- A return to elective surgery in a safe way is paramount. The question is how to do that safely.
- Creating Covid-light facilities is necessary. At the present moment patients are more at risk of catching Covid from staff than vice versa.
- Therefore, we require ruthless, universal and frequent testing of staff to ensure hospitals are Covid secure. This should be preferably twice weekly, but at a minimum weekly.
- Covid-light hospitals are preferable to Covid-light areas within hospitals that also have Covid patients, where this is possible.
- Each hospital will need to look at work practices which carry an infection risk such as keypad entry and coffee rooms where social distancing is not possible.
- A second wave in the autumn and winter is highly likely but we cannot afford to stop all elective surgeries again. Therefore plans, procedures and stockpiles need to be put in place to allow surgery to continue alongside Covid treatment.
- If we continue to see a plateau of cases over the summer this will degrade the NHS’s ability to return to core services and cope with a second wave.
- Measures to increase surgical capacity such as upskilling theatre nurses should be explored, as should alternative treatment options such as radiotherapy, but this must not undermine the NHS’s total capacity.
- Currently Trusts are having to work out pre- and post- operative procedures such as when and how to test, self-isolation of patients before surgery and information sheets independently. These need to be standardised national rules.
- NHS IT equipment and infrastructure is largely incapable of conducting video consultations or allowing non-clinical staff to work from home. These need to be rapidly upgraded, including allowing remote access.
Introduction to the Royal College of Surgeons of Edinburgh.
- The Royal College of Surgeons of Edinburgh is the oldest and largest of the UK’s four surgical Royal Colleges, and one of the largest of all the UK medical Royal Colleges. First incorporated as the Barber Surgeons of Edinburgh in 1505 it has almost 30,000 members worldwide. Approximately half our membership are based in the UK with 80% of that in England and Wales.
- The RCSEd is committed to representing the views of our members and fellows, to lobbying to improve outcomes for clinicians and patients and to providing expertise and information from the frontline to policymakers. We are committed to protecting, promoting and championing the highest professional standards of surgical and dental practice in Westminster and the devolved administrations.
Covid-19 and surgery.
- The NHS carries out approximately 700,000 surgical operations a week under normal circumstances. During the Covid-19 pandemic however all but the most urgent surgeries were stopped and delays to surgical treatment will cause a further wave of secondary pandemic deaths. To take cancer treatment as an example of this, the Health Service Journal reported that urgent cancer treatment had dropped by 60% in the month of April. UCL in partnership with DataCan – the Cancer data research hub – estimated an increase of 20% in deaths from cancer, approximately 18,000 people, because of treatment delays caused by the pandemic.
- This means that a return to elective surgery is vital. However, two research papers published in the Lancet show clearly that peri-operative Covid-19 has a high mortality rate, up to between 20% to 30% in some sub-groups. This is in stark contrast to the low risks of modern surgery that clinicians and patients expect and are comfortable with. Covid-19 will remain endemic in the UK for the foreseeable future, despite the welcome and significant falls in new cases we are now seeing. Therefore, minimising the risks attached to peri-operative patients from Covid-19 is vital in order to return to the equally necessary work of resuming operations and dealing with the backlog of cases which have been delayed.
Covid-light facilities and testing of NHS staff.
- Lord Hunt of Kings Heath asked the government, on behalf of the Royal College of Surgeons of Edinburgh, whether the Covid-19 R-number was calculated separately for transmission in the community, in hospitals and in care homes. Lord Bethell, responding for the government, confirmed that the infection rates were not calculated separately. We therefore do not have the exact data, however despite stringent infection controls, we know that currently patients are more likely to contract Covid-19 in a hospital setting than the community. Given the mortality rate for peri-operative Covid patients establishing and maintaining Covid-light facilities is imperative.
- Achieving this requires ruthless, universal and frequent testing of every individual who enters the hospital. We saw in Weston-Super-Mare the result when this does not take place and asymptomatic carriers passed the virus on. Twice-weekly testing is desirable, weekly is the bare minimum, of clinicians, patients, cleaners, administrators and anyone else stepping foot in a Covid-light facility. The number of individuals entering should be as low as possible, with administration staff working from home if possible.
- Significant resources also need to be allocated to make hospitals Covid secure for staff as well as patients. Each Trust and hospital needs to scope its potential risk factors. For example, many hospital areas require touch buttons or keypad access. These are a significant infective risk; hospitals will need to establish whether these should be switched off for the duration or whether an area needs to remain secured by keypad entry. Coffee rooms and offices for staff are frequently too small for social distancing, these will need to be assessed and measures put in place to allow staff to get some downtime without risk of infection. Each hospital will have their own issues based on logistics and the geography of its site and these need to be identified and resolved.
- Staff who work in Covid-light facilities should not also be working in Covid areas. Wherever possible a geographic area should have a Covid-light hospital and a Covid treatment hospital rather than Covid-light and Covid treatment areas within a single hospital. The Nightingale Hospitals may well have a part to play in this, some areas may find it most effective to establish the Nightingale Hospital in the region as the Covid facility with ordinary hospitals being devoted to non-Covid care. NHS block booking of private hospital facilities may also remain necessary.
- The UKs efforts to establish these Covid-light facilities and prepare for a second wave are being degraded by the lingering first wave of infections. The R-rate is hovering at around or only slightly below 1 in many regions of the country, resulting in a stubborn long plateauing tail of infections. The UK is still recording deaths in triple digits, compared to low single digits or zero in comparable European countries.
- This means that staff are less able to have time off to recuperate and the NHS is less able to establish stockpiles of PPE and treatment drugs. Nevertheless, this is the eye of the storm and we need to take advantage of it to prepare as best as possible for a second wave of Covid-19. It is vital that we therefore begin to stockpile PPE such as masks, gowns, the drugs required for ventilation and drugs to treat Covid such as Dexamethasone and Remdesivir.
- Strong sunlight destroys SARS-Cov-2 in under two minutes. The current good weather is destroying the virus outside and is also leading to people congregating out of doors. This is keeping us safe. However, when we reach the autumn and dark, cloudy and wet weather returns the virus will be able to survive longer outside and people will begin to congregate indoors again. This would be expected to lead to an increase in infections and we will need to be able to continue elective surgery during this.
- It is unlikely that we will be able to return to the volume of surgical operations carried out pre-pandemic before a vaccine and/or highly effective treatment options are in place. This is not only because of the issue of hospital capacity in light of Covid but also because the PPE required to undertake surgery safely on a patient who is potentially Covid-positive is bulky. This means it takes longer to put on and take off, slowing down turnaround times. It also means that the actual operation is slower. Therefore, we need to look at ways to increase surgical capacity if at all possible. A scheme to rapidly upskill theatre nurses to be able to carry out minor operations such as hernias should be explored as a possible way to do this. Further alternative treatment options such as radiotherapy should be considered wherever possible. This needs however to be done in a way which does not overload those treatment options, so this needs to be done in a way that does not undermine the total capacity of the NHS.
- If patients are confirmed to be Covid negative, as well as surgical staff, then surgical capacity can be increased as the additional bulky PPE that slows down operations and turnaround times can be dispensed with. For this reason hospitals and trusts are putting in places requests for patients to self-isolate prior to their operation and other such measures to allow for this to happen. However at present individual trusts, hospitals and even departments are each drawing up their own rules and advice on how long patients should self-isolate for and when and how they should be tested. This is confusing and sub-optimum. Standardised national rules and guidelines on self-isolation and testing need to be established so that patients and clinicians alike can have confidence in them. These need to be set out in simple, easy-to-understand information sheets available in plain English and in a number of translated languages.
The NHS’s IT infrastructure.
- At present the NHS’s IT infrastructure is simply not up to scratch to deal with the pandemic. Most NHS IT equipment does not include an integrated webcam and microphone and is not set up for remote access. This means that many administration staff have to go into hospitals to do their job as they are unable to work remotely from home and their workplace is attached to a clinical setting. Remote access to NHS workstations and systems for these staff should be a priority, to allow for home working for NHS administration, legal, HR and other non-clinical staff. This means less people having to be tested before stepping foot in a hospital.
- In addition, this prevents the NHS from undertaking virtual consultations. As well as the issue of the lack of webcams and microphones in NHS IT equipment security processes and the sporadic availability of WiFi and 4G access in most hospitals mean that clinicians cannot utilise their own IT equipment. NHS hardware and software both need to be rapidly upgraded to allow for virtual consultations to be utilised, again reducing the number of individuals who have to come into hospitals. In addition remote access to NHS workstations also needs to be established for clinicians to allow for those clinicians who have to self-isolate or shield to undertake virtual consultations from home, freeing up the capacity of those still able to work to focus on carrying out surgical operations.
 Clover B. 2020. Urgent cancer treatment down 60 per cent in April. Health Service Journal. Published 11th June 2020. Available here.
 Lai A. et al. 2020. Estimating excess mortality in people with cancer and multimorbidity in the COVID-19 emergency. ResearchGate. DOI: 10.13140/RG.2.2.34254.82242. Available here.
 CovidSURG Collaborative Group. 2020. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. The Lancet. DOI: 10.1016/S0140-6736(20)31182-X. Available here; Lei S. et al. 2020. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. The Lancet. DOI: 10.1016/j.eclinm.2020.100331. Available here.
 Parliamentary written question HL4775, available here.