The government warns that case numbers will increase sharply in the coming weeks and most Covid-positive cases will need to start isolating at home, Justin Giovannetti writes in The Bulletin.

Preparing for the next phase of the delta outbreak. Cases numbers in Auckland are expected to double over the next fortnight, to around 140 a day, as the delta resurgence in the city is on track to surpass the outbreak’s August peak. Caroline McElnay, the director of public health, issued a sober warning yesterday that the country’s contact tracing system will begin buckling once daily cases surpass 170 a day. As those numbers continue to climb, and pressure mounts on the health system, what will begin to matter more is the number of intensive care beds that are in use and available. Auckland’s vaccination rates have plateaued around 87% for first doses, shy of the number needed to achieve widespread immunity. Officials at the Beehive and the country’s DHBs are now focused on preparing the health care system for what’s to come.

The end of elimination means a pivot away from hospital care. Bridie Witton reports for Stuff that modelling for the Ministry of Health now warns that up to 5,300 cases a week, around 740 a day, could be reported in the Auckland and Northland regions next year as restrictions ease, even with a 90% vaccination rate. Most positive cases are now going to quarantine-facilities established for returnees from overseas. To take stress off a border system that would be overwhelmed, the government is now preparing to manage up to 95% of future Covid cases at home. Nurses and GPs could monitor patients remotely, but the days of quarantine at dedicated facilities for community cases is nearly over.

Speaking with the NZ Herald, Covid-19 response minister Chris Hipkins said low risk positive cases can self-isolate from today. The move likely means a faster than expected change to border facilities, where the minister said the vast majority of returnees are Covid free. Coming at the end of two weeks of extensive tinkering with the Covid-19 strategy, it’s another dramatic change to how the country is handling the virus.

The health minister is confident ICUs can handle a coming wave. Andrew Little said yesterday that only 0.2 to 0.4% of delta patients will be sick enough to need ICU care and the system will cope. According to RNZ, ICUs are now running at roughly two-thirds of capacity in Auckland and 16% of ventilators are being used. Of the 133 ICU and high-dependency unit beds across Auckland’s hospital network, about 90 are currently occupied, five by Covid-19 cases. Little said that the number of ICU spaces can be surged to about 550 beds nationally. To prepare, DHBs have followed guidance from the UK’s National Health Service. They have given nurses a crash course in ICU work and drawn up plans to move other patients out of hospitals as more ICU beds would take up much more room, possibly taking over operating theatres.

The real measure of ICU is not available beds, it’s all about the staff. ICU spaces are staffed by highly-trained nurses around the clock, especially when ventilation is required. The number of staff and patients is generally around one for one. According to the NZ Herald, doctors are challenging the minister’s assertion that about 100 new ICU beds have been staffed since the pandemic began and the system is ready. Two of the country’s senior most ICU specialists told Newshub last week that they’re concerned the system could be overwhelmed in an outbreak “We have a limited ability to flex. We will keep going until we run out of breathing machines,” one of them said.

The biggest problem can’t be fixed in time. While the government can buy beds and ventilators, it can’t buy staff—although it is planning to allow more doctors and nurses through the border system eventually. An ICU nurse needs up to five years of specialist training, while a doctor needs nearly a decade. Significant underinvestment before the outbreak meant that Australia has twice as many ICU beds per capita as New Zealand. The UK has nearly 50% more beds, per capita, as New Zealand. The College of Intensive Care Medicine of Australia and New Zealand warned in August that while health staff were preparing for an outbreak, “New Zealand does not have the buffer of empty beds or staff that other countries may have had, but we have learned many lessons from our colleagues overseas”.

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