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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) Cite this as: BMJ 2020;369:m2238

Linked Editorial

Covid-19 related hospital admissions in the United States

Rapid Response:

The show is not over; we are just at the end of Act 1

Dear Editors

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."

References

1. https://www.bmj.com/content/369/bmj.m2422

2. https://www.recoverytrial.net/files/recovery_dexamethasone_statement_160...

3. https://www.mja.com.au/system/files/issues/212_09/mja250577.pdf

4. https://www.bmj.com/content/369/bmj.m2238

5. https://www.theguardian.com/world/2020/jun/16/beijing-coronavirus-outbre...

6. https://www.bmj.com/content/369/bmj.m1665

7. https://www.bmj.com/content/369/bmj.m2188

8. https://www.bmj.com/content/369/bmj.m1718

9. https://www.bmj.com/content/369/bmj.m2195

10. https://www.bmj.com/content/369/bmj.m2282

Competing interests: No competing interests

17 June 2020
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia