When Covid immunisation rates have hit their ceiling, how will the health system cope with the added workload caused by the unvaccinated falling sick? Nicholas Jones reports.
Covid was in the community, and intensive care units braced for impact.
New Zealand was in the uncharted waters of its first lockdown. ICUs freed space for any influx of coronavirus patients.
One way to do that was delaying surgery for people who would need recovery time in intensive care.
The restrictions strangled the spread of the virus, and patients were rebooked. However, many were in worse condition, an ICU nurse at a major hospital told the Weekend Herald.
"Those patients were so sick. And we don't see those numbers come up in Covid-related deaths, because they are not a direct correlation. But they are there. It's a big impact.
"I don't have the numbers to back it up. It would be hard to get those numbers. But we all felt that those deferred patients were really sick when they eventually came in."
Concerns about hospital capacity - and the impact of delaying thousands of surgeries and appointments - are front and centre again, as New Zealand battles the more infectious and dangerous Delta strain.
An exhausted health workforce is stretched thin after redeployments to maintain record testing, vaccination and contact tracing rates.
Health Minister Andrew Little told the Weekend Herald he's very concerned about that strain, and is considering what can be done to help, including building up the workforce.
"They are under extraordinary pressure at the moment - not only having to deal with and adapt to responding to the Covid virus, but also, it is an understaffed system, there are a large number of vacancies, and public expectation about being kept safe is very high.
"I get very disturbed when I get the stories, and there have been a lot of them, of nurses and other clinicians finishing their shifts absolutely exhausted, and finding it really hard to go back to work the next day."
Documents obtained by the Weekend Herald point to what services will struggle in the months ahead. The recovery plans were filed by all 20 DHBs after last year's lockdowns, and show clinicians feared for those caught in delays.
For example, people overdue for eye care reached into the thousands in some regions (wait lists were still lengthy before the current outbreak), with Waikato DHB warning delays could lead to loss of eyesight and even blindness.
Diagnostics including CT, MRIs and heart scans couldn't match demand before Covid-19, and backlogs for women's health services in South Auckland meant people were living in severe pain. A lack of operating theatres in many hospitals meant emergency cases bumped planned operations further down the list.
The recovery plans estimated how quickly delays could be reduced.
Those proved overly optimistic - shortly before the current outbreak the Herald revealed progress for some services were off-track, and nearly 30,000 New Zealanders were caught in delays for hospital treatment.
That group will be much larger now. DHBs have estimated more than 4500 planned procedures have been postponed so far this lockdown, a figure that doesn't include first specialist appointments and follow-up consultations.
It's not just surgeries; the redeployment of hundreds of workers to help maintain record testing and vaccination levels, along with physical distancing restrictions, have hit public health efforts.
An estimated 50,000 cervical smears were missed during last year's lockdown, for example, and childhood immunisation rates have dropped alarmingly, which experts fear could lead to another measles outbreak when border restrictions ease.
Health Minister unhappy over ICU training
Even if this outbreak is contained and immunisation rates reach high levels, Delta's infectiousness - and ability to be spread by the vaccinated - means Covid could soon be back, something that would put the unvaccinated minority at significant risk of hospitalisation.
ICU is a pressure point. New Zealand has fewer ICU beds per capita than other developed countries and in "normal" times hospital ICUs are often nearly full, particularly in winter. Surgery teams call through to see if they can operate on patients who will need a post-op ICU bed. Often, they're told, "Sorry, not today".
DHBs have plans to scale up intensive care capacity temporarily, including by seconding anaesthetists and anaesthetist nurses to do the work of their intensivist colleagues.
The Government has bought more ventilators and funded extra ICU beds, but actual capacity hasn't improved since the pandemic began. That's because each patient needs one-to-one care by an ICU nurse, and they need years of training and experience.
The ICU nurse who spoke to the Weekend Herald said her unit lost nurses to better pay in Australia. (A strike by nurses over pay and conditions was abandoned because of the current outbreak). That meant they were down one to two nurses per shift, and more patients had their surgeries deferred.
"A lot of our staff work an extra 12 hours per week. And that has been our norm, running on overtime shifts.
"Which is why with Covid coming in, there are going to be a lot of patients who would normally be using those ICU beds who aren't going to be able to access them. And the actual non-Delta impact is going to be huge."
Little told the Weekend Herald that increasing the number of nurses who could help with intensive care would be a focus in the months ahead. Some DHBs hadn't done enough in that area, he said.
"Most DHBs have done an extraordinary amount to be ready and prepared, and they have been. Some things I think could have been done a little better.
"There was extra funding provided last year, and an online module for more nurses to do ICU learning, so that they could go into an ICU environment if they were called for. Some DHBs got on top of it. Others haven't so much."
Delta has roughly double the risk of hospitalisation of other variants.
In New South Wales, new daily cases are over 1000 and some ICUs are at capacity. A nurse at one ICU recently told the Sydney Morning Herald that her team were "just holding on".
"The patients are air-hungry, starving for breath. Just to turn a patient over, from on their back to on their stomach – which we must do regularly – and keep them breathing, needs six nurses. And we simply don't have enough of us."
Unvaccinated patients frequently expressed regret at not taking Covid seriously, the nurse said. That was heartbreaking.
"Usually, when you intubate someone and put them in an induced coma, you say 'We're just going to put you to sleep, and wake you up in a few days'. But with Covid patients we can't say that because we don't know if we can get them back. And they know that."
Staff shortages at other Sydney ICUs reserved for non-Covid patients are so bad that nurses have spoken of giving some patients the maximum prescribed sedative dose, to keep them safe when attention is needed elsewhere.
The unvaccinated 'will potentially will lead to hospital overload'
Even in New Zealand's much smaller outbreak, Auckland hospitals are having to take extraordinary steps, including asking for up to 30 ICU nurses to be sent from elsewhere in the country, last-minute alterations to create more negative pressure rooms, and transferring some non-Covid patients south of the Bombay Hills.
There will be bigger changes in the longer-term. Some overseas hospitals including in the United Kingdom test all inpatients for Covid, and have entirely separate treatment areas and pathways for positive patients.
That requires different work teams and onerous precautions around PPE and distancing.
A senior specialist at an Auckland hospital, who asked not to be named because he didn't have his DHB's permission to talk to the media, told the Weekend Herald that future waves of unvaccinated Covid patients would need expensive resources including intensive care.
"They will block up the ICU and other hospital resources - which will impact them and also the vaccinated people - which potentially will lead to hospital overload and a fundamental breakdown of our current version of an already stressed but basically good health care system.
"Staff will burn out and suffer their own issues. And when the medical system starts to break down due to overload the only defence is lockdown, tracing, quarantine etcetera, which is very expensive."
He believed many private and some public organisations would ban people who could get vaccinated, but declined to do so. That is already happening overseas.
Much would depend on how many people chose not to be vaccinated, the specialist said.
"We are getting to the place of establishing the rights of the non-vaccinated within the next three to four months."
The beginnings of that debate are under way. In Parliament this week National's Covid-19 spokesman Chris Bishop said mandatory vaccination should be considered soon for early childhood teachers and aged-care workers.
A broader discussion would soon be needed, he said.
"Is it the current legal position that shop owners can say, 'I'm only allowing you on my premise or into my bar or club or my concert', for example, 'if you've been doubly vaccinated'? And these conversations have happened overseas already, because they've got such a high level of courage.
"It's a tricky one, in which the health and safety obligations of employers intersect with the human rights of citizens, but also intersect with the broader rights of the collective in New Zealand to be kept safe as well."
Act party leader David Seymour pointed out major American companies including Google and Amazon were working through the same issue.
"No doubt firms in New Zealand, from your fish and chip shop up to your large corporate on the Auckland waterfront, are going to have to grapple with those same issues. So I believe that that is a debate that needs to happen in an open and respectful way."
Border reopenings, and who is most at risk
University of Otago experts this week made the case for continuing the elimination strategy in the medium term. Recent modelling predicted reopening borders without any measures could lead to more than 11,000 hospitalisations and at least 1000 deaths within only two years - even if nine in 10 people were vaccinated.
Last month, when the Government set out its "roadmap" for reconnecting New Zealand and the world - just days before the Delta outbreak was uncovered - it released the advice of an expert advisory group, chaired by the epidemiologist Sir David Skegg.
The panel urged a review of the system including primary care and intensive care facilities. "Our hospitals have often been dangerously stretched, even by routine winter outbreaks of influenza," Skegg's report stated. "In the winter of 2022 or 2023, a region in New Zealand could experience a large outbreak of Covid-19, at the same time as influenza is leading to many hospital admissions."
Little told the Weekend Herald a "front and centre" consideration in reopening was the burden the unvaccinated would put on the health system, should Delta or future variants circulate.
Could capacity be boosted enough in the medium-term to cope?
"It will be a push," the Health Minister said. "We have got a ways to go to improve facilities, to fill a lot of the vacancies that are in the workforce at the moment.
"There is a lot of work and attention on that at the moment. We know there are some people who have left the health workforce, and might be attracted back if the conditions are right and they have confidence in them being kept safe and not put under undue pressure."
Some communities will be hit harder if the virus does circulate; the Government has faced strong criticism for not prioritising Māori and Pacific more for vaccination, despite research showing they are at much greater risk of illness and death from Covid, including because of having other health conditions.
Little defended the vaccination rollout as based on the best information at the time about who was most vulnerable. However, Dr David Tipene-Leach, chair of Te Ora, the Māori Medical Practitioners Association, said it was a political decision.
"The Remueras and the Green Meadows of this world would have been up in arms. The one-size-fits-all mentality has prevailed. And one-size-fits-all is code for, 'don't you let anybody else get ahead of us'."
Delta is now hitting Samoan communities hardest, and Pacific health groups are, too late, being asked to plug vaccination gaps that Wellington officials had been warned about for months, Tipene-Leach said.
He agreed that society would be separated into the vaccinated and unvaccinated, and that vaccine passports and similar measures would soon be part of daily life.
However, the unvaccinated would also be split - those who actively choose not to be immunised, "and those who are unvaccinated because they are underserved, and they didn't get around to it, they don't understand it, nobody has explained it to them, they can't read, they don't have a home - all the reasons people don't access care.
"What we need to do is to constantly be at work trying to get the unvaccinated, vaccinated. And those who are making an active choice, well, you've just got to sit around and say, 'look, ICUs are full of people like you, what the hell is the matter with you?'" Tipene-Leach said.
"But the other lot, who didn't actually make a choice? We need to work really hard on them. And the trouble is that they don't vote, so the likelihood is that nobody is going to give a stuff."
Before Covid, the health system was already under sustained pressure in the form of an ageing population, sickening with chronic conditions, often linked to obesity.
The Labour Government in April announced major reforms, to be phased in over three years, including scrapping DHBs, and establishing a new public health agency and Māori health authority.
Clearing the latest elective and appointment backlogs will be one of the final challenges for the DHB system.
Most affected, Tipene-Leach said, are older New Zealanders waiting for procedures like hip replacements, and another group, disproportionately Māori and Pacific, needing crucial care such as renal transplant assessments and diagnostic MRIs.
The latter group were less likely to make a fuss, he said.
"They stay at home, they don't know what to do, they die. But the others, and, heavens, I'm in the other group - I would squeal, and I would put my hand up and say, 'Me, me, me, over here, I'm in pain, or my cataract is playing up'.
"And the guy over there whose kidney function is now down to .1, he's not saying anything. Because he doesn't know how to."
A plea from the frontline: 'Vaccination is our best form of protection'
Intensive care nurses are "anxious and worried" about any Covid-19 surge, now or in the future, says the chairwoman of the College of Critical Care Nurses.
Tania Mitchell told the Weekend Herald those feelings weren't only about themselves and their whānau, but for patient wellbeing.
"Attention to detail and recognising subtle changes in patient condition are the hallmark of the care we provide, and we want to be able to continue to provide exceptional detailed care for our patients. We are concerned that we will not be able to provide the level of care that our patients require and ought to have."
The number of resourced ICU beds in New Zealand hasn't increased significantly since the pandemic began, Mitchell said. Even before Covid, patients could have elective surgery deferred until an ICU bed is available for their post-op recovery.
"We now have more ventilators and monitoring equipment, and plans on how to increase bed capacity by extending outside the current physical walls of ICU. The problem that remains is the lack of staff with enough experience to care for these patients.
"As nurses, and ICU nurses, we would encourage everyone to get vaccinated, isolate as requested to and wear a mask. Vaccination is our best form of protection."