System improvement opportunities in COVID-19 lessons

As emergency clinicians our focus is on ensuring our patients – consumers in our healthcare systems – receive the emergency care they need when they really need it.

This has remained constant throughout a COVID-19 pandemic which has disrupted our ways of working – adding complexity, exacerbating and creating issues.

Among many challenges, there are opportunities for lasting improvements to the care we provide consumers. Partnering with consumer groups has never been more important to achieving these necessary improvements.

Rapid response

In the early stages of COVID-19, governments and health authorities in Australia and Aotearoa New Zealand implemented strong measures to limit spread, while healthcare systems swung into gear with impressive levels of co-operation.

In anticipation of a wave of very sick people, as seen in Europe and North America, intensive care capacity was increased, elective surgeries postponed, sections of the medical workforce redeployed, new infection control and personal protective equipment guidelines developed and telehealth initiatives embraced with a particular focus on primary care.

An inconsistent resurgence

By June it appeared we may have avoided some of the worst international experiences. Some measures were wound back. Then came the Victorian resurgence and its tragic consequences.

Already vulnerable populations – aged care facilities, public housing towers – were disproportionately affected. Far too many healthcare workers were infected, impacting their colleagues and families, and stretching the ability of parts of healthcare systems to maintain services.

‘Non-essential’ elective surgeries and cancer diagnostics were again postponed, stringent lockdowns re-imposed. While these helped drive down cases which in Melbourne peaked at over 700 per day, an ongoing challenge is how to sustainably avoid further dangerous outbreaks.

The ‘elimination vs suppression and mitigation’ discussion affects consumers, as illustrated in Australia where many state borders have remained closed.

As New Zealand demonstrated in August – when after 102 days without a case there was an outbreak – the most stringent measures will not guarantee elimination of this virus.

Unfortunately elimination is neither an achievable nor realistic long-term strategy for this virus, now endemic in the world. Allowing the virus to run unchecked in communities as seems to be happening in pockets of North America and Europe is unlikely in the short term to bring the levels of ‘herd immunity’ required to return completely to pre-COVID normal and we keenly await a vaccine to boost this community immunity. Until then, we must find ways to sustainably manage and live with COVID-19, seeking to suppress large-scale outbreaks and mitigate unintended and potentially-harmful impacts of not just the virus, but the economic and psychological impact of preventative measures.


Throughout the pandemic, Emergency Physicians at various stages have reported temporary downturns in emergency department (ED) presentations, with the exception of mental health presentations.

This is certainly multi-factorial, with patients potentially avoiding necessary ED visits, and there has also been at times less traffic and reduced industrial activity. However, many ED patients have also been more acutely unwell than those presenting pre-COVID-19 – suggesting people have waited for conditions to significantly worsen before seeking help.

With elective appointments, surgeries and diagnostics down, and GPs worried about consumers delaying healthcare, this is concerning. We encourage all consumers to continue accessing healthcare. Consult GPs if unsure, and EDs are ready in an emergency.

The move to telehealth has some benefits, allowing consumers in remote locations to access regular appointments, while also providing people with underlying conditions access to at-home healthcare.

However, it is not perfect, and no substitute for healthcare resourcing equity in regional and remote areas. Already marginalised community members – those without access to computers; those with pre-existing conditions who may be technology illiterate – are also disadvantaged.

Addressing inequity

Healthcare equity must be at the heart of our ongoing pandemic response, as already vulnerable or marginalised groups disproportionally feel the crisis’ impacts.

Aged care home residents have borne a significant burden, and crowded housing estates and households where English is not a first language have faced challenges.

Healthcare workers need to advocate for patients, ensuring they do not suffer racial, cultural or age-based discrimination.

In New Zealand, where I am based, the Australasian College for Emergency Medicine in consultation with professional bodies and community organisations, has acknowledged the pandemic response must include equity for Māori, and Pasifika peoples. I have recently spoken on new work entitled Choosing Wisely Means Choosing Equity. It highlights shared decision making has potential to address health inequities among Indigenous populations by rationalising (not rationing) healthcare to allow reinvestment whilst facilitating participation in healthcare that better meets self-identified need.

In Australia, Aboriginal, and Torres Strait Islander communities face not dissimilar, yet distinct, issues. While COVID-19 has not reached remote communities, we must remain focussed on protecting these. There is much more to do to provide culturally safe and accessible healthcare for Indigenous peoples.

Mental health

The pandemic has exposed system gaps as chasms. We need to work with consumers to address structural issues together.

Issues of dangerously long waits for admission to hospital or more definitive care for patients needing mental health support in EDs have accelerated or worsened during the pandemic. ACEM recently released the Nowhere else to go report, examining Australia’s mental healthcare crisis. It contains recommendations to improve care for consumers seeking mental health support, within EDs, healthcare systems and in the community. People with lived experience of seeking ED help while in mental health crisis have helped us better understand their needs. They have inspired us to change ways we work, and are vital partners in the campaign for structural mental health reform.


We need to know when things go wrong. Important here is the Emergency Medicine Events Register. Consumers, their families and carers can provide feedback on experiences of emergency care, and anonymously enter incidents to help us identify issues and improve.

We have an obligation to continue advocating strongly, in partnership with consumers, for necessary healthcare system improvements.

No going back

Meaningful systemic solutions can be found.

We must address longstanding and unethical issues of ED crowding and access block, resulting from systemic and resourcing shortcomings.

These issues harm consumers, increasing the risk of medical error, morbidity, and even patient death. It is unacceptable and we must partner with consumers, to make our voices heard.

Consumers have a key role to play in advocating for safer EDs and better health systems in the new COVID normal. Joint advocacy can help us engage a broader range of stakeholders with these important issues. Together we can work towards the healthcare systems we know we deserve. Seizing on lessons learned and unprecedented levels of co-operation, there can be no going back. We must address healthcare inequity; push for equitable resourcing of rural and regional emergency care; and find holistic improvements to mental healthcare systems.