Covid-19: Waiting times in England reach record highsBMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3557 (Published 11 September 2020) Cite this as: BMJ 2020;370:m3557
All rapid responses
We really enjoyed reading your paper and found it very interesting. We have had some thoughts regarding the reasons behind increased surgical and medical waiting lists and have shared them below:
Covid-19 has had a significant impact on the National Health Service (NHS). Various specialities have been impacted differently. For example, the Royal College of Ophthalmologists  has suggested cancellations of elective surgeries and face-to-face consultations, whereas guidance from NHS England states that cancer treatments should continue as normal where feasible . Therefore, in certain departments there will be an increase in waiting times, while others will remain largely unaffected.
There are a number of hospital factors that will increase waiting times. Alongside advice from regulatory bodies, reductions in surgical schedules and clinic capacity due to social distancing and increased preparation time between patients will cause a backlog. This is particularly true in theatres in which anaesthetic aerosol generating procedures are taking place  and within hospitals with multiple Covid wards. Emergency procedures and treatments will take up a larger proportion of hospital resources due to the reduced capacity. Finally, there may be reduced staff numbers due to self-isolation and positive Covid-19 test results.
Similarly to staff, patients may have positive Covid-19 test results or self-isolation requirements which prevent them from attending hospital. This will contribute to the backlog of patients who require medical attention. Fear of Covid-19 in the community may result in an unpredictable pattern of patient behaviour and lead to an increased number of ‘did not attends’ (DNAs). Another important patient factor is lack of transport; reduced transport services will add to increased DNA rates. These factors, compounded by reduced hospital capacity, will contribute significantly to the increase in waiting times.
The NHS states that the maximum waiting time for treatment after referral should be 18 weeks . There is a zero-tolerance policy for waits longer than 52 weeks . Prior to Covid-19, financial incentives were put in place to encourage trusts to maintain a referral time of less than 52 weeks; however, when these are reinstated, a backlog of patients will place strain on the NHS. As we move out of the Covid-19 pandemic, sufficient protocols will need to be executed to increase hospital capacity. These could include weekend lists and clinics, using additional trust sites for clinics and theatres, and financial investments in staff and facilities. Furthermore, increased time from referral to treatment will result in delayed presentation, late-stage disease and poorer outcomes. Protocols will also need to consider medical interventions and surgical risk stratification. The Covid-19 pandemic has had a global effect . Therefore, measures put in place to address increased waiting times may be applicable to other countries.
1) Burdon M. The Royal College of Ophthalmologists. Protecting Patients, Protecting Staff. https://www.rcophth.ac.uk/wp-content/uploads/2020/03/Protecting-Patients... (accessed 26 July 2020).
2) NHS. Advice on maintaining cancer treatment during the COVID-19 response. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/... (accessed 25 September 2020).
3) Odor PM, Neun M, Bampoe S, et al. Anaesthesia and COVID-19: infection control. BJA 2020;125(1):16-24 doi: 10.1016/j.bja.2020.03.025 [published Online First: 8th April 2020].
4) NHS. Referral to treatment. https://www.england.nhs.uk/rtt/ (accessed 28 July 2020).
5) NHS. Referral to treatment (RTT) waiting times statistics for consultant-led elective care. https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2013/04... (accessed 28 July 2020).
6) Nair AG, Gandhi RA, Natarajan S. Effect of COVID-19 related lockdown on ophthalmic practice and patient care in India: Results of a survey. Indian J Ophthalmol 2020;68(5):725 doi: 10.4103/ijo.IJO_1067_20 [published Online First: 25th May 2020].
Competing interests: No competing interests