Part 2: What plans were in place for responding to a pandemic?

2.1
The national health emergency system requires integrated planning and collaboration (between the Ministry, DHBs, and others in the health and disability sector that the Ministry oversees).

2.2
In this Part, we describe the planning for pandemics and, in particular, the aspects of the plans that relate to PPE. We look at the extent to which the Ministry and DHBs implemented those plans during the response to Covid-19 and how well those plans assisted the response.

2.3
We looked at the health emergency response planning framework, each of the individual plans that form part of the framework, and the monitoring and reporting arrangements associated with those plans.

Planning framework to support readiness for a national health emergency

2.4
The planning framework guiding health responses for a national emergency mainly comprises:

• the National Health Emergency Plan (the Emergency Plan);⁴
• the New Zealand Influenza Pandemic Plan;⁵
• the National Health Emergency Plan: Infectious Diseases (the Infectious Diseases Plan)⁶ – the Ministry is responsible for preparing and maintaining these plans;
• the Operational Policy Framework (set by the Ministry), which includes expectations about DHBs’ health emergency plans; and
• the health emergency plans developed by DHBs.

The national plans

2.5
The Emergency Plan is an overarching plan that sets out how the health and disability sector needs to co-ordinate with other government agencies to respond to an emergency. It has six risk components – risks, risk understanding, readiness, reduction, response, and recovery. The Emergency Plan has several subsidiary plans for managing specific health emergencies. Its policies include the National Reserve Supplies Management and Usage Policy (the Reserve Supplies Policy).

2.6
The Emergency Plan notes that every health provider has an obligation to understand the hazards and the risks it faces so that it can make informed decisions about how best to manage risk and develop needed capabilities to respond to an emergency.

2.7
The Emergency Plan refers to approaches or options for managing emergency surge capacity during periods of significant increased demand on health services. The Emergency Plan describes options for managing the risk of general supply shortages, including:

• prepare – routinely maintain stockpiles of necessary items or their equivalents;
• substitute or adapt – use a clinically equivalent or alternative item or technology;
• conserve – use less of a resource by reviewing dosage and utilisation practices;
• reuse – use again after appropriate disinfection or sterilisation; and
• reallocate – move therapy or technology from one patient to another with a higher chance of benefit.

2.8
The Emergency Plan requires DHBs to manage their “business as usual” supplies and supply chain capacity at a level that can support all reasonably predictable local events without needing additional resources from national reserves.

2.9
The Ministry prepared further specific plans to guide emergency responses that sit underneath the Emergency Plan. The New Zealand Influenza Pandemic Plan describes how an influenza pandemic (and other respiratory pandemic) disease outbreak should be managed. It provides an overview of activities to prepare for an influenza pandemic and describes all-of-government response measures that could be implemented.⁷ It was this Plan that was operationalised to support the Covid-19 response.

2.10
The Infectious Diseases Plan focuses on how to respond to a potentially containable emergency infectious disease such as SARS and describes the role of DHBs in supporting emergency responses to infectious disease outbreaks. This Plan contemplates that, in an emergency, the Ministry may consider national procurement where there are difficulties procuring critical supplies, but it lacks any detail about how and when this would be done.

DHB health emergency plans

2.11
The Ministry’s Operational Policy Framework for DHBs (executed through funding agreements between the Ministry and DHBs each year) tasks DHBs and public health units with developing and maintaining regional health emergency plans. Those plans, among other matters, identify how DHB-funded ambulance, primary, secondary, tertiary, mental health, disability support, aged residential care, and public health services will be prioritised, structured, and delivered during the response phase of health emergencies.

2.12
DHBs are required to develop, maintain, exercise, and operate their own health emergency plan. They also need to ensure that health care providers and supporting agencies (through contractual arrangements) plan, maintain, exercise, and continue to deliver health services in an emergency.

2.13
The DHB’s health emergency plan is also meant to identify the roles and resources of health-related non-governmental organisations, volunteer organisations, and iwi/Māori and Pasifika providers.

2.14
The health emergency plan should describe its links with, assumptions about, and critical dependencies on the emergency response plans of those organisations. It does not state any expectations about these organisations needing to maintain their own PPE supplies or whether they could expect to rely on DHBs’ national reserve supplies of PPE in an emergency.

2.15
DHBs are expected to require all the services they fund (for example, ambulance, primary, secondary, tertiary, mental health, aged residential care, and public health providers) to have emergency plans and resources, and to ensure that those plans are integrated, co-ordinated, and exercised alongside the DHB’s health emergency plan. DHBs are meant to post their health emergency plans on their websites. We could not find complete or up-to-date health emergency plans on every DHB website.

2.16
The Ministry is responsible for leading planning for health-related emergencies and for ensuring a co-ordinated planning approach between the DHBs. The Ministry told us that it does not check whether DHBs have published their health emergency plans and does not have any process to formally review them.

Our observations

Integrated planning is needed

2.17
Several plans have supported, and continue to support, the response effort of the Ministry and DHBs. There are also arrangements for the Ministry and each DHB to hold national reserves.

2.18
The semi-devolved nature of the health and disability sector, with 20 DHBs and different health provider contracting models, makes effective planning more complex than it would be under a centralised model. However, it is critical that there is a co-ordinated response to emergency situations.

2.19
DHBs are meant to publish their health emergency plans on their websites, but they have not done this consistently and some plans are out of date. The Ministry is responsible for co-ordinating health emergency responses but has not reviewed these plans. In our view, the Ministry needs to exercise stronger leadership and ensure that plans are complete, up to date, and consistent with each other, as well as with the Ministry’s overarching Emergency Plan.

2.20
We observed some inconsistencies with the roles and responsibilities for providing PPE between aspects of the planning framework, particularly the Operational Policy Framework and the Reserve Supplies Policy. We discuss the Reserve Supplies Policy in Part 4.

2.21
There were also gaps in the planning about how and when supplies would be procured to mitigate the risk of shortages if the national reserve of PPE came under pressure during a health emergency response.

2.22
In our view, a new policy should set out how and when a centralised procurement system would need to be set up and how this should work. This policy should be clear about the roles and responsibilities of those involved in procurement and should consider and document the main risks to the supply chain.

The need for national operations during a response

2.23
The planning documents contained few details about how a national PPE system would operate. The working assumption appears to have been that the usual processes for procurement and logistics could be used.

2.24
During the response, those processes were not effective. We discuss this in more detail in Parts 5 and 7.

2.25
As a result, the Ministry needed to urgently implement new models for procuring and distributing PPE. In our view, the Ministry should have considered this as part of readiness planning, rather than having to resolve it during the response.

2.26
It would be advisable that plans include more detail on what an operating model for procurement and distribution in a national emergency should look like.

2.27
The Ministry was due to revise the Emergency Plan this year. This gives the Ministry and DHBs an opportunity to update the Emergency Plan based on the lessons learnt from Covid-19 and better prepare for future health emergencies.

4: Ministry of Health (2015), National Health Emergency Plan – A framework for the health and disability sector, Wellington.

5: Ministry of Health (2017), New Zealand Influenza Pandemic Plan, Wellington.

6: Ministry of Health (2004), National Health Emergency Plan: Infectious Diseases, Wellington.

7: This plan had two substantive updates. The first was in 2010 based on insights gained from the SARS outbreak in 2004 and the Influenza A (H1N1) pandemic in 2009. In 2017, there was a minor update to reflect changes to legislation and terminology. The decisions, interventions, and phases of pandemic planning and response remained unchanged.