Virus Response Not ‘Fit For Purpose’ in the Long-Term

Covid-19

A review of border testing before the August outbreak has issued wide-ranging recommendations for reshaping the way New Zealand responds to Covid-19, Marc Daalder reports

A review of the failure to roll out regular border testing prior to the August Covid-19 outbreak has concluded that New Zealand’s current response model isn’t “fit for purpose” over the next two to three years.

Sir Brian Roche and Heather Simpson, who chaired the investigation, told then-Health Minister and current Covid-19 Response Minister Chris Hipkins in September that “we don’t have a status quo model which is well understood and could serve effectively for the next 24 to 36 months – while the model is improving it is not yet fit for purpose over a longer time period”.

Hipkins has now agreed to a wide range of changes to the way the response is run, centralising it under the Ministry of Health and a dedicated All-of-Government team. He also announced funding to keep testing, contact tracing and managed isolation facilities resourced through June 2022, if necessary.

“We are committed to continuing our sustained approach of keeping Covid-19 out, preparing for it, and stamping it out, for as long as it takes, and have funded that for another 18 months if needed,” he said.

Report found impediments to cohesive border testing

The Roche/Simpson review has been the focus of political controversy in recent weeks, as National Party Covid-19 spokesperson Chris Bishop called on Hipkins to release the report as soon as possible. By the time it was released on Friday, it had been in Hipkins’ hands for nearly three months.

Hipkins says the Government is now well on the way to implementing the recommendations of the report. Indeed, Roche and Simpson found while writing their review that the Ministry of Health had already addressed some of their concerns, saying, “by the time this report was being written all elements of the strategy, including border testing were under way.

“However, the Committee also notes that, a full and cohesive implementation has been impeded by poor communications both between and within, the Ministry of Health, various parts of the public service and different parts of the health sector; a lack of appreciation of operational implications of directives; and poorly designed risk targeting of testing regimes particularly at the border.”

The review acknowledged that New Zealand’s response to the coronavirus crisis has been “first class […]  and while there will always be room for improvement, recommendations in this regard should not be seen as minimizing the success which has been achieved”.

Nonetheless, Roche and Simpson identified shortcomings in the rollout of border testing.

“There appears to have been a reluctance on the part of some agencies to contemplate mandatory testing regimes, there was a general lack of forward planning with respect to testing, there was a reluctance to work with employers about how testing could best be implemented at particular sites and there was a lack of clarity about who was in charge of implementing and monitoring the testing regimes.”

The report claims ministers were unaware of the poor state of border testing and had been informed that it was going ahead as planned. However, as Newsroom reported in October, Cabinet was fully informed via weekly updates of the ongoing rollout of border testing. One document provided to Cabinet the day before the August outbreak was discovered notes, “Work is underway to commence weekly testing of asymptomatic workers in quarantine facilities and a rolling schedule of fortnightly testing for workers in managed isolation facilities”.

Testing at Port Taranaki and the Port of Lyttleton had begun that week but testing at the Ports of Auckland was deferred until the next week.

For all workers, it was unclear how many would say ‘yes’ if offered a test. “Rate of consent to test will vary depending on frequency of testing,” officials noted.

Alongside the comments, Cabinet was provided with a breakdown of the number of workers in each cohort and the number who had been tested. Of the 2,000 MIQ staff, just 290 had been tested in the previous week. Of 5,000 Auckland Airport staff, 211 had received a test. At the ports, where 2,100 people were estimated to be eligible for testing, just 12 had been tested in the past seven days.

Yet, just a week later, Ardern told reporters: “No one of course said to any point – that I recall – that what we asked for was not happening.”

The source of this continuing dissonance between the documents provided to Cabinet and ministers’ and the reviewers’ interpretation of those documents remains unclear.

Breakdown in communication

The review also highlighted breakdowns in communication, with every stakeholder they interviewed saying they had trouble with engagement at times and every government department interviewed expressing “concern at their inability to be ‘heard’ by the Ministry of Health”.

As an example of poor communication, the report notes that a new case definition for when to test for Covid-19 was distributed by the ministry in June. It was meant to ensure the same people could still get tested, but that people in a Higher Index of Suspicion (HIS) – those linked to the border – would have to stay home while awaiting test results and others would be free to move around once their symptoms disappeared.

“While from a strict medical view the Ministry of Health advises us that when they distributed a new case definition in late June, there was no real change because the definition still advised practitioners to use clinical judgement to test broadly. To everyone else however, the message was that people with symptoms but who did not meet the HIS (Higher Index of Suspicion) criteria, did not need to be, and should not be, tested,” the report found.

Roche and Simpson found the existing All of Government (AoG) team, which was meant to coordinate the response across different departments and sectors, had become a “‘Rest of Government unit’, being everything other than Health”. This was exacerbated by decision-makers failing to consider non-health advice when making Covid-19 decisions, the review found.

“Too often decision-making papers have gone to Cabinet with little or no real analysis of options and little evidence of input from outside health or even from different parts of the health Ministry or sector. While this may have been understandable in the first weeks of the response it should not be continuing eight months into an issue as we are currently facing.”

Moreover, the team was diminished after the country returned to Level 1, leading “to a longer hiatus in planning than was desirable”.

In response, the Government will stand up a new Covid-19 Response Unit to assume the functions of the AoG team, coordinating stakeholder engagement and engaging in long-term planning and outbreak preparedness.

There were also accountability and reporting issues within the Ministry of Health.

“Within the Ministry of Health itself it has been difficult to ascertain the accountabilities under the Director-General. Recently a new COVID-19 Directorate in the Ministry of Health has been established which may assist in transparency. However, there are major concerns over the siloing of this directorate given that areas such as Public Health seem to be separate. There is a danger that the Ministry of Health by creating a separate directorate is attempting to try to do everything itself rather than sharing accountabilities throughout the system.”

That the Covid-19 Public Health Response Act 2020 grants decision-making powers to the Minister of Health and the Director-General of Health has meant the Director of Public Health Caroline McElnay has been sidelined, Roche and Simpson said.

“While this drafting may have not changed the legal powers of the Director of Public Health, the signal it sends is unfortunate in an environment where some independence of Public Health advice is deemed to be essential, It appears to have led to a degree of marginalization of the public health expertise within the Ministry of Health, with it being reported that their advice is not being routinely sought, for example, on issues such as the development of Orders under the Act, the determination of Alert level rules, or the finalisation of mask/face covering policy.”

While Ashley Bloomfield has a background in public health, the review recommended altering the legislation as this would not always be the case for future Director-Generals.

Centralising the response

Fundamental changes to the way we manage our response is needed to ensure it works in the long-term, Roche and Simpson recommended. The report says that Covid-19 “can in one form or another, potentially impact upon the country detrimentally for the next 24-36 months”.

In addition to the Covid-19 Response Unit, to be built within the Department of the Prime Minister and Cabinet, Hipkins said the Government will create a new Border Executive Board of interdepartmental chief executives to run the end-to-end management of New Zealand’s borders, including where it touches on managed isolation and quarantine (MIQ) facilities.

Hipkins also said the Ministry of Health would manage “the public health response, including strengthened surveillance and testing, and public health advice”. It is unclear how or whether this differs from the existing response.

“The system of multiple interconnected agencies and portfolios is complex but has stood up well overall. Continual improvements have and continue to be made – but making substantial changes at the same time as focusing on keeping Covid-19 out has been a challenge,” he said.

“With much-improved testing, contact tracing and border control now in place however, the Government is in a position to consolidate and strengthen administration and governance of the response. This is increasingly essential to meet the added complexity of keeping New Zealanders safe, implementing the biggest immunisation programme in our history, while further stimulating the economy and managing a staged opening of our borders.”

In addition to announcing the review, Hipkins said Cabinet had agreed to an additional $1.12 billion to fund testing and contact tracing through June 2022, as well as “additional support for the Ministry, and for DHBs on an as-needed basis”. Another $1.74 billion will go to running MIQs through June 2022 and will be split up across the agencies involved in that work.

“These are significant investments that are critical to keeping our defences strong. Keeping Covid-19 out and quickly managing any incursions that do occur is an expensive business but it’s the best investment we can make for our health and our economy,” Hipkins said.