Published in The New Zealand Herald, 20th April 2020

Coming out of level-f lockdown, what have we learned in Auckland healthcare, and what can we carry forward from this experience?

We can work as a region. We always have, but the level of cooperation has been unprecedented, and good things have come out of this. This presages a future configuration in New Zealand of effective, integrated regional healthcare systems.

The hospital system can adapt quickly under pressure. The number of intensive care beds available in the region has been nearly doubled. Exceptional circumstances of course, but it would be nice to see this carried over to new and more flexible ways of working elsewhere in the hospital system.

Skill and role boundaries between staff can be blurred. Temporary exemptions have been sought under legislation to allow more role flexibility. Can we make this permanent?

The future is digital. We knew this, but “bricks and mortar” and staff and bed numbers have been privileged in the hospital system over enabling technologies that could greatly increase productivity. Major investments have gone begging.

Family doctors can work well in networks. While there are some larger practices, many are small and could be unviable on their own in circumstances out of the routine (e.g. specialized equipment, after-hours care, staff sickness, support staff). Let’s hope these practice networks can be formalized.

Fee-for-service and patient co-payments in primary care are problematic. Family doctors are losing income because they rely on patient fees, and patients are not attending. Patients can be put off by fees. A simple extension of ACC cover to illness in family practice along the Australian lines, plus an emphasis on capitation, would fix this.

Planned, ambulatory, out-patient, and elective care needs to be clearly separated out. Both Waitemata and Counties Manukau DHBs have separate facilities. Auckland DHB needs to develop its Green Lane site to institute this and free this work from the imperatives of acute work. Also we should revisit low-value elective care and cut in-person out-patient visits.

The demand for acute hospital care is surprisingly “elastic”. Inpatient bed occupancy is half what it is usually, as is use of the ED, and intensive care has been stepped down substantially. Of course, regrettably, in many instances this may be people not coming for needed care, but it also suggests that there might be more flexibility in the system, as also evidenced by the stand-down of acute facilities over week-ends. Why not more hospital care in the home?

The National Health Index (NHI) number can be used more. Northland DBH is using the NHI to target vulnerable populations for flu vaccination. We need more of this. At present privacy considerations are blocking useful initiatives of this kind on screening and outreach programmes. 

Ethnic inequalities not evident. Disadvantaged ethnic minority groups are not being disproportionately affected by COVID-19 at present in New Zealand (unlike the United States, for example). And testing rates in Auckland broadly reflect the ethnic profile of the region. This is also the case for the two Maori providers of testing: ten per cent Maori, 50 per cent Pakeha, with other ethnic groups proportionate.

The aged care sector needs a thorough review. The DHBs have very limited powers to check the quality of care and supervision in this sector. Furthermore, families have very little objective quality of care information to go on in deciding where to place an elderly relative. Two reviews have been announced.

You don’t miss public health – until you miss it! The country is very fortunate that it has a stellar public health professional leading the Ministry of Health. This in part makes up for the erosion of key infrastructure. This is quite aside from dealing with the epidemics of diabetes and obesity which are gathering pace and where evidence-supported interventions are waiting to be implemented.   

You need a strong centre. The country has benefited greatly from the strength and expertise that the Auckland regional grouping – including Northland – has provided to decision-making and mobilisation. There have also been strong independent voices in the academic sector. Without these two, it is questionable whether the guidance and steering from the centre could have got up to speed so well given the steady erosion of key public service resources over the last decade.

Conclusion

We have ramped up services across the region – and across the country – to handle an expected peak of disease rates and a surge of patient need. These never came, but this has demonstrated the marvellous professionalism and commitment of staff and management. Let’s learn from this, blow out some of the cobwebs of inertia, and build back better.

Peter Davis

Elected member

Auckland District Health Board