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How is the pandemic affecting non-covid services?

BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n215 (Published 22 January 2021) Cite this as: BMJ 2021;372:n215

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  1. Gareth Iacobucci
  1. The BMJ

As NHS hospitals struggle to find enough beds for patients with covid-19, Gareth Iacobucci examines the strain this is placing on other services

“One of the operating suites that normally does routine surgery has been converted into a 12 bed intensive care unit. We’re doing very little routine work, and we’re struggling to try to get some of the cancer work done. On a day to day basis, we very rarely get intensive care beds at the moment.”

Like many doctors, consultant anaesthetist Helgi Johannsson was moved from working in planned surgery to the intensive care unit because of the high volume of covid admissions. And he expects to remain there for several months.

“Although [covid cases are] flattening off a little bit, it certainly hasn’t reached the stage where we’re emptying intensive care beds,” he told The BMJ.

Postponement of cancer surgery

The picture Johannsson paints will be familiar to most hospital doctors in the UK. Earlier this month it was reported that one London trust was so overstretched that it had to postpone all “priority 2” surgery, such as cancers and urgent cardiac surgery, which are deemed medically necessary to be done within 28 days.1

Fiona Donald, vice president of the Royal College of Anaesthetists, told The BMJ, “London appears to be having the biggest pressure at the moment. Some of the priority 2 surgery is having to be cancelled. In other areas, that’s definitely not the case.”

But there is evident nervousness. After cancellations of cancer surgery in London and in the East of England, NHS England reportedly wrote to all regional health bosses earlier this month instructing them to ensure that urgent cancer care was given the same priority as covid-19, the Health Service Journal reported.2

Restrictions on planned care

With covid-19 rife across the country, Donald said all trusts were being restricted in their ability to provide planned care.

“It’s partly because there’s staff sickness—so that restricts the number of people that we’ve got in operating theatres. It’s partly because intensive care units are filling up with covid patients, and it’s also being able to find space within the hospital, because once you have a ward with covid patients, you can’t put your planned care patients on that same ward,” she said.

Last April the NHS stopped doing most planned surgery for several months to help it deal with the covid-19 pandemic.3

In the second wave of the pandemic, Johannsson, who is council member at the Royal College of Anaesthetists, said huge efforts were made to avoid this. “We’ve got this enormous mountain to climb to get back on top of the elective waiting list,” he said. “We are trying to get through as many of the routine operations as we can, because we know we cannot afford to shut everything down. It’s actually been harder work [than in the first wave] from that angle.”

And as Neil Mortensen, president of the Royal College of Surgeons of England, highlights, this has created a catch 22 situation. “This time around, everybody tried very hard to keep everything going. But that meant the hospitals were all rammed and they didn’t have enough space for the incoming tide of covid patients.”

Daily prioritisation meetings

Some hospitals have been able to keep more services running by separating patients without covid, those with suspected covid, and those with definite covid.

But Mortensen said that the sheer number of patients in intensive care units has meant that almost every trust has had to prioritise care because of the limited number of beds.

He said that most trusts were still doing priority 2 procedures but that they have stopped all priority 4 cases (elective treatments that can be deferred for longer than three months) and most priority 3 cases (electives that need to be done within three months) for the time being.

Local clinical networks were meeting every day to assess capacity and identify critical care beds available, he added.

“If there is a bed, then they carefully weigh the demands of all the cases on the book and say, ‘This one gets the green light and must go,’” Mortensen said.

“It’s really tough, because it is like the judgment of Solomon sometimes, trying to decide between one and another. But on the whole, [staff] have been very grown up about it and have been working on getting those patients done.”

In the short term, he said, some hospitals were being forced to adapt treatment schedules for some cancer patients while they await a bed for surgery. For example, he said oesophageal cancer now has a treatment schedule that includes upfront chemoradiotherapy before the operation.

Use of the private sector

Last April the NHS took the unprecedented step of block booking most private hospital capacity in England so that cancelled or postponed NHS treatment could continue.3 This gave the NHS breathing space, but the Treasury subsequently raised concerns that it did not deliver value for money because capacity went unused in some areas.

This time there is no national deal, although NHS trusts in some areas—London, Nottingham, and Oxford, for example—have continued to seek help from the private sector for services such as cancer treatment, Mortensen said.

He acknowledged that the private sector had been a “safety valve for cancer” during the pandemic but said that in the longer term the government needed to make a sustained investment in NHS capacity to deal with the huge backlog in elective care, with 4.5 million people currently on the waiting list.

“We have to have a plan for it,” he said. “Business as usual is not going to be enough.”

How the pandemic has affected care

  • Elective care—At the end of November 2020 a total of 192 169 patients had been waiting more than 52 weeks for planned surgery, whereas in the same month in 2019 the number was just 1398. Around 4.46 million patients are now waiting for NHS treatment to start.4

  • Emergency care—In December 2020, 3745 patients waited 12 hours or more before being admitted to emergency departments, the highest number on record and an increase of 60% on December 2019.5

  • Cancer—Between April and October 2020 around 3500 fewer patients than expected were given a diagnosis of bowel cancer in England.6

  • Heart disease—The number of heart operations such as coronary bypass and heart valve surgery fell to around 25 000 by the end of the November 2020 lockdown, from 37 000 in the same period in 2019.7

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References

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