The covid-19 pandemic has caused the largest ever waiting list for NHS treatment with 4.95 million people waiting—430,000 of those for over a year. [1] The Royal College of Surgeons of England are calling for action with their new 12 point plan, a “new deal” for surgery to support the recovery of elective surgical services. The Royal College of Surgeons have requested £1 billion per year to enable trusts to set up “clean” elective surgery hubs using existing hospitals where there would be no interruptions to elective surgical services from further pandemic surges or winter bed pressures. While the plan is welcome some may feel sceptical about how it will be actualised until there is a hard commitment to the changes required to carry it through.
The pandemic has demonstrated the greatest resource of the NHS is it’s staff. However, many of those redeployed to intensive care during the surge were theatre staff who have felt the pressure, with physical and mental health problems now coming to the fore. Staff are exhausted and pushing them to their limits to increase elective surgical capacity is not sustainable. While increasing numbers of staff seems more logical, trained staff cannot be magicked up overnight. Analysing anaesthetic and surgical higher speciality training numbers reveals decreasing numbers of funded training places despite consultant workforce census in these specialities showing large numbers of funded, but unfilled consultant posts that existed even pre-covid. [2] High quality trainees exist. An estimate from the Royal College of Anaesthetists showed nearly 700 core trainee anaesthetists were unable to secure higher speciality jobs in the last recruitment round, but the funding for training numbers isn’t available. [3] The report calls for workforce expansion, but this is not enough without a concrete plan to deliver it. If we are to have the workforce to continue to address this backlog in six years time, we need surgical, anaesthetic, operating department practitioners and nursing training numbers to be expanded, and we need it now.
More detail is required about how these hubs will work. Many trusts who have multiple hospitals have tried having a “clean” site for elective operating. While this works to reduce the risk of contracting infection during the trough of the pandemic, it does not eliminate the main risk to elective operating that exists in the peak: bed pressure. It is difficult to justify ear-marking beds for relatively well post-operative elective patients if there are unwell patients as a result of a pandemic or winter pressures. While the plan aims to reduce the use of the independent sector the difference between this and the planned NHS surgical hubs is that the former provides beds and staffing for solely post-operative patients so the option to move unwell patients from other specialities into these beds simply doesn’t exist.
Limited procedures in relatively fit patients could take place in surgical hubs, but major surgery such as cancer operations often requires PACU/HDU/ICU capacity at a surgical hub site and this may be challenging in terms of both physical space and more importantly, staffing. One of the biggest challenges of the pandemic was staffing the ICUs that already existed. And that was without creating more beds run by exhausted staff who are now burnt out or signed off work. The incidence of mental health problems in ICU staff is particularly high. [4]
The model that we have had for elective surgery in the UK pre-covid has long since needed modernising and the pandemic has presented us with an opportunity to address this. The waiting list that has existed since pre-covid has been compounded, not by a few months of interrupted operating as we see each year from winter pressures, but by a sustained interruption of 16 months of a pandemic. The problem with the system, like many that run within the NHS, is the reliance on running at 100% capacity. Resilience and flexibility need to be built into any plan going forward. If the pandemic has taught us anything it is that the NHS needs more breathing room—both in bed and staff numbers. Running any system at capacity over long periods of time is unsustainable and we need to move our focus away from maximising efficiency which comes at a cost to sustainably providing care for patients.
Becoming more comfortable with a short-term loss of efficiency is important when we consider training, which inevitably reduces efficiency in the short term, but enables provision of care to be sustainable in the long term. Overbooking lists and utilizing experienced staff to get through the backlog as quickly as possibly might get through the highest number of patient operations in the next year, but this is short-sighted—we need competent surgeons, anaesthetists, and theatre staff in the years to come. A loss of efficiency now will translate to sustainable working in the future.
Most importantly we must not lose sight of what 5 million people on a waiting list really means. The psychological impact on those patients of having chronic pain and the inability to work or carry out daily activities to a normal level cannot be underestimated. This is impossible for most surgeons and anaesthetists to forget. Instead of twiddling their thumbs waiting for elective surgery to restart, they are continuing their clinics and seeing increased demand in emergency care from patients the elective waiting lists have not got to in time. Being forced to cancel patients because of a lack of intensive care beds, the loss of purpose and job satisfaction, compounded by the guilt that they cannot help the very people they committed to heal, causes moral injury. A plan to tackle this waiting list is welcomed, but a guarantee to provide training for a workforce to enact this plan in a sustainable way is the essential next step. Surgeons and patients will be looking to the government to see the financial commitment that will allow the plan to be carried out and the detail on how this can occur.
Roopa McCrossan, chair of the Association of Anaesthetists Trainee Committee, locum consultant anaesthetist, Freeman Hospital, Newcastle-upon-tyne.
Clara Munro, editorial registrar The BMJ, Higher Speciality Trainee in General Surgery.
Competing interests: none declared.
References:
1.NHS England. Consultant-led referral to treatment waiting times. https://www.england.nhs.uk/statistics/ statistical-work-areas/rtt-waiting-times/ (accessed May 2021).
2.Royal College of Anaesthetists Medical workforce census report. https://www.rcoa.ac.uk/sites/default/files/documents/2020-11/Medical-Workforce-Census-Report-2020.pdf
3.Royal College of Anaesthetists, Anaesthesia National Recruitment 2021 applicants CT1 and ST3 https://www.rcoa.ac.uk/news/anaesthesia-national-recruitment-2021-applicants-ct1-st3
4.Greenberg N, Weston D, Hall C, Caulfield T, Williamson V,Fong K. Mental health of staff working in intensive care during Covid-19. Occupational medicine 2021, 71(2):62-67.