New Zealand's health system is already stretched to its limits and Omicron could tip it over the edge. What does a health system under pressure mean for everyday New Zealanders? Marc Daalder reports
Analysis: People seeking healthcare could face long waits or even be turned away during the peak of the Omicron wave, doctors and nurses have warned.
A new report from Covid-19 Modelling Aotearoa - a successor to Te Pūnaha Matatini's disease modelling division - estimates that between 30 and 70 percent of the country will be infected by Omicron over the course of the wave. In the worst case scenarios, thousands of people would need hospital beds at the same time, exceeding the health system's capacity.
Even more optimistic scenarios are likely to put serious pressure on a health system that is already stretched to its limits. Hospitals are expected to postpone elective surgeries to make space for Covid-19 cases. Significant numbers of healthcare workers will be infected and have to isolate at home, further reducing the system's capacity. And the response to the virus will likely create a backlog of those needing non-Covid-19-related care, so the system will have no respite even once the acute epidemic wanes.
Millions of cases possible
The new modelling breaks scenarios into three different rates of transmission, two different levels of booster uptake and five different potential start dates for the outbreak. It was finalised prior to the discovery of Omicron cases in the community in New Zealand and is therefore based on outbreaks overseas, though the researchers say they'll incorporate local data into future reports as it becomes available.
The research also incorporated the expected impact of the red light setting of the traffic light system.
Disease modeller Shaun Hendy told Stuff that New Zealand was likely to experience an outbreak between the low transmission scenario (based off South Australia's Omicron outbreak) and the medium one (based on London's).
That indicates the outbreak could see between 1.7 and 2.6 million New Zealanders infected. Because some of these would be asymptomatic and other people might not get tested (due to a shortage of tests or not wanting to), only 447,000 to 680,000 people would actually return a positive result.
Daily cases would peak between about 10,000 and 20,000 but true infections could peak at nearly 50,000 a day.
At the height of the outbreak, between 1200 and 2600 people might be in hospital, representing 10 to 20 percent of the country's hospital bed capacity.
The researchers said predicting deaths is very difficult because of the lack of data from overseas about death rates from Omicron. With that caveat acknowledged, they found that between 560 and 950 people might be killed by the Omicron wave in these two scenarios.
When the ambulance doesn't come
The health sector was already bracing to be swamped with demand even before the release of this modelling. The message from overseas was clear: Omicron can't be stopped and it will hit every health system hard.
Prime Minister Jacinda Ardern herself conceded that at a press conference on Tuesday afternoon.
"Omicron and the sheer rate at which cases are moving has tested most hospital systems. That's why we are putting that emphasis on those preventive measures" like boosters and masks, she said.
Covid-19 Response Minister Chris Hipkins said he expects intensive care units (ICUs) will come under pressure during the epidemic but that they will be able to manage it.
But doctors and nurses say the pressure will be felt far beyond ventilated beds in negative pressure rooms. As the health system shoulders a heavier burden from Covid-19 cases, it will be less able to handle both Covid-19 and non-Covid-19-related issues.
This is a spectrum, not an overnight change, University of Otago epidemiologist Amanda Kvalsvig said.
"The changes are very subtle at first. For example, waiting times get a little longer, but it’s more of an inconvenience than anything else," she told Newsroom.
"But beyond a certain level, systems will start to be reorganised to prioritise life and limb above other health issues, and then to prioritise those with more survival chances above others. At that point people can become seriously unwell or die in situations that wouldn’t be a problem in normal times.
"This risk can be hard to grasp if all your life you’ve known that an ambulance will come if you call, and that the hospital will take you in if you need urgent attention. Those certainties may disappear if we see the large numbers of cases that an Omicron outbreak can generate. Most people, especially if they’re vaccinated, won’t have any need to access the health system during the Omicron outbreak and they won’t be affected by capacity issues. But an important safety net will be missing."
Pressure on hospitals and EDs
This summer has seen unusually high demand on hospital and emergency services, even though Covid-19 hasn't been prevalent.
On January 20, two thirds of ICU beds were full and 85 percent of general hospital beds were taken. That left only about 1800 beds for the coming Covid-19 surge.
The numbers don't translate perfectly either, because each Covid-19 case requires more time, PPE and resources to care for than other patients. Even someone who reports to hospital or an urgent care clinic with an unrelated issue but who turns out to have Covid-19 still has to be isolated on a Covid ward, putting more pressure on the entire system.
"We're all just waiting for the wave to break. We've seen what's happened in Australia," John Bonning, the president of the Australasian College for Emergency Medicine, told Newsroom.
"It's going to be tough. It's inevitable, the Omicron surge, but generally it's not causing a significant number of people to become significantly unwell. Where it will cause pressure is in primary care, emergency departments and to some extent in the wards."
These departments have little capacity as it stands.
"The trouble is, we've got a health system that is under duress already and emergency departments that are absolutely chocka," he added.
"Around the country, we've got very, very full emergency departments. That is where there will be a straw that breaks the camel's back, if you add a little bit of extra duress."
Kate Weston, a nurse and a spokesperson for the New Zealand Nurses Organisation, agreed. "We are expecting more pressure across the entire spectrum of healthcare, there will be disruption if numbers escalate in the way that they have overseas."
While New Zealand has high vaccination rates, there are still a few hundred thousand unvaccinated people who could be hospitalised by the virus.
"We've heard from our colleagues in the UK that their hospital wards and their intensive care units are stacked with people who are not vaccinated," Alistair Humphrey, the chair of the New Zealand Medical Association, told Newsroom.
"They said it's galling to keep people alive, day and night, who they know could have got over that infection like everyone else had they got vaccinated. There is going to be particular pressure in those parts of the country where they have low vaccination rates. That's going to bring to bear quite a lot of pressure on our hospitals."
As Omicron spreads, it will not only mean more demand for health services but also take out healthcare workers who will have to isolate after high-risk exposures or being infected themselves.
"It's across the board. The people who are going to become unwell are going to be the health workforces as well as the patients themselves," Weston told Newsroom.
"It's a double whammy of an increased presentation rate or an increased demand coupled with high rates of nurses having to isolate. We are expecting pressure from that situation."
"Hospitals are going to be under an enormous amount of strain, particularly when staff start to get unwell themselves," Humphrey agreed.
Bonning said that, at the peak of the outbreak, up to 25 percent of the emergency department workforce could be off duty. While he still expects to be able to treat every patient, waiting times for less urgent cases could stretch past 12 hours as Omicron burdens the department.
Primary care crunch
Primary healthcare providers will also face serious pressure, to a degree unrivalled by previous outbreaks. For starters, they'll undergo the same workforce issues as hospitals.
Kelvin Ward, the medical director of Wellington's urgent care centre, told Newsroom that his clinic was "coping at the moment but we're at the limit of our staffing".
"One of the major things that potentially could happen is that staffing is just going to get stretched to breaking point, if it gets much busier at the moment or if we have problems with staff having to be isolating."
Covid-19 cases also take up added resources at Ward's clinic. There, possible Covid-19 cases have to be dealt with outdoors because the building doesn't have enough ventilation to prevent the virus from spreading to other patients.
"We may get to the point where, if we get an excessive number of patients, to essentially triage people to phone conversation or suggest they see their GP when we wouldn't have done that in the past," Ward said.
Primary care providers will also be delegated new tasks of managing Covid-19 cases - a role that was previously picked up by health officials in MIQ facilities, where most cases used to be cared for. Humphrey said the Government had high expectations for how GPs would play a role in case management.
"Most of the profession are expecting some very heavy caseloads over the next month or two," he said.
"There are concerns among general practitioners that, first of all, the Government appear to have underfunded general practice in terms of caring for people at home." The Government isn't offering to pay the usual IRD mileage rates for doctors and nurses to travel to cases who need in-home care.
"They will bear the brunt of the caring from home. There are already some District Health Boards who are saying that they are expecting general practice to do the job, irrespective of the fact that originally there was a suggestion that general practice could opt out," Humphrey said.
"There's an enormous expectation on general practice to keep in touch with vulnerable patients. To give them a call every day to make sure they're okay. For an average GP, that could be hundreds of patients. There's no way a GP can be ringing around 200 people every day, as well as delivering services to everyone else."
Reducing demand
Everyone Newsroom spoke with for this article said the Government had to strike a balance in its messaging: People shouldn't take unnecessary risks or go to hospital for minor issues, but those who need healthcare should still seek it. People can also help the system by getting boosted and wearing a mask - a point Ardern made on Tuesday.
"None of it's inevitable. Some of the ranges I've seen from some who are doing that scenario work show quite a difference in the level of peak that New Zealand might experience and that is coming down to the uptake of boosters," Ardern said. "It is not out of our hands, we do have some control over what happens next."
"We need to do everything possible to flatten the curve: vaccination, masks, staying outdoors, ventilating indoor spaces, staying at home when unwell, and all the rest. Even though it’s a very transmissible variant we do actually have quite a lot of control over Omicron spread. If anywhere can prevent cases and avoid health system overwhelm it will be New Zealand," Kvalsvig agreed.
"But it’ll take effort from everyone, and during times when there are high case numbers some extra avoidance of risk would be sensible, for example avoiding high-impact sports or getting up on the roof. These activities should wait until we can be confident that help will be there promptly if we need it."
"The trouble is, when you put publicity out saying save emergencies for emergencies, those that you want to turn up don't," Bonning said. "Don't be climbing up ladders and up roofs, just be really, really careful."
"It's really important that, if people are needing healthcare, that they absolutely do access it," Weston added.
Some doctors are also concerned about the downstream impacts of delaying screening and elective operations.
"We have been in touch with the ministry about ensuring that the ministry prepare for the backlog," Humphrey said. "We would like to see it measured, we would like to see preparation for it, because there will be a lot of very late presentations of serious illness as a consequence of the pressure we're about to face over the next few months."
"The other thing to bear in mind is, compared to Australia, we are 12,000 nurses down. We are 3000 doctors down," he said.
"The odds are stacked against the health professions given that we have had decades of under-resourcing. We shouldn't have to face a pandemic 12,000 nurses short. We shouldn't have to face a pandemic 3000 doctors short."
