Almost a million cervical cancer screening notifications not sent out, review finds

Almost a million notifications did not get sent to people eligible for cancer screening due to flaws in the national cervical cancer screening programme, a review has found.

As a result, the system was not providing a comprehensive safety net.

A national register was launched in September 2023, along with a change to HPV primary screening instead of a smear test.

A review by a Health New Zealand expert panel, released on Monday, said the register was working satisfactorily in many ways but the clinical safety of the register could not be assured in some situations.

The register was not making contact with everyone eligible for screening due to the way it was designed, as well as unintentional flaws in the way it was built, the review said.

More than 800,000 notifications for screening were not triggered and another 160,000 notifications were triggered but not sent as of June 2025.

That included more than 600,000 notifications not sent or triggered due to people considered "inactive" because of Health NZ's "NHI active rule" that meant people who had not accessed health services for three years were not sent cervical screening eligibility information.

Others were not contacted due to postal addressees being incorrect or lacking.

A process aimed at prioritising those most in need - referred to as cohorting - also resulted in people only in the most high-priority group being contacted.

Eligibility and recall notifications were only sent to people in Cohort One - people ageing into the scheme and unscreened or underscreened Māori or Pacific people who were not enrolled in primary care.

The review made 48 recommendations, including identifying and contacting all unscreened and under-screened people as a priority.

The system needed to ensure there was appropriate follow-up when screening detected abnormalities, it said.

The register does not currently have access to complete screening histories for all participants.

This meant it might not be able to determine next steps and if additional work was required to review participants with complex histories, including previous high-grade results or other persistent HPV infections to ensure they were receiving appropriate care, the review said.

"Failure to do so poses a significant risk to affected individuals, potentially leading to delayed diagnosis or treatment and so proactive measures must be taken to safeguard patient outcomes," it said.

The review called for the National Cervical Screening Programme and Health NZ's Digital Services to develop an action plan to address the issues identified by the notification review.

National Public Health Service director prevention screening Alana Ewe-Snow said it was grateful to the work of the panel in identifying the areas for improvement.

"We acknowledge there is further work to do to improve the register. We are working hard to address the panel's recommendations. The main recommendations centred around improving clinical case review, data quality and notifications to women," Dr Ewe-Snow said.

Screening rates were higher than ever with increases across all ethnicities following the introduction of HPV primary screening with more than a million people screened since the register was introduced in September 2023, she said.

"This progress is heartening but there is much more work to do. Improvements to the register will mean we can reach even more women for screening. We'll be able to support more women to progress through the screening assessment and treatment pathway earlier."

There had been 13,000 case reviews and so far there was no indication anyone had been harmed as a result of the system's issues, Dr Ewe-Snow said.

"We are well on the way towards enacting the panel's recommendations. We've completed six already with a further 11 in progress