Derek Alderson: To operate now or later—that is the surgical question

To support medical teams determine what is truly urgent, and what is not, I have spent the last ten days working with colleagues across the country to produce new guidance

Our aim was to cover the widest array of conditions, to arrive at a shared view across the surgical royal colleges and surgical specialties: on which surgery could and should be postponed during the covid crisis and which operations should go ahead.

Our framework divides surgical procedures into five categories:

  • Priority level 1a Emergency – operation needed within 24 hours to save life
  • Priority level 1b Urgent – operation needed with 72 hours 
  • Priority level 2 – surgery can be safely deferred for up to 4 weeks
  • Priority level 3 – surgery that can be delayed for up to 3 months with no predicted negative outcome
  • Priority level 4 – surgery that can be delayed for more than 3 months with no predicted negative outcome

A common worry among medical royal colleges, is that, while the NHS is rightly now focused on increasing ITU capacity, infection control, and the multi-pronged strategies needed to defeat covid, the unintended harm caused by cancelled or delayed treatment will be huge.

Weighing this up is not easy. The surgical team must balance the risks of deferring surgery against the risk of complications and death, should the patient become infected with coronavirus in the post-operative period.

Indirect harm takes many forms; from chemotherapy that is never embarked upon, to major heart operations now deemed too risky for patients, in the absence of an intensive care bed.

Any delay in treatment, especially of cancers, trauma, and life threatening conditions, may lead to serious adverse outcomes and even death.

In surgery, assessing risk is complicated further by a dearth of research on the likely success or otherwise of operations undertaken on covid positive patients. Early evidence from other countries indicates that outcomes are far worse in this group, but more research is needed.

A balance must be struck between postponing treatment that is too risky in the current environment, and continuing to save the lives of patients with urgent health needs, unrelated to covid-19. The guidance is designed to support NHS leaders to plan the re-allocation of surgical resources. 

By covering all specialties, the hope is that surgeons and surgical teams will gain understanding of the bigger picture beyond their own specialty, and support the reallocation of resource to those patients in the greatest need. This “one team” approach has been key to ensuring hospitals have not (so far) been overwhelmed by covid-19.  

We have been encouraging surgeons to work differently, in new roles, to postpone their elective lists and take on a range of different tasks suited to their early training as doctors. Many are being re-trained to support patients on ventilators, others are returning from retirement to support the national effort. Once we have beaten this virus, it’s essential this ‘one team’ approach continues.

Patients who have waited patiently for operations must not be forgotten. Their condition may not be life-threatening, but treatment can be vital to improving quality of life, mobility, mental health and ability to work.  

We will all need to continue working as ‘one team’ when this is over, just as we will need sustained investment in the NHS, to deal with the inevitable resulting backlog.

Derek Alderson, President, Royal College of Surgeons of England

Competing interests: None declared