5.5 What happened: provision of non-COVID-1­9-related healthcare during the pandemic I aha: te whakaratonga o ngā ratonga hauora ehara mō te KOWHEORI-19 i te wā o te mate urutā

In addition to managing the health system response to COVID-19, the Ministry of Health and DHBs were responsible for ensuring New Zealanders could continue to receive appropriate preventive, diagnostic, therapeutic and supportive care for non-COVID-19 health conditions. This was a challenging task given the need to simultaneously upgrade infection prevention and control settings, scale-up key public health functions, and ensure sufficient health system capacity was held ready in case of rapid increases in COVID-19 infection and illness.

The national response frameworks for hospitals and community care outlined in the previous section were the primary mechanisms used to balance all these considerations. The intent of these frameworks was to allow ‘business as usual’ health services to be delivered to the greatest extent possible during the pandemic, while still enabling the system to be ready to cope with an outbreak of community transmission, should this occur.

5.5.1 Reprioritising primary care, routine screening, immunisations and hospital-based care

Holding a health system ready for a potential influx of cases during a pandemic will inevitably require the reprioritisation of ‘business-as-usual’ services. As noted by a senior health official in one of our direct engagements:

“Even in a context where you don’t have any active COVID cases in a hospital, all the other infection prevention and control measures slowed down services. It’s quite difficult to measure these impacts and work out what is a reasonable level of planned care.”

In practice, it seems most DHBs took a cautious approach to this assessment. As a result, many non-COVID-19-related healthcare services were temporarily suspended or deferred during the pandemic. These decisions were first required during the national lockdown in March and April 2020.

5.5.1.1 Care for non-COVID-19 health issues during lockdowns

Not surprisingly, the delivery of ‘business as usual’ health services was heavily disrupted in March, April and May 2020.

During this time, we heard that many district health boards around the country assessed themselves as ‘red’ on the national response framework – at the highest perceived risk of severe impact from COVID-19. At this level, they provided emergency and urgent care only – in order to preserve capacity.

According to a working report by the Ministry of Health in November 2020, inpatient stays in public hospitals declined sharply during the Alert Level 3 and 4 lockdown: in April 2020, the first full month in lockdown, the number of stays fell by almost 40 percent and remained at historically low levels in following months. However, by June 2020, there were signs that hospitals were beginning to reduce the backlog.⁵⁷

The lockdown also affected general practices. The Ministry’s report showed general practice consultations declined in late March and April 2020, and had not reverted to pre-lockdown levels by July of that year.⁵⁸ Patient experience survey data found one in three (34.4 percent) of respondents reported that the Level 3 and 4 lockdowns in 2020 affected their access to general practice: they felt they weren’t supposed to attend or that their health problem wasn’t urgent enough, or they delayed or substituted general practice care.⁵⁹

These disruptions prompted some immediate concerns. In a letter to the Minister of Health in April 2020, the Health and Disability Commissioner expressed concern about ‘unmet need’ that was building in the community due to the reduction in healthcare service activity. He noted that the consequences would be ‘particularly serious for those for whom early diagnosis and treatment is the key to success, including cancer and coronary disease’, raising ‘clear equity issues’.

The Commissioner called for the health system to act now in preparation for the surge in demand that would occur once lockdown ended – including by strengthening coordination between primary, secondary and private providers to ensure ‘maximum availability of and access to services’. His letter also highlighted ‘inconsistencies across the country in the ways in which DHBs are applying the National Hospital Response Framework’, with some DHBs declining primary care referrals and referring other patients back to primary care.⁶⁰

Responding to the Commissioner’s concerns, the Ministry of Health noted that while DHBs were ‘redesigning workspaces and reassigning workers to ensure preparedness for a possible influx of COVID-19 patients’, many non-urgent surgeries were deferred for this purpose. This was consistent with the framework if DHBs had determined they needed to lift the status of their facilities to ‘red’ or other higher levels. However, ‘care will continue to be provided according to a patient’s clinical priority. DHBs will actively review waiting lists and manage a patient’s risk of deteriorating whilst waiting’. The Ministry said it had been ‘clear with DHBs that any deferred patients […] must not be removed from waiting lists’, but also noted that ‘limiting the risk of COVID-19 infection remains a key priority’. This reflected the challenge of balancing the health system’s response to the pandemic with its responsibilities to provide non-COVID-19 care.⁶¹

By November 2020, the new Health and Disability Commissioner told the incoming Minister of Health that her office had received 224 complaints related to COVID-19, representing 15 percent of all complaints received that year. Many centred on reduced access to care and delayed treatment in primary, secondary and emergency healthcare.⁶²

In 2022 and 2023, the Health Quality and Safety Commission documented numerous pandemic impacts on wider health services, some of which are covered in section 5.6. Relevant to this section, the Commission reported that planned care in hospitals returned to normal levels in mid-2021 after falling sharply during the first national lockdown.

However, the situation worsened considerably following the Delta outbreak and the long regional lockdowns that began in August 2021. Afterwards, planned care remained ‘consistently lower’ than expected on the basis of earlier years.⁶³

5.5.2 Steps taken to preserve wider health system capacity and workforce during the pandemic

Despite the disruptions that inevitably occurred, considerable efforts were also made to preserve wider health system capacity and ensure the health workforce was available to deliver necessary and ongoing care. A number of different strategies were utilised to expand the available health workforce, including recruiting health professionals who were working outside the health system.

When health workers were absent from work with COVID-19 or redeployed into other parts of the sector, there could be flow-on effects for other services. In response to these challenges, steps were taken throughout the pandemic to minimise system capacity disruptions and ensure that health workers could keep coming to work.

...considerable efforts were also made to preserve wider health system capacity.

5.5.2.1 Deeming health workers ‘essential’

When the country first went into Alert Level 4 lockdown, most health services were deemed ‘essential’.⁶⁴ This was intended to preserve access to essential healthcare during lockdown, and to minimise disruption to the health workforce.⁶⁵ See Chapter 3 for more on the definition of essential services.

While the classification of health workers as essential was deliberately quite broad, it did not necessarily correspond to what was understood to be essential in the moment. For example, we heard of some people in preventative or community health roles, who were essential workers, often being redeployed into other areas considered to be more ‘essential’. A report for the Well Child Tamariki Ora governance group in June 2020 found that:

“ […] not all organisations understood that WCTO staff were still providing an essential service and WCTO staff were redeployed to other areas of business. This will have an impact on the work required to catch-up with whānau who may not have received contact during the lockdown period.”⁶⁶

5.5.2.2 Enabling some health workers to return to work early after a COVID-19 diagnosis

In April 2020, the Northern Regional Health Coordination Centre (supporting Auckland, Counties Manukau, Waitematā and Northland DHBs) developed an evidence-based risk matrix⁶⁷ to help make decisions about when staff who had been infected with COVID-19 could safely return to work should staff absences be putting critical (e.g. lifesaving) services at risk. The framework was then adapted in May 2020 by the Royal New Zealand College of General Practitioners for GP services delivered in general practice and in the wider community, including schools, with several versions for different alert level settings.⁶⁸

This practice continued through into 2022, and was supported by the Ministry of Health for all critical health services, and under specific conditions. An order issued in May 2022 allowed the Director-General to make an exemption to stay at home orders, but only if the person was a critical health worker whose work was required to prevent immediate risk of death or prevent serious social or economic harm to significant numbers in the community. If all other options had been exhausted, they were not acutely unwell, and agreed, they could return to work.⁶⁹

As a result, throughout the pandemic, some essential health workers were given special dispensation to return to work early following a COVID-19 diagnosis, subject to specific conditions.

5.5.2.3 Temporarily exempting some staff from vaccination requirements to prevent disruptions to critical services

Later in the pandemic, when vaccination mandates were in place for the health and disability workforces (see Chapter 8), DHBs could apply for temporary exemptions to staff vaccination requirements if there was a risk of ‘significant service disruption’ to a critical health service due to a lack of available vaccinated workers.⁷⁰

To qualify, the DHB had to show that a critical health service would not be able to be provided, that no alternative option was available, and that the organisation had done all they could to mitigate the risk of COVID-19 transmission from having unvaccinated staff.

5.5.3 Innovation and adaptation in service delivery

Despite significant disruption and pressure, people in the health system worked hard to find ways of continuing to provide care without relying on face-to-face contact. There were many examples of innovation and adaptation that allowed ‘business as usual’ healthcare to continue as much as possible. These included the rapid adoption of alternative models and methods, such as telehealth and remote delivery.

5.5.3.1 Community and iwi and Māori health providers quick to mobilise

We heard many examples of iwi and Māori health providers quickly adapting, developing new models, and taking a holistic and flexible approach to ensure their communities had ongoing access to essential services, including healthcare.^xviii The Ministry of Health recognised and supported the strength of this response – as one senior health official told us: ‘Māori got the “why” of the protection measures and mobilised rapidly – sometimes ahead, sometimes more rigorously than the national response’.

Examples of iwi and Māori initiatives included:

• A Māori primary health organisation’s six general practices partnered with an acute care centre and a local supermarket to deliver food, health and hygiene packages, testing, and later vaccination to their wider community.
• Māori health providers purchased and distributed mobile phones to households they knew didn’t have them, ensuring they could maintain communications during lockdown. These providers also stepped up to fill gaps when required – for example, when Police were unavailable to attend mental health crisis callouts.

“Māori got the “why” of the protection measures and mobilised rapidly – sometimes ahead, sometimes more rigorously than the national response.”

5.5.3.2 Rapid uptake of new technologies

“We’ve been talking about the barriers to e-prescriptions for 15 years. Lo and behold, it happened in 48 hours.”

As happened in other sectors, the arrival of COVID-19 and the first national lockdown required the health sector to shift rapidly to using new technologies. Many of these existed already or were being piloted in small pockets, but they were rapidly adopted at scale early in the pandemic.

E-prescribing – whereby medications were prescribed, dispensed, administered and recorded electronically – was one such technology. Because it could be done remotely, it was a useful tool during the COVID-19 pandemic, reducing exposure to the virus among patients and health professionals. It offered other advantages too, such as improving patient access, convenience, and reduced harm from medication errors and adverse drug events.⁷¹

A gradual shift to e-prescribing had begun before the pandemic, but it was rapidly accelerated in March 2020 – in fact, we were told it was effectively adopted nationwide overnight, two days before the first national lockdown. While some technical barriers affected transmission between general practitioners (GPs) and pharmacies,⁷² we heard that the move to e-prescribing was overall a ‘superb’ example of how the health system can make significant changes when it ‘identifies priorities and steps into action’. In the words of one GP: ‘We’ve been talking about the barriers to e-prescriptions for 15 years. Lo and behold, it happened in 48 hours’.

Similarly, there was a rapid uptake of online systems for communication between health professionals and patients (or ‘patient portals’) early in the pandemic, as well as an ‘extraordinary’ increase in the use of phone and virtual consultations. Health staff made videos showing patients the correct way to swab themselves for COVID-19 testing. National telehealth services scaled-up to provide additional support.

The Ministry of Health also took steps to ensure that wherever there were qualified health and disability workers willing and able to work during the COVID-19 response, they would be connected with employers who needed them. To this end, an online portal was established to connect health and disability workers with sector employers. More than 3,700 workers registered an interest to work, and 25 employers used the service.

5.5.3.3 Additional support from national telehealth services

Whakarongorau Aotearoa, the National Telehealth^xix Service was established in 2015, a consolidation of several existing phone support lines into one entity using the same cloud-based system. At the time of writing, it comprises more than 35 services.⁷³

Under ‘normal’ circumstances, Healthline and the many mental health and addiction phone lines that are part of Whakarongorau can be considered a ‘backstop’ to primary health services. But during the pandemic, when people’s ability to access standard healthcare was significantly reduced, they were critical and became the first port of call for many. This was reflected in increased call and text demand across many of these services:

• Calls to Healthline jumped from an average of 30,000 calls per month pre-pandemic to almost 74,000 calls in March 2020.
• Texts and calls to mental health and addiction support services (depression, gambling support, assistance with alcohol and other drugs) increased. They peaked in March–April 2020, with 20,483 calls received in April alone. Call volumes did not return to pre-pandemic levels until late 2021/early 2022.
• Calls to Plunketline (especially maternal mental health related calls) rose sharply in late 2020, peaking in the second quarter of 2021 at four times the number of calls received before the pandemic.⁷⁴

People contacted these telehealth services about a myriad of issues – including family violence, mental health, lockdown rules, and COVID-19 symptoms and testing. Agreements and operating protocols with other agencies meant health lines were able to refer callers to appropriate alternative services (businesses wanting advice on implementing COVID-19 requirements were referred to MBIE helplines, for example). If necessary, they could also prioritise callers they referred to these other lines, so they were dealt with urgently.

We heard from several sources that Whakarongorau was a pandemic success story. According to one senior health official:

“Whakarongorau were unbelievably invaluable in the response […] if they didn’t exist, we’d have struggled to build a national workforce as fast as we did to do what they did. They grew from a few hundred people to over 3,000 in a number of months.”

Factors in the service’s success were described as its ‘scalability’, its strong pre-existing relationship with the Ministry of Health and the Auckland Regional Public Health Service, a high-trust contracting model, its use of remote technology that allowed people to work from home, and to rapidly recruit, train and surge their workforce.