New Zealand's health system was so poorly prepared to "keep out" Covid-19 that we have had to endure extraordinary sacrifices to "stamp it out", the Epidemic Response Committee heard this morning.
"We squandered our major advantage, which was geography," said University of Auckland Professor Des Gorman, who is advising the committee.
"The hard work we need to do to stamp it out is because we had failed to keep it out."
New Zealand should have closed its borders in mid-February, not the end of March, he said, but we didn't have to resources to do so.
"We went into this pandemic profoundly under-prepared and when we should have closed the borders hard, we couldn't."
Being properly resourced meant being able to call on the army and police to set up motels, and even a tented village.
"If you haven't sorted that out beforehand, the likelihood to do it on Wednesday afternoon at 3pm is pretty skinny.
"I think we were spectacularly complacent. Our casualness, born out of 'that's a problem over there' has left us figuratively with our pants down."
The Government asked most overseas arrivals from March 16 to self-isolate, and from March 20 all non-New Zealanders were not allowed into the country.
A quarantine for all sympomatic overseas arrivals was put in place from March 26, when the level 4 lockdown started, and this was expanded to a blanket quarantine from April 10.
• Covid 19 coronavirus: Three new Covid-19 cases; Ashley Bloomfield's takeaways warning
• Covid 19 coronavirus: Virus won't be eliminated until there's a vaccine, says PM
• Covid 19 coronavirus: NZ not 'out of the woods' - Prime Minister Jacinda Ardern
• Premium - Covid 19 coronavirus: Revealed - the data showing the success of NZ's lockdown over Australia's
Prime Minister Jacinda Ardern rejected Gorman's comments, saying New Zealand was among the first country in the world to close its borders to foreigners.
"At a point we were able to manage a system where everyone was quarantined, keeping in mind we had tens of thousands of people returning in those early days, we moved to that."
More than 70,000 New Zealanders have returned home from overseas since March 16, and there are only an estimated 43,000 hotel rooms in the country.
Ardern has also previously expressed concerns about possibly turning a quarantine site into a Petri dish where a handful of cases could have become a major outbreak.
She said the counter-argument to Gorman was the good position New Zealand was now in, with Covid-19 seemingly well-contained.
"If that's his claim about where we stood, then how is it we've managed to produce what we have?"
Director General of Health Ashley Bloomfield said the ministry has constantly asked itself what was needed in two weeks' time and then tried to put that in place immediately.
"The proof's in the pudding. For an under-prepared or ill-prepared country, we've done remarkably well - and I don't think we were ill-prepared.
"We were incredibly responsive to what we saw emerging."
He added: "You have to live life forward but you understand it looking back."
Gorman said that Kiwis arriving from overseas who tested negative could have been sent home but in a "low trust" environment, meaning for instance having someone checked on the moment they turned off their phone.
"Public health measures have failed all around the world because they keep assuming that humans behave consistently rationally.
"People don't make rational decisions."
He said Australia had 10 ICU beds per 100,000 people, Germany had 33, but New Zealand had only three.
"You want to know how under-resourced we are, that's a living example. If you can't manage a pandemic then for goodness sake keep it out of society."
The committee heard from frontline healthcare and community care workers about the need for Government support and ongoing access to PPE.
Gorman, who is a former dean of Auckland Medical School, told the committee that New Zealand was unprepared to adequately test and contact trace at the start of the Covid-19 pandemic - despite the recent global experience with Sars.
He said the use of the term "elimination" was "a silly way to use language which disengages people".
"We're talking absolute gibberish. If we're going to engage them, let's use common language and common usage."
He said a vaccine would provide widespread elimination, and until then "the best we can hope for is disease control".
He also criticised the way the healthcare system was structured and funded, and if he had one word to describe it he would not use "universal" but "inequality".
Reform was needed in the way health services are commissioned, purchased and funded, he said.
"If we do not seize this opportunity, our children and our grandchildren have every right to judge us very harshly."
He said the existing system - 20 autonomous DHBs - was too focused on provincialism and lacked a way to connect the DHBs nationally.
The system was "inherently counter-innovative" and flexibility was needed because, for instance, a pandemic might require a national response, but obesity or diabetes might require a local or even a specific household response.
There was now an opportunity to "accelerate system reform", and there might even be the bipartisanship required to achieve it.
But he said he had to temper his enthusiasm because the last comprehensive reform of the health system, in his mind, was in 1938.
Community midwives having to deal with mental health and family violence issues
College of Midwives chief executive Alison Eddy said the Covid crisis had exacerbated access problems to mental health or family violence services, and midwives have had to adapt their work accordingly.
"Even though those services were seemingly available in a certain way, for all intents and purposes those services were not available. The service they have turned to is one that is present in their lives - and that is the community midwife."
She said she wasn't criticising Oranga Tamariki, but Covid-19 had meant fewer face-to-face assessments.
She noted a case where concerns were raised by the community and hospital midwives about a woman who gave birth in hospital.
"Oranga Tamariki did an assessment by phone and deemed there was no concern to be followed up - which was not the midwife's assessments.
"She's the one going into the home, seeing this environment and feeling deeply concern for the family's safety."
Eddy said that the Government's direction to DHBs about discharging new mums and their babies during the Covid crisis had been interpreted in different ways by each of the 20 DHBs.
One provincial DHB, which she didn't name, had taken the message as meaning "you must leave immediately", she said.
That had led to a "potentially avoidable readmission" for vulnerable babies who should not have gone home so early.
She said access to PPE had been difficult in the first weeks of the pandemic, which had caused considerable anxiety and forced many midwives to buy their own at inflated prices.
Many community midwives had to find their own PPE at "significant" cost to them.
Cabinet had been considering whether to recompense midwives for out-of-pocket expenses, but Eddy said no progress had been made despite advocacy from Associate Health Minister Julie Anne Genter - who is not in Cabinet.
This lack of progress had impacted on staff morale, she said.
Ardern told reporters after the committee that those reimbursements were still being considered.
Still not enough PPE
Geneva Healthcare chief executive Veronica Manion said there were only about four masks per community healthcare work to do 250,000 home visits a week.
Many vulnerable people had refused services because they were anxious about the risk to healthcare staff who didn't have the PPE they needed, she said.
She read a letter to the committee from a person with a 99-year-old mother, saying they would move the mother home to manage her "while I work and school our children".
Another letter from someone with a vulnerable 87-year-old father said: "Why haven't dad's carers been issued with gloves and plastic aprons? How long does it take for the ministry to supply the much needed [PPE]?"
Manion said the Government was unprepared for the sheer volume of PPE needed for residential and home-based support.
"This unfortunately has resulted in a number of DHBs giving us less stock than required, or not sending any at all as they simply didn't have enough to go around.
"There's been little action and it's nearly too late."
She said it was fortunate that frontline workers were not going on strike because they cared about the people they looked after.
She added that funding for the sector was inadequate.
"I sound like a bit of a broken record [along with] everybody else.'
Funding was barely enough for some services to break even, while others are in the red.
"Many continue to operate but many are technically insolvent. Many providers will close and redundancies will be occurring."
City hospitals too full most of the time
Association of Salaried Medical Specialists executive director Sarah Dalton said the pandemic had exposed the health system's capacity issues.
"Hospital demand far outweighs our ability to meet acute medical and surgical need."
Hospitals in urban areas typically ran at 100 per cent occupancy, she said.
"That is not how you design systems to run efficiently.
"We cannot afford to return to those occupancy rates as part of the return to business as usual."
Dalton said there were nearly 500,000 people with "unmet need" who should be seeing a hospital specialist, but were unable to because they may not qualify for a waiting list or couldn't afford a GP.
"There is a massive level of need out there and, Covid or no Covid, that's not going to change."
There was a 24 per cent shortfall in senior medical and dentistry staff, she said, and New Zealand ranked 80th in the world in hospital beds per capita and 42nd in doctors per capita.
GPs in desperate need of funding support
GPs have had to reduce face-to-face contact with patients to about 5 per cent, according to Tim Malloy, interim chair of GP advocacy group GenPro.
But that had led to income falling through the floor, he said.
GPs had expected Government assistance that amounted to saying "we appreciate your work", but instead were met with "unreliable supply and distribution of PPE - variable around the country - hiccups in the flu vaccine package", and misunderstandings about Government funding.
GPs were proud to be part of the national response, he said, but now the workforce had diminishing incomes and uncertainty about whether they will keep their jobs.
"We have practices on the brink of financial unsustainability. We don't want destabilisation within the workforce. We need resourcing now."
Malloy said the $11m in funding that was still in negotiation with the Government would send a message that GPs were valued.
"We feel almost abandoned."
GPs had managed their finances on the assumption that the $11m would be forthcoming, and in its absence GPs were now rushing to their accountants seeking financial advice on how to stay afloat.
National MP Michael Woodhouse said there might be a risk of "the cure killing the patient" because of the treatment and screening that has been pushed aside to make room for the Covid-19 response.
Malloy said: "If we act now, we're probably going to be okay."
More screening was already taking place under level 3, he added.
The committee, chaired by National leader Simon Bridges, was set up to empower MPs to scrutinise the Government's response to Covid-19 in the absence of Parliament.
It is still sitting even though Parliament returned this week in a limited capacity.
Many themes today were also aired to the committee last week, including general practices accusing the Government of blocking funding to stay afloat during the second half of the alert level 4 lockdown.
The Ministry of Health said the $22.4 million package was part of an "ongoing conversation" with the sector and the Government.