Executive summary: A window on quality 2022 (Part 2) | Whakarāpopototanga matua: He tirohanga kounga 2021 (Wāhanga 2)

Contents

• Introduction
• Chapter 1: Continued lines of inquiry
• Chapter 2: Mental health and COVID-19
• Chapter 3: Workforce
• Chapter 4: Disabled patient experience and Health and Disability Commissioner complaints
• Conclusion

You can read the full report here.

Introduction

Around the world, the COVID-19 pandemic has placed a massive strain on health systems, which have recovered only partly or, in some cases, not at all. Aotearoa New Zealand has been globally recognised for its response to COVID-19 through multiple phases of the pandemic. We have had a very different pandemic to many other places in the world. Before the pandemic, however, a wide range of measures and feedback from people in the health and disability sector indicated that Aotearoa New Zealand’s health system was already experiencing a steadily rising tide of need caused by under-funding over time while our population has been growing and ageing. The effects of the pandemic added to this rising need rather than leading to the sudden pandemic ‘tsunami’ in 2020 and repeated waves afterward that many other countries experienced.

In this report, A window on quality 2022: COVID-19 and impacts on our broader health system (Part 2) | He tirohanga kounga 2022: Me ngā pānga ki te pūnaha hauora whānui (Wāhanga 2) (Window 2) we use perspectives from respondents in the health and disability sector and hard data to continue important lines of enquiry we began in A window on quality 2021: COVID-19 and its impacts on our broader health system (Part 1) | He tirohanga kounga 2021: Me ngā pānga ki te pūnaha hauora whānui (Wāhanga 1) (Window 1), published in December 2021. We then investigate some aspects of what we know about the effects of the pandemic on the population’s mental health and on our health care workforce. Focusing on a key issue Window 1 identified, we also examine the impacts of the pandemic on the experience of disabled people using health and disability services.

The broad view: stringency and mortality

Aotearoa New Zealand has maintained more freedoms (or level of ‘stringency’) on average than many countries over the whole period of the pandemic to date. However, lockdowns associated with arrival of the Delta variant have now brought our level of stringency to a level similar to that of some Scandinavian countries. Measures of excess mortality using data to mid-2022 suggest that, during the initial lockdown period in 2020, fewer people died than would be expected for the time of year and over the winter of 2020. Most of the lives saved were people aged over 60 years. Most recent data shows that our excess mortality rate has risen above expected levels. Over the entire period of the pandemic in total, as of mid-2022, about the same number of people have died as would be expected in this period, but at different times. This is an extraordinary achievement, rare in the world, but we await more recent data to complete the picture.

We note that Pacific and Māori communities of south Auckland in particular have now faced three waves of COVID-19. These waves have had impacts on wellbeing, employment and mental health, on top of the physical effects of the virus itself in terms of infections, hospitalisations and deaths. The Pacific and Māori responses to the pandemic show that community agency and voice have been key in leading effective responses.

‘E fofo le alamea le alamea’ – solutions for problems lie within the collective intelligence of that community. A response that looked and felt Pacific to Pacific peoples, and looked and felt Māori to Māori, was acceptable and effective. This remained true for initiatives ranging from promoting COVID-19 vaccinations to delivering care in the community during the first wave of the Omicron variant.

Chapter 1: Continued lines of inquiry

In this chapter, we continue and extend analyses from Window 1, looking at immunisations, cancer screening, the experience of emergency departments, delays in planned care/electives and cancer care.

• The pandemic has contributed to reductions in the rate of childhood immunisations in Aotearoa New Zealand. Since March 2020, rates of immunisations among six-month-olds have fallen from 80% to 66% in June 2022. Coverage of 24-month-olds has fallen from 91% in March 2020 to 83% in June 2022. This has particularly impacted Pacific and Māori babies and babies in families living in poverty.
• The pandemic has contributed to reductions in rates of screening for breast and cervical cancer. Total breast screening coverage fell from 72% in June 2019 to 66% in June 2020 and has remained at a lower level since then, after six years of stable 72% coverage. Pacific women have experienced the greatest change, and coverage for wāhine Māori remains most inequitable. In cervical screening, we have lost the gains achieved over the last 14 years. Coverage, already declining since 2016, fell further from 71% in June 2019 to 68% in June 2020. A slight uptick in 2021 was followed by another fall in 2022 to 67%, the lowest in 14 years.
• Emergency departments have experienced increasingly difficult circumstances. Feedback from frontline staff indicates the main reason for these difficulties is that limited system resources (made worse by pandemic effects on staffing levels) have come up against greater, more complex, demand arising from the pandemic. Recent data suggests the number of presentations to emergency departments has been steady overall but the number of more urgent presentations has increased since the first lockdown in 2020.
• Access to planned care has become clogged. The percentage of patients waiting longer than four months for their first specialist assessment has increased from 14% to 26% in the year to May 2022. The number of patients who were given a commitment to treatment but did not receive that treatment within the required timeframe (four months) has more than doubled in the last year to almost 28,000 (41%) in May 2022. Planned care activity in hospitals dropped sharply over the first lockdown, creating a backlog, but this elective activity returned to expected levels. Starting again at the Delta outbreak in August 2021, however, the situation has worsened, with activity consistently lower than that expected based on earlier years.
• Disruption to cancer services has been minimised according to data from Te Aho o Te Kahu, the Cancer Control Agency. Despite the lower and inequitable rates of some kinds of cancer screening noted above, and early falls in registrations, diagnostics and treatment in March 2020, since then services have largely been maintained. Since June 2020 new cancer registrations have increased slightly.

Chapter 2: Mental health and COVID-19

The pandemic has had a profound impact on people’s mental health. However, quantifying and understanding this impact is challenging. We look at selected indicators of how the pandemic has impacted mental health over the life course.

Maternity

• Well Child/Tamariki Ora checks help with maternal and whānau mental health in the infant’s first year of life. The pandemic disrupted these checks: the percentage of contacts fell dramatically from March 2020, while recovering slightly to March 2022.
• Calls for help with mental health issues to PlunketLine rose strongly in late 2020. They peaked in the second quarter of 2021 at four times the number of calls received before the pandemic.
• Referrals to Aronui Ora, a maternal mental health service that serves the entire Auckland District Health Board (DHB)[1] area, rose sharply in the 2020/21 financial year after a steady number of referrals over the three previous years.

Child and youth

Data indicates the pandemic has had an impact on the mental health of children and young people in particular.

• Calls to the Whakarongorau/1737 helpline from those aged 13–19 years asking for help spiked in April 2020. The volume of calls with a significant risk of suicide began to rise above the volume of all earlier periods from April 2020, peaking in January 2022.
• There appears to have only been a small disruption to the percentage of clients aged under 25 able to see a mental health specialist within three weeks of referral for reasons that clearly relate to the pandemic. However, this first appointment is usually for an initial suitability assessment. Waiting times for follow-up appointments for further assessment and formulation of a treatment plan are not captured in the available data but information from the sector, media reports and recently published work suggest that treatment has been harder to access with longer waiting times since the start of the pandemic.
• The number of antidepressants and antipsychotics dispensed to those aged 0–17 years clearly increased at the start of the pandemic. More children aged 0–15 years were admitted to hospital for mental health reasons than would be expected from June 2020 to the August 2021 lockdown. Among children aged 10–14 years, hospital admissions with diagnoses of intentional self-harm (especially intentional self-poisonings) have risen since March 2020.
• The Eating Disorders Association of New Zealand reports a 58% increase in requests for assistance through its helpline in the 2020/21 financial year. New community referrals of those aged under 19 years to Auckland’s Tupu Ora community-based specialist eating disorder service rose from around 100 per year to a new high of 180 in 2020/21. Hospital admissions likewise rose to an unprecedented high in 2020/21 for young people in the area of metro Auckland DHBs who have become medically unstable as a consequence of the severity of their eating disorder.

Working-age adults

• New Zealand Health Survey data in 2020/21 shows an overall prevalence of 9.6% of adults aged 15 years and over reporting psychological distress in the last four weeks, which is in line with the steady year-on-year increase occurring in previous years. However, the proportion of Pacific women reporting psychological distress nearly doubled in one year, from 11% in 2019/20 to 19% in 2020/21.
• Whakarongorau/1737 helpline data shows clear spikes in calls from younger working-age adults related to the first lockdown.
• The number of antidepressants dispensed increased after March 2020 and remained higher than the steady rates observed between January 2016 and January 2020. The change is not due to the introduction of wholesale limits to dispensings of medication for a period early in the pandemic.
• Zero seclusion project data shows short-term rises related to the pandemic in the rate of seclusion as a strategy to deal with people with mental health needs in inpatient mental health services. The main reason for the first rise was that the overall number of inpatients held in inpatient facilities decreased while the number of seclusions remained steady. In contrast, another spike in the rate in August 2021 was related more strongly to an increase in the absolute number of patients being secluded. During this phase of the pandemic, services reported significant impacts on staffing, such as through illness, isolation and staff redeployment. Pressures on services related to lockdown and community spread of COVID-19 may therefore have contributed to decreased capacity and ability to pursue quality improvement work, and to these spikes in rates of seclusion.

Older people

Despite the obvious disruptions to the networks, organisations and connections between whānau that support older people, including restrictions on those in aged residential care facilities, it is challenging to find data to quantify the mental health impacts of the pandemic on older people. Recent qualitative work has shown the pandemic has had effects on loneliness in older people, coalescing around three inter-connected ways older people themselves conceptualised and experienced loneliness: feeling disconnected, feeling imprisoned and feeling neglected.

Chapter 3: Workforce

The health care workforce across the entire system has felt the impacts of the pandemic. Virtually all have been affected professionally and personally. Impacts on inequity and quality and safety follow on from this.

The Government has made ‘Developing the health workforce of the future’ a priority in its Interim Government Policy Statement on Health 2022–2024. It announced a raft of new measures to support, grow and develop the workforce on 1 August 2022.

Around the world, staff in many industries have changed their jobs or left their field of work entirely since the pandemic began. This trend has affected health care in particular, as examples from the United States, England and Australia show. Large-scale surveys show high and rising levels of burnout and mental health issues in health care staff during the pandemic. In some countries, the departure of staff was delayed until after the first phase of the pandemic. Aotearoa New Zealand managed to avoid this trend at that time due to the effective nature of our response. With the arrival of COVID-19 in this country, however, this overseas experience potentially holds a warning for the future.

Staff turnover in Aotearoa New Zealand has been rising rapidly from the beginning of 2021 after dips for most role categories at the beginning of the pandemic in March 2020.

Long-standing system settings

Existing workforce shortages and under-staffing have been reported across services. The Omicron outbreak has added to staffing pressures in terms of staff illness, isolation requirements and inability to recruit more staff offshore.

Immediate effects of the pandemic in creating a workforce deficit

At the height of the first Omicron outbreak, services noted that the pandemic was having three simultaneous effects that combined to create substantial workforce deficits. The pandemic created more demand for health care, while reducing the available workforce through both ill health and the demand for isolation, and at the same time making supply of care less efficient in various ways.

Compounding effects of workforce stress and environmental instability

Long-standing stresses on the health system are compounded by their effects on the workforce. Burnout leads to higher sickness rates and turnover, both of which further increase the workforce deficit. These effects bring the risk of creating a vicious cycle of further stress and departures.

Distraction occurs where staff simply have too few resources to provide the level of care they would like to, often with activities foundational to good-quality care being foregone. This risks worse health outcomes and adverse events, which result in a psychological toll on staff and make burnout more likely. Again, a vicious cycle of reduced staffing and poorer care can develop. Several surveys report high levels of burnout in general practitioners (GPs) and the specialist medical workforce.

Impact on health outcomes

There are early signs that health outcomes associated with good quality and safety practice have worsened since mid-2021. Worse outcomes have been evident over repeated months in terms of increasing numbers of in-hospital falls that resulted in a fractured neck of femur (broken hip), in-hospital Staphylococcus aureus bacteraemia infections and postoperative deep vein thrombosis/pulmonary embolism.

Chapter 4: Disabled patient experience and Health and Disability Commissioner complaints

The Health Quality & Safety Commission’s large survey of primary care patient experience shows the pandemic has neither worsened nor improved the disparities in access to and experience of primary care between disabled and non-disabled people. However, these long-standing disparities remain stark and must be addressed.

Access

From August 2020 to May 2022:

• on average, about a quarter (24%) of disabled people could not always get care when they wanted it, compared with 17% of non-disabled people. This disparity is largely consistent with findings before the pandemic
• young disabled people experienced worse access to care than those in other age groups
• young disabled Māori (aged 15–44 years) reported the worst access to care of any ethnic group, with 41% reporting they were not always able to get care from a GP or nurse when they wanted it
• 43% of disabled people of another gender reported not always being able to access care when they wanted it in the last 12 months
• those who self-identified as being disabled or who had multiple impairments reported worse access to care than those with one impairment
• the most-reported barriers to getting primary care when people wanted it were long wait times to get an appointment, pandemic alert levels and restrictions, difficulty taking time off work and other reasons.

Experience

Fifteen percent of disabled people were not involved in decisions about their care and treatment as much as they wanted to be, compared with 10% of non-disabled people. This difference did not change over the pandemic.

Disabled people wanted their health professionals to be better at communication and listening, and to spend more time with them.

Health and Disability Commissioner complaints

The Health and Disability Commissioner (HDC) has received an unprecedented number of complaints in the financial year 2021/22, 45% higher than 2018/19. In 2021/22, 26% of all complaints received were about issues related to COVID-19. HDC is currently receiving around 60–70 complaints related to COVID-19 a month. In the latest year’s data, 18% of the complaints related to COVID-19 (158 in total) were about the impact of the pandemic on the system, including delayed care, staffing and other issues.

Conclusion

The pandemic has been a transformative experience for our society and our health care system. As well as having a different experience of the pandemic from many other places in the world, we met the pandemic with a health system in a different state compared with others. Services have experienced the pandemic as adding to a rising tide of need in a context of decades-long under-funding rather than as the sudden tsunami of need other countries have experienced. Aotearoa New Zealand has no ‘before’ state to return to. We need to understand the different ways in which the pandemic has affected those who live with poverty, disability or mental health needs. To improve this understanding, we need to make better use of data and learn from the examples of dynamic response that Pacific and Māori communities and health care providers have given us.

Data is never values-free. Better use and understanding of data with an eye for resilience and adaptive capacity can:

• show us how outcomes differ for different groups
• detect signs that the system may be decompensating, that is, becoming unable to maintain its functions
• increase our understanding of system performance by combining what we learn from ‘soft’ intelligence (such as feedback from staff and consumers about their experiences) with measurable data
• highlight keystone risks – that is, critical resources or vulnerabilities that create significant risk across multiple areas. For example, the workforce shortage is a keystone risk that is already having system-wide impacts.

The experiences of the pandemic are now woven into the whakapapa of the health care system, shaping its future. If the pandemic has shown us anything, it is that the future is not the same as the past. There is no going back and the reforms offer an important opportunity for transformation and building a more resilient health care system that is better suited to the uncertain and dynamic realities we face.

Endnotes

[1] We use the term ‘district health board’ in this report where the content relates to pre-July 2022, when the district health boards transitioned into being health districts under the auspices of Te Whatu Ora – Health New Zealand.