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‘Restarting Is Harder Than Stopping’: UK Elective Care Faces Challenges Beyond COVID-19

‘Restarting Is Harder Than Stopping’: UK Elective Care Faces Challenges Beyond COVID-19

Source : Medtech Insight

When the UK government declared a COVID-19 national lockdown on 23 March in an attempt to halt the spread of the SARS-CoV-2 outbreak, all elective surgery and non-urgent elective outpatient activity for orthopedic and other care was suspended.

This added to the one issue that was already weighing heaviest on the National Health Service: how to process and deliver elective care for a waiting list that was already at record levels before coronavirus arrived. ("NonCOVID19 Hospital Care Back Soon Says UK Govt And Medtech Industry" "Medtech Insight" )

More than one million UK patients are now waiting more than 18 weeks, which includes 165,000 orthopedic patients, British Orthopaedic Association VP-elect John Skinner told an Association of British HealthTech Industries (ABHI) webinar on 29 June.



Outpatient referrals seen in April totalled 34,000, whereas the figure is normally around 176,000, representing a drop of 80%. Patients have avoided seeking primary care, and this has led to a large unmet need. “There is no doubt that the world looks different” in the post-COVID-19 period, said Skinner.

Orthopedics and ophthalmology have the longest waiting lists in the UK, and will be prioritized. But NHS capacity is much lower than it was, and work practices will change markedly. This will have benefits for patient safety, if not for productivity.

Staff at the Royal National Orthopaedic Hospital (RNOH), where Skinner is professor of orthopaedic surgery, must have COVID-19 tests every two weeks. Temperature checks for surgeons precede every operation, and this applies to company reps attending the operating theaters.

The scheduling of orthopedic operations will also change, with patients needing to self-isolate for 14 days prior to surgery, and to be tested 48 to 72 hours before surgery, if the surgery is to proceed. They are also contacted by the surgeon prior to surgery as part of the consent process.

Surgery will be slower, to allow for air to clear in the operating room. Among other things, full personal protective equipment (PPE) will have to be donned and doffed safely by theater staff, and the time for this must be factored in.

In-person outpatient numbers are down, and 87% of all outpatients at the RNOH, for example, are currently receiving virtual consultations. There is a big unmet need, however, with X-ray capacity dropping markedly as a function of radiology departments needing to separate patients and to clean equipment between uses.

This is one of the reasons why private sector capacity is being used: these hospitals may be better at offering the clean, “COVID-19 protected” capacity that the NHS requires. While the independent sector is likely to be a critical element in this respect, there is no agreement at present on funding for the current arrangement to continue in the post-COVID-19 phase.

 “As many have said, it was easier to stop than to restart, and we need to rebuild confidence, capacity and resilience,” said Skinner. The NHS has become “digital by default” in a very short period. There are fewer in-person consultations now, “but we will always need them for surgical practice,” he added.

The ABHI expects normal activity to increase gradually, but it is possible that the NHS will not reach its pre-COVID-19 capacity until late in 2021 if at all, the association said in a 12-page report, NHS Restart: Briefing Document, issued on 29 June. The Royal College of Surgeons has urged a five-year strategy to address these issues. ("What Next For Medtech And Investors PostCoronavirus" "In Vivo" )

The medtech industry stresses that a combination of factors and needs must be addressed before patient flows are back to normal: the increase in waiting list times; the decrease in routine referrals by 90% (urgent referrals and two-week referrals for suspected cancer have fallen by 78% and 67%, respectively); the reduction in accident and emergency attendances during peak COVID-19 (although this is now starting to return to pre-COVID-19 levels); and the reduction in patients presenting at primary care.

Diagnostics underpin much of the clinical activity in hospitals, said the ABHI document, and it is projected there will be a backlog in MRI/CT scans, laboratory tests and endoscopy, with departments possibly operating at as little as 20% of normal capacity. One NHS trust has estimated that social distancing guidelines have reduced its bed capacity by 20%.

The document’s release coincided with the ABHI webinar, which was chaired by the association’s digital lead, Andrew Davies. He said that, as a priority, the restart should revolve around patients’ needs, but noted that UK health care delivery is driven locally. ("UK Industry Prepares For Post-COVID-19 Normal As Non-Urgent And Planned Elective Care Get Green Li" "Medtech Insight" )

Setting up individual COVID-19 and non-COVID-19 pathways at providers might prove very challenging, he said, and this would add to all the other constraints that clinicians and health care systems must adjust to. On the positive side, the whole platform of the NHS and primary care has moved to “digital first.”

“A different way of working is needed,” said Davies. He added that matters do appear to be moving in the right direction regarding the stand-up of services and from the patient's point of view, if not as fast as the sector wanted. The industry, for its part, seeks a collaborative effort with the NHS.

By Ashley Yeo