Very unfortunate and troubling though it has been for all concerned, in retrospect the Auckland outbreak has been a salutary experience from which everyone can learn something.
The commentariat have been working off our first wave. But the cases then seemed to involve for the most part youngish and healthy middle-aged, middle class, travelling Pakeha and their networks, and was thwarted by a complete lockdown. Now we have a very different “demographic” affected, including multi-generational households, people gathering in churches and on public transport, and with more at-risk health profiles and poorer access to health services. This is the mix that has fomented so much of the spread internationally. The commentariat need to re-calibrate accordingly.
The Government has been tip-toeing around issues of public consent. Yes, it has been “following the science”, but it has also had to take the public with it. Can you charge people for their quarantine? Can you require pre-departure virus tests as some airlines and countries already do? Can you require border workers to take regular tests? Can you stop nurses moonlighting between border and hospital employment? Can you require masking in confined spaces and on public transport? In contrast to the firmness and rigour of the first lockdown, all these have had to be negotiated in real time. This outbreak provides an opportunity to resolve many of these issues of public consent.
The Auckland outbreak has demonstrated that our laboratory testing and contact tracing systems are now up to scratch. But, If any further evidence was needed on the balkanised nature of our health system, then this outbreak has provided it; we have a system in which there is a policy health ministry in Wellington, there are 20 DHBs normally focused on hospitals rather than broader health considerations, we have family doctors and corporate primary care usually driven by their local business models, and we have under-resourced public health units. Under circumstances of crisis these different segments unite and rise magnificently to the occasion – as they did with the first outbreak under lockdown – but in the present circumstances the operational weaknesses of the system are revealed, particularly the threadbare IT systems that are barely interoperable, are sometimes no longer supported by the vendor, and are often on the verge of collapse.
It goes without saying that the health system endured nine years of “soft austerity” as the system was treading water while easy and discreet cost savings were quietly stripped out of it. That said, the system has always placed higher priority on hospital staff, beds, and bricks and mortar, and IT systems have been left to languish. For example, the National Immunisation Register is said to be on its last legs. Furthermore, the broader register of which it is part has an “opt on” system over the age of six, which means those in the community most in need of scrutiny and help are often least likely to be in touch with the outreach potential of such a register of record. Also, a good five per cent of the population is not even registered with any family doctor. Furthermore, while we have a unique national health identification (NHI) number, there are duplicates, NHI details held by different parts of our system are not routinely updated and reconciled, mobile phone numbers are not routinely entered, and lesser trained personnel at the border were having difficulties dealing with finding and determining NHI numbers, despite the fact that a name, a date of birth and gender should give you almost all you want t identify an NHI (at least for people who have been allocated one).
This outbreak has also been a “wake-up call” for our public service beyond the health system. For all the talk of an all-of-government approach, somewhere something went wrong in the chain of command and among the silos of different parts of the bureaucracy such that an apparent edict from Cabinet was not fully implemented, despite reassurances. It was said that in ancient times the orders of the Emperor might never go beyond the palace gates, and certainly no further than the boundaries of the surrounding city. It appears that this may apply to the modern New Zealand public service, albeit under conditions of an unprecedented crisis with multiple system changes and many moving parts. At the very least the State Services Commissioner should be initiating his own inquiry into the capacity of the system since much can be learned for future improvement from the successes and failures under these conditions of duress.
Finally, unfortunate as it might have been, this has been an outbreak that was, in retrospect, predictable, but one from which we must learn very fast as it will not be the last, even with the best systems in place. We had got complacent. We rejoiced in a return to our old freedoms. The public needs further guidance, so that we can return to a “new normal” that takes into account the new sense of alertness and urgency we need to have, while also getting back to as normal a life as is possible during a global pandemic. We also need to have those discussions about how we can manage around this virus for the forseeable future, how our public services can adapt and respond better, and how our economy can flourish and be more resilient and effectively future-proofed for a very different world.
Elected Member, Auckland District Health Board
Emeritus Professor in Population Health and Social Science, University of Auckland
Published in The New Zealand Herald, 31st August 2020