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9 - The health system response Te urupare a te pūnaha hauora

Home Reports Summary Report Part Two: Lessons learned from Looking Back 9 - The health system response

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Introduction | Kupu whakataki

In addition to preventing people becoming sick and dying from COVID-19, part of the rationale for the elimination strategy and the wider pandemic response was to ensure the health system was not overwhelmed by COVID-19.19 By the time the virus reached Aotearoa New Zealand, its potential to do so – and what an overwhelmed health system looked like – was already apparent. Graphic images from hospitals in Italy and elsewhere showed every available bed occupied by COVID-19 cases, operating theatres turned into makeshift intensive care units, and patients being treated in overflowing corridors and administration areas. Meanwhile, the wider health needs of many citizens in those countries went unaddressed due to the cancellation of nearly all ’planned care’ (specialist medical and surgical care for people who don’t need to be treated right away).

For Aotearoa New Zealand, it was a frightening demonstration of what might lie ahead. If the sophisticated health systems of developed countries like Italy and France could be so quickly swamped by surging COVID-19 case numbers, what would happen here?

Our country’s health system comprises a large and complex network of organisations. In 2020, publicly-funded specialist and hospital care was overseen by 20 district health boards (DHBs). The control of communicable diseases (such as contact tracing) sat with 12 public health units spread throughout the country, supported by testing capacity and services within the Institute of Environmental Science and Research, and both public and private laboratories.vii Primary care – delivered by a range of private, NGO, and not-for-profit providers – sat somewhat apart from hospital-based services. The Ministry of Health provided overall system leadership, including policy and regulation, high-level pandemic preparation, and monitoring. The Inquiry focused on assessing the health system response to COVID-19 in relation to these publicly-funded functions.viii

Images from other countries were a frightening demonstration of what an overwhelmed health system looked like

 

The Inquiry assessed how ready Aotearoa New Zealand’s health system was for the emergence of a global pandemic like COVID-19. We looked at:

  • The activation of public health services and measures to respond to the virus itself, including early steps taken, testing, contact tracing and, briefly, vaccination (which is also addressed in Chapter 11).ix
  • How the wider health system geared up to respond to COVID-19 cases, including the steps taken by DHBs, hospitals, and other healthcare settings to manage potential cases safely, and how services and resources were reprioritised and deployed to be ready for an influx.
  • The provision of non-COVID-19 healthcare during the pandemic. We looked at what was done to ensure people could still access health and disability services, including steps taken to prevent further outbreaks within services, reorient service delivery and preserve workforce capacity for non-COVID-19 services. We addressed disruptions to healthcare delivery resulting from efforts to prepare to respond to COVID-19.

Note: detailed information about these topics and what occurred during Aotearoa New Zealand’s response to COVID-19, along with our complete assessment, can be found in the corresponding Looking Back chapter in our main report.

Finally, we assessed how all three of these areas impacted the health system itself, the population at large, and its most vulnerable members.

In the main report, the Chapter includes case studies (spotlights) on facemasks, and the delivery of cancer care during the pandemic.

 

Through the Inquiry’s public submissions process, people shared their experiences of and perspectives on how the health system responded during the pandemic. People said that response measures gave the health system time to prepare for COVID-19 outbreaks, and felt outbreaks of COVID-19 were handled well. People told us they felt restrictions also protected the health system from being overwhelmed.They appreciated efforts to ensure people had continued access to medical care throughout the pandemic via online and over-the-phone GP appointments.

Many people shared their gratitude for the efforts of essential workers during the pandemic, including frontline health workers, and acknowledged the significant role they played to help keep the country going. Facemasks and contact-tracing tools were described as easy, effective measures that helped stop transmission and made people feel safe; and access to antiviral medication and free COVID-19 tests were also valued by submitters.

On the other hand, people also told us they felt access to healthcare was impacted by an over-prioritisation of COVID-19 compared to other health issues. Submitters shared how they experienced delays in accessing healthcare during the pandemic and how phone appointments with GPs were inadequate at times. The effects of this are ongoing for some.

Concerns around the health system’s preparedness for a global pandemic were also raised by submitters. Many spoke of it being over-stretched and under-resourced, which created stressful working conditions for frontline health workers. Others raised their concerns around contact tracing, with this being viewed as a violation of privacy or a form of surveillance; and experiences of COVID-19 testing being poorly managed or difficult to access.

For future pandemics, people suggested:

  • screening and treatment for diseases like cancer should always continue without disruption
  • ventilation of indoor spaces should be addressed to improve air quality and reduce transmission of airborne diseases
  • essential workers, especially health workers, be better supported
  • Aotearoa New Zealand invest more into the health system and create a comprehensive pandemic plan
  • antivirals be made easily accessible for anyone who needs them, regardless of age or ethnicity.

 

“I work in health administration. It was terrifying, we didn’t know what the future held for us all. I honestly felt relief when we were told we were locking down. I seriously thought we were in safe hands with a government that cared about the people over money.”

“I think we had been complacent, our facilities weren’t ready for isolating large numbers of sick patients, and we scrambled to catch up. Future planning for the healthcare system, especially in Auckland with a growing/aging population, needs to have flexibility and resilience integrated into decision-making.”

“We need to be more grateful and supportive to essential workers. Higher pay and status with extra training for situations that will reoccur.”

“Shutting down hospitals ’in case’ it was needed for COVID-19 cases is not ok. Our local hospital was dead!! They had very few patients, minimal outpatient clinics, and huge waiting lists. In the initial lockdown we had NO COVID-19 patients. People are now waiting months and months longer for appointments that should have happened a long time ago. Three years down the track and we are still in a shambles.”

Note: this material is taken from the Inquiry’s Experiences Report, which is a summary of the public feedback submitted to Phase One of the Inquiry during early 2024.

1. Aotearoa New Zealand’s health system – like those of other countries – was not well prepared for a pandemic of the scale and duration of COVID-19.

  • While the country had done fairly well in recent assessments of pandemic preparedness, meeting the demands of the COVID-19 response required ’significant, extraordinary sector-wide effort’.

  • Publicly funded health services faced long-standing challenges with workforce capacity, financial deficits and long waiting lists for some planned healthcare. These issues were exacerbated by the demands the pandemic placed on the health system.

2. The elimination strategy was highly effective in preventing the health system from being overwhelmed and protecting vulnerable groups, although there were notable costs.

  • By preventing widespread COVID-19 infection until the population was vaccinated and the virus had become less deadly, the elimination strategy prevented the premature deaths of thousands of New Zealanders – particularly older people, Māori, Pacific peoples, and people living with disabilities or medical vulnerabilities.

  • Peak hospitalisation rates in Aotearoa New Zealand (in March 2022) were around half those in the United Kingdom (January 2021) and the United States (January 2022). Unlike other countries, Aotearoa New Zealand recorded very few COVID-19 deaths among people living in residential facilities such as aged care homes.

  • While strict public health and infection prevention measures were effective in keeping people safe from COVID-19, this came at a significant human cost. People who were in aged care, in hospital or who were sick or dying were isolated from families and loved ones, causing distress and suffering to many.

3. While many people and organisations worked hard to provide effective public health and clinical care, the pandemic exposed some key vulnerabilities and pressure points in our health system.

  • There was a scramble to scale-up public health functions such as testing and contact tracing, which started from a low baseline. Given this starting point, the expansion of these functions was generally done well, although limited forward planning and flexibility caused problems in some areas (such as the shift in COVID-19 testing from PCR to RAT tests).

  • Dated infrastructure made it difficult to apply best-practice infection control measures, including air ventilation, in many healthcare facilities. However, innovative approaches and substantial effort by staff produced good results.

  • Although efforts were made to expand health system capacity in areas such as caring for ventilated patients, we did not find evidence of sustained increases in capacity during the pandemic.

  • While the country’s health system was never overwhelmed by people sick from COVID-19 (as happened in many places internationally), the pandemic took a substantial toll on healthcare workers. An already stretched health workforce is now in a worse position because of the pandemic, representing a key vulnerability for the health system going forward.

4. Provision of non-COVID care was substantially disrupted during the pandemic, to a greater extent than was necessary.

  • Many parts of the health system – including general practices, Māori and Pacific providers, emergency departments, pharmacies, midwifery, cancer services and others – worked extremely hard to deliver as much care as possible during the pandemic.

  • With hindsight, the health system took an overly cautious approach to reducing non-COVID care to protect its capacity to provide pandemic-related care. This resulted in avoidable delays or omissions in healthcare, with ongoing consequences for the health of those affected.

  • Efforts were made to balance the risk of hospitals being overloaded with the need to continue delivering necessary care, but effective decision-making was complicated by a lack of real-time data on hospital capacity, occupancy and staffing levels. Improving data systems and infrastructure to support smart decisions about the utilisation of resources would be beneficial not only in a future pandemic, but in general.

  • Delays in providing healthcare had significant negative impacts on the health of New Zealanders. The Health Quality and Safety Commission found the pandemic contributed to lower childhood immunisations, reduced participation in cancer screening programmes, and increased waiting times for specialist care and planned surgery.

vii This devolved model has since been replaced with a single planning and funding agency, Health New Zealand | Te Whatu Ora, including a National Public Health Service.

viii From time to time, we touch on – but do not comprehensively address – the pandemic response in other important parts of the health system (like disability support services, oral healthcare, and ambulance services). We do not cover the parts of the health system that are entirely private. Furthermore, while primary care is a vital part of the health system, data on delivery models and service provision are less accessible for primary care than for specialist and hospital-based services. Discussion of primary care is therefore less prominent in this chapter.

ix We do not, at this stage, look at decisions to mandate these measures in certain circumstances or for certain groups of people: vaccine and testing mandates are addressed in Chapter 12.

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