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Healthcare resources at Alert Level 3 – Expert Reaction

New Zealand will move to Alert Level 3 in less than one week’s time, with various implications for the healthcare system.

One of the key criteria for moving to Level 3, established by the Government last week, was that New Zealand must have “capacity in the health system”.

The SMC asked experts to comment on whether we have met that criterion.

Associate Professor Mark Thomas, School of Medical Sciences, University of Auckland and Auckland District Health Board, comments:

“We certainly have capacity and resourcefulness in the healthcare system. There have been huge adjustments made to the way we work, whether in general practices, or in hospitals, and I see no evidence of people being overwhelmed by the challenges at present.

“No doubt there will be delays and shortages of equipment, whether for personal protection or for laboratory testing or other aspects of care. However, the health system is very used to making do, and can be relied on to continue to provide an excellent service for all who need help. A more sensible approach to limiting precious resources would be appreciated. Health care workers should not be encouraged to wear PPE just because it makes them feel more comfortable. PPE should be used correctly when necessary, not used incorrectly, and not used at all when not necessary.”

No conflict of interest.

Dr Michael Maze, Respiratory and Infectious Disease Physician, University of Otago, comments:

“The time spent in Level 4 lockdown has been extremely useful for hospitals. In the last month, major changes have occurred to the systems in hospitals to prepare us for COVID-19. We now are much better placed to manage a surge in COVID-19 cases, and to prevent transmission within our hospitals.

“A good example of this is the development of hospital COVID assessment units, where patients can be quickly assessed, and acute care given in a safe environment where other patients and staff are at minimal risk. These simply didn’t exist a month ago. Similarly, detailed plans around expanding capacity in response to a surge in cases have been made. The preparation time that has been afforded to the health system by the Level 4 lockdown has been vital.

“The move to Level 3 is critical if we aim to eliminate COVID-19. One aspect that has not had a lot of attention is the implications of an imperfect diagnostic test on community spread during Level 3. We know that the nasal swab PCR test will not pick up every case of COVID 19 – it picks up more like 70 out of 100. In medical jargon, we would say the test has a sensitivity of around 70%. Ideally we would have a test with a sensitivity of close to 100%. This low sensitivity for a number of reasons, but mostly because sometimes the virus is infecting the airways in the lungs but not in the nose.

“The implication of a diagnostic test with a low sensitivity is that some people with COVID-19 will test negative and be told they don’t have it. Doctors are alert to this, and so the ‘probable’ cases we see on the MOH website are when doctors remain suspicious despite the negative test. However, doctors judgement is also not perfect.

“So how does this relate to Level 3? In Level 3 we are likely to see some spread through the community, and in time cases may be identified who can’t be easily linked to a known case. So if you or I have a flu-like illness (snotty nose, achey muscles, fever etc) we need get tested (of course), but also stay home until we feel well again – even if the test is negative. This is a critical message to spread, as there will be a lot of pressure on small business owners in particular to get their business up and running, and not to stop for a ‘cold’.”

No conflict of interest.

Associate Professor Lynn McBain, Head of Department of Primary Health and General Practice, University of Otago, Wellington, comments:

“For general practices, the transition to Alert Level 3 will mean very little difference to the services delivered in Level 4.

“General practices are open for business and able to care for their patients with a wide range of services. The main difference is that planning for each appointment means a decision about whether this can be conducted by email, telephone, video consult (if available) or if a face to face visit is required.

“Having had over four weeks running a system like this in Level 4, practices are quite good at determining that most appropriate way to consult with patients. If a face to face appointment is required, very good precautions are in place for protection of both practice staff and patients. People should not be afraid of visiting their doctor or nurse.

“It is important to continue to consult for medical care and not ignore symptoms. Things may not be able to wait until were are at a lower Alert Level and if everyone waits, then practices will be overwhelmed at that stage.

“The key message is: if you think you need to see your doctor or nurse, you probably do – so please contact your practice to organise a consultation.

Conflict of interest statement: Dr McBain owns a general practice in Wellington.

Professor Les Toop, Head of Department of Primary Health and General Practice, University of Otago, Wellington, comments:

“General practices will be available and working to meet whatever health need you have, as they have throughout the pandemic so far. The message is unchanged: if there is something you would seek an appointment for or contact the health centre under normal circumstances, don’t delay in getting in touch.

“What may continue to evolve is the way those services are accessed and delivered. Those of you who have contacted your usual GP team in recent weeks will have noticed a marked difference in that many consultations are now taking place over the phone, some by video and some have been asked to come at specific times to the surgery for face to face consultations and procedures like immunisation which cannot be managed from a distance. These arrangements will probably continue for some time, and the movement of an increasing number of practices to offer distance consultations for certain things as an alternative to face to face consultations (which was well in train before the pandemic) will accelerate and become routine alternatives in certain circumstances after the pandemic has passed.

“What will not change for some time is the need for us to be very careful about how we limit possible transmission of infections within health centres. The use of traditional waiting rooms for multiple sick patients will, in most places, remain curtailed. The consensus is that even with our obvious successes during Level 4, sporadic cases of COVID 19 will likely pop up in coming months, and we need to remain alert to that possibility and employ all of the proven measures of protection for both patients and staff. Extra precautions are likely if you have respiratory symptoms, so don’t be alarmed if the doctor or nurse greets you in a gown and mask etc. This PPE is for the protection of you both.

“The next few weeks, as we progressively move out of lockdown, are inevitably uncertain, and we all need to be patient as the decision makers adapt their thinking and recommendations to the circumstances. Our success so far has been in no small part by decision makers and the public being guided by science, and working as one team looking out for each other. Hopefully this will continue.

“In summary, your usual general practice team remains available. The business “as new usual” will remain comprehensive and will come with necessary precautions.”

Conflict of interest statement: Professor Toop works part-time in a general practice in Phillipstown, and is a member of the GPNZ National Executive.