The scramble to contain one of last year's deadly Covid clusters was too reactive, lacked clear lines of accountability, and didn't seek enough expertise outside the health sector, a review has found.
The Rapid Review of the Covid-19 All-of-Government Response identified a number of shortcomings that may have made a substantive difference if they were in place when Auckland's August Covid cluster emerged, while also acknowledging the overall response the outbreak was "outstanding".
Commissioned by the chair of national crisis group ODESC (Officials' Committee for Domestic and External Security Co-ordination), the review was completed in October but only just released.
The August cluster - which had 179 cases and included three deaths - began after four community cases emerged on August 11 last year, sending Auckland into level 3 for two and half weeks, level "2.5" for three and a half weeks, and level 2 for two and half weeks. The rest of the country spent six weeks at level 2.
The Government says the key recommendations have been implemented, but the review - which interviewed 48 officials including dozens of public sector chief executives - has led to questions about the role of luck in keeping our communities Covid-free.
The Government's rapid response plan to a new community outbreak - which Cabinet had signed off the day before the cluster's cases first emerged - hadn't been stress-tested when the outbreak was detected.
The surge capacity of contact-tracing had also yet to be stress-tested, even though director-general of health Dr Ashley Bloomfield had said more than two months earlier that it would be tested in "the next few weeks".
The contact-tracing gold standard is to reach 80 per cent of case contacts within 48 hours of a positive case being returned, but only 60 per cent were reached in that timeframe for the August cluster.
"Preparation and planning could have been speeded up and improved between the initial outbreak [in March] and the August resurgence," said the review, which was led by Security Intelligence Service director Rebecca Kitteridge.
"At the time Auckland went back to AL3 [alert level 3] and the rest of New Zealand went to AL2 [alert level 2], there was still a need for more detailed planning to aid in the implementation of Cabinet's decisions.
"Stress-testing beforehand would have helped identify potential issues and solutions."
Interviewees told the review that the response was "largely reactive", and the need to get ahead of risks and issues before they arose was "critical".
"The more planning and preparing that agencies can do in advance across a range of likely and foreseeable scenarios and risks, the less that agencies will need to 'create policy on the hop' if such new events develop quickly," the review said.
It also singled out travel exemptions for people to move in and out of Auckland during level 3 as particularly problematic; 10 days into the lockdown, the Government made changes - including the ability to transit through Auckland without stopping to travel for work - to smooth out the issues.
The review was meant to look at the Government's readiness to respond to an outbreak, but it started in August and ended up being a real-time review of the response to the cluster. It also found:
• The Ministry of Health didn't do enough to seek expertise from outside the health sector, which was reflected in the issues with travel exemptions. "Any exemption process should be made by agencies with understanding of those industries."
• Agencies felt there was no single governance structure tasked with governing the Covid response.
• There needed to be more clarity for agenda-setting, recording and communicating decisions, and lines of accountability. Layers of structures and roles hurriedly put into place for the March-April lockdown had made accountability unclear throughout the system.
"For some novel issues (such as testing of all workers at the international border), agency responsibility was not immediately clear. In some cases, agencies have struggled to have end-to-end ownership of the issue, even once it has been assigned to them," the review said.
Others questioned the ongoing need and purpose of the Covid-19 group in the Department of Prime Minister and Cabinet (DPMC).
"The DPMC Covid-19 group has no clear mandate and has few levers to pull," the review said.
"A lot depends on the ability of the Chief Executive and staff of the Group to influence, cajole and coax other departments to co-operate. That has an impact on its ability to lead, its ability to 'herd cats', and its ability to get the best possible workforce on a sustainable basis."
It was also vital for the Health Ministry to be more open to external advice.
"This is going to be the 'biggest game in town' for the foreseeable future: it is critical that all elements of the living standards framework (health, social, economic and environmental) are considered in decisions made."
This echoes the Simpson-Roche report into the ministry's testing regime, which found that other government agencies and the private sector struggled to have their views heard.
Act leader David Seymour said the review showed how lucky New Zealand had been in avoiding more or bigger outbreaks, despite cases - such as the Jet Park nurse with Covid-19 who attended exercise classes - that seemed likely to pass on the virus.
"There seem to be cases and cases where they haven't spread that much. Maybe the next one will. That's why we need to be better prepared," Seymour said.
"The lack of stress-testing and the lack of preparation - we did not use the 102 days we were Covid-free to mend the roof while the sun was shining. We had a number of natural advantages and I think the Government has been overly credited for the outcome.
"With vaccinations, variants of the virus, new technology for testing and tracing, public fatigue of the old measures - we're going to need a more sophisticated response. I don't see it at the moment."
Govt says shortcomings have been addressed
Covid-19 Response Minister Chris Hipkins said the key recommendation - a Covid chief executives board in charge of oversight and governance of the response - has been implemented.
And the Covid-19 unit in the DPMC has been refocused and funded to end of June 2022. It now includes a team that co-ordinates the national response plan, which is governed by ODESC.
The unit also has a team that has developed a framework to identify issues across the system before they eventuate.
"This work is well advanced and is sponsored by the Covid-19 CEs Board," Hipkins said in a statement.
"A strategy work programme is currently being developed. A lot of work is underway to support this from across the system."
Planning and preparation is now mainly done by the accountable agency; the Health Ministry looks after personal travel exemptions, while the Ministry of Business, Innovation and Employment are in charge of exemptions for businesses.
The Government has also set up a special advisory group, led by business executive Sir Brian Roche and which includes former Air NZ boss Rob Fyfe, to help ensure independent advice to improve the Covid-19 Response.
Read the full review here.