Executive summary: A window on quality 2021 (Part 1) | Whakarāpopototanga matua: He tirohanga kounga 2021 (Wāhanga 1)

Contents

Introduction
Chapter 1: Distraction: Primary care, immunisation and screening
Chapter 2: Difference: Primary care patient experience in 2020/21
Chapter 3: Delay: Emergency departments
Chapter 4: Deferral: Backlogs of elective care
Chapter 5: Delivery: Cancer care and COVID-19 – a case study in resilience
Conclusion
Recommendations

You can view the full report here. 

Introduction

Aotearoa New Zealand has been recognised internationally for a successful early response to the global pandemic of COVID-19. This year’s A window on quality 2021: COVID-19 and impacts on our broader health system – Part 1: March 2020 to August 2021 | He tirohanga kounga 2021: me ngā pānga ki te pūnaha hauora whānui – Wāhanga 1: Poutū-te-rangi 2020 ki Here-turi-kōkā 2021 (Window) explores the secondary impacts of our response on selected aspects of the functioning of our health system so we can learn from that experience and shape resilient system responses in the future.

A second part of this Window, scheduled for June 2022, will explore other critical aspects not covered here, as data emerges from the system, revealing the effects of the Delta outbreak on other services.

The Window begins with a broad view of the conditions and context in which the Aotearoa New Zealand health system responded to the challenges of COVID-19 between 2020 and 2021. Since the beginning of 2020, we have, on average, experienced less-stringent restrictions than any comparable country. Our economy has been less badly affected than elsewhere, and lockdowns have had the effects of decreasing all-cause mortality since 2020 (mostly among older people) and increasing life expectancy, in sharp contrast to most other countries.

However, Aotearoa New Zealand’s particular patterns of inequity before the pandemic were both a failure of the Crown’s obligations under Te Tiriti o Waitangi (Te Tiriti), and presented fertile ground both for the virus and for the unintended negative effects of measures to contain it. The impacts of COVID-19 on health care must be considered in view of inequitable health service provision that has occurred historically and continues today, but also because pandemics compound and promote pre-existing social and economic inequities, especially in terms of precarity of housing, overcrowding and poverty.

The pandemic presents an opportunity to think about what a future health system in Aotearoa New Zealand can look like. A return to ‘normal’ is not desirable. A system that is underpinned by a whole-of-government approach to health, is pro-equity, complies with Te Tiriti and is anti-racist must provide the transformative policies and actions necessary to address systematic, entrenched and pervasive inequities.

Chapter 1: Distraction: Primary care, immunisation and screening

Primary care has responded to COVID-19 with unprecedented focus, but the additional work under time and resource pressures has distracted from our system’s business-as-usual work, exacerbating already entrenched inequities by ethnicity. Many Māori and Pacific provider organisations, general practitioners (GPs) and primary health services have felt shut out of meaningful input into the development and rollout of the COVID-19 vaccine strategy. However, once those providers were supported to lead their own approaches, there have been significant increases in vaccination rates for both Māori and Pacific peoples.

Despite a lack of readily available primary care data, we can see that immunisation and screening programmes have been substantially disrupted by the pandemic, in particular for Māori and Pacific peoples.

Immunisations of two-year-old and six-month-old babies have fallen steadily for several years and lockdowns have reduced immunisation rates further (from 91% in March 2020 to 83% in September 2021). Measures to contain COVID-19 appear also to have had the effect of increasing inequities by ethnicity.

• Coverage rates for two-year-old Māori children (already lower than those of other ethnicities and falling since 2017) have declined sharply from 86% in March 2020 to 70% in September 2021. Rates for two-year-old Pacific children have fallen from 94% coverage in March 2020 (and consistent coverage above 90% in the years prior) to 82% in September 2021.
• Coverage of all six-month-old babies was lower at 80% prior to lockdowns and by August 2021 this figure was only 70%, lower than rates in 2012. By September 2021 fewer than half (49%) of six-month-old Māori babies received their immunisations, down from 65% in March 2020. Coverage of six-month-old Pacific babies has dropped from 80% in March 2020 to only 57% in September 2021.

Breast and cervical cancer screening has also been disrupted, likewise with the effect of exacerbating inequities by ethnicity. At alert level 4 all screening appointments were paused.

• Breast screening data shows a sharp decline in coverage in 2020. For most ethnicities, this decline slowed by September 2021, however, coverage of Pacific women continued to steeply decline, from 71% in 2019 to 61% in September 2021. Coverage of Māori women remains lower than all other ethnicities and has declined from 62% in 2019 to 58% in September 2021.
• Cervical screening data shows a visible dip in 2020 in otherwise stable coverage for women of ‘other’ ethnicities (mainly those of European descent) followed by recovery to previous levels in 2021 (76%). In contrast, cervical screening coverage for Māori and Pacific women has declined since 2016, from 67% to 59% and from 76% to 61%, respectively.

Chapter 2: Difference: Primary care patient experience in 2020/21

Patient experience survey data shows how lockdown affected access to primary care and for whom, the reasons why people did not access care, what people did instead and how it worked for them.

People differed in their experience of access to care

Around one in three (34.4%) of respondents reported that the level 3 and 4 lockdowns in 2020 kept them from going to their GP in the way they usually would have. These respondents were more likely to be under 65 years old, disabled and live in areas of greatest socioeconomic deprivation. More than 40% of disabled people surveyed could not see their GP as they normally would.

The barriers to access

The most common reason cited for not accessing services (42.9%) was that alert level restrictions meant they weren’t allowed – the people who cited this reason were more likely to be working aged and disabled. Those who decided their reasons for accessing care in the context of lockdown weren’t urgent enough (38.9%) were more likely to be younger (15–24 years), not disabled and living in areas of least deprivation.

What people did instead

In general, people used telehealth options, delayed their care or substituted other options. One-third of people (35.4%) who were unable to access health care during lockdown as they usually would, delayed their care. One in five (19.6%) people who were unable to access health care during lockdown as they usually would, substituted care with other options like advice from family/friends, internet searches or using medicines at home.

To August 2021 COVID-19-related reasons for not accessing primary care fell but long waiting times to get appointments, however, grew as a barrier, to 14% of respondents from 11% in August 2020.

Limits of telehealth

Telehealth, in particular phone, appointments grew strongly from 9% of respondents to 55% of respondents under level 2/3 in 2020, while in-person appointments fell from 95% of respondents to 55%. Those who used phone appointments were more likely to be of Māori or Pacific ethnicities rather than European/other, aged 25–64 years, living in the most deprived neighbourhoods and living in the North Island outside of the Auckland metro area. Those who used video were more likely to be younger and living in the area of Auckland metro district health boards (DHBs).

When asked what they did not like about telehealth, 39.2% said they liked everything but just over one in ten (12.3%) didn’t like anything about it, and these people were more likely to be disabled (14.7% vs 10.9% not disabled). For telephone appointments in particular, people were less likely to have positive experiences in terms of being informed about and involved in care, and having enough time with
the GP.

Chapter 3: Delay: Emergency departments

The response to COVID-19 in early 2020 caused dramatic falls in emergency department (ED) activity in both Aotearoa New Zealand and comparable countries. By June 2021 nearly 90,000 people had not attended an ED when we thought they would have, based on the data from the three previous years.

The initial large drop in presentations in early to mid 2020 was followed by slow returns to historically expected activity and, in some cases, periods when presentations of more acute cases increased beyond expected activity. In October 2020, when Aotearoa New Zealand went to its second alert level 1, the number of patients classified as triage level 1 or 2 (life-threatening or imminently so) at EDs began to rise above expected levels, putting pressure on services. This may to some extent represent deterioration in control of chronic non-communicable disease over lockdown periods.

European/other populations returned to expected levels of ED presentations by July 2020. The return to expected levels for Māori was far slower (finally back to expected levels in November–December 2020, then falling below expected again). There has been a cumulative shortfall of 40,000 Māori presenting to ED since March 2020. A similar pattern of slower return of lower presentations was visible for Pacific peoples.

Unlike in other countries, patterns of admission to hospital tended to follow patterns of ED presentation to June 2021, suggesting no changes in clinical thresholds for admission. As we enter a period of widespread community transmission of COVID-19 in the Auckland area and the spread of COVID-19 further through the country, we should learn from other countries’ experiences in terms of their lower rates of admission to hospital (in response to stricter infection control procedures and protection of hospital capacity for COVID-19 patients). We must plan appropriately for the early months and the winter of 2022.

Chapter 4: Deferral: Backlogs of elective care

Many planned care services, or ‘elective’ procedures performed in hospital were cancelled, delayed and deferred because of pandemic restrictions between 2020 and 2021 in comparable countries and in Aotearoa New Zealand. This chapter looks at two different views of how big a backlog of care was created to mid-2021, whether we have managed to substantially reduce it and, if so, if we did it equitably.

DHBs submit annual plans of elective activity to the Ministry of Health each year then actual activity is compared with these plans. This data suggests that, after the April‒June 2020 quarter, in which elective activity dropped 16%, DHBs over-delivered elective activity to June 2021 when between 8% and 12% more procedures were carried out than planned.

However, using different techniques that exclude minor procedures such as skin lesion removal, and looking at the top eight surgical specialties by usual volume, we find a significant backlog – 16,000 fewer waiting list and arranged admissions occurred between March and June in 2020 compared with what would be expected based on three years’ prior data. For a variety of reasons, including changed settings for elective care, coding changes and less disruption to minor procedures caused by COVID-19 restrictions and lockdowns, DHBs delivered more minor procedures than usual and fewer inpatient surgical procedures. Since the start of 2021 to June, progress in reducing this backlog stalled generally, though orthopaedics appeared to make progress to June 2021.

Shortfalls in elective activity decreased for all ethnicities. Yet Māori and Pacific peoples are still not receiving as much elective care as they were before the pandemic, however inequitable that amount may have been. That is, there is no evidence that recovery from COVID-19 prioritised or favoured those who already face the greatest inequities in access to health care.

Chapter 5: Delivery: Cancer care and COVID-19 – a case study in resilience

In some other countries, cancer screening, diagnosis, treatment and supportive care has been substantially disrupted by the pandemic. However, data from Te Aho o Te Kahu (Cancer Control Agency) suggests monitoring and reporting on service access and performance to inform coordinated national and regional decision-making minimised disruption in services in Aotearoa New Zealand.

Data to September 2021 show that there were lower numbers of new cancer registrations in the first level 4 lockdown in April–May 2020 (40%, or approximately 1,000 fewer) in comparison with 2018 and 2019. This was followed by increased registrations in 2021 (5% more compared with the 2018–19 average). For Māori, cumulative new cancer registrations from January to August 2021 were 9% higher than the 2018–19 average.

Diagnostic procedures also fell steeply in the first lockdown in 2020. However, the number of diagnostic procedures performed rapidly returned to baseline in 2020 and increased (notably including for Māori) in early to mid 2021.

Treatment seems to have been less effected. Numbers of curative prostate, colorectal and lung surgeries show minimal effect of COVID-19-related measures, including for Māori.

These apparently good results are attributed by Te Aho o Te Kahu to rapid clinical governance of the COVID-19 cancer response; development of an Equity Response Framework to identify how existing inequities might worsen and what should be done; development of national ‘minimum treatment’ clinical guidance; rapid adoption of telehealth to deliver cancer care; escalation and central coordination of specific regional issues and issues for multiple centres; and close monitoring and reporting of the impact on cancer services.

Conclusion

Future decisions must be made in spite of the volatility, uncertainty, complexity and ambiguity of the situation we face. We identify how the cancer care response exemplifies four capacities of a system that allow it to perform resiliently: the capacities to anticipate, monitor, respond and learn.

Anticipating

Early recognition of the potential impacts that COVID-19 might have for cancer treatments, and a particular recognition that this impact was likely to exacerbate existing inequities within cancer care, meant a wide array of data was collected to help make visible the impacts, both intended and unintended.

Monitoring

Rather than being an exercise in reassurance, monitoring of nuanced data that reflects local conditions and priorities, bringing together multiple perspectives, should focus on making visible any unintended consequences of changes implemented.

Responding

Anticipated effects and early signals within the data should be responded to through coordinated actions across the system. Capacity to do this is key and is challenging to do in a system that is designed for optimal efficiency under existing conditions, but that may be surprisingly brittle when it faces dynamic changes.

Learning

Effective governance of complex, multi-provider problems seems to have involved forming a network of interested parties from many levels, using data to understand the impacts of actions and being able to mobilise resources from across the system.

Importance of data and how we make meaning from it

What we choose to measure determines how we respond. Building an equity lens into measurement from the outset, for example, shapes both what becomes visible and what the system responds to.

Do we use data to seek reassurance that the system is functioning as measured by often narrow performance targets or do we collect data to make visible the impacts of decisions on those providing care or controlling resources?

Collection of data alone will not lead to resilient performance; we must use data to inform a response. Without the ability to allocate resources or change our focus, we will be data-rich but fail to make meaningful improvements.

Summary

A health care system that performs resiliently is one where the system, at all levels, is able to adapt to shocks and change to ensure we provide high-quality care. The cancer response is one example of a resilient response but there are many more, including in the Māori community sector.

Recommendations

The fast pace and changing nature of the pandemic, and in particular the predominant impact on Māori and also Pacific peoples, means some of the recommendations below arise from the findings of this Window and some relate to the emerging issues of the impact of the COVID-19 Delta variant.

1. District health boards/Health NZ, from July 2022, must, with some urgency, find a stronger approach that is appropriately resourced, to support the mana motuhake of Māori and Pacific providers and their unique knowledge of and abilities to serve their populations. This is even more critical in the context of these providers supporting community self-isolation and quarantine (CSIQ) arrangements while their populations bear the main burden of COVID-19 under the most challenging conditions.
2. Mechanisms that provide governance of quality (including clinical governance) need to be established, also with urgency, at local and district levels for the current and expected CSIQ responses. This must be based on a Te Tiriti partnership with iwi and Māori providers, given the lower rates of vaccination for Māori and the higher vulnerabilities to illness in affected Māori and Pacific peoples. Partnerships with Pacific providers must also be established, with active input into quality governance as well.
3. A formalised national network for data and intelligence sharing for EDs across the country should be established, or one of the existing network arrangements strengthened, with proper resourcing and data analytic capability.
4. DHBs/Health NZ, from July 2022, must approach addressing the backlogs of elective activity created by COVID-19 restrictions with greater thought and stronger emphasis on understanding the particular make-ups of their backlogs and prioritisation of work according to need. The Ministry of Health reports that it anticipates access to elective care and screening (and all other health care) would be improved under the COVID-19 Protection Framework (CPF).
5. What we have learned about the nature of patient experience of primary care during COVID-19 restrictions as discussed here is valuable but high level. Local primary health organisations should use their survey data to look at the experience of their populations, consider evidence of difference in that experience for different parts of their populations and tailor services, including telehealth care services, appropriately.
6. A national primary care data set is a long-standing deficiency that needs to be addressed. There is a notable gap in our understanding of how the health system as a whole responded to COVID-19 due to the absence of consistent national primary care data, despite primary care having powerful local clinical systems.