Several advantages have helped New Zealand avoid the worst of the covid-19 pandemic and allowed the government to pursue a plan to eliminate the virus from the country. [1] New Zealand, small in size and population density with a population of 4.88 million people, has no land borders (it consists of two main islands) and is situated a considerable distance from the rest of the world. It has a stable government, a trusted and popular prime minister Jacinda Ardern, and a Director-General of Health, Ashley Bloomfield, who is trained in public health medicine. The advantage of time helped the Government instigate a rapid and potent response that leveraged our advantages, including learning from nations overwhelmed by covid-19.
On 23 March 2020, the “burning platform” occurred in New Zealand’s primary care: i.e. when there was sufficient concern about the status quo that rapid change was embraced. The Royal New Zealand College of General Practitioners advised members to move immediately, in advance of a government directive, to majority remote consulting (“go remote, go hard, go now”). [2] The sector responded, and within days this had happened. Learning that some Italians had caught the covid-19 virus in the waiting rooms of health centres was a potent incentive. [3] A countrywide lockdown lasting a minimum of four weeks was implemented three days later.
The days before lockdown were tense as covid-19 virus testing was undertaken in general practice clinics while the Government set up covid-19 Community Based Assessment Centres (CBACs).
Many GP clinics suspended online booking. Instead, patients were phone triaged by clinic staff about risks for covid-19 before a clinician made contact to determine the need for face-to-face versus remote consultation, or covid-19 testing.
Over 70% of consultations in primary care are now done via phone and or video consultation. Phone calls, either land-line or mobile, are most familiar to patients and staff alike. Fortunately, the electronic ordering of laboratory testing was already available. However, electronic prescribing was not yet established, and the installation of this was one of the truly rapid changes in the system. Digital processes that had been in a slow planning and development phase were adopted in a widespread fashion. Most prescriptions are now emailed to pharmacies. Another significant change was in the administration of influenza vaccinations. Most influenza vaccinations are were done in people’s cars to ensure that patients did not come into the practice. “Best practice” was pragmatic, under advice from the New Zealand Immunization Advisory Centre, so that patients who had received an influenza immunisation in the past without issue could leave after five minutes when previously a 20-minute wait was required.
While remote consultations appear to be a practical strategy in urban settings, rural settings highlight gaps that could also exist in urban areas: low digital literacy when technological experience is limited to low-cost mobile technology such as smartphones, smart TVs, and “apps.” [4] This digital divide compounds existing barriers of digital access, limited transport to clinics, and systemic ethnic bias.
We work in communities with a significant proportion of Māori, the Indigenous people of New Zealand, and people on low incomes. Modelling predicts worse health outcomes for this population if the virus gets established in their communities, akin to what is happening with African-Americans in the USA. [5] In some rural settings, where the proportion of rural Maori is higher than the percentage of rural non-Maori, we see a triad of barriers to healthcare with low income, inadequate mobile coverage and a lack of suitable hardware which can impair even those who are considered digital natives (born after the 1980s). The imperative for remote consultations could exacerbate inequities with devastating consequences for Māori.
Karl Cole, a primary care physician and health IT planner of many years, expressed our sentiments: “I was impressed by how quickly we change. Think about all the years of talks and meetings and the possibility (of remote consultations, e-prescribing and e-lab tests) and all the reasons why it could not be possible. We showed them.” [1] He articulates the relief that the “burning platform” could bring about much-needed change. However, we must remain vigilant about health inequities that can occur with the widespread adoption of digital health solutions.
Bruce Arroll, Department of General Practice and Primary Health Care, University of Auckland
Emily Gill, Department of General Practice and Primary Health Care, University of Auckland
Rachel Roskvist, Department of General Practice and Primary Health Care, University of Auckland
Matire Harwood, Department of General Practice and Primary Health Care, University of Auckland
Competing interests: None declared
References:
- Baker MG, Kvalsvig A, Verrall AJ, et al. New Zealand’s elimination strategy for the COVID-19 pandemic and what is required to make it work. April 3 2020. NZ Med J 2020;133:10-14 3
- Cole K. ‘We showed then’: Fast and furious changes and give hope for a better system. Opinion NZ Doctor https://wwwnzdoctorconz/ Thursday 16th April 2020
- Livingston E, Bucher K. Adapted from the COVID-19 Task Force of the Department of Infectious Diseases and the IT Service Instituto Superiore di Sanità. https://www.iss.it/infografiche JAMA. Published online March 17, 2020. doi:10.1001/jama.2020.4344.
- Greenhalgh T, Choon Huat G, Car J. 10-MINUTE CONSULTATION Covid-19: a remote assessment in primary care. BMJ 2020;368:m1182 doi: 101136/bmjm1182 pages 1-5,
- Strongman S. Covid-19: Virus and recession a devastating combination for Māori and Pasifika: https://www.rnz.co.nz/news/in-depth/414499/covid-19-virus-and-recession-a-devastating-combination-for-maori-and-pasifika, 2020
Authorship
All four authors contributed equally to the writing of this manuscript and have no conflicts of interest.