Looking ahead: the post pandemic future of surgery

Covid-19 has had an immeasurably profound effect on our healthcare system in the UK. While it may be true that we are now past the peak, and hospitalisations as a result of the virus are slowly, but steadily, decreasing, the NHS has a long way to go before returning to normality. 

In fact, it could be said that the health system will never return to “normal” as it was pre-coronavirus. As healthcare professionals, we have had to learn and adapt so much throughout the course of the pandemic, that it seems clear to me that the system is undergoing changes which will last for many years to come.  

As surgeons, we’ve had to drastically change our ways of working. With swathes of elective procedures postponed, our efforts shifted to focus on the frontline, dealing with covid patients and emergency operations only in many cases.  

However, now that we are facing the biggest backlog of operations in a generation, it’s time to focus our attention on how we move forward and begin to tackle this, and how learning from this crisis might shape how our caring system works long into the future.

A key long-term effect of coronavirus will be the public’s confidence and comfort level in coming into hospital, and that’s something we can boost in the short term through rigorous testing of all staff, patients, and visitors.

At the moment, nosocomial infections are still a problem. There have been suggestions that NHS workers will be tested every two weeks, but I believe that daily or at least twice weekly testing is needed to establish and maintain the “covid-free” environments we need to safely carry out operations. Scrupulous testing is also required for patients ahead of their surgery to ensure both they and the surgical team are not carrying the virus. My concern is that resource is dictating policy rather than science dictating the strategy.  

Testing at present needs to be done with a targeted and strategic approach aimed at creating “covid-lite” areas within hospitals or in other designated healthcare establishments.  We need a clear and transparent strategy on how the swab and antibody tests can be harnessed in tandem, to ensure hospitals can become and remain as covid-lite as possible. 

As we move beyond the immediate short term, I believe taking a regional approach is key to getting elective work back on track. 

Hospitals across the country will have different infrastructures, and factors such as regional prevalence of coronavirus and the availability of covid-lite sites must be taken into consideration as surgical work begins to resume in earnest. Rigorous plans must be put in place to react to any regional spikes in infection, so that clinicians and patients know how to respond when such outbreaks occur.    

I agree that the overarching strategy must be agreed at a national level, and the guidance document from NHS England which sets out the prioritisation of surgical categories is extremely valuable and a positive step forward.  

However, while the principles must remain the same across the board, when it comes to the implementation and timing of carrying out elective surgery, the decisions must be made at a regional level, allowing individual health boards and trusts to decide what is most appropriate for them and their patients.  

Where we carry out surgical procedures in the coming months, or even years, is another crucial part of the strategy. I’ve already touched on covid-free environments, and while many of these are now up and running across the country, we still need to increase the capacity of suitable locations in order to tackle the backlog.  How we can keep these sites infection free is absolutely key, especially as the winter pressures hit, when multiple patients will present with respiratory symptoms, and will be treated as suspected covid cases, until proven otherwise.

One solution could be the use of the independent sector as well as Nightingale Hospitals, either to care for patients not requiring surgery in order to increase capacity in existing hospitals, or to themselves be set up to carry out operations.  There are, however, some concerns around this, particularly when it comes to quality of care, and the availability of support, perioperative staff, and suitable facilities and training, as well as the stretching of an already thin workforce. We must not forget our surgical trainees in the recovery plan. The majority have been redeployed and had their training and career progression disrupted. They need to be part of the surgical recovery plan, whether it be in NHS hospitals, or commissioned private institutions.

The NHS also needs to negotiate further with the private sector to allow us to utilise their facilities where possible, with appropriate safeguards in order to address our concerns. We need to think about using private facilities for the next year at least in order to increase the numbers of procedures taking place, in ways that do not undermine the main NHS response.  

We also have to think about the healthcare professionals who have been working so incredibly hard over the last few months at the frontline of this pandemic—this is something that is going to be important far into the future. Many are now absolutely exhausted, and the recovery plan is going to be very labour intensive. We need to think of innovative ways to increase capacity, while looking after the wellbeing of healthcare workers in the wake of such a taxing period of time.  

It’s reasonable to suggest that surgeons will be carrying out just 40% of the number of procedures each week as would have been performed pre-coronavirus. This is due to the additional time required between patients to allow aerosol emissions to settle in theatres and rigorous cleaning procedures that will follow, as well as extra time needed for surgical teams to don and remove PPE safely.  

In the mid to long term, and potentially permanently, working patterns for surgeons may have to change considerably. We may take a lead from the European model, where surgeons usually spend between three and four days a week operating, as opposed to the one and a half days a week that is the norm in the UK. Spending more time in the operating theatre rather than in clinics or doing administrative work would allow surgeons to maximise their skills and more effectively deal with the backlog.  

By carrying out more elective surgery, we will be able to improve the lives of so many who have been suffering with serious, although not necessarily “urgent” conditions, throughout the last few months. We can help those who have been living with debilitating conditions get back to work. It’s vital that surgeons are able to resume this kind of work as efficiently as possible, and adjusting working practices may be the key to achieving this.  

It’s going to be a long and complicated process, but with the right approach, I am confident we can get the system back on track and create positive changes for both surgeons and patients which will last long into the future.   

Michael Griffin, President of the Royal College of Surgeons of Edinburgh

Competing interests: None declared