Over the next few weeks we will be publishing letters written by Northland DHB chief executive Nick Chamberlain to all Northland DHB staff, primary and community care providers, Māori providers, aged care and home and community support providers as well as iwi and social sector and council leaders. They will run regularly from today until the conclusion of the Covid-19 crisis. He describes them as letters to those who will become our "war heroes" as they fight to save lives and keep the rest of us safe. "They will hopefully give you an insight into the amount of planning and preparation required and also provide reassurance that we are doing everything we possibly can." Today's letter was sent on March 27, day two of the lockdown.
Hi everyone and kia ora tatou
Day two of lockdown. It's weird, surreal, unprecedented in our lifetimes, and, for all of us working in healthcare, the most essential of all services (something I've been telling Wellington for years), there is the added complication of continuing to work in what has become a high-risk profession.
Because both his parents work in health, my youngest son attended his primary school for the last two days of school before the lockdown - the first day there were 26 pupils in attendance and on the last day there were five out of a school of more than 400 children.
I've heard of parents who both work for us who have sent their children away for the next month so that they can continue to work on the front line and not have to worry about their children. Others have developed quarantine arrangements in their own houses using separate entrances and sleeping arrangements.
We now know that those parents who are both working in "essential services" can access a funded childcarer who can then become part of their "bubble". More information on this can be found at Covid19.govt.nz as well as the NDHB intranet and internet sites.
Even the most resilient of us will be feeling a level of anxiety and stress with the changes we are facing. I've touched on this a bit before but I'm going mention it again. I'm now at three weeks working every day and for the last two weeks they've been 16+ hour days so I'm probably writing to myself as much as all of you.
You'll have seen lists similar to the one I provided in my first letter to you, but the principles of healthy food, exercise, sleep and non-Covid-19, non-TV, non-device time. And make sure you get and enjoy your days off!
You can all easily access advice and support online, and there will also be counselling support through Mahitahi Hauora as well as various employer assistance programmes (EAP). Northland DHB's EAP is prepared for a significant increase in demand, so please use these confidential programmes if you need them.
I want to acknowledge our entire mental health workforce in our inpatient, subacute units, and the community - they sometimes get forgotten early on in a medical crisis, but they are also at the front line. Their patients are going to get sick, so they face the usual risks, but on top of that they will need to provide much more support because of the added stressors that we are all experiencing. They also have to deal with the longer-term psychological impacts of this pandemic.
To our general practices and pharmacies, thank you for your innovation and commitment to your patients. The whole way you deliver care has changed overnight, and in some ways it will change forever, hopefully for the better. Telephone triage and telehealth solutions have and are now almost the norm.
Funding was agreed and yesterday I sent a letter to all PHOs, general practices and pharmacists in NZ which provides $30 million to the sector to assist with the costs of the work you are doing and the loss of revenue from going virtual. We hope to get this money out to you early next week. It will not be enough nor the last payment as we all know that this is going to go on for some time. You also should explore the various business subsidies that are available as I know that all of your incomes will be impacted severely. We are monitoring this closely and I'm in contact with the various national organisations as well as working closely with the Ministry of Health.
I know that Flu vaccine supply is an issue for some of you, but when this is solved, please continue to vaccinate our population. Continue to recall your elderly and vulnerable patients for flu vaccinations. It's the best thing you can do for them. At the moment they are the only patients that qualify and it's essential that they are ALL protected from flu as Covid-19 on top of flu would be a lethal mix, not to mention the unnecessary impact of this preventable illness on an already overwhelmed health system.
You should also continue with childhood immunisations. Please consider running separate clinics and streaming your flu patients through a separate entrance, vaccinating patients in their cars etc.
A huge thank you to the staff in our Community Based Testing Centres which is taking the pressure off many general practices. There have only been a small number of these set up around NZ and we went very early with seven of them to try and support our very scarce GP workforce. As our numbers of cases grow, we will need to supplement and change the workforce because our staff will be needed for contact tracing and other vital public health duties. We are working with Mahitahi Hauora on this.
I've also been asked to provide clarity regarding referrals to secondary care. I won't be able to give you a list of conditions or procedures/investigations/clinic appointment criteria as they haven't been developed, and frankly we don't have time right now.
However, what I can give you are some principles - basically, if a patient can wait, even if they are suffering with pain or disability, they will need to. Please don't refer them and try to manage them in the community. Any "elective" or planned procedures will clearly have to wait, and I don't know for how long. If a patient would end up on an urgent/emergency list or there is a threat to life or limb, then please continue to refer these patients. Some may still be declined at this time, but that may require a specialist decision.
Obviously, cancer and suspected cancer patients should be referred.
Remember, any time that clinicians are taking prioritising and declining referrals, is time that they can't spend assisting their colleagues managing Covid-19 or dealing with our most urgent cases. It's tough, I know, but these are very tough times.
Another issue to weigh up is the risk to your elderly and vulnerable patients of attending the hospital for surgery/urgent assessment vs the benefit of the treatment. That will be a judgement call, and you can only do your best. In this situation we all find ourselves, medico-legally, this is understood, and you can only do your best and document your decisions.
Although we are behind some parts of the world and are able to learn from them, there is no playbook for how to do this. We are learning as we go. The Ministry of Health, District Health Boards and PHOs are working really well together. At my level we have multiple video-conferences each day. There are teams of clinicians working on protocols and pathways which are then agreed nationally and passed down through the National Health Co-ordination Centre (NHCC) (who are effectively our controllers) to the health sector. It's really important that we all adhere to this instruction, noting that it may change as time goes on.
Our latest visitor policy and Personal Protective Equipment (PPE) policy will be coming out today. Again this is regionally and nationally agreed by expert clinicians. It is not just for our hospital staff, but includes primary care, pharmacies, Māori providers, aged care, home based support workers, ambulance workers etc. There is also direction coming for those essential workers outside of health such as police etc. I genuinely understand how much anxiety there is over this issue, but we do have to ensure we don't run out later and until our future supplies can be guaranteed we do need to follow these guidelines which may be modified over time.
Finally I wanted to share a text that I saw from a senior member of staff. I believe it reminds us all why you are all working so hard for your patients and communities.
I can't tell you how comforting it is to know the DHB is so well prepared. It's hugely reassuring.
"I don't know if you know this but Māori died seven times more than Pākehā in the Spanish flu epidemic. We were turned away at hospitals and medical attention was just not sent to the communities. We all remember that even if we weren't there. There are mass graves in Māori cemeteries around Northland where people were literally rolled down the hill and covered up. Māori are scared that we will be forgotten again, but seeing how the DHB has responded makes me feel so much calmer and confident that the whole community will be cared for."
Personally, I'm still really worried about Māori and our rural and poorer communities, our homeless, and our elderly - much work has been done but there's so much more to do!
The weekend approaches and I'm planning to have it off. I'm going to choose option A this weekend (those who've seen the various Covid-19 videos and memes will know what I mean) and spend time with my wife and 6-year-old, and FaceTime my older three children. I hope that some of you can do the same!