Elective care backlog: the struggle to catch up and stay COVID-free

Can the push to get surgery services back on track resist winter pressures and the second surge of coronavirus?

• Acute providers are juggling their staff and buildings to deliver COVID-free pathways for elective surgery
• Nurses in perioperative teams have transferable skills that make them ripe for redeployment as COVID-19 admissions rise
• Nurse staffing will be pivotal as planned services battle to recover from the wholesale disruption of the pandemic

COVID-19 has had a huge impact on surgical teams.

From the mass cancellation of operations in the spring, to the overhaul of services to create COVID-19-free units, surgery has undergone change like never before. But will measures designed to keep planned care going be enough this winter?

The knock-on effects on surgery of pressures in critical care

‘We are at a critical point,’ says RCN professional lead for acute, emergency and critical care Suman Shrestha.

‘So much work has gone into creating COVID-19-free sites, but with cases rising there is a lot of pressure on staff and intensive care, which unfortunately has a huge knock-on effect on surgery.

‘Nurses working in this field, such as anaesthetic and theatre nurses, have some of the most transferable skills that are needed for COVID-19 patients, which means they are at risk of being redeployed.

‘Yes, knee and hip replacements can wait in the way cancer treatment can’t, but it still has a huge effect on quality of life and you risk patients’ health worsening the longer they wait’

Suman Shrestha, RCN professional lead for acute, emergency and critical care

‘And as intensive care units fill up, that affects the ability of hospitals to keep all but the most urgent planned surgery going.

‘Children’s surgery and cancer is being prioritised, but in areas with high infection rates we are already seeing the cancellation of the least urgent work.’

Fears for elective care as COVID-19 admissions rise

Chancellor Rishi Sunak announced in the November spending review that the government will provide an additional £3 billion next year to support the NHS recovery from the impact of COVID-19. He said this would include £1 billion to begin tackling the elective backlog and funding to help enable hospitals to cut long waits for care by carrying out up to one million extra checks, scans and additional operations or other procedures.

And this funding can't come too soon.

During late October and November, hospitals in Liverpool, Birmingham, Nottingham, Bradford and Leeds all announced some non-urgent operations would be delayed, as the number of patients in hospital with COVID-19 increased. And such cancellations are not confined to England.

At the start of September there were just over 800 COVID-19 patients in UK hospitals, but by mid-November that had increased to 15,000 – about 5,000 short of the peak seen in the first wave.

Mr Shrestha, a board member of the Centre for Perioperative Care, says: ‘The rise is really worrying – and the concern is the impact on planned care will just get worse. This will be detrimental to people’s lives.

‘Yes, knee and hip replacements can wait in the way cancer treatment can’t, but it still has a huge affect on the quality of life of patients and you risk their health worsening the longer they wait.’

Increasing numbers of patients facing long waits for operations

In the spring of 2020, elective work was cancelled wholesale. In England, the number of operations carried out plummeted to 15% of normal levels in April.

Since then, activity has increased, but is still not back to normal.

The latest figures from NHS England and NHS Improvement, covering the month of September, showed the number of people undergoing surgery was less than three quarters of the figure for the same month in 2019.

‘Despite the huge amount of work to address the waiting lists for children and young people, elective procedures are still unlikely to return to pre-COVID-19 levels by the end of the financial year’

Sally Shearer, chair of the Association of Chief Children’s Nurses

The slowdown has resulted in growing numbers of people facing long waits. Of the 4.35 million people on a waiting list in England, 1.7 million have waited beyond the target time of 18 weeks and almost 140,000 have waited for more than a year; before the pandemic, that figure was just over 1,600 people.

There are also many thousands of others who have not made it on to a waiting list.

Backlog in treatments and care is accentuating health inequalities

An analysis by the Health Foundation found referrals in England for routine care fell by a third between January and August, equating to 4.7 million people in a ‘hidden backlog’. Orthopaedics and ophthalmology were the worst-affected specialties.

The Institute for Fiscal Studies (IFS) says older people, particularly from the most deprived areas, are the most affected.

A survey it carried out found that between March and May, one in six people over the age of 50 in England had hospital operations and other treatment cancelled.

Acute providers prioritising children’s operations

But Association of Chief Children’s Nurses chair Sally Shearer says children have been affected too.

Research by the Royal College of Paediatrics and Child Health found 50,000 operations for children were cancelled during March and May.

Professor Shearer says they have been prioritised since, with hospitals ‘working hard’ to tackle the backlog. But she says she expects the winter period to be difficult.

‘Despite the huge amount of work being undertaken to address the waiting lists for children and young people, elective procedures are still unlikely to return to pre-COVID-19 levels by the end of the financial year. The challenges related to surgical waiting times are therefore not just confined to adult care.’

Cancer services returning to pre-pandemic levels of activity

The situation is more promising for cancer surgery. Figures for September showed the numbers in England starting treatment that month – chemotherapy and radiotherapy as well as surgery – were back to pre-pandemic levels.

Nevertheless, since the pandemic began, 35,000 fewer people have started treatment for cancer than would have been expected during this period.

RCN cancer and breast care forum chair Nikki Morris says a major factor in this has been a drop in people coming forward with symptoms or via screening, which all but stopped in the first wave. ‘The fear of COVID-19 has been a big deterrent.’

She says the return to pre-pandemic levels of activity is ‘really pleasing’, but, like Mr Shrestha, she is concerned the pressure on intensive care beds could have an impact on planned surgery.

‘We need to think creatively about this. There are areas using enhanced monitoring facilities – a kind of step down from intensive care. It is not always an option for all patients who come out of surgery, but for some it is.’

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Enhanced perioperative care that does not use critical care resources

Enhanced monitoring is an approach being championed by the Centre for Perioperative Care.

Along with the Faculty of Intensive Care Medicine, it has produced guidance calling for the increased use of enhanced perioperative care units.

These are alternatives for patients who require enhanced monitoring after major surgery, but do not need ventilation or complex cardiovascular support that requires a critical care admission.

‘Availability of staff is the key. We are beginning to see perioperative nurses being redeployed into intensive care and onto general wards. They don’t always feel prepared. They are worried’

Lindsay Keeley, Association for Perioperative Practice

The guidance cites the examples of facilities set up in York and Cardiff where post-surgery recovery nurses hand patients over to multidisciplinary teams with higher nurse-to-patient ratios than would be found on a standard ward.

NHS England national clinical director for critical and perioperative care Ramani Moonesinghe says: ‘In most hospitals, the only environment in which this type of care is available is the critical care unit.

‘However, the majority of postoperative patients, including those at increased risk of adverse outcomes, do not require specific critical care interventions.’

She believes setting up more of these services could avoid the last-minute cancellations of planned surgery that are increasingly likely with the ‘magnified pressure’ on critical care because of COVID-19.

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COVID-free surgical pathways

But maintaining planned surgery schedules is also going to require the continued availability of COVID-19-free surgical pathways that deliver surgery, critical care, and inpatient ward care with no areas shared with patients who have COVID-19.

Hospitals have done this in a variety of ways. At some sites, hospitals have established COVID-19-free wings with separate access from the main hospital site. In other places where there is a group of hospitals in close proximity, whole sites are designated as COVID-19-free.

The independent sector has played an important role, with NHS teams sent to private hospitals to run planned surgery lists.

But a survey by the Royal College of Surgeons in September found more than one in five of its members were unable to access COVID-19-free pathways, with particular problems reported in Wales, Northern Ireland and north east England.

In some cases, hospitals have established COVID-19-free areas that have had to be relinquished as COVID-19 cases increased. In others, it has simply not been possible to achieve full separation because of the design of hospital buildings and sites.

Staff availability is key to keeping services COVID-19-free

Lindsay Keeley, from the Association for Perioperative Practice, which represents surgical staff including nurses, healthcare assistants and theatre managers, says staff have worked hard to establish COVID-19-free care pathways for surgery.

But Ms Keeley, who works as a surgical first assistant and is a registered nurse, adds: ‘It is difficult. Quite often it reduces the amount of patients you can operate on – although hospitals and staff have done an amazing job to get to where they have. Being able to use the private sector has made a big difference.

‘But we are beginning to see hospitals struggle to maintain this in some parts of the country.

‘Adult electives are really being affected, particularly in specialties such as orthopaedics and ophthalmology.

‘The availability of staff is the key. Staff are having to isolate or are sick themselves with COVID-19 and we are beginning to see perioperative nurses being redeployed into intensive care and on to general wards in parts of northern England and other areas where we have seen the highest rates.

‘They don’t always feel prepared. They are worried. Those working in post-surgery recovery roles are less likely to be redeployed than those in the theatres, as hospitals can use healthcare assistants and operating department practitioners to do some of their work. But the more this happens, the more difficult it will be to keep planned surgery going.

‘It is, unfortunately, going to be a very difficult winter for patients and staff alike.’

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Further information

• Enhanced Perioperative Care Services guidance
• Institute of Fiscal Studies report
• Health Foundation report
• NHS England: NHS diagnostic waiting times and activity data

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Nick Evans is a health journalist