Health board’s PPE squeeze revealed
Canterbury rest homes had to meet strict tests to get vital protective equipment, internal emails show. David Williams reports
It was the Tuesday in between. The previous day, the Prime Minister announced a national lockdown; the day after, the lockdown would come into force, at midnight.
On that Tuesday, March 24, the Health Ministry revealed 40 new confirmed Covid-19 cases. Hospitals were on high alert, postponing surgeries ahead of an expected surge in cases, and preparing to use facilities like gyms as an overflow.
Many aged care facilities were already closed to visitors. And questions were beginning to emerge about the supply of personal protective equipment, or PPE, such as gowns, masks, goggles, gloves, and disinfectant.
The World Health Organisation had warned of a global shortage because of “rising demand, panic buying, hoarding and misuse”, and suggested manufacturing increase by 40 percent.
At March 24’s press briefing in Wellington, Director-General of Health Ashley Bloomfield said there’d been a stocktake of PPE in its national store, and of what was held by district health boards. Millions of masks were also being produced at a factory in Whanganui, starting at 200,000 masks a day and increasing.
“So we’re very confident about our access to PPE here,” Bloomfield said.
Asked about a shortage of swab tests and protective visors, he said: “We don’t have an issue with the supply of those. But of course what we need to do is make sure that wherever they are needed in the country we are able to resupply practices or district health boards as soon as possible. There’s a team working on that constantly.”
The national narrative of “enough PPE” had begun. Access is one thing, availability is another.
There was a disconnect between the messages from Wellington and what was happening on the ground, including reports of frontline health workers washing disposable masks and decades-old masks crumbling in the hands of hospital staff.
The communications divide is exemplified by an email sent by the Canterbury district health board that Tuesday, March 24, released to Newsroom under the Official Information Act. A week later, PPE supply would become such a hot issue it was suggested the Defence Force should help distribute it.
“The CDHB will support you when your supply chain has broken down or you have an immediate need driven by a highly suspected or confirmed Covid-19 case within your care.” – Canterbury DHB email
The March 24 email, drafted by Canterbury & West Coast District Health Boards supply chain manager Renee Montgomery with others, stated how external requests for PPE would be dealt with.
“Please ensure the communication below is circulated widely,” says the email, copied to several emergency control centre addresses. Specific mention was made of sending it to age-related residential care facilities, of which Canterbury has 103, and mental health facilities.
External organisations were to be pushed back to their existing suppliers. That’s despite correspondence, sent on March 11, from a clinical nurse specialist saying she’d been told the previous week aged care facilities were “unable to order masks”.
The text to be sent says: “Due to limited supplies and increased demand (especially for PPE and cleaning/disinfection products), the CDHB needs to manage the allocation of products in a structured and equitable way that ensures our ability to support the entire health system through a prolonged pandemic.”
The tone is very much ambulance at the bottom of the cliff: “The CDHB will support you when your supply chain has broken down or you have an immediate need driven by a highly suspected or confirmed Covid-19 case within your care.”
Requests for equipment should be accompanied by evidence of: “your inability to source requested products”, “delays within your supply chain”, “current stock on hand”, and current consumption rates “to highlight the shortfall”.
Providing such evidence “will ensure the most timely provision of goods to support your request”, the email said.
Therefore, one of the tests of whether a facility would get more PPE, the purpose of which is to protect staff and patients against infectious diseases, would be whether there was evidence the infectious disease was already in the facility. And this applied to rest homes, where some of society’s most vulnerable people live, and who, international evidence has shown, are at high risk from Covid-19.
Defence of definitions
Canterbury DHB’s acting chief medical officer Dr Mark Jeffery explains “limited supplies” didn’t mean short supply. “This was simply an indication that there was not an endless supply and therefore that our supply needed to be managed appropriately,” he says in an emailed statement.
The Aged Care Association didn’t think it was appropriate. In April, it called out the DHB as the country’s “standout” for not providing adequate equipment to its members.
In a statement that will rub salt in the wounds of those facilities which couldn’t get PPE, Jeffery says: “The DHB has had adequate supply of PPE and cleaning products at all times throughout the Covid-19 pandemic.”
Canterbury stuck to the Ministry of Health guidelines for PPE distribution, he says. “And as the ministry guidelines changed over the duration of the pandemic response, so did our supply and distribution.”
There’s a hint of blame-shifting in that statement. But the ministry became increasingly unhappy with how slowly PPE was being distributed by DHBs. (That tension took on extra weight yesterday, after a major health review called for a cull of the country’s 20 DHBs.)
Swirling above it all were accusations, now confirmed, that DHBs were rationing.
On March 31, the government stepped in.
An email from director-general Bloomfield said a national process was being established to coordinate supply chain orders through its national crisis management centre. It would also “assess any funding constraints to ensure continuity of supply”. An initial meeting with various parties, including Canterbury DHB, was fixed for that day.
“Over the next 48 hours, 1.2 million masks are being released to DHBs for distribution to all health and disability providers in their districts (whether or not they are funded by DHBs),” said the email, released to Newsroom under the OIA.
(Bloomfield mentioned the release of masks at the daily briefing, saying: “We don't want this PPE to be locked away for a rainy day.” The nationally coordinated supply – which union E tū said took weeks to bed in – was announced weeks later.)
Canterbury DHB’s emergency control centre snapped to attention. A day after Bloomfield’s email, a request went to Dan Coward, the DHB’s incident controller, asking for approval “to access support from the military” to help get PPE to “key areas”.
Jeffery tells Newsroom this possibility was mooted after the Defence Force indicated it was available. “However, it was decided that the DHB was able to manage the supply itself with the support of local couriers.”
The strict conditions imposed by Canterbury DHB on PPE distribution provide rare common ground for E tū and the rest-home-representing Aged Care Association.
“They were rationing their supplies,” association chief executive Simon Wallace says.
“But that wasn’t the message that was coming from higher powers than that, that all frontline health workers, whether they were in aged care, hospital, or anywhere else, should have the PPE that they need.”
He adds: “I find it quite revealing they were imposing these quite strict conditions, and that was probably the reason why it was so hard for [rest homes] to get the equipment that they needed and why so many of them had to purchase it themselves.”
Sam Jones, a national director of E tū, says the Health Ministry prevaricated about the health benefits of mask-wearing, when the “real reason” was a lack of supply.
He describes Canterbury DHB’s position as: “We’ll give you masks when it’s too late.”
Five of the country’s 16 significant clusters were at rest homes, including two in Christchurch – Rosewood and George Manning. “We’re clear that those homes that got clusters didn’t have PPE until it was too late,” Jones says. “They didn’t have adequate PPE.”
Wallace, of the Aged Care Association, says the DHBs’ priority was the tertiary care sector – “that’s public hospitals”.
According to E tū’s Jones, some DHBs were basically hoarding supplies, even after being told to send it to external facilities.
Releasing the national stockpile earlier might have eased the pressure. Wallace says: “There was supply in the country but the distribution chain just fell apart.”
Sixteen of the country’s 22 Covid-related deaths were linked to rest homes. The deadliest cluster, with 12 deaths, was associated with Christchurch’s Rosewood facility, a 64-bed rest home and hospital in Linwood. (All its dementia patients were shifted to Burwood Hospital in early April.)
Newsroom reported PPE wasn’t readily available to Rosewood staff until the rest home had its first confirmed case.
Stuff reported last week the Canterbury DHB had established Rosewood breached its contractual obligations on several counts, including emergency provision of “personal supplies”.
Spotlight on rest homes
Last week, the Health Ministry released an independent review of Covid-19 clusters at aged residential care facilities. (Other inquiries include DHB “readiness assessments”, as well as investigations by the Chief Ombudsman and Auditor-General.)
Staff and managers from 12 facilities were interviewed, out of the country’s more than 650 aged care providers. Despite the small sample, the report makes sweeping statements.
There were initial problems obtaining PPE from DHBs, the report said, but “most” facilities had access. “Most” rest home staff were allowed to wear PPE “which made them feel safe”.
That jars with what Jones, of E tū, heard.
Early on, many workers were bullied and abused by managers for wearing PPE, or for bringing their own masks to work, he says. (Initial ministry guidelines were that rest home staff and carers handling elderly and disabled patients didn’t need to wear masks.) One South Island rest home manager took all PPE supplies off staff and locked it away.
“I know of at least five scenarios where the workers just refused to deal with residents and patients until it was given to them,” Jones says.
The independent report said: “While all anticipated the impact of a pandemic in general, no facilities were prepared for the impact of a positive case, let alone an outbreak/cluster.”
Wallace, of the Aged Care Association, says his sector is not beyond reproach – there are things it could have done better. “But equally there were things that the public health units and the DHBs could have done better.”
He notes proudly that the virus infected less than 1 percent of all facilities in the country.
That’s a “success” Jones of E tū finds hard to swallow, since 73 percent of Covid-related deaths happened at rest homes. It also papers over the cracks of an industry with what he calls “systemic unsafe staffing”.
Jones is sceptical about the independence of the report released last week. As he puts it, private providers are hardly going to admit their failings, and neither are the DHBs, which act as regulators.
“Given how widespread norovirus is every year, tell me that the performance of infection control is adequate. It’s just not,” Jones says.
He hopes Covid-19 doesn’t get into another rest home, “because I can’t see different results happening”.
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