considering this rate against the known CRC incidence rate for the DHB population, and (ii) the proportion of new CRCs diagnosed via emergency department presentation. Additionally, DHBs should be required to disclose complaints and issues raised with DHB management pertaining to endoscopy service provision in the years preceding NBSP-onboarding assessment.

There should be recognition, at the level of government, of the potential for health targets to incentivise perverse behaviours by organisations and individuals. The reliance on the CWTI as the sole metric of performance of colonoscopy services should cease, or at least be coupled with a more transparent evaluation of performance, which looks for and reports on unmet need. This is particularly important given that some other DHBs are yet to commence bowel screening, and the same failings of readiness assessment may produce similar adverse outcomes to those seen within the symptomatic population of the SDHB. Concerns about these possible failings have been recently aired in the public media.[[11]]

Need for better planning before DHBs join the NBSP

There should be greater planning capability within both the MoH and DHBs when introducing new services. It is noted that the preliminary groundwork for bowel screening in New Zealand began over twenty years ago, and workforce development was considered a critical pre-requisite at that time. Despite this early awareness, successive governments have failed to prioritise workforce development in any meaningful way.[[1]] The opportunity to use the intervening years to build a specialist workforce sufficient for the task of bowel screening was wasted. The introduction of a national bowel screening programme has not been effectively planned for in this regard. It is hoped that current plans to mitigate the resourcing deficiencies will be successful. It is a serious concern, however, that the final letter from the MoH (Appendix Figure 1) expresses the view that the high level of performance of the SDHB’s bowel screening programme suggests that the MoH’s permission for screening to begin there was correct. That opinion ignored or ascribed no importance to any possible adverse clinical consequence that the concomitant restrictions on colonoscopy access had for numerous symptomatic patients in the SDHB region. The deficiencies clearly revealed in subsequent reviews[[1–3]] outline the serious consequences of the poor decision-making process.

The introduction of new health policy and services must be accompanied by well-defined lines of responsibility and accountability, particularly in environments of constrained resource. Where new policy or service provision creates inequities in access, as this innovation has, clear leadership and accountability for remediation is essential.

The potential for harm to symptomatic patients resulting from the additional demand on already limited resources occasioned by the introduction of the National Bowel Screening Programme warrants further research.

Good bowel screening programmes and timely colonoscopy for symptomatic patients are equally important in the battle against CRC. This is particularly so in a country such as New Zealand where CRC is so common. Indeed, screening should have started here many years earlier, should have a lower positive test threshold, and should provide coverage starting at a younger age, particularly for Māori. Both screening and symptomatic colonoscopy services must be adequately resourced (probably the main underlying problem) and run separately so they are never allowed to compete for resources—as they did in the SDHB.[[1]]

Appendix

Appendix Table 1: Original OIA requests to Ministry of Health, early September 2019.

Appendix Table 2: Re-scoped OIA requests to Ministry of Health, late September 2019.

Appendix Table 3: P Bagshaw OIA requests—progress timeline, September 2019 to August 2020.

Appendix Figure 1: Letter from Ministry of Health, Population Health and Prevention, to P Bagshaw 30 October 2020.

Summary

Abstract

We examined the documentation underlying the decision to permit the Southern District Health Board (SDHB) to join the National Bowel Screening Programme (NBSP) at a time when it was not providing an adequate colonoscopy service for symptomatic patients. A coordinated sequence of relevant Official Information Act 1982 (OIA) requests was lodged with the New Zealand Ministry of Health (MoH), which is responsible for determining the readiness of district health boards (DHBs) to join the NBSP. However, the MoH OIA process was obfuscating, unduly long and responded only after they anticipated imminent intervention by the Office of the Ombudsman. The amount of information provided was massive, partly irrelevant and presented in an inconvenient format. It revealed that the MoH readiness process was incomplete, and permission for the SDHB to join the NBSP was given prematurely without following due process and despite concerns expressed by some MoH staff. Subsequently, the MoH has failed to admit that they made errors in this case or have any weaknesses in their readiness assessment process. The MoH readiness process failed to determine that the SDHB was not ready to join the NBSP in 2018. Concerns have been expressed in the public media that such failures have occurred with the assessment of other DHBs. The process needs to be overhauled or replaced before further permissions are granted to DHBs. Requests for information under the OIA from the MoH, and similar public entities and agencies subject to the OIA, are too easily deferred, derailed or declined. The OIA is in need of revision.

Aim

Method

Results

Conclusion

Author Information

Philip Bagshaw: Chair, Canterbury Charity Hospital Trust. Paula Goodman: Independent. Brian Cox: Hugh Adam Cancer Epidemiology Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine.

Acknowledgements

Correspondence

Philip Bagshaw, Chair, Canterbury Charity Hospital Trust

Correspondence Email

philipfbagshaw@gmail.com

Competing Interests

Nil.

1. Bagshaw P, Cox B. Adequacy of publicly funded colonoscopy services in New Zealand. NZ Med J 2020;133(1526):7-11.

2. Agenda Southern District Health Board Meeting 3[[rd]] November 2020. https://www.southernhealth.nz/sites/default/files/2020-10/2020-11-03%20SDHB%20Board%20Agenda_Public.pdf

3. Bissett I, Broome K. Colonoscopy Patient Review Report for Southern District Health Board September 2020 https://www.southernhealth.nz/sites/default/files/2020-10/2020-10-06%20SDHB%20Board%20Agenda_public.pdf

4. Statement from Dave Cull, Chair, SDHB - Colonoscopy Services. Issue: Tue 6[[th]] October 2020. https://www.southernhealth.nz/publications/statement-dave-cull-chair-sdhb-colonoscopy-services

5. National Bowel Screening Programme Business Case 2017/2018. https://www.health.govt.nz/system/files/documents/pages/nbsp_business_case_2017_18_v2_redacted-optimised.pdf

6. Official Information Act 1982. https://www.legislation.govt.nz/act/public/1982/0156/latest/whole.html

7. University of Otago Review. Department of Surgical Sciences. University of Otago; June, 2017.

8. Amnesty International. Joint call for overhaul of Official Information Act. 9[[th]] October 2020. https://www.amnesty.org.nz/joint-calls-overhaul-oia

9. Palmer G. A hard look at the New Zealand experience with the Official Information Act after 25 years. Address to International Conference of Information Commissioners, Wellington 27[[th]] November 2007. https://www.lawcom.govt.nz/sites/default/files/audioFiles/Palmer%20Speech%20on%20Official%20Information%20Act.pdf

10. Ecclestone A. An updated Official Information Act must strengthen our right to know. 14[[th]] July 2020. https://www.stuff.co.nz/national/politics/opinion/122114366/an-updated-official-information-act-must-strengthen-our-right-to-know

11. Broughton C. Screening despite demand failings. The Press, Christchurch 23[[rd]] January 2021.

Contact diana@nzma.org.nz
for the PDF of this article

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Three independent external reviews showed that between 2013 and 2018 the Southern District Health Board (SDHB) colonoscopy service delayed or denied colonoscopies to numerous symptomatic patients, with adverse clinical outcomes for some.[[1–3]] The SDHB Board has subsequently accepted responsibility for these unacceptably poor outcomes and has apologised to all those affected.[[4]]

During this same period, the SDHB wished to join the National Bowel Screening Programme (NBSP). As a result, in April 2017, following a request from the Ministry of Health (MoH) in December 2016, the SDHB submitted a draft business case for inclusion in the NBSP Business Case for 2017/2018 to Treasury for Budget 2017. Funding was subsequently approved, and in April 2017 the SDHB began preparing for an April 2018 ‘go-live’ for the screening programme.

The NBSP Business Case 2017/2018[[5]] identified six evaluation areas to be used to assess district health board (DHB) readiness for delivery of the bowel screening programme (Table 1).

Table 1: NBSP Readiness Assessment Evaluation Areas.

To assess the SDHB’s readiness to begin offering bowel screening to their population, the MoH’s NBSP team monitored progress and achievement against these criteria, via a series of self-assessment reports, document reviews and site visit-based assessments by NBSP personnel. After going through this process, permission for the SDHB to commence delivery of the NBSP to its eligible population was granted by the NBSP Leadership and Governance Groups on 18 April 2018. The service went live in the SDHB region on 24 April 2018. Given the state of the SDHB colonoscopy service and some related colorectal cancer (CRC) clinical management services, the authors of this article feel it is their professional responsibility to ask how permission was granted under the circumstances that prevailed at the time.

Requesting information under the Official Information Act

In order to systematically investigate the adequacy of the assessment process, a series of requests for information under the Official Information Act 1982[[6]] (OIA) were lodged with the MoH (Appendix Table 1). These were refused on the grounds that the requests, as worded, were for “a very large volume of information and may be refused under section 18(f) of the Official Information Act 1982, because the information requested could not be made available without substantial collation or research.” It was suggested by the MoH that by narrowing the scope of the requests, either by selecting a shorter time frame and/or specifying a topic, the information may be provided. However, even with the requests narrowed, the MoH may still have required them to be narrowed further, extend the amount of time necessary to respond or even refuse the requests.

Accordingly, a series of refined requests was then made. This second series focussed on two main areas of interest: (i) the introduction and operationalisation of the Colonoscopy Waiting Times Indicator (CWTI), as the only metric of colonoscopy performance management information on which DHB readiness to assume bowel screening would be assessed; and (ii) the National Bowel Screening Programme at the SDHB, with particular emphasis on the identification, awareness and mitigation of risk to colonoscopy access for symptomatic patients arising from either of these, as evidenced by reports, meeting minutes, emails or discussions. The timeframe covered by the OIA requests was reduced by half as a result of re-scoping and refining. Individual questions were assigned an indicative priority to allow the MoH to stratify the timing of their responses according to their resources (Appendix Table 2).

The second series of refined requests was also declined under section 18(f) of the OIA 1982 because the information requested could not be made available without substantial collation or research. However, following intercession by the Office of the Ombudsman, and after an understandable slowing of the process due to the necessity of dealing with the COVID-19 pandemic, 3,516 pages of documents (in hard copy only) were received from the MoH in August 2020, relating to the OIA requests made to the MoH. The lengthy process to obtain any information under the OIA is detailed elsewhere (Appendix Table 3).

The 3,516 pages received constitute a partial response to the information requested of the MoH. For example, no information was provided on the recollections of ministers of health, directors-general of health or MoH staff of discussions relating to colonoscopy access for symptomatic patients within SDHB, as had been requested. It is worth noting that in the time period covered by these requests (2016 through 2019) there were, within the SDHB, ongoing concerns regarding access to colonoscopy raised on multiple occasions with the SDHB Chief Executive Officer (CEO) and Chief Medical Officer.[[1]] Given the ‘no surprises’ expectations in the CEO–MoH relationship, it seems unlikely that no such discussions occurred. A question as to whether monitoring of referral trends for symptomatic patients requiring colonoscopy was undertaken as preparation for SDHB implementation went unanswered. A number of other questions were apparently ignored, with no rationale for a non-response provided.

The documents obtained

Despite earlier communication with the MoH representative handling these requests regarding the file size of the aggregated documents and the possibility of providing them electronically, the entire document set was subsequently printed and then couriered. There are a number of remedies to the issue of email file size limitations, any of which would have preserved the electronic format. Instead, the format in which the documents were received defied meaningful analysis. This required the entire document set to be scanned to portable document format (.pdf), then converted to optical character reader (OCR) format, in order to become fully searchable documents. Trial and error revealed the best resolution settings in the OCR conversion process to overcome the issue of pages being watermarked with ‘Released under the Official Information Act 1982’. It is clear that receiving documents of this volume and in hard-copy format precludes any useful analysis for most people most of the time.

The documents were then searched for key words and phrases. The context in which the word or phrase occurred could then be assessed and the containing document identified for further analysis as required. After further analysis, a ‘once over’ read of documents assessed as low relevance was undertaken to ensure all relevant information had been seen. Much of the information provided was irrelevant to the question of the identification and management of risks to provision of clinically appropriate levels of diagnostic colonoscopy to symptomatic patients, in either a pre- or post-bowel screening SDHB environment. Unsurprisingly, copious pages of National Bowel Screening communications/promotional material, which were included, failed to shine any light on risk awareness or risk management strategy in this regard.

Deficiencies in the plan for the SDHB to join the NBSP

The ‘onboarding’ process driven by the MoH included a requirement for the SDHB to provide a colonoscopy production plan with a six-month horizon. The only production plan included in the document set is populated out to the end of June 2018, just two months after go-live. The template beyond that date is empty, yet it is precisely at this time that the first increase in demand for colonoscopy arising from bowel screening participants with positive results would be experienced. There is no modelling of the increased volumes required by radiology, surgery or oncology arising from additional cancers detected through the screening programme. The information obtained under the OIA was devoid of evidence of capacity to support additional volumes in diagnostic and treatment services. This is a concern, as a formal review by the University of Otago of the SDHB Department of Surgical Sciences in June 2017 was informed by staff that access to both elective and acute operating theatres on the Dunedin site resulted in patient delays and suboptimal treatment experiences.[[7]]

The specific risk of reduced access to colonoscopy for symptomatic patients as a result of the introduction of bowel screening was not obviously mitigated through the SDHB NBSP implementation process. Instead, there appears to be reliance solely on the CWTI target performance. It is now understood that the CWTI can easily be manipulated by a number of means, including applying direct access referral criteria inappropriately to specialist referrals, applying the criteria inconsistently and even choosing to decline referrals using tone and language that discourages referrers from future referrals to the service. Pre-implementation referral management practices were not assessed, and the impact of these on the apparent performance of the endoscopy service was therefore never considered nor associated risks identified.

Referral management practice was not audited or otherwise reviewed, though a document provided suggests that a national change to data collection by the MoH meant that the rate of declined colonoscopy referrals would have been known. It would also have been known that the SDHB declined referral rate was high compared to other DHBs.[[3]] From 2016 there were repeated formal written complaints to the SDHB CEO from senior surgeons concerned at the difficulty they were experiencing getting patients they referred accepted for colonoscopy. Also, in 2017 the SDHB surveyed the views of their endoscopy services users. Here 32.4% of respondents were aware of patients they thought came to harm because of declined endoscopies. None of these concerns are evident in any of the documentation provided under the OIA. That the SDHB was already failing to fully assess symptomatic patients in a clinically timely manner, before the bowel screening programme was introduced, was not revealed.

Concerns about the DHB capacity to join the NBSP

From the emails provided it is apparent that there were significant concerns among the MoH NBSP team in the week immediately prior to NBSP granting permission for the SDHB to go live with screening in their region. These concerns related to the ability of the SDHB to provide sufficient capacity for both NBSP participants and symptomatic patients, in terms of colonoscopy, radiology, surgery, medical oncology treatment and radiation oncology treatment. These concerns arose after months of preparation and site-readiness assessments undertaken by the MoH NBSP team. In an email from 11 April 2018, the Clinical Lead for NBSP asked NBSP staff to obtain some reassurance from SDHB that “symptomatic patients will not be disadvantaged in any way.” The documents provided did not include a response to that request.

Several MoH staff emails to SDHB personnel stressed the need for a letter of assurance on these matters from the SDHB CEO, prior to seeking approval five days later for SDHB to go live with bowel screening. A letter was received by the MoH NBSP team from the CEO of SDHB (dated 10 April 2018) in which he advised that surgery, medical oncology and radiation oncology staff were committed to making the programme work and he was satisfied they will be able to provide the additional volumes that the programme will generate. No CEO assurance was provided for colonoscopy or radiology capacity. Subsequent to receiving this letter, the Clinical Lead for NBSP at the MoH expressed her concerns (in an email dated 12 April 2018 to the MoH NBSP Programme Director and the Implementation Manager – Bowel Screening at the National Screening Unit) that the SDHB CEO letter did not say “without compromising the waiting times for symptomatic patients—that is the ethical concern we have.”

The decision to join the NBSP

In a memo requesting permission from NBSP Governance and Leadership Groups for SDHB to go live with screening, NBSP personnel note having received a letter from the SDHB CEO giving assurance that there will be sufficient colonoscopy capacity. The letter obtained under OIA offers no such assurance of sufficient colonoscopy capacity. Despite this, permission was granted on 17 April 2018—in our opinion inappropriately—and screening commenced in the SDHB region on 24 April 2018.

The MoH was asked to confirm if the CEO letter of assurance provided under OIA was the only written assurance as to capacity availability obtained from the SDHB in the process to commence bowel screening in that region. A letter of reply from the MoH (Population Health and Prevention) in October 2020 (Appendix Figure 1) confirmed that: (i) there is no additional written correspondence the MoH received from SDHB beyond what was sent to us in August 2020; (ii) “the decisions relating to SDHB were taken by an earlier leadership team so [they were] unable to provide further context”; and (iii) “the delivery by SDHB of a consistently high-performing bowel screening programme, exceeding national targets would suggest the confirmation of readiness was sound.”

Problems encountered with the OIA

The authors have confidence in their analysis of the material provided under the OIA, and in the conclusions drawn. They are experienced in analysis of complex information and had access to the technology and skills required to ‘drill-down’ through what was provided, even though the format was not analysis-friendly. The unduly long process required to obtain the requested information fails to diminish the value of analysis in this instance—in fact, it emphasises necessity of the analysis. The authors are aware that the intent of the OIA 1982 is sometimes undermined by the obfuscation, delay and deliberate barriers used by some entities and agencies subject to the OIA. For many people wishing to use the OIA mechanism to make enquiries of public institutions, the net confounding effect of these tactics would be insurmountable. The authors conclude, along with others, including its principal sponsor, that the OIA 1982 is no longer fit-for-purpose and needs to be revised.[[8–10]]

We, the authors, stress that the evidence for this investigation was obtained from the MoH under the conditions of the OIA. We assume that their answers were correct and complete. On the evidence, we conclude the process to assess SDHB capacity to assume NBSP did not ask critical questions. Further, the SDHB was not required by the assessment process to disclose relevant issues, and apparently did not choose to disclose voluntarily.

Analysis of the process to join the NBSP

It has become clear that the MoH process for assessing the readiness of a DHB to join the NBSP was flawed and should be made more open and transparent. There is a need for specific targets, and their method of calculation, to be identified and consistently met before screening is implemented. Any additional clinical load on a DHB must be considered in the context of its current ability to meet the needs of its population. In the case of the SDHB, uncovering the true level of unmet need in symptomatic patients would have allowed an opportunity to ensure safeguarded access for these patients to colonoscopy as clinically indicated. Instead, reviews have found that their access and clinical outcomes were jeopardised.[[3,4]]

Further, the authors believe that significant value and safety would be added to the NBSP-onboarding assessment process by ensuring that it includes benchmarking (i) the rate of declined colonoscopy referrals with other DHBs, and considering this rate against the known CRC incidence rate for the DHB population, and (ii) the proportion of new CRCs diagnosed via emergency department presentation. Additionally, DHBs should be required to disclose complaints and issues raised with DHB management pertaining to endoscopy service provision in the years preceding NBSP-onboarding assessment.

There should be recognition, at the level of government, of the potential for health targets to incentivise perverse behaviours by organisations and individuals. The reliance on the CWTI as the sole metric of performance of colonoscopy services should cease, or at least be coupled with a more transparent evaluation of performance, which looks for and reports on unmet need. This is particularly important given that some other DHBs are yet to commence bowel screening, and the same failings of readiness assessment may produce similar adverse outcomes to those seen within the symptomatic population of the SDHB. Concerns about these possible failings have been recently aired in the public media.[[11]]

Need for better planning before DHBs join the NBSP

There should be greater planning capability within both the MoH and DHBs when introducing new services. It is noted that the preliminary groundwork for bowel screening in New Zealand began over twenty years ago, and workforce development was considered a critical pre-requisite at that time. Despite this early awareness, successive governments have failed to prioritise workforce development in any meaningful way.[[1]] The opportunity to use the intervening years to build a specialist workforce sufficient for the task of bowel screening was wasted. The introduction of a national bowel screening programme has not been effectively planned for in this regard. It is hoped that current plans to mitigate the resourcing deficiencies will be successful. It is a serious concern, however, that the final letter from the MoH (Appendix Figure 1) expresses the view that the high level of performance of the SDHB’s bowel screening programme suggests that the MoH’s permission for screening to begin there was correct. That opinion ignored or ascribed no importance to any possible adverse clinical consequence that the concomitant restrictions on colonoscopy access had for numerous symptomatic patients in the SDHB region. The deficiencies clearly revealed in subsequent reviews[[1–3]] outline the serious consequences of the poor decision-making process.

The introduction of new health policy and services must be accompanied by well-defined lines of responsibility and accountability, particularly in environments of constrained resource. Where new policy or service provision creates inequities in access, as this innovation has, clear leadership and accountability for remediation is essential.

The potential for harm to symptomatic patients resulting from the additional demand on already limited resources occasioned by the introduction of the National Bowel Screening Programme warrants further research.

Good bowel screening programmes and timely colonoscopy for symptomatic patients are equally important in the battle against CRC. This is particularly so in a country such as New Zealand where CRC is so common. Indeed, screening should have started here many years earlier, should have a lower positive test threshold, and should provide coverage starting at a younger age, particularly for Māori. Both screening and symptomatic colonoscopy services must be adequately resourced (probably the main underlying problem) and run separately so they are never allowed to compete for resources—as they did in the SDHB.[[1]]

Appendix

Appendix Table 1: Original OIA requests to Ministry of Health, early September 2019.

Appendix Table 2: Re-scoped OIA requests to Ministry of Health, late September 2019.

Appendix Table 3: P Bagshaw OIA requests—progress timeline, September 2019 to August 2020.

Appendix Figure 1: Letter from Ministry of Health, Population Health and Prevention, to P Bagshaw 30 October 2020.

Summary

Abstract

We examined the documentation underlying the decision to permit the Southern District Health Board (SDHB) to join the National Bowel Screening Programme (NBSP) at a time when it was not providing an adequate colonoscopy service for symptomatic patients. A coordinated sequence of relevant Official Information Act 1982 (OIA) requests was lodged with the New Zealand Ministry of Health (MoH), which is responsible for determining the readiness of district health boards (DHBs) to join the NBSP. However, the MoH OIA process was obfuscating, unduly long and responded only after they anticipated imminent intervention by the Office of the Ombudsman. The amount of information provided was massive, partly irrelevant and presented in an inconvenient format. It revealed that the MoH readiness process was incomplete, and permission for the SDHB to join the NBSP was given prematurely without following due process and despite concerns expressed by some MoH staff. Subsequently, the MoH has failed to admit that they made errors in this case or have any weaknesses in their readiness assessment process. The MoH readiness process failed to determine that the SDHB was not ready to join the NBSP in 2018. Concerns have been expressed in the public media that such failures have occurred with the assessment of other DHBs. The process needs to be overhauled or replaced before further permissions are granted to DHBs. Requests for information under the OIA from the MoH, and similar public entities and agencies subject to the OIA, are too easily deferred, derailed or declined. The OIA is in need of revision.

Aim

Method

Results

Conclusion

Author Information

Philip Bagshaw: Chair, Canterbury Charity Hospital Trust. Paula Goodman: Independent. Brian Cox: Hugh Adam Cancer Epidemiology Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine.

Acknowledgements

Correspondence

Philip Bagshaw, Chair, Canterbury Charity Hospital Trust

Correspondence Email

philipfbagshaw@gmail.com

Competing Interests

Nil.

1. Bagshaw P, Cox B. Adequacy of publicly funded colonoscopy services in New Zealand. NZ Med J 2020;133(1526):7-11.

2. Agenda Southern District Health Board Meeting 3[[rd]] November 2020. https://www.southernhealth.nz/sites/default/files/2020-10/2020-11-03%20SDHB%20Board%20Agenda_Public.pdf

3. Bissett I, Broome K. Colonoscopy Patient Review Report for Southern District Health Board September 2020 https://www.southernhealth.nz/sites/default/files/2020-10/2020-10-06%20SDHB%20Board%20Agenda_public.pdf

4. Statement from Dave Cull, Chair, SDHB - Colonoscopy Services. Issue: Tue 6[[th]] October 2020. https://www.southernhealth.nz/publications/statement-dave-cull-chair-sdhb-colonoscopy-services

5. National Bowel Screening Programme Business Case 2017/2018. https://www.health.govt.nz/system/files/documents/pages/nbsp_business_case_2017_18_v2_redacted-optimised.pdf

6. Official Information Act 1982. https://www.legislation.govt.nz/act/public/1982/0156/latest/whole.html

7. University of Otago Review. Department of Surgical Sciences. University of Otago; June, 2017.

8. Amnesty International. Joint call for overhaul of Official Information Act. 9[[th]] October 2020. https://www.amnesty.org.nz/joint-calls-overhaul-oia

9. Palmer G. A hard look at the New Zealand experience with the Official Information Act after 25 years. Address to International Conference of Information Commissioners, Wellington 27[[th]] November 2007. https://www.lawcom.govt.nz/sites/default/files/audioFiles/Palmer%20Speech%20on%20Official%20Information%20Act.pdf

10. Ecclestone A. An updated Official Information Act must strengthen our right to know. 14[[th]] July 2020. https://www.stuff.co.nz/national/politics/opinion/122114366/an-updated-official-information-act-must-strengthen-our-right-to-know

11. Broughton C. Screening despite demand failings. The Press, Christchurch 23[[rd]] January 2021.

Contact diana@nzma.org.nz
for the PDF of this article

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