In response to the pandemic earlier this year, the priority became freeing up as much bed and staffing capacity as possible within hospitals in anticipation of the incoming tide of Covid-19 patients. One way of doing this was postponing all non-urgent elective operations for a period of at least three months. It was estimated that this would free up 12,000-15,000 hospital beds in England alone.[1]
This approach was successful in the short-term, helping the NHS to meet the immediate demand created by the pandemic. However, it has produced a longer-term challenge as we transition back to ‘normal’ with a large backlog of cases. Decisions about how these are prioritised will have significant implications for the health and wellbeing of patients. In this blog, we look at the patient safety implications and highlight where we need to focus on to avoid patient harm.
Scale of the problem
Worldwide, approximately 28 million elective surgeries will be cancelled or postponed in 2020 as a result of Covid-19 disruption.[2] In the UK, the decision taken to postpone all non-urgent elective operations for at least three months is estimated to result in 516,000 surgeries being cancelled.[3]
These cancellations have created a backlog of cases that need to be addressed as we return to ‘normal’ levels of care. The existing number of patients waiting for routine referral to treatment for consultant-led elective care was around 4.4 million at the end of March 2020.[4] New estimates suggest that the waiting list ‘could reach 10 million by the end of the year, possibly higher if there is a second wave of Covid-19 and a lack of treatment or vaccine’.[5]
The UK faces serious challenges in seeking to address this backlog. The NHS Confederation has recently highlighted that providers will face restrictions on their capacity to deliver care due to the need to separate Covid-19 and non Covid-19 patients.[6] They note that, as a result of this, hospitals will have to run at significantly lower occupancy rates than usual.[7] In addition to these constraints posed by directly by the pandemic, there are practical problems to meeting the increased demand, such as having enough beds, physical facilities and high enough staffing levels.[8]
The Health Foundation recently looked at this issue through the lens of the 18-week elective waiting list standard, considering how to get back to this standard after the pandemic.[9] It painted a stark picture of the challenge ahead:
‘Even if the government is willing and able to increase NHS funding by £500m a year over the next 4 years, delivering the additional activity required to recover the 18-week standard is unlikely to be feasible. Around a third of people on the waiting list will need a spell in hospital. This would require hospitals to increase the number of patients they admit by an amount equivalent to 12% of all the patients admitted for planned care in 2017/18. This would be an unprecedented increase in activity.’[10]
The sheer scale of this problem and the practical challenges it poses means that there will be no quick solution; it will likely be an ongoing issue for years to come. How we deal with this problem will have serious implications for the safety and wellbeing of patients.
Lack of timely surgery is a patient safety issue
When making decisions about which cases of the surgery backlog to prioritise, it is vital to understand the impact that these choices will have on the safety of patients. Delays to surgeries for a range of health conditions can have a variety of implications. How will elective surgery be prioritised? Who will make these decisions and how will patients be informed and engaged in these decisions?
Cancer care is one major area of concern. Recent modelling indicates that just the initial postponement of surgeries may have already had a significant impact. A study has suggested that a surgical delay of three months over one year could result in 4,755 excess deaths, with patients who may have been effectively cured by surgery at an earlier point now at a higher risk.[11] This is particularly concerning for less survivable diseases, such as pancreatic cancer, where timely surgery is vital before the cancer becomes inoperable.[12]
For people living with heart and circulatory diseases, they are already at increased risk from coronavirus and there are concerns that surgical delays will significantly impact this group too.[13] Estimates suggest that around 28,000 planned heart procedures have been delayed as a result of the pandemic in England alone.[14] Dr Sonya Babu-Narayan, Associate Medical Director at the British Heart Foundation, noted:
‘This backlog will only get larger and the patients in need of treatment could get sicker as their care is delayed further. If hospital investigations and procedures are delayed too long, it can result in preventable permanent long-term complications, such as heart failure’[15]
These delays also present major implications for people living with chronic diseases, such as arthritis. The impact of delays in fairly common surgeries, such as hip and knee replaces, have a significant impact on an individual’s quality of life.[16] Versus Arthritis has pointed to growing evidence on the negative impact of delayed joint replacement surgery, noting that delays can reduce functional capacity gain and lead to increased pain and disability for patients who endure longer waits.[17]
These are only three broad examples highlighting how significant delays in surgical interventions affect patients’ quality of life and, in some cases, their survival. Charities have been at the forefront of assessing the implications for their beneficiaries, but more analysis is needed to ensure that the impact is known and quantified across the range of specialities.
How do we ensure a patient-safe restart of elective surgery?
As we move back towards ‘normal’ levels of care and elective surgery resumes, it is crucial that patient safety considerations are placed at the heart of the process. We will need to address the backlog of cases while also meeting the regular demand for services, with decisions based on clinical urgency and need.
Patient Safety Learning believe that a strategy is needed to tackle the demand on NHS services in a systemic way; a published strategy that will help to ensure that decisions regarding the priority of cases are made transparently and with patient safety at the forefront. We argue that such a strategy accounts for the following:
Good quality data
So that the NHS is able to effectively prioritise urgent versus non-urgent surgeries, ensuring the safety of those with the highest clinical need, it is vital that there are reliable and up-to-date data to draw on and to inform decision-making.
Targeting additional capacity
Charities, such as Macmillan Cancer Support, have been calling for ‘surge capacity’ to address the backlog of cases in cancer care.[18] However even with the full support of the NHS, our ability to tackle this backlog will be limited to what can be done within existing staff levels and hospital capacity. We believe it is vital that capacity is targeted where it is most needed, for instance in cases of aggressive cancers where short delays can have a significant impact on life expectancy.
Waiting list management
There needs to be clarity about how waiting lists will be managed and by whom. Questions will need to be addressed, such as who will triage patients, and on what basis? Who will ensure that changing patient needs are considered, and who will provide information to help manage patient expectations? The NHS will need to consider whether current approaches to waiting list management are sufficient or whether there is need to reform their approach.
Post-surgical care and rehabilitation
Delays in surgery may result in higher support needs for those in recovery, longer hospital stays and potentially higher mortality rates. This will need to be modelled, planned for, and prioritised, within services in hospital, the community and social care.
Safe staffing and support
It is vital that any strategy considers the workforce implications of tackling the backlog, ensuring there are enough staff to undertake surgery, and provide post-operative care and rehabilitation in hospital, the community and in social care. The number of staff and amount of support necessary may vary across different areas of the country; workforce modelling may be required to assess demand and match it to capacity.
Staff availability will be key to meeting the backlog, and it is vital that commissioners and trusts work together to ensure that there are sufficient staff and that they are well-supported. Front-line staff have been sharing stories on our online shared learning platform, the hub, expressing concerns about how the pandemic has affected their mental and physical health. Some staff are feeling ‘burnt out’, demoralised and exhausted. Prior to the pandemic, the health and social care system were already operating with significant workforce vacancies. Now, with some staff considering leaving the profession, the current troubling situation will be further exacerbated. Without sufficient and motivated staff, there is a risk that patient safety will be significantly compromised.
Maintaining safety standards
In a recent report, the NHS Confederation has argued in favour of extending ‘lighter-touch’ regulation by bodies such as the CQC.[19] We recognise the need for flexibility in a period of unprecedented pressure, but it is important that we avoid the trap of attempting to meet this challenge in the quickest, rather than the safest, way. If we are to ensure patient safety during this time, we must continue to regularly report safety incidents and implement learning from these.
Investigating patient safety incidents
Due to the backlog, some individuals will not receive surgery in a timely manner, with some delays potentially leading to harm or even death. Should cases where surgery delays lead to significant health issues or even death be considered serious incidents? If so, it is important that we are clear on the criteria to investigate. There also needs to be further thinking and guidance as to what could be considered negligence and what litigation options will be open to patients and their families.
Clear communication with patients
We believe that engaging with patients is crucial to achieving a patient-safe future. As we mentioned earlier, resolving this backlog is not a quick or easy issue, and difficult prioritisation issues will need to be made. We will need to have a clear and effective approach for communicating with patients about delays in their care. This concern has been echoed in recent publications by the British Medical Association and NHS Confederation.[20] [21]
Tackling the challenge with patient safety at the centre
Transitioning back to ‘normal’ non-elective surgeries following the postponement of surgeries due to the pandemic is a complex affair. The scale of the challenge is unprecedented; meeting it will require a collaborative effort across health and social care. As we tackle this challenge, patient safety must be at the centre of our thinking and action so that we keep patients safe from avoidable harm.
[1] NHS England and NHS Improvement, Important and Urgent – Next steps on NHS response to Covid-19, 17 March 2020. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/urgent-next-steps-on-nhs-response-to-covid-19-letter-simon-stevens.pdf
[2] CovidSurg Collaborative, Dmitri Nepogodieve and Aneel Bhangu, Elective surgery cancellations due to the COVID-19 pandemic: global modelling to inform surgical recovery plans, British Journal of Surgery, 12 May 2020. https://bjssjournals.onlinelibrary.wiley.com/doi/10.1002/bjs.11746
[3] University of Birmingham, COVID-19 disruption will lead to 28 million surgeries cancelled worldwide, 15 May 2020. https://www.birmingham.ac.uk/news/latest/2020/05/covid-disruption-28-million-surgeries-cancelled.aspx
[4] NHS England and NHS Improvement, Statistical Press Notice: NHS referral to treatment (RTT) waiting times data March 2020, 14 May 2020. https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2020/05/Mar20-RTT-SPN-publication-version.pdf
[5] NHS Confederation, Public reassurance needed on slow road to recovery for the NHS, 10 June 2020. https://www.nhsconfed.org/news/2020/06/road-to-recovery
[6] NHS Confederation, Getting the NHS back on track: Planning for the next phase of Covid-19, June 2020. https://www.nhsconfed.org/-/media/Confederation/Files/Publications/Documents/REPORT_NHS-Reset_Getting-NHS-back-on-track_FNL.pdf
[7] Ibid.
[8] The Health Foundation, Returning NHS waiting times to 18 weeks for routine treatment, 22 May 2020. https://www.health.org.uk/publications/long-reads/returning-nhs-waiting-times-to-18-weeks
[9] Ibid.
[10] Ibid.
[11] Amit Sud et al, Collateral damage: the impact on outcomes from cancer surgery of the COVID-19 pandemic, 19 May 2020. https://www.annalsofoncology.org/article/S0923-7534(20)39825-2/fulltext#%20
[12] Less Survivable Cancers Task Force, Written evidence submitted by the Less Survivable Cancers Taskforce (DEL0286), May 2020. https://committees.parliament.uk/writtenevidence/4835/pdf/
[13] British Heart Foundation, Heart disease most common pre-existing condition for coronavirus deaths, 17 April 2020. https://www.bhf.org.uk/what-we-do/news-from-the-bhf/news-archive/2020/april/heart-disease-most-common-pre-existing-condition-for-covid-19-deaths
[14] British Heart Foundation, Nearly half of heart patients find it harder to get medical treatment in lockdown, 5 June 2020. https://www.bhf.org.uk/what-we-do/news-from-the-bhf/news-archive/2020/june/half-heart-patients-harder-get-medical-treatment-lockdown
[15] Ibid.
[16] Royal College of Surgeons of England, Surgery and the NHS in numbers, Last Accessed 8 June 2020. https://www.rcseng.ac.uk/news-and-events/media-centre/media-background-briefings-and-statistics/surgery-and-the-nhs-in-numbers/
[17] Versus Arthritis, Written evidence submitted by Versus Arthritis (DEL0173), May 2020. https://committees.parliament.uk/writtenevidence/4453/pdf/
[18] The Guardian, Cancer undiagnosed ‘for nearly 2,000 people in UK every week’, 28 May 2020. https://www.theguardian.com/society/2020/may/28/cancer-undiagnosed-for-nearly-2000-people-in-uk-every-week
[19] NHS Confederation, Getting the NHS back on track: Planning for the next phase of Covid-19, June 2020. https://www.nhsconfed.org/-/media/Confederation/Files/Publications/Documents/REPORT_NHS-Reset_Getting-NHS-back-on-track_FNL.pdf
[20] British Medical Association, Written evidence submitted by the British Medical Association (DEL0205), May 2020. https://committees.parliament.uk/writtenevidence/4517/pdf/
[21] NHS Confederation, Getting the NHS back on track: Planning for the next phase of Covid-19, June 2020. https://www.nhsconfed.org/-/media/Confederation/Files/Publications/Documents/REPORT_NHS-Reset_Getting-NHS-back-on-track_FNL.pdf
