Thread by @CarlShuker

Buckle up. What’s Covid done to Aotearoa New Zealand’s healthcare system since Omicron overran our keep-it-out response?
It’s not all bad news and it’s way more interesting and complicated than most news stories seem to suggest. Thread. 1/n

I lead a project called the Window on Quality for the @HQSCNZ. We published our first Covid Window in December '21. Delta had hit, it was days before Christmas, it was too nuanced to make news. The follow-up published yesterday, covering the Omicron wave: hqsc.govt.nz/resources/reso…

@HQSCNZ The Window is evidence-based, expert-informed, and necessarily curated. A catalogue of effects would be Bible-sized. We continue stuff we looked at before, including immunisations, cancer care, emergency departments, and planned care (elective or non-urgent surgeries and stuff).

Then we do deep dives on new topics: the impacts on our mental health, on our workforce, and on the experience of care for disabled people during the Omicron period. With some HDC complaint data.
But first a few throat-clearing bits of data on our overall response.

Funding: After the GFC everybody cut their health funding. We were already spending less, but we cut it more and stayed lower. The small-dotted line is what our healthcare funding would have been if we matched the trends of other countries recovering from the GFC.

Stringency – how stringent have the limitations on our freedoms been? We were lower than everyone for a long time (more freedoms) but Delta and Auckland lockdowns have brought us on a par with some of Scandinavia.

Mortality – “excess mortality” measures ALL deaths during the pandemic, and if that number is more than usual. We are one of the very few countries in the world that has not seen significant excess mortality since the start of the pandemic.

The lives we saved in 2020 and 2021 have not as yet been wholly outweighed by the lives lost in 2022. Approximately net zero. It’s a tremendous achievement.

In ch.1 we extend the stuff we published in December, beginning, critically, with childhood immunisations. Imms are tanking, creating a large group of young kids vulnerable to vaccine-preventable disease.

Immunisations for Māori and Pacific babies and the poor are most affected by the pandemic. Look at the lines post-March 2020 dropping and more volatile. The vaccinating health workers scheme doesn’t cover very young babies, cos it’s a difficult skillset.

Now cancer screening. Breast and cervical screening have fallen since 2020. Cervical screening in Pacific women alarms me – a consistent and steep decline that Covid has just worsened, now down to under 60% of women. More on cancer later, and some good news.

Emergency departments (EDs) are under greater pressure. Staff shortages and understaffing due to Omicron. Greater numbers (nearly 5000) of more urgent presentations (triage 1 and 2 – ie drop everything and care for these people). Result? Ambulance ramping.

We’re holding on – other place, like Ontario, show 20-hr wait times in ED.

Planned care 1 – elective surgeries, ie not acute stuff. Think hip replacements. In the UK there are MASSIVE increases in waiting lists.

Planned care 1: Here, access is clogged. The percentage of patients waiting longer than four months for their first specialist assessment has risen from 14% (18,000) in May 2021 to 26% (35,500) in May 2022. Specialist breakdown below.

Planned care 2 – the number of patients who were given a commitment to treatment but did not receive that treatment within four months more than doubled from 12,797 (23%) in May 2021 to almost 28,000 (41%) by May 2022.
And there’s still the backlog from 2020.

Planned care backlog: blue line is the number of procedures we’d “normally” expect to be done. Red line is what happened. Gaps between them are people not getting procedures. Red line above blue means we’re addressing the backlog. It’s not happened.

Cancer care is a great story. Other countries now face cancer survival going backwards for the first time in decades. Te Aho o Te Kahu under @DiSarfati predicted the impacts, monitored and responded and Aotearoa has good news.

@DiSarfati Cancer – new cancer registrations have risen but only slightly since the big dip (missed registrations) in our first lockdown, then stayed consistent. We may be still capturing most cancers.

Cancer diagnostics (testing): for Māori, this critical part of diagnosis and treatment has actually improved for some cancers. More is generally better for diagnostic tests. Services are working.

Cancer surgeries: for non-Māori/non-Pacific peoples, consistent and steady. No clear Covid disruption. For Māori, more cancer surgeries than before. Amazing.

Now chapter 2: Impacts of the pandemic on our mental health. How can you measure it? We went trawling for data sources and organised what we found by impacts along our life course.

Pregnant mums’ mental health was affected by Covid – they lost support networks and grew fearful of healthcare. Well Child/Tamariki Ora services were hit hard – down to half of families getting their five core checks (inc. wellbeing and mental health) by infant’s first birthday.

Calls to PlunketLine for maternal mental health reasons shot up.

And in 2020/21 Aronui Ora maternal mental health service in Auckland saw the the highest number of women referred in 10 years.

The effects of the COVID-19 period to date on the mental health of young people is the most alarming to me. Calls to Whakarongorau/1737 with a significant risk element of suicide rose and rose after March 2020.

Mental health for young people and COVID-19: dispensing of antidepressants to kids aged 0-17 years jumped up after March 2020.

Kids aged 0–15 years admitted to hospital for mental health reasons (red line) jumped way above what would normally be expected (blue line) from Mar 2020 but may have returned to prior experience recently.

The pandemic really affected the quite young. Admissions to hospital for intentional self-harm in those aged 10-14 rises worryingly from about May 2020.

Many of these admissions to hospital were for kids intentionally self-poisoning, which mostly involved using non-opioid analgesics like paracetamol, antipyretics and antirheumatics. What was around. A clear rise in these hospitalisations is evident from mid-2020.

COVID-19 and mental health in kids – eating disorders are rising and getting more severe. Tupu Ora treats people with acute and complex eating disorders in metro Auckland. Their under-19 year old referrals are way up in 20/21.

At the very hard end, if a kid’s eating disorder becomes so severe they become medically unstable, they are admitted to hospital. 16 and unders hospitalised for eating disorders spikes in 20/21.

Adults’ mental health and COVID-19. I have no graph, but think about south Auckland’s three waves and note: the Health Survey shows in 2019/20 that 11% of Pacific women reported psychological distress in the last four weeks. A year later? 19% of Pacific women.

One in five.

Working age adults’ mental health and COVID-19: dispensing of antidepressants are up and on a clear new level.

The impacts of the pandemic on mental health of older people was really challenging. I couldn’t find much recent data but people are scrambling to fill this hole.

The most recent quali study I found was unpublished but solid. Older people – isolated in rest homes, or their own homes - felt disconnected, imprisoned, and neglected.
Disconnected, imprisoned, and neglected.

So in sum? The mental health of all of us has been affected by the pandemic but the data points to major impacts on young people, as young as ten. Major.

On to Chapter 3. Workforce impacts. UK NHS data show staff stuck around for 2020 then left in droves. The great resignation.

The NHS might be our canary in the coalmine because in Aotearoa staff turnover in most occupational roles is increasing through 2021.

The pandemic and our workforce: so many surveys are showing increased rates of burnout across specialties. Look at radiation oncologists, top right. Too few, no leave, no nonclinical time, urgency of the cases they see, many palliative patients and emotional load.

COVID-19 can create a vicious circle for workforce: longstanding shortages => Omicron creating more demand and further staff deficit => staff burnout => increased turnover and sickness => more stress, more departures. Government have created a workforce taskforce. It’s urgent.

Because the workforce impacts may be beginning to affect safety. We collect a few measures of safety. Falls in hospital that result in a broken hip? Six dots over the median in 21/22. That’s called special cause variation. It’s not chance.

Pandemic impacts and safety: in-hospital Staphylococcus aureus bacteraemia infections per 1,000 bed-days.
Seven dots over the median in 21/22.

Pandemic impacts and safety: deep vein thrombosis and a pulmonary embolism after operations, a major post-operative risk. More than expected, in a group, in 2021. Support for our workforce increases our safety.

Last, chapter 4: Disabled patient experience and the pandemic. This one’s kind of remarkable but also sad. Large-scale survey data show disabled patients are less able to access primary care than non-disabled, but somehow the pandemic hasn’t worsened this.

Once they can access a GP, disabled patients felt less involved in decisions about their care than non-disabled people, but again somehow the pandemic hasn’t worsened this.

Things to look out for with disabled people and primary care: young disabled people reported worse access, and being Māori made it worse. 41% of younger disabled Māori weren’t always able to get care when they needed it.
41%.

Similarly for experience – it’s mostly the young disabled people who report not being involved in decisions about their care as much as they want to be. There’s more great data and advice in the report.

Now to the hard end – when people are so dissatisfied with something in healthcare they can complain to the Health and Disability Commissioner (HDC). Complaints are way up, a lot related to COVID-19.

About half of COVID-19 HDC complaints were about vaccination, but these are falling over time. In 21/22, 18% of the COVID-19-related complaints were about the impact of the pandemic on the system, including delayed care, staffing and other issues.

So conclusions? What we have here, thanks to the wisdom of @HorsleyCarl, looks something like precarious success. We avoided the major mortality. Staff held on, for now.

@HorsleyCarl We have worked lean for a long time, and sometimes “lean” means no slack to adapt to shocks. See Janice Wilson and Dale Bramley’s Stuff oped: stuff.co.nz/opinion/130288…

@HorsleyCarl It’s been a journey and a pleasure putting this thing together and I’m proud of it. Ralph Hotere’s Kūaka/Godwit graces the cover. So many brilliant people have contributed selflessly, while caring for patients in an unprecedented Omicron outbreak. Thank you to all.

@HorsleyCarl Thank you to tweeps online @HorsleyCarl and @richardhamblin, whose guiding hand and wisdom are throughout. The report is here: hqsc.govt.nz/resources/reso…
Fin.

@HorsleyCarl @Richardhamblin Whoops that shout-out misdirected. Thanks and salute to @DirHqe Richard Hamblin, who has guided and encouraged and contributed untold amounts of wisdom and expertise.