UPDATED late on March 22 to reflect and include comments from an interview with Ministry of Health senior official, Covid-19 response group manager testing and supply Dr Kelvin Watson, provided after Newsroom’s original story was published.
New Zealand’s national health emergency plan hasn’t been updated since 2015, the section dealing with stocks of critical PPE (personal protective equipment) and pandemic supplies is two years older than that. The most recent publicly-available information about how much PPE sits in the country’s stockpile comes from August 2020 – ancient history in a pandemic. And while the Ministry of Health says it is now collating data about PPE stocks every week, it also says it isn’t ready to release numbers to health professionals, let alone the public. This isn’t good enough, says a new report from an independent pandemic preparedness think tank. One year after New Zealand went into lockdown, we deserve to know whether our health system is ready for a big upwards spike or a future emergency.
On March 25, 2020, the day we moved into our big level 4 lockdown, Wendy McGuinness wrote a letter to the 20 district health boards in the country.
Well, the think tank boss called it a letter; really it was a request for information under the Official Information Act.
Tell us about your stocks of personal protective equipment and other critical medical supplies, she asked the DHBs. How many face masks do you have, how many ventilators, gowns, gloves, CT scanners, oxygen tanks?
Why the lack of transparency around our preparedness for more Covid outbreaks? Click here to comment.
It wasn’t an idle request. McGuinness is chief executive of the McGuinness Institute and a leading international expert on pandemic supply chains. She studies emergencies. She knew – before the rest of us found out the hard way – how difficult it can be to get vital resources during a global crisis.
And she believes the information about our PPE stocks is critical. And not just for officials – for all of us. If we don’t know what PPE we have, how can we know what we are short of? And if we don’t know what we are short of, how can make sure those gaps are getting filled?
There’s something else too, she says: The amount of PPE we hold will make a difference to decisions about whether or when to go into lockdown – and how long to stay in lockdown. If we have masses of PPE, maybe we can be a little bit more relaxed about our lockdowns. If we don’t have enough, we need to be super-careful.
“Collecting and sharing information about our healthcare system’s lack of preparedness for a pandemic is an important part of shaping public behaviour and gathering support for lockdowns during this pandemic,” McGuinness says in a draft working paper released this month.
“We hope the collected information will help New Zealand navigate this pandemic… and, crucially, redesign the health system in preparation for future pandemics.”
A confused picture
Official Information Act requests aren’t really requests. They are demands, backed up by legislation. Not only are public sector organisations obliged to provide the information, but there are deadlines they have to meet.
So McGuinness was optimistic she would get the data she needed to get on with her assessment of whether New Zealand had enough PPE, or whether we needed to boost stocks of certain things.
She was wrong.
A few DHBs responded quickly: Bay of Plenty DHB sent all the information she asked for within a month. Some provided all the information, but slower. South Canterbury completed the request, but not until mid-September. Nelson-Marlborough asked for more time, but had provided the data by the end of May.
Eight DHBs rejected the request under section 18(f) of the Official Information Act – the clause that allows an organisation to refuse to provide information if “the information requested cannot be made available without substantial collation or research”.
The fact almost half the DHBs were basically saying, ‘We don’t know what we’ve got and it would be too hard to find out’, is not reassuring.
McGuinness pushed back against section 18(f) and most of the recalcitrant DHBs caved – Northland and Waikato for example completed the process at the end of August.
But three of the country’s biggest DHBs passed the buck or simply didn’t come up with the numbers at all. In Auckland, Waitematā and Counties Manukau DHBs initially diverted her request to something called the Northern Region Health Coordination Centre. This finally provided data on mask numbers – but nothing else. Nothing on gloves, gowns, goggles, ventilators, CT scanners or oxygen tanks.
Auckland and Gisborne’s Tairāwhiti provided no information at all.
Do we have enough PPE?
McGuinness ended up with more data on masks than anything else, partly because that’s where the most confusion arises in terms of PPE, so that’s where she pushed hardest to get information.
But even with masks she can’t get an accurate picture, she says, because the different DHBs reported their numbers at different times, in a year when masks would have been going in and out of stocks all the time. So comparing the numbers from one DHB in April to another in September isn’t comparing apples with apples.
Bay of Plenty DHB held 13 masks per person; Taranaki had one mask per 24 people.
Still, it’s an indication that different district health boards are taking very different attitudes to the number of masks they have on hand.
At one end of the scale is Bay of Plenty DHB, which held just under 3 million masks for its 234,000 inhabitants. That’s approximately 13 masks per person in the area.
But that’s an outlier. The next highest are Wanganui, Mid Central and Nelson-Marlborough DHBs, which all held around three masks per head of population. Canterbury held two masks per person.
At the other end of the list are a number of DHBs with fewer masks than people. Sometimes way fewer.
In Wellington, Capital & Coast DHB has 68,000 masks for a population of 315,000. That’s one mask for every 4.6 people. In Taranaki it’s one mask for every 24 people, according to the numbers the McGuinness Institute received.
At Waitematā and Counties Manukau, two of the biggest DHBs in the country, it’s one mask for every 1.8 and 6 people respectively.
McGuinness stresses to Newsroom it isn’t a league table. It’s not even a snapshot of what’s going on, because the data was gathered at different times. Early in the pandemic, when Bay of Plenty DHB provided its figures, there might have been more masks in regional stockpiles.
“But it gives you an understanding how unequal DHBs were in terms of what PPE they were keeping. And how that could impact on inhabitants in different parts of the country.”
“If some DHBs think it’s important to have more stock than others, that should be important information that should be collected and understood. Because we want to deliver an equal amount of health services across the country.
“If one DHB thinks they need ‘x’ in terms of PPE supply but a poorer one thinks they need ‘y’, I don’t think that’s where the country should be going.”
“Much more work needs to be done around managing PPE so we know who’s got what, and you have a system where everyone is looked after equally, and if you have an outbreak you can share,” McGuinness says.
One of the things that came up in the responses from the DHBs was differences in how they saw their role in providing PPE for their local populations. Some saw that as an important part of what the DHB should be doing; others didn’t, McGuinness says.
“During the pandemic, it has never been the role of the DHB to provide PPE to the general public.” – Waitematā DHB spokesperson
“One DHB responded: ‘Our principal concern would be that you have drawn conclusions about DHBs’ ability to provide PPE to our communities. DHBs do not carry stock to provide for the community, the Ministry of Health does. The graphs about deprivation and Māori population percentages and PPE availability are flawed as they are based on the assumption we supply the community with PPE.”
Newsroom received similar messages. For example, a Waitematā DHB spokesperson told us:
“The information provided cannot be interpreted as the DHB lacking sufficient PPE to safely care for our population. During the COVID-19 pandemic, it has never been the role of the DHB to provide PPE to the general public. Our responsibility is to provide safe and timely care to our population, as such, we have always had enough PPE for our people to use in the course of their work.
“The Ministry of Health has clear lines of communication with DHBs at all times, including communications about PPE levels and distribution, as part of the national COVID-19 response.”
What the Waitematā spokesperson is referring to here is what is known as our “national reserve supply” This is a stockpile of emergency supplies – flu vaccines, body bags, masks, syringes, antibiotics, sharps bins, disposable linen and other unnamed “critical clinical supplies of PPE”.
Items from the stockpile, some of which is held centrally and some of which sits at individual DHBs, can be made available “to ensure that as far as is possible, DHBs and the wider health sector have continued access to essential supplies during large or prolonged emergencies [pandemics for example] that generate unusual demands on normal health service stocks or supply chains.”
In theory, anyone can find out what’s in the national reserve just by looking on the Ministry of Health website. It’s a public document – you can find it here.
Item one in the stockpile is “H5N1 pre-pandemic influenza vaccines. Volume: 150,000 courses (300,000 doses). Year of purchase: 2018, Year of expiry: 2020.”
What? We have 300,000 doses of an expired vaccine in our national reserve supply to protect us against an H5N1 flu pandemic?
Probably not. Newsroom can only assume the Ministry of Health has replaced the expired vaccines. But you certainly wouldn’t know that from the national stockpile data.
Because right there, in the top row of the document, is one reason McGuinness is worried about the national reserve supply document as a useful tool for the general public – and particularly for experts like her – to work out whether we are ready for another wave of Covid-19, or even a future pandemic.
Because it’s old data.
The stockpile document was last updated in August 2020 – seven months ago.
Which matters, particularly when it comes to PPE like masks in a pandemic.
“We store two different types of mask: P2 and general purpose,” the table says. There are 11 million P2 masks – the higher-protection ones with a filter – and 7 million general purpose surgical-type masks.
But during a pandemic, the numbers will be changing all the time. The table even says as much:
“The Covid-19 response has resulted in the use and replenishment of the National Reserve Supply of masks. As this is an evolving situation, stock levels may change at short notice. Stock levels below are as of 25 August 2020.”
The information about other PPE is even more vague. The table says “contingency supply of critical clinical supplies” – presumably the sort of personal protective equipment McGuinness was asking about in her official information requests – is held at individual DHBs.
“Volume and specific composition varies by DHB, based on individual DHB requirements.”
Since it took many months and in some cases several requests for McGuinness to get the DHBs to provide this information, this lack of specifics is not reassuring.
Meanwhile, the stockpile table lists 10.2 million syringes. This is, the note says “adequate to support a pandemic mass vaccination campaign”.
Given a team of 5 million all potentially requiring a two-dose Covid vaccination, 10.2 million syringes might be cutting it quite fine.
We have enough PPE: Ministry of Health
Early last week, Newsroom asked the Ministry of Health for an interview on the topic of PPE stocks. Unfortunately no one was available in time for the original publication of this story, however, Dr Kelvin Watson, group manager for Covid-19 testing and supply, agreed to an interview the following day.
Watson says after a difficult start in March and April last year, ministry officials have been working hard to establish a centralised supply and distribution system for PPE and to set up inventory and forecast reporting.
The ministry now has a weekly dashboard, with the latest information on what is in the central stockpile, what has been dispatched and what is on its way, Watson says. There is also much more focus on the quality of the PPE coming in, particularly if it is from new suppliers, and on knowing exactly which stock is approaching its expiry date.
“That gives us level of confidence of what we have,” Watson says. “And we have used this model to address other supply chain problems. We track things that are globally constrained, and have gone out and secured supplies of, for example, pipette tips and blood tubes, where there might be shortages.”
So is there enough? Yes, Watson says. The aim is to have eight weeks’ supply of essential PPE items in stock. Or when there isn’t that much, the ministry should know and be taking steps.
For example, there are 270 million disposable nitrile gloves in the central stockpile and a further 23 million in the DHB stores. There are 270 million procedure (surgical) masks in the national store and just under 5 million at the DHBs.
But the higher quality N95/P2 masks are in tight supply. There are only 3 million in the stockpile and 200,000 in the DHBs.
“Just before Christmas we placed orders [for N95 masks] on hold because we had quality problems. But we have made progress over the last three months, and we will get to close to 30 million.”
So if the Ministry of Health knows how much PPE we have, why are the publicly-available national reserve numbers seven months out of date? And the emergency strategy supply management documents more than eight years old?
It’s been busy, Watson says. Even though New Zealand hasn’t been nearly as stretched as other countries in terms of Covid cases, the ministry has been dealing with MIQ and community outbreaks, as well as difficult supply chains.
“Public reporting on PPE is not high up the list of priorities.”
Surely if you have the numbers there, it can’t be that hard to put them into a spreadsheet once a month?
“Suppliers globally are making allocation calls. There is a risk publishing [national stockpile reserve] information regularly could work against us as a country.”
Actually, there are two things that worry Watson about making the stock numbers public.
First, if it got out that New Zealand had heaps of PPE, health professionals or people in the community might demand PPE when the ministry has decided their sector doesn’t need it – or ask for more than the ministry thinks they need, he says.
“If we’ve got lots, people who aren’t eligible might ask why isn’t [the ministry] giving it to us,” Watson says. “They might want PPE when it’s not clinically appropriate.”
The second reason the ministry is reluctant to reveal all, Watson says, is it doesn’t want the world to know New Zealand is well-supplied.
“Suppliers globally are making allocation calls. If you make an order for a constrained item and you’ve already got lots they won’t give you any. There is a risk publishing that information regularly could work against us as a country.
“While we agree making [the national PPE reserves] public is good idea – we are still looking at when, to what level and how regularly.”
The Auditor General’s report
That might sound a touch paternalistic to an outsider – or even a tad selfish from an international perspective.
It also goes against clear instructions last year from the Auditor General, John Ryan that the ministry must be more transparent.
In March and April last year, Newsroom and other media wrote a number of stories highlighting the deep concerns of health professionals, community health providers, home carers, disabled and elderly people at being refused the PPE they urgently needed to keep themselves safe.
Stories including this one from March 27, 2020.
The stories questioned official guidance about the use of masks, gloves, gowns and other PPE, and they highlighted the lack of connection between what pandemic response leaders like Jacinda Ardern and Ashley Bloomfield were telling vulnerable New Zealanders and their carers about what they were able to access, and what the DHBs and the Ministry of Health were actually giving them.
Following the seeming chaos and confusion described in stories like these, the Auditor General was tasked by the Government with conducting an independent review into how the Ministry of Health had been managing both the national reserve of PPE, and the supply of PPE during the pandemic.
“In times of crisis, people need to have trust and confidence in the systems and arrangements set up to support them,” Ryan said in the overview to his report, released last June.
– The health emergency planning framework contain specific guidance about responsibilities for procuring and distributing personal protective equipment;
– The Ministry of Health regularly reassess assumptions for the categories and amount of personal protective equipment to be held in the national reserve;
– The Ministry of Health implement a centralised system for regular public reporting on the national reserve and implement periodic stocktakes to confirm the accuracy of the data and the condition of the stock;
– The Ministry of Health reintroduce a requirement for district health boards to manage national reserve stock in such a way as to reduce the risk of stock becoming obsolete;
– The Ministry of Health, in collaboration with district health boards, prepare more detailed operational plans and processes that describe how the national reserve system should operate (including distribution mechanisms) and test these as part of future national health emergency exercises; and
– The Ministry of Health and the district health boards strengthen the procurement strategy by including an analysis of risks to the supply chain and have a plan to address those risks.
Kelvin Watson believes the Ministry of Health has responded appropriately to the Auditor General’s criticisms, implementing many, if not most of the recommendations, although not the one about “regular public reporting on the national reserve”. He says updating the emergency plans will happen in the future.
“We consider we have completed actions in response to those recommendations.”
McGuinness says the purpose of her OIA requests to DHBs and her draft working paper is to add to the work of the Auditor General and “highlight not only the data evidenced at that time but what a better system might look like”.
For example, McGuinness believes during a pandemic the national reserve numbers should be updated monthly.
“And vaccines should be on this list – and they are not there.”
Cross over between MOH and DHBs
Another part of the PPE decision-making puzzle worrying McGuinness – and the Auditor General – is the fact it is far from clear how the masks in the DHBs and the masks in the national stockpile fit together.
If you want to know the total number of masks in the country, do you add the two numbers together, or are some of the masks that are stored in the DHBs part of the national stockpile?
Enter another Ministry of Health pandemic preparedness document: the National Health Emergency Plan National Reserve Supplies Management and Usage Policies, 3rd edition.
This is the Bible for the management and use of national reserve supplies, McGuinness says, and details the principal responsibilities of the Ministry of Health and DHBs in managing and using these “significant national resources”.
The trouble is this document is eight years old; it dates from 2013. If there’s a newer (4th) edition, neither McGuinness nor Newsroom has been able to find it.
At the top of page 1 of this emergency plan usage policies is this table pointing out masks should be stored inside and outside DHBs, but that DHBs should hold other PPE supplies, including gloves, gowns and syringes.
Kelvin Watson says centralising PPE supply and distribution away from the DHBs in August was a significant change to the previous system – and will also have had an impact on DHB’s stocks reported to the McGuinness Institute. He says one benefit of the centralised system has been creating much more collaboration between DHBs and between DHBs and the ministry.
Instead of guarding their hard-won supplies, DHBs are more willing to share, he believes.
“We have built trust in our ability to get a flow of product into New Zealand, so they don’t have to hold lots of stock. It has fundamentally changed how DHBs think.”
“This draws attention to the effectiveness of other risk management systems that exist in New Zealand that may also be outdated and unprepared to deal with other types of emergencies.” – McGuinness Institute
Still, Wendy McGuinness is nervous. The new McGuinness Institute working paper worries the Ministry of Health is not able to easily identify PPE shortages or to plan effectively.
“The Institute’s opinion is that the lack of central direction represents a failure of risk management.”
The paper has three “major suggestions for consideration”:
– establish a real-time, publicly accessible PPE stock reporting system;
– put in place minimum per-capita levels of pandemic PPE and ensure each DHB has enough gear to meet these minimums; and
– introduce a standardised product code system for PPE so DHBs and the Ministry of Health know exactly what protective equipment they hold and can coordinate to make sure they know if anything is in short supply.
Kelvin Watson says work is already going on around standardisation.
What does this mean for other systems?
The McGuinness draft report says the lack of central oversight “highlights that DHBs across New Zealand were not ready to deal with Covid-19” and wonders whether this reflects on a wider failure.
“This draws attention to the effectiveness of other risk management systems that exist in New Zealand that may also be outdated and unprepared to deal with other types of emergencies.
“How can New Zealand ensure our systems are robust and able to deal with shocks without finding out the hard way?”