Estimates Debate — Health Sector

So we are actually at the end of the time that was agreed for education. The Minister responsible for the next sector, which is health, of course is in the chair. I’m just not sure whether we—we’re going to move on, the whip’s nodding. OK. So we move on to the Vote in the health sector (B.5, Volume 6). The question is that Vote Health stand part of the Schedules.

Tēnā koe, Madam Chair. It is my absolute pleasure, as the chair of the Health Committee, to speak on this Estimates debate for Vote Health. In doing so, can I acknowledge Minister David Clark, who actually presented to us on 24 June, and, obviously, acknowledge that we have a new Minister of Health in the Hon Chris Hipkins.

From that hearing, I do want to highlight some points, but before I do so, I just want to note that my colleague Michael Woodhouse is in the Chamber today, and I know he will be focusing on DHB deficits and also management of DHB assets. My colleague Matt Doocey has got a particular interest in mental health and addiction services, and my colleague Liz Craig will talk about personal protective equipment. Given that I know those other topics will be spoken about, I, really, have three distinct questions for the Minister in the chair, the Hon Chris Hipkins.

They are, really, to outline the overall response to COVID-19. I think there’ve been many initiatives that we, through our Minister of Health and our Ministry of Health, have engaged in to protect New Zealanders as we strive to eliminate COVID-19. So, obviously, the highlighting of those initiatives is incredibly important.

Also, I think it’s pertinent, given there was a disruption to business as usual—and particularly when we went into alert level 4, during the lockdown period—there has been an appropriation of $233 million in investment over three years for planned care to address issues such as waiting lists and waiting times. So the opportunity cost of our response in those initiatives I think it would be incredibly important for the Minister to highlight.

Just finally, from 10 April 2020, we transitioned to managed isolation for 14 days. Before that, those New Zealanders returning home were self-isolating at home. I think it would be good for us to understand that transition period and, in fact, where we are today, and I’d like to know the role of the Director-General of Health. Obviously, Mr Bloomfield’s become somebody that we all have high regard for—so understanding his responsibilities in that process.

It would also be good to understand the importance of our public health services and our public health capacity in the implementation of our elimination strategy.

And then, finally, within our response to COVID-19, it would be really good to know what our contribution to the global effort in the development of a COVID-19 vaccine is. I think we’re all vested in understanding our contribution, because we did go hard and early, but the reality is—

CHAIRPERSON (Hon Anne Tolley): Can I just remind the member that her role as chair of that select committee in the committee of the whole House at this stage is to present a report of the major findings of that committee. The questions are able to be asked, but it’s got to be non-political. When you start to getting into phrases like “we went hard and early”, that are contentious, then the member is, sort of, straying from the role of the chair.

OK. Other than that, everything I’ve highlighted, initially, was in our report. They were the headlines in our report.

CHAIRPERSON (Hon Anne Tolley): You just need to refer to that.

I have. Everything I’ve referred to—other than the “go hard and early”. Obviously, that was my political contribution. But those are my questions to the Minister in the chair, the Hon Chris Hipkins. Thank you.

Thank you, Madam Chair. It’s a pleasure to speak to this debate and reflect back on the Estimates from 24 June when we had David Clark and the Director-General of Health in front of us. We spent a lot of time discussing the pandemic response—I’m looking at the transcript here. We spent a lot of time talking about testing—testing at the border, asymptomatic testing. I have four or five points across that range which I’d like to raise with the Minister and seek his advice on—and my colleague could be in and out, as is the format for this discussion.

What I want to start with, first of all, is data collection for Māori health under the coronavirus. We talked about data in the Estimates, how dependent we were to know that we were making progress. When we look back at around the time of the Epidemic Response Committee, we had an issue early on with testing for Māori; we couldn’t tell what level of testing was happening out in the regions. It either wasn’t being collected or, more specifically, it was needing to be a tie up between National Health Index (NHI) number and then the actual testing database, and that was complex. I’d like to acknowledge several academics who threw their weight to this discussion and got it moving along. Well and good. So we learnt from that that it is really important that we gather data, particularly around ethnicity, during coronavirus.

The very brief extension that I want to go to, then, is that there was a story that was reported three weeks ago about an overloaded Air New Zealand flight out of Auckland, where 11 people were offloaded, and the comment was made: “My kids pointed this out to me … ‘all of us in here are Māori apart from one lady’ ”. My concerns with that is that maybe Māori were disproportionately offloaded from that flight. Here’s where I come to the ethnicity testing part, because I needed to know if that was correct or not.

So I posed questions to the Minister and asked him how many of the 11 people placed in quarantine—so they got off the flight and got put into quarantine on Saturday, 4 July—were Māori. The reply was that it’s not a requirement that individuals arriving at managed isolation disclose information about their ethnicity. Now, that’s a bit of a challenge. I couldn’t understand that, because I’m pretty sure that everyone going into isolation, as we learnt through the Estimates, has to have an NHI number. If you have an NHI number, you need to report ethnicity. So I thought I’d just double-check that, and, sure enough, on the Ministry of Health site, it says that ethnicity data must be collected during the first interaction with the health agency, must be collected at any time in a certain number of years, and it must be collected if the ethnicity already held is either not stated or not elsewhere classified. So in all those instances, I might have reasonably expected that ethnicity data of these 11 people, as they moved into managed isolation, was recorded.

The first point that we needed to know was did they have NHI numbers, and the Minister kindly replied that, yes, they did. So we know that happened. So my question becomes: why was ethnicity not recorded on these people, and is it routinely recorded for Māori who go into isolation? That then leads to another set of questions, but if the Minister could talk to that or help us with that, that would be useful.

If I could just run through the variety of issues that have been raised so far, and then I’m sure there’ll be more. In terms of the overall response to COVID-19, it is interesting to reflect on that now. Of course, we learn more as every day goes by around COVID-19, and it’s easy to reflect back to March and assume that we knew everything back in March that we know now. Of course, we have continued to learn more about COVID-19, about the way it is spread, and a whole lot of the things that we didn’t have good information on when we made those early decisions. Of course, we’ve got better information on them now.

In terms of the increased investment in planned care, the Ministry of Health is currently negotiating, with district health boards, plans for that investment to ensure that that money does flow through to increased electives and other planned care to make sure that we’re increasing the overall number but also clearing the backlog that was created by COVID-19.

The couple of questions around the role of the director-general with regard to managed isolation and quarantine facilities: of course, the director-general sets the requirements around who should isolate and for how long. The operational aspects of that now rest under Megan Woods’ delegation as the Minister responsible and Air Commodore Webb, who will answer questions on that.

The role of the public health services, the ongoing role of the public health services in relation to our COVID-19 response: of course, testing and tracing is a vitally important part of our response as a country to keeping COVID-19 out of the country, and the Ministry of Health has oversight of that.

Work on the development of a vaccine: Dr Woods is leading that for the Government as Minister of Research, Science and Innovation. As Minister of Health, I am leading the preparation for when a vaccination is ready. We cannot wait until we actually have a vaccination before figuring out how we would administer the vaccination, because nobody wants to see 5 million vaccinations at the point where we actually get them sitting in a fridge while we figure out how to actually administer them. So that work is already under way now, and I’ve had some early discussions with officials about being ready and making sure that we’re in a position to administer the vaccine when it’s available.

In terms of the data questions that Dr Reti raised, again, I think it would be fair to conclude that things have gotten better as we have gone along, and some of that early data-collection, as I think has been well canvassed, was not as good as it should have been. When I visited the border in Auckland about two weeks ago, I can now tell him that as everyone comes off a plane, before they even leave the airport they go and see someone from Health who finds their NHI, their National Health Index number, so that that’s recorded right from the minute they basically set foot in New Zealand. That will certainly help with the data collection, because that number can then follow them all the way through.

The member raised a concern around the offloading of the Air New Zealand flight. Again, the response to that issue was predominantly managed by Megan Woods and Air Commodore Webb. Of course, it was an operational decision by Air New Zealand. The advice that I’ve had is that Air New Zealand selected which of the passengers were removed from the flight. It wasn’t Health; it was Air New Zealand who selected that, based on the operational requirements of the plane—i.e., making sure the plane was not overloaded. I’m very happy to look into whether we can get an ethnic breakdown of those passengers. Certainly, I now get—and it’s publicly released on the Ministry of Health website—a breakdown of the ethnic testing done every day in New Zealand. And of course, the managed isolation and quarantine facilities are doing testing every day of the people at day three and day 12. So therefore, in order to supply the breakdown, they will have to have an ethnic identifier for those people who are having those tests. So I’m sure that there’ll be data now. That was several weeks ago that that incident happened, but I’m certainly happy to go back and look and see whether we can provide more detailed data for the member.

Thank you, Madam Chair. Thank you to the Minister for that—that would be very useful. He mentioned that we know more now than we did then around the coronavirus response, meaning several months ago, and that’s probably true, but I would contend that around asymptomatic testing, which came up in Estimates—the Minister said, “Then there’s an element which is asymptomatic testing, which is looking across the whole system,”. And if I look back on 4 March, Minister David Clark stood in the House just over there and said to the House that coronavirus is not transmitted by people who are asymptomatic. How could that be true when expert modelling for the ministry a week earlier had told him that at least 48 percent of positive tests could be asymptomatic?

Then, of course, as the knowledge progressed, in April, we know from written questions that there were then 15 asymptomatic cases and, in my view, played around with the words “pre-symptomatic” and “asymptomatic”. That sort of came to me for a while, which I think just confused everything—that is, “pre-symptomatic” meaning they were on the way to infection; “asymptomatic” meaning never going to get it. Well, that’s playing with words. Then, on 9 June, the ministry took up the programme of testing asymptomatic arrivals completely at the border. So I have some angst that, way back then, way back in March—in fact, two days in a row—the Minister stood in this House and said asymptomatic people cannot catch coronavirus. I just don’t accept that we didn’t know that knowledge there. Does it help us here today? Maybe not, but just to talk to the point where he said we know more now, and so we’re better—we actually knew back then.

I want to talk to one of the points the Minister raised around vaccines. Correctly, in my view, we introduced the flu vaccine earlier this year so that people who developed flu symptoms, one—let me say that again: so that people hopefully didn’t develop the flu that could look like coronavirus, firstly; and secondly, so they didn’t consume hospital resources or primary care resources. That was the correct decision. We deliberately give the flu vaccine at a certain date because the immunity has six months. We brought it forward two weeks. My question to the Minister is—and that was to our vulnerable, high-risk population—is our vulnerable, high-risk population going to run out two weeks early this year while we’re still in flu season? And have we ordered vaccines? Are we planning on doing a second run of flu vaccine to all our high-risk people at the end of this year?

With regard to the first part of the member’s comments, the advice that I have now, which was similar to the advice that we received at the very early phase of our COVID-19 response, is that, yes, it is possible for asymptomatic people to have COVID-19, but they are much, much less likely to be spreading it to other people. And that remains the advice as of now: the spread is much more likely if someone is showing symptoms than if they are asymptomatic. There are no certainties here, so it is still possible but much, much less likely.

With regard to flu vaccines, one of the challenges that our early vaccination campaign has provided is that we are seeing many, many fewer people presenting with flu-like symptoms at the moment. Of course, that has an impact on our desire to see a good rate of community surveillance testing, because fewer people are presenting with those symptoms in the first place, whereas if we had the typical seasonal rates of infection, there’d be more people being tested for COVID-19. So it creates some interesting challenges. I still think our testing rates are too low, and the member and I have had this conversation before. We’re leaning very heavily on Health to make sure we get those numbers up to a level where we can be confident.

In terms of whether a second vaccination round is planned, no, there is no intention at this point to do a second immunisation round for flu vaccines.

Thank you, Madam Chair. One of the things that we discussed in our Estimates hearing was the effectiveness of the response to COVID-19 in our country, and what we talked about was that we are in a fortunate position as a country to be able to pursue the elimination of community transmission. I think a lot of that comes down to the efforts of the team of 5 million but also some really amazing and dedicated health workers—those working on Healthline and in our community-based assessment centres, GP clinics, and hospitals—but also I think it comes down to planning and it comes down to significant investment.

Budget 2020 made some significant investments in our health system, but there’s also been a number of other packages that have been there to assist with the COVID response, and so I’m just thinking about the spending that’s gone into extra personal protective equipment and medical equipment, and, basically, looking at testing and contact tracing and also looking at telemedicine and the way that GPs were able to pivot quite quickly into virtual consultations. I think the other thing is in terms of stepping up some of those community-based assessment centres and also investing in our public health units, which have been under-invested in historically for probably a decade or so, and so being able to put that extra resource in was incredibly important.

But thinking through, again, going through lockdown and what we basically understood, there had been ongoing emergency care provided with our hospitals and also ongoing cancer treatment, but we’ve got a huge backlog now of other elective procedures and surgery, basically, with the DHBs already, coming after a decade of under-investment, and they were then having to step up and deliver a whole backlog of care as well as their routine care. Budget 2020 has put some significant investments into our DHBs, and for us down in Southern DHB, that’s $78 million per year, which is incredibly welcome. But there’s also that extra catch-up funding so that we can catch up on the surgery, on the delayed procedures, etc.

So it would just be good if the Minister could talk a little bit more about how Budget 2020 interfaces with the other investments that have gone into the COVID response and your view of the success of our response to date.

Of course, I think our response to date has been incredibly successful when you look at the fact that we have no evidence of community transmission in New Zealand as of today. We’re up to about day 80-something of no evidence of community transmission in New Zealand, and I think that’s something that all New Zealanders can be incredibly proud of.

With regard to Dr Craig’s questions around extra investment in things like medicines, equipment, personal protective equipment, contact tracing, and telemedicine, the member may be familiar with the fact that I did make an announcement on additional funding for those things last week. One of the big challenges that Pharmac has faced during this period is that the cost of medicines that it currently funds has increased as a result of the supply chain challenges that are being experienced around the world, and it is a reminder for us in New Zealand that whilst we’re doing all right here, many of the countries that we trade with, including ones we buy medicines from, are still experiencing quite significant restrictions in their ability to undertake commerce, and that’s having an effect on the amount we’re having to pay for those things.

With regard to telemedicine, it’d be fair to say that the response there has been mixed. Yes, we’re putting more money into things like Healthline and other services, and some GP practices have really embraced this. Others seem to think the idea of telemedicine is to ring their patients back, talk to them on the phone, and then tell them they need to come in for an appointment, which kind of defeats the purpose. So there are a variety of different experiences around telemedicine out there, but look, I think our overall response has been a very good one.

Thank you, Madam Chair. This would be described, I think, as the “Hotel California” contribution to the health Estimates debate. I’ve checked out, but I never really left!

The reason I am contributing, actually, is that Matt Doocey isn’t able to ask the questions that he has around mental health. So I am going to kick off in that regard. I certainly appreciate the candour with which the Minister has approached his new portfolio and the fresh eyes that he’s brought to it. And it’s in that spirit that I want him to perhaps give a view on how effectively we have spent the mental health funding that was appropriated in Budget 2019, because it started with a big number—$1.9 billion—but that included some pay equity settlements and the normal cost increases. My kindest estimate was around $780 million or $800 million, and then we’ve got a number of $455 million over four years for what was described as front-line mental health services. The problem is that, at the end of April, only $20 million of that had even been committed, much less spent.

Now, admittedly, it was only going to be $48.1 million in the 2019-20 year, but it still suggests to Matt Doocey—and it’s a view that Dr Reti and I share—that this is much slower to get out of the blocks than was anticipated. I would really appreciate almost a commentary rather than a specific answer to that question on whether the Minister, having come in and had a look at that, is satisfied that we’re making sufficient progress to give effect to the recommendations of the Paterson report, which is so fundamental to improving the mental health and wellbeing of New Zealanders.

I’ll just finish on this point: Dr Gluckman made comments at the Epidemic Response Committee, around PTSD in the wake of COVID, that potentially up to 10 percent of people who have suffered job loss or other loss as a consequence of the COVID lockdown could suffer PTSD. So not only were we seeing this bow wave of mental health need; that wave could well get bigger, and obviously we share the Government’s desire to make sure that we can manage the effects of COVID on mental health and mental health more generally. I would like to hear from the Minister on whether or not he feels we’re going far enough fast enough.

I thank the member, and I will make a reasonably general contribution. It’s an area which I have been looking at. Of course, if the member asks me in any of my portfolios whether we are making fast enough progress, my default answer to that question will always be no, because the machinery of Government never works fast enough for my liking. In every aspect of my ministerial work, I want to see faster progress, and mental health is certainly one of those where there’s a crying need. Can we make faster progress? Yes. Are we making faster progress since the lockdown ended? Yes, we are. Can we move even faster? Yes, I believe we can, and I’ll be leaning very heavily on that.

A couple of issues at play here: the member will be aware that the funding profile of that $400 million - plus that he talks about increases as the years go on, and it was a relatively small investment in the first year. One of the reasons for that is around building capability, particularly building up the workforce capability, and there has been significant progress in committing the funding since the lockdown ended. Things did slow down during the lockdown period, and it did push time frames out by a couple of months, but I am now satisfied that that first-year funding is now, by and large, committed and that actually a significant proportion of the second-year funding has also been committed as we go into the second year of that funding allocation.

I don’t have updated numbers on expenditure against commitments, but I’m certainly happy to get those to the member. But my overall conclusion is: are we moving fast enough? No. Can we do more? Yes.

I thank the Minister, the Hon Chris Hipkins. Just by way of follow-up, we were quite exercised in the Estimates discussion around this in the context of the quality of the information that was being provided through, because when Mr Doocey asked the Minister around data around the 40 sites that had been selected for those front-line mental health services as sort of the vanguard for the improvements, members on this side of the House were very disappointed at the lack of detail of the answers—didn’t know where they were, didn’t know how many staff were reemployed, didn’t know how many referrals had been received, and didn’t know when they had started receiving patients.

This goes to a concern that I have about the quality of the information that’s being provided or even collected. So there’s a specific question around mental health but also around health data and health targets more generally. Now, the Government, it would seem to me at least, has been reasonably lukewarm on the previous national health targets that were introduced by the Clark Government in 2007 and committed to their continued collection and then their replacement. Now, that was a commitment made shortly after coming into Government. It hasn’t been achieved, and we haven’t seen any data on any health throughput published on the Ministry of Health website since September 2019—that’s 10 months ago. So that’s the second leg of my question around data.

The third leg is on financial performance. Now, I now see today when I look at the DHB combined financial performance data for the nine months ended March 2020, it’s now on the website—some nearly five months from when that period ended. That’s been the pattern: four to five months it’s taken to get financial performance data online. So I’d like the Minister just to address the question of collection of data on mental health, national health targets and where we’re going with that, and his confidence and comfort level with the degree to which the financial performance data is being recorded and reported in a timely manner.

Yeah, I think those are all fair questions from the member. With regard to data, it is something that I’ve been looking very closely at. As you can imagine, as a new Minister, one of the first things you want to do with a portfolio is actually get the data so that you can understand what you’re dealing with. So many of those questions that he has just asked are questions that I have asked over the last three weeks as well.

It’s well canvassed, I think, previously that the new Government coming in three years ago didn’t agree with all of the focus on the Better Public Services targets of the previous Government, although they have continued to be reported against in the meantime. So that data is still on the website. My understanding is that the most recent data released for that is imminent. Of the most recent, up-to-date data on that, I know I’ve read something about that in the last couple of weeks. I can’t remember the exact date, but I do understand it’s imminent in terms of the latest release of that data.

I have also recently signed out a report to the Ministry of Health to prepare a report for the Cabinet on what a broader set of measures will look like. I have asked for some more information on some of those, and I will be aiming to progress that as quickly as I can. If I can do that before the election, then I’ll aim to do that. I do think it would be useful to have a broader set of performance measures for the system, not just around financial but actually around what the system is actually delivering in terms of wellbeing and health and wellbeing outcomes. So we’ve done some work—and that work was starting before I became the Minister, and I’m trying to speed it up a bit now—to actually get that better set of outcomes out there, because I think transparency is an important thing.

In terms of DHB performance, I’ve been scrutinising that very closely. I’m sure the member’s going to have lots of questions about DHB financial performance—I can see he’s got a list of dauntingly large highlights on his page there. My overall impression there is there’s been a significant increase in personnel costs across the DHBs, and I’m trying to get underneath that and understand a bit more about what’s driving that. Some DHBs will be faster to return to a break even or even a surplus position than others. I am currently in the process of going through, with the Ministry of Health, a letter to each DHB setting out the Government’s expectations around their pathway back into surplus, because their current financial performance simply isn’t good enough. As I said, some may take a couple of years, and some may be much more quick as a result of the additional investment we’ll be making, but I’m taking some time—I was aiming to sign them out by last week; I have not done that yet. The reason for that is I’m going through each DHB individually to understand a bit more about their individual financial performance, what’s got them to the position that they’re at, and what it’s going to take to get them out of it.

Good luck answering that question. It’s one thing I think the Minister and I have in common, which is that degree of interest in the detail. My ministerial staff, when I had that privilege, described me as annoyingly interested—

💬 Hon Shane Jones: Like my good self.

—and I think that was—ha, ha! Hasn’t lost his sense of humour.

I want to just elaborate, firstly, in respect of targets. I don’t actually mind what those targets are or if they are changed. Well, I do mind what they are, but I think if there’s change, that’s fine. The Simpson report, which the Minister will be considering with his Cabinet colleagues at the moment, did talk about population targets. I think that’s an entirely appropriate alternative to the output-based targets that the previous two Governments had. But the important thing is that we have a very clear expectation about what good looks like in the sector, and I don’t believe we have that right now. There’s a sense of drift, and it certainly is manifesting itself in the financial performance, which I want to draw on. The nine-month performance shows a combined deficit of $375 million, which is $61 million more than the previous year—19 percent unfavourable. Now, in that previous year, it was $264 million, and even that was $56 million or 27 percent more than the previous corresponding period.

We have a sector that is now spiralling out of control financially. The previous Minister kept blaming us, the previous Government. That’s fine—it’s not true, but that was his answer to just about everything. I would like to hear from the Minister, now that he has had his feet under the desk for a couple of weeks, what he believes is possible, because the answer he’s just given around the two years back to financial sustainability and break even has been talked about since I started in the health sector in 1995. So I’ve been hearing this for 25 years, and it ain’t happening. In fact, it’s getting worse. That is despite increases in Vote Health that have been above what was previously allocated. Get all political if we like, but the expectation was that deficits would go down, not up, and they’re going dramatically the other way, even when you take out the one-off costs for things like Holidays Act and—what was the IT system?

💬 Dr Shane Reti: National Oracle Solution.

National Oracle Solution. So we have a problem here. My first question is: does the Government actually have a reasonable expectation for DHBs to break even, and, if so, how? Secondly, is it appropriate for those great clinicians and health administrators in the Canterbury DHB to forecast a $180 million deficit this year? Thirdly, will he commit to this information being made available in a more timely manner? Because we’re talking about data that’s now four months old. We’re at the end of the financial year. Can he give the committee a sense of whether or not the projected $643 million, which was the March projection for full-year financials—we won’t be able to go to the exact numbers, but was it achieved? Can we expect bad news? Better news? What’s happening now? Because that’s, essentially, the role of the committee, to assess those financial estimates.

The member perhaps won’t be surprised but will probably be disappointed to learn that the numbers are worse for the latest quarter than were projected. Of course—

💬 Hon Michael Woodhouse: I’m not surprised, actually.

—they’ll be—yeah, he’s not at all surprised. So not surprised, but hopefully disappointed, like we are. I am, as I said, getting underneath those numbers and trying to understand what’s driving them. Personnel costs have been a big contributor to that. One of the issues that I’m trying to understand a bit more is the safe staffing model implementation, which was going to result in an increase in the number of nurses employed by DHBs. It would appear that it’s resulted in significantly more nurses being employed by DHBs than were first modelled, and so I’m trying to, again, get underneath that and understand that.

In the case of some DHBs—and the member mentioned Canterbury. Depreciation, of course, does play a significant role around Canterbury’s costs, because they have a very, very significant level of capital investment there. Whilst the Government is centrally funding the capital charge, the depreciation component of that still sits with the Canterbury DHB.

There is an intractable dilemma in health. The member mentioned, you know, his challenge back to the 1990s, and that is that the more money we spend on health, the more we need to spend on health. That will be the dilemma for every Government from now into for ever. The more you spend on people, the healthier you keep them, the more they, ultimately, end up costing. So there’s always going to be that challenge in the health system, and any Minister of Health is going to grapple with that. I don’t think our Government’s any different to the previous Government in that regard.

But I do think the final point the member makes around transparency is an important one. As I’ve indicated, I’m going through those numbers at the moment, DHB by DHB. I will be sending a letter to each of those DHBs in the next week or two, setting out my expectations. I have no hesitation in making that information public and being transparent about that. I’d like to get it to them first so that they’ve got a week or two to think about it before I make it public, but then, actually, I do think it is important that it’s made public.

Before I call the member, could I just ask colleagues in the Chamber to show a little more respect for the members who are seeking the call, because it’s really hard to hear them when other members who have quite loud voices use them.

Thank you, Madam Chair. I’d just like to acknowledge the Minister in the chair, the Hon Chris Hipkins. I’m pleased to be a new member on the Health Committee; I wasn’t a member at the time of these Estimates hearings.

My question, really, to the Minister is—you talked about, I guess, the expectations you’ll have on DHBs. I’ve got a very local issue, of Counties Manukau. Given the significant funding that’s gone into the additional support for DHBs, I’ve been asked to come in and, I guess, provide a pathway in terms of the Nga Hau birthing unit in Māngere, which was opened just over a year ago, to provide a model of care for an area of need. So if you were in Māngere prior to this birthing unit, you would be having your baby either at Middlemore Hospital or at Papakura or Botany Downs, which is still a significant distance for those mothers giving birth there.

So my question, I guess, to the Minister is, in terms of the expectation, in terms of the level of engagement that this birthing is a privately funded birthing unit—and I understand that they have tried to engage with Counties Manukau District Health Board to see a way through into getting some sort of support. At the moment, it doesn’t get a single cent. I would just like to get some clarification from the Minister on, perhaps, whether there is an expectation that there will be a reasonable level of engagement in terms of this model, and could there be a pathway of some sort of part funding or shared funding in this new amount that’s been allocated? Thank you.

Look, very briefly for the member, I am aware that there are a number of private birthing units popping up around the country. Of course, the Government’s expectation is that district health boards, through their publicly funded facilities, should be supplying the birthing services that is required for local communities. Where they’re not able to do, of course, they can talk to third-party providers, but our first expectation is that DHBs will be providing those services and will have arrangements in place to provide those services.

Thank you, Madam Chair. I’d like to extend a question that we did raise generally in the Estimates, in the area we were talking about—testing—and it’s an area that I raised last week. It’s around testing at the border, particularly testing in isolation, and the concern that I continue to have that there is some sense of autonomy under duress. I know the Minister’s been concerned about this, because we’ve had some dialogue. I want to approach it from a different angle, because maybe I wasn’t clear from how I did last week, and I’ll talk to some of the notes. It’s like this. We know that the legislation allows four sorts of tests in isolation. It allows you to ask about coronavirus symptoms, listen to the chest, temperature, and to do a swab. OK, we know that that’s what’s allowed.

My question partly, then, is around what is required for informed consent from someone who’s in isolation—more specifically, in writing. It was written to me that informed consent is only required in four situations: the consumer is participating in research; the procedure’s experimental; consumer’s under a general anaesthetic; or the significant risk to adverse effects on the consumer. My question, then, is: which of those criteria does nasal swab testing meet? Because you wrote to me in written questions, saying that that is the only form of written informed consent that occurs with nasal swab testing. So which of those four criteria do nasal swabs meet?

I’m not entirely sure what the member means. There are a variety of different rules at play here. The rules around nasal swab testing are clearly articulated and are subject to a separate arrangement. In terms of any other tests that might happen in managed isolation or quarantine facilities, of course, they are governed by the same laws and the same professional standards that would apply if someone was being subject to those tests around consent—you know, the same rules around consent—as if someone was being subject to those tests in an outside facility such as going to visit their GP. But, of course, if, as I’ve written to him, the member has any evidence that people are being subjected to tests in a managed isolation or quarantine facility that they have not consented to, then of course I would expect him to, if not supply that to me—he doesn’t have to supply that to me—to supply it to the appropriate people who could investigate it, because that would be a very serious matter.

Great. So I want an understanding here. I guess my question is: how come there’s written consent for nasal swabs—or for throat swabs, or whatever—but not for blood tests? How do we explain that?

And then, secondly, does he really get the importance here? This is a unique situation. There is a sense of duress, because if you’re not compliant, the duress is that you’ll have another 14 days in isolation. Otherwise, you could say, “Well, how is this different to a prison?” Well, in a prison, you can do a cost-benefit analysis and decide whether to say yes to a test, and there’s really no other consequence. In managed isolation or quarantine, there is a consequence. There’s a punitive sense of duress. Something will happen if you’re not compliant with the behaviour being asked of you. I think that in that environment, great care needs to be taken around consent and that different sense of autonomy. I’m just getting a sense—does the Minister understand it’s a different sense of autonomy in restrictive isolation compared to out in the environment?

Yes, yes, I absolutely do. One of the differences between blood tests and nasal swabs, of course, is that we expect most people to do nasal swabs, all people to do nasal swabs. They do have the ability, however, to say no to those tests. But, of course, the consequence of that is that we expect everybody to get a clean bill of health before they leave a managed isolation facility. If they are not willing to consent to nasal swabbing, then the period of time that it takes for us to have absolute confidence that they’ve got a clean bill of health will be longer. So that’s ultimately a trade-off that every individual in that circumstance can make for themselves.

I want to come to extend from what my colleague the Hon Michael Woodhouse was speaking about regarding some of the DHB financials, and talk about Capital and Coast District Health Board, which more recently have announced their financials, which are significantly different to what was announced earlier in the year. We did touch base on Christchurch, specifically, in the Estimates, and a number of the other DHBs. This is one that more recently has shown a significant variance to what was projected. I also note the comment that the DHB must also pay $10 million in payroll breaches made by the Government. Is that holiday pay, or what is being meant there by “payroll breach”? Can the Minister explain that, please?

Yeah, look, I don’t have the particular piece of paper in front of me that the member has in front of him, but I would say it is highly likely to be payroll breaches. These payroll breaches have accumulated over a period of time. Resolving issues around the Holidays Act is something that we’re grappling with across Government. It’s clear that for a period of time, well before we even became the Government, many public sector agencies—and private sector agencies too, I dare say—have not been paying people in compliance with the Holidays Act. Sizing and scoping that problem and finding a way out of it is a very complex process, and the Government, across the board, is engaged in that process at the moment.

Thank you. On 9 June, the policy for the border was that people would be coronavirus tested around day three and day 12, and this was discussed in Estimates as well. I want to ask the Minister in the chair, the Hon Chris Hipkins—because I still don’t understand—why day three testing is not compulsory. Particularly if we look at the majority of cases from 9 June that have been positive, they’ve all been day three positive. The majority of positive cases have tested positive at day three. We may have different numbers, but I checked this last week, and that’s how I see it, but I’m prepared to hear a different explanation.

So the day three test would seem to be absolutely critical, and yet the argument that I’m hearing is “Oh, don’t worry; they’re having a day 12 test.” If you have a day three test and you’re positive—like the people in Hamilton not last weekend but the weekend before—what happens is that you escalate, if you’re in managed isolation, to a higher level of security in full quarantine. That’s very clear as to why you’d do that: because if you’re positive, you don’t want to be mixing and mingling with others in the managed isolation facility. If we don’t test by compulsion on day three, how will we know that? Surely we’ve got a huge risk of day three people who aren’t being tested, who may be positive, who are then infecting others in the managed isolation facility. How hard can it be to make day three compulsory just like it is for day 12?

I think the member, perhaps, based on the previous discussion we had, might be misusing the word “compulsory”. Actually, the vast majority of people do have tests on day three, and there are a significant number of cases—and there have been cases of those ones and twos that we’re getting in recent days—where people have tested negative on day three and positive on day 12, which highlights the importance of the day 12 test, because we are picking up people who—if we just went on a day three test and then said, “You’re still not showing symptoms. You can leave on day 14.”, we wouldn’t be picking up some of those positive cases. In some cases, they’ve been asymptomatic for the entirety of their stay, tested negative on day three and positive on day 12, and if we did not do that testing on day 12, we wouldn’t pick that up. I think that that is very, very important.

Now, of course we want everybody to do both tests. The consequence of not doing tests is that you’ll ultimately end up being in those facilities for longer than you might need to be.

Thank you. The Minister’s talked about those who were negative at day three and then positive at day 12, maybe the false positives. He wrote to me when I asked that question—what is the rate of false positives—and the reply to me was 30 percent. That’s a big number. It’s not your fault or anyone’s fault, but it’s still a big number—one in three who test and say “I’m negative; I’m fine.” but in fact may be positive. What plans does the Minister have to address that? How do we look at the impact of that? What do we do about that other than sequential testing of some duration?

Sequential testing is the best answer at the moment. There is no foolproof solution here. Obviously, a lot of work is going on in New Zealand and around the world on testing regimes and on how we can get faster testing results, testing results that don’t require being taken off to a lab—more instant test results. The advice that I’ve received so far is that the rapid tests results are even less reliable than the polymerise chain reaction (PCR) tests. Those tests that we’re getting at the moment are quite reliable. They’re the most reliable that we’ve been able to identify so far. Of course, we’re keeping an eye on what the testing solutions are that might be available here and around the world. Where good solutions emerge, of course, we’ll aim to be fast adopters of them. But at the moment, one of the best things we can do is test more frequently in order to eliminate false positives.

I do just want to highlight this because, actually, it’s come up just in the last 48 hours again with the case that’s in the media today about the person who left New Zealand and arrived in South Korea, where they got a positive result there. That was from a rapid test, and those rapid tests are internationally recognised as being less reliable than the PCR tests. We have been in this boat once before with someone who left New Zealand, arrived in Singapore, and got a false positive off a rapid test when they arrived, and the PCR test highlighted them to be negative, which is one of the reasons why if we see any people leaving New Zealand and getting a positive where they arrive, we ask automatically for a PCR test to be taken, because that means that they’re being tested at an equivalent level to what the test would be if they were in New Zealand, and that gives us better data, thus far. It will be interesting to see what the case in South Korea highlights in the next 48 hours if we can get a PCR test done there. But the only other case that I’m aware of, it highlighted that it had been a false positive that they received in the rapid test.

Is there any position, then, for exit testing from New Zealand, whether or not this comes up positive from South Korea? Is there any work being done—modelling, any thinking—around exit testing, bearing in mind we do that for Samoa already? You have to have a medical certificate within three days showing you are PCR negative to go to Samoa—so it’s not new, this precedent. But is there any work being done towards that being rolled out more fully as we depart, as an exit test?

Yeah, one of things that we will be looking at, of course, is we look at the overall border arrangements that we have in place, as we talk about things like safe zones, where we may be opening up the border to isolation-free travel for some areas such as, potentially, some parts of the Pacific, Realm countries, and so on—very active consideration about whether or not testing should be part of that conversation. I think the last thing anybody in New Zealand wants is to see us spreading something into the Pacific. We have a bad history in New Zealand and Australia of doing that in the past, and I don’t think anyone wants to see that repeated. So, of course, we’ll have conversations about testing, and that would include a conversation about exit testing as well. In terms of the conversation about broader exit testing, at this point, no, we don’t have plans in that space for countries where someone is leaving New Zealand with no intention to return. However, I’d never say never.