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From response to recovery in elective care: balancing surgery alongside COVID-19

As the first wave peak of COVID-19 has now passed, attention across the health sector has rapidly shifted to recovery. Trusts are now preparing for the return of non-elective demand and the delivery of elective care. On 29 April Simon Stevens set out a series of expectations for the following six weeks which included ensuring that urgent and time-critical surgery is provided at pre-COVID-19 activity levels, and that routine elective surgery is restarted where capacity allows.

As we have looked across elective care in our ‘response to recovery’ series we are seeing organisations rapidly reconfigure sites and services to prepare for activity to return, with a clear separation of COVID-19 positive and negative patients. For elective surgery, it will be a similarly long and complex return to pre-COVID-19 activity levels. But we believe there are five key considerations that will help Trusts re-establish elective surgery in a safe and coordinated way.

Understand the full factors affecting available capacity

Work is underway to understand available capacity for resuming elective surgery with each Integrated Care System (ICS) and Sustainability and Transformation Partnership (STP). They have been asked to model their total bed capacity requirements, firstly by forecasting the COVID-19 and returning non-elective demand with remaining capacity then prioritised for elective activity. Use of Independent Sector capacity, which has been commissioned through to the end of June, should be considered along with Nightingale facilities as a further potential enabler.

Understanding the bed capacity requirements across the health sector is a good place to start in the transition to recovery. However, it is not yet known whether other resources such as theatres, workforce or testing capacity will be earlier constraints in elective surgery recovery. Based on our experience helping the NHS use data to provide better patient care, we believe that flexible, modular assumption-based models will be needed to support systems to determine the capacity available for elective surgery. We have developed new models to meet these needs which can forecast COVID-19 and non-elective demand along with known use of hospital resources such as theatres, workforce, equipment, services, consumables and PPE.

It will be challenging to assess the capacity available for elective surgery while the impact of constraints is not yet fully understood. Capacity will also need to scale up and down in response to continued COVID-19 demand and an assumed return of non-elective demand. Given these factors, along with additional measures required to protect patients from COVID-19 exposure, we expect to see a tentative return to elective surgery as capacity across all resources are tested and carefully balanced.

Adopt flexible theatre scheduling and timetables

The available capacity of operating theatres is expected to be severely impacted. There will need to be a clear separation of COVID-19 positive and negative patients, and for some organisations this will require reconfiguring whole sites accordingly, and subsequently whole theatre suites may be lost to the majority of elective activity. Additional inefficiencies will be introduced to operating lists by the necessary measures taken to reduce risk to staff and patients, such as changing PPE or additional infection control procedures. Some mitigations could be considered with extended operating hours and weekend working but clearly only where it can be accommodated within the available workforce.

New, agile theatre timetables will be required for elective surgery and should include any capacity used within the Independent Sector. Increased waiting times and urgent cases will impact all specialties, and surgical teams should work collaboratively on the relative prioritisation of cases and transparency over allocation of available theatre time.

Based on our experience helping trusts use data to optimise theatre scheduling we know how important it is to get robust and accurate data, that is tailored to each surgeon and anaesthetists’ median case time and then linked to surgeons’ waiting lists so that bookings can be prioritised. Our tools are being rapidly adjusted with engagement from surgical teams to incorporate any further adjustments and inefficiencies related to minimising COVID-19 risk. These inefficiencies may include additional PPE requirements or the need for extra measures around high risk Aerosol Generating Procedures where minimum numbers of theatre staff can be present.

A reduction in total theatre capacity and the additional inefficiencies introduced to operating lists highlights the importance of flexible solutions to accurately book patients. In addition, robust ‘on the day’ processes and effective patient communications will be increasingly important to remove avoidable inefficiencies and maximise use of the total theatre time available.

Ensure robust guidance for pre-operative assessment, isolation and testing

Robust pre-operative pathway guidance will be a critical component in reducing risk to elective surgical patients. Small but emerging studies, recently summarised by The Lancet, suggest surgery may accelerate and exacerbate disease progression of COVID-19. Patients operated on during the incubation period of COVID-19 or post-operatively appear to have a significantly increased need for Intensive Care Unit (ICU) support and significantly increased mortality.

The robust and clear guidance which Trusts will currently be developing should include a period of pre-surgical isolation, pre-assessment (completed virtually where possible) and pre-surgical testing for COVID-19. Any COVID-19 positive test results should postpone surgery unless the risk of doing so outweighs the risk of significantly adverse outcomes caused by a delay. Some organisations are considering whether all inpatients should be tested daily as part of the management of COVID-19, which would require a significant increase to testing capacity. Robust pre-assessment protocols, including clear patient communications, should reduce the number of DNAs and ‘on the day’ cancellations which would otherwise lead to further inefficiencies.

Continue to address workforce constraints

Even as we move into a period of recovery, the continued impact on the workforce is likely to have the biggest impact on elective surgical capacity. This will be due to staff absence for sickness or isolation, staff at higher risk working remotely and a continued need to redeploy staff to supporting delivery of COVID-19 care. A wide-ranging set of requirements have been set out to mitigate the impact of COVID-19 on Black, Asian and minority ethnic (BAME) staff and may mean that a proportion of BAME surgeons are assessed as too high risk to be able to undertake surgical procedures.

Another concern for elective surgery recovery will be the availability of anaesthetists who will have been central to efforts to redeploy workforce to care for COVID-19 patients. As elective surgery is re-established, many surgeons, anaesthetists and theatre staff will find themselves working on different sites, in different theatres and in different teams presenting a further challenge to efficient working.

We know many organisations are significantly reconfiguring sites to create a clear separation of COVID-19 and non-COVID-19 patients (e.g. cancer or elective hubs). While the rationale for this is clear, there will be a significant impact to some staff. There will be risks for those who are working at a designated COVID-19 site, and others will be impacted by the change in working location or practice which may include significant additional travel time. There may also be apprehension within the impacted workforce that some of these short-term reconfigurations will emerge as effective solutions, that then become a longer-term reality.

Maintain the positive flexibility and virtual alternatives from the initial response

A common theme we are hearing from healthcare leaders is that there have been many positive changes in the initial COVID-19 response and that these benefits cannot be lost as we transition to recovery. The collective efforts in the initial response led to the health sector successfully managing through the first peak of COVID-19, so it will be important to learn the lessons from the positive changes and embed these in the transition to recovery.

Although elective surgery has been largely shutdown through the initial response, there are still relevant lessons to be taken into the transition to recovery. The huge uptake we have seen in virtual consultations will be an important component of safe pre-operative assessment and post-operative follow-up care going forward. The flexibility demonstrated by the workforce to convert many theatres to ICU surge capacity and to undertake rapid training to support COVID-19 patient care will be important in re-establishing elective surgery which may require working in different locations and with different teams.

There will be no quick fixes

Recovery of elective surgery will be challenging and complex, as delivery flexes around COVID-19 and non-elective patient demand. Given the many constraints outlined above, we anticipate the return to pre-COVID-19 elective surgery activity will be slow. The greatest risk from this will be that the waiting list backlog will continue to grow and create adverse outcomes and further disease progression for those patients waiting.

To mitigate this risk, detailed planning and robust operational protocols will need to be stepped up so that every hour of operating time that we can make available is maximised. In recent weeks we have seen the NHS able to expedite delivery of large-scale transformation from years to weeks, to cut through red tape and organisational boundaries or hierarchies, and to pull teams together with a common goal and instant cohesion. This gives us hope that while elective surgery may take many months to fully recover, we will see further transformation and innovation in the way services are delivered as we transition through recovery and towards a new reality.

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