BMA urges plan to tackle backlog of patients awaiting non-covid treatmentBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2238 (Published 04 June 2020) Cite this as: BMJ 2020;369:m2238
All rapid responses
As various media outlets throughout herald their next "cinderella" miracle drug, the cheap and humble dexamethasone (ref 1), based on a press release from researchers from UK's very own RECOVERY trial (ref 2), many of us await further details of this claimed success as corticosteroid therapy has not been shown to improve clinical outcomes in patients during previous coronaviral outbreaks (including SARS and MERS) and observational COVID-19 studies using methylprednisolone had changed that view either (ref 3).
Similarly BMA's call for "a plan to reduce the huge backlog of patients waiting for NHS treatments unrelated to covid-19 in the wake of the pandemic" (ref 4) should be treated with caution.
The BMA suggested various issues for consideration by the government to tackle this backlog, including "provision of up-to-date data on waiting lists, the prevalence of certain conditions, and health inequalities", while allocating NHS "resources it needs to tackle the backlog, as well as the capacity to meet demand in the long term", and “retain, support, and protect the valuable staff who have given their all in fighting the pandemic, prioritising their wellbeing and mental health” (ref 4).
Fellow readers suggested there may be reluctance and hesitation by patients to attend hospitals for their care due to concerns of contracting COVID-19 from healthcare activities.
I am concerned that some may miss the purpose of curtailment of many (but not all) healthcare activities in NHS trusts. While it is partly to reduce COVID-19 transmission by contact and human traffic, it is mainly to prepare and enhance resources currently available to the NHS to respond the COVID-19 healthcare crisis including PPE stockpiling, ventilator deployment and training, as well as accommodation and monitoring of COVID-19 patients. These goals necessarily require cessation of other healthcare activities that are not life or limb threatening within a short period in order to access equipment, staff and up-skilling training.
And all this is just 3 months ago.
As I type, another 233 deaths in UK are attributed to the COVID-19 pandemic (June 16) and while it appeared we have passed the peak mortality rates from COVID-19 in UK, it is by no means gone from the British Isles and certainly not from the European continent. Despite proposed quarantine for incoming visitors and other activities measures for local residents, events occurring in China (ref 5) right now show that even with restrictions (far stricter than those proposed for UK) in place for the last 2 months, no country can be certain to prevent the return of the pandemic in successive waves and where/how it can occur.
While the UK has managed to formulate policies and guidelines relatively quickly despite the late (and abrupt) about-turn in government strategy in dealing with the pandemic, there are few apparent review and formal inquiries on the roll-out and effect of many policy decisions made on the fly by the NHS hierachy and SAGE advisories.
Another outstanding (and outrageous) issue involving the NHS COVID-19 response is the PPE guidance (ref 6) which is obviously ongoing (ref 7). The legal obligations of the NHS as employer of healthcare workers (ref 8) is still being debated, but potential use of in extremis excuse by the force majeure clause should not be allowed to go unchallenged, especially when the expected PPE available to frontline workers including many junior staff, is obviously inadequate to the public, much less the healthcare professionals themselves.
Some readers seemed to defend the NHS response saying that the UK government cannot be expected to keep a stockpile for a "novel situation" and that it is the "NHS procurers who need to do their job properly". Whatever the reasons for the initial shortage were (and China somehow managed to secure adequate PPE for their staff showing that when adequately kitted there is no transmission to healthcare professionals according their studies from Jan to April 2020 at the height of their own pandemic crisis - ref 9), we must make sure we cannot accept a repeat PPE shortage again.
And while the NHS did not end up using the full extent of the temporary facilities and capacity for COVID-19 patients, the distrust and mental distress caused by the PPE debacle certainly form a dangerous breach in the foundation of the NHS staff resilience which had put up with years of cost-cutting, target setting and spin doctoring.
The lack of acknowledgement of the risks and issues in ethnic minorities (ref 10) including NHS staff of BAME origin is splitting the service for show in inequities in both the carers and the cared.
The pandemic is not over; many people are still dying in excess from the effects of COVID-19. Much as I admire the advocacy role of BMA on behalf of the patients and the greater public to bring back some normalcy in the NHS healthcare activities, the nightmare of this pandemic is still not over, and many opinions and feedback not properly canvassed, much less reviewed. There is still probably little (if any) confidence amongst healthcare staff in NHS dealing with PPE availability and the NHS management looking after their back. If we do not spend enough effort mending the cracks now, the entire NHS may split wide open with the next wave.
For the COVID-19, to quote Winston Churchill: "now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning."
Competing interests: No competing interests
People are scared. Some fear a prolonged period of restriction and isolation. Others fear premature or aggressive easing of the restrictions. Clinicians fear a second wave of infections, a lack of PPE, changes to their working lives, and as Elisabeth Mahase discusses, (BMJ 2020;369:m2238) a return of “normal” NHS workload with an accompanying backlog of non-Covid-19 treatments.
It is recognised that during the Covid-19 surge, rates of attendance at health care providers decreased dramatically, with 25% less attendances in Emergency Departments witnessed in the early stages of lockdown (BMJ 2020;369:m1401). This presumably is the combined effect of an effective public health campaign – Stay at home – Protect the NHS – Save Lives, the restrictive lockdown, and an element of fear about leaving the house for anything other than life or death essentials.
As we consider a return to a new normal of NHS activity (BMJ 2020;369:m1793) and perhaps vaguely familiar working patterns, the backlog of the non-Covid-19 workload looms large. This presents a huge challenge to an NHS which is already under-resourced and stretched to its limit. The NHS will have to shoulder this burden. Patients will be invited for clinic appointments, investigations, surgical attendances, medication reviews, follow-up, and therapy. It remains to be seen how the pandemic has affected patient’s willingness to attend for health care and what the public perception of the risks involved are.
Many patients remain fearful of contracting Covid-19 and this significantly influences their willingness to attend hospital. We have contacted 250 of the longest waiting from our elective orthopaedic surgery waiting list. All were considered high priority due to severe symptoms. All had previously agreed to surgery at a consent appointment prior to the Covid-19 pandemic. However, in the Covid-19 world, we observed a considerable reduction in the willingness to proceed with planned orthopaedic surgery (Kinghorn et al. Submitted BMJOpen).
Interestingly, whilst there were some correlations with risk profile, many patients considered low risk for complications or death following Covid-19 infection, expressed an unwillingness to attend for surgery. Fear of contracting Covid-19 was the most cited reason. The pre-operative pathway, involving two weeks of self-isolation also presented a barrier to many patients, particularly with the imminent relaxation of lockdown and the prospect of returning to work.
The fear of Covid-19 is now presenting an additional challenge for clinicians, one requiring urgent and widespread discussion. How will our risk-benefit discussions around shared decision-making change in the post-Covid-19 era? Most surgeons can readily state their personal rate of the common complications associated with their specialty, allowing patients to judge the risk benefit ratio to themselves of the proposed procedure. In this current state of widespread uncertainty, it is not yet possible to counsel patients about the risks associated with a simple hospital out-patient visit, let alone a prolonged post-operative course following surgery.
The undercurrent of fear of contracting or transmitting a virus, that we continue to know little about, cannot be underestimated, even as the number of newly infected individuals continues to wane. For many, it seems that living with their pain or coping with their functional losses is preferable to taking these uncertain risks. People are scared.
1 – Elisabeth Mahase. BMA urges plan to tackle backlog of patients awaiting non-covid treatment. BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2238 (Published 04 June 2020)
2 – Gareth Iacobucci. Covid-19: NHS outlines services to be prioritised to restart in next six weeks. BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1793 (Published 01 May 2020)
3 – AF Kinghorn, ST Mercer, T Yasin, A John, RW Trickett. Is it safe yet? Surveying patient readiness and perceptions about returning to hospital for planned orthopaedic care. Submitted awaiting review BMJOpen.
Competing interests: No competing interests