The policy retreat from virus suppression to virtually no control has placed the nation’s pathology industry, and health services overall, under crippling pressure.
We all have some understanding of waves. We can sit on the beach and watch a morning lap transform into an afternoon tempest. A safe and gentle environment can become a destructive surge with waves undermining and destroying human infrastructure and threatening our lives.
In simple terms, waves are characterised by wave length, frequency and amplitude. Optimum surfing conditions are when spacing, frequency and size allow surfers time to manoeuvre between waves, share the resource with fellow surfers and assess the risk of each wave and its characteristics. There is a sweet spot between too little wave energy (flat), when there is no interest in getting wet, and too much energy, when the waves are too big (wild) and there is considerable risk to life and limb when getting wet. As wave conditions can change quickly, a weather eye is needed to constantly evaluate risk and accordingly adjust equipment and activity.
And so to pathology and the surfing of Covid variant waves. The practice of pathology in Australia is now highly regulated. However, these tight and appropriate controls were developed after a volatile “let it rip” period in the 1980s, which was a time of minimal regulation, significant corruption and lack of quality control and service assurance. Public pathology services, especially in rural and remote areas, were often run-down and underfunded with variable quality control and service provision.
In parallel, the private industry enjoyed an open market that provided rich financial rewards but often delivered questionable reporting practices, which at times bordered on criminal negligence The situation became so serious that the Commonwealth in 1986 legislated for NATA accreditation of pathology services and linked payment of Medicare benefits to this quality assurance system.
The resulting lift in standards has meant that clinicians and patients can be assured that laboratory results and reports for the most part are fit for purpose. The Medicare arrangements have provided a reasonable return to service providers and help control out-of-pocket costs to patients.
Laboratory tests and reports need to be accurate, relevant and timely. Each step of the pathway from specimen collection to clinical report needs to be strictly quality-controlled and supervised. Typically, these steps are described in laboratory protocols which provide detail and mandate direction on specimen type, priority, batching, test methodology and analyser operations, result checking and processing, staffing requirements and finally report transmission.
Clearly these highly ordered systems are capitalised and staffed to manage foreseeable throughput and standard referral patterns. In surfing terms, pathology has inhabited an environment of gentle swell and there appeared to be no danger of being swept away by wild surf.
Come the Covid waves. Early in the pandemic, the focus in Australia was on suppression of the variant waves. Principally the idea was to dampen the amplitude and increase the wave length so that illness and death could be managed without overwhelming essential services. The test/trace/isolate/lockdown procedures were manageable from a laboratory perspective. The swell had increased in amplitude but spacing and frequency were still within the capacity of testing equipment and staff availability.
With Omicron came pathology’s second “let it rip” moment. The retreat from suppression to almost no control and adoption of the “living with the virus” mantra meant that the amplitude of the Omicron wave was, and continues to be, enormous. The elected officials and government administrators who made these decisions did not seem to either understand or care that a giant wave in the middle of a moderate set has the capacity to overwhelm even the most accomplished surfer or, in this case, mission-critical clinical services that have been carefully calibrated on a predictably increasing workload.
The suggested short wave length for the Omicron outbreak was not enough to ameliorate the damage to health services caused by the wave’s growing amplitude, driven by a massive broadening of the testing requirements for tourists, travellers, border crossings etc. It is therefore not in any way surprising that laboratories found themselves short of equipment, reagents, staff and the energy and focus to keep paddling.
Batch protocols were unsuitable for the sheer volume of testing because of the high rate of positive results and the need to validate each individual result. Work intensity increased while staffing levels were reduced. As standard protocols and control mechanisms break down, staff become exhausted. The great surprise is how well the industry has actually coped. By some estimates productivity is down by 30 per cent and thus it is a miracle of human endeavour and grit that the system has managed so well and the Sydpath outcome seems to be an outlier.
As for the rapid antigen test (RAT), it has been in some ways a more profound disaster. Point-of-care technology has its uses but a totally unregulated “let it rip” approach shows the total lack of understanding and planning by modern government and officialdom on the need to have an accredited process for test efficacy, a quality validation reporting system for these tests, identified user databases as well as an unambiguous price signal. It is difficult to imagine how the current RAT rollout could have been made worse. This is more than a rogue wave; it is a continuing maelstrom of policy incompetence.
What next? It is unlikely that Omicron will be the last variant. Can we be certain that each successive variant wave will be less deleterious than the previous one? Pathology is not alone and provides a window into the whole health system. It is clear that the “let it rip” philosophy of elected and departmental officialdom has seriously damaged health service provision. Will the officials continue to disregard expert medical advice on pandemic management generally?
And how do we plan solutions for laboratories so that they can rapidly gear up for increased staff and equipment when the next giant waves arrive, as they will? How do we rebuild public health expertise generally and integrated national pandemic planning? Surely governments of all colours and persuasions must now understand that a healthy economy is dependent on a skilled and healthy workforce operating within a safe environment guided by an evidence-based policy framework. Without reinvestment in these capabilities, we will continue to fail our health workers and our wider community.