Introduction and executive summary
1. The Royal College of Surgeons of England (RCS England) is a professional membership organisation and registered charity, which exists to advance patient care. We support over 25,000 members in the UK and internationally by improving their skills and knowledge, facilitating research and developing policy and guidance.
2. Throughout the course of the COVID-19 pandemic, RCS England has been determined in its efforts to ensure that surgeons and surgical teams are supported in delivering vital patient care and are not exposed to unnecessary risk.
3. With this in mind, we welcome the opportunity to provide evidence to the Health and Social Care Committee’s inquiry into delivering core NHS and care services during the pandemic and beyond. This evidence submission primarily addresses the inquiry’s second point of focus, namely ‘meeting the wave of pent-up demand for health and care services that have been delayed due to the coronavirus outbreak.’ Key points made in this submission are set out below:
The wave of pent-up demand
4. Since the beginning of the emergency response to the pandemic, a significant number of elective procedures have been cancelled as part of efforts to free up 100,000 critical care beds across England. NHS England issued a letter to providers on 17th March 2020 setting out measures to rapidly increase hospital capacity – this included trusts being advised to assume that they would need to postpone all non-urgent elective operations from 15th April at the latest.
5. RCS England supported this measure and, to ensure that urgent surgery continued, we led on production of guidance to support trusts across the country with surgical prioritisation during the pandemic. This classifies patients requiring surgery during the COVID-19 crisis into the following groups
6. As part of transmission reduction measures all routine, non-urgent dental care including orthodontics has been stopped in England until further notice. While the guidance and standard operating procedure is national, the responsibility for delivery has been regional. Regional Emergency Preparedness Resilience Response (EPRR) teams have provided contingency planning for urgent dental care provision (UDC). This has involved triaging through 111 and local dental practices with onward referral to UDC centres as appropriate.
7. As of 5th May 2020, evidence continues to suggest that the UK has passed the peak of COVID-19 deaths and infections. Although COVID-19 will be around for the foreseeable future, this is encouraging news and indicates that elective surgical services can begin to recover in areas where everything is in place for it safely to recommence.
Measures to address pent-up demand during and after COVID-19
8. RCS England and the surgical community are under no illusions about the task of recovering surgical services and recommencing elective operations. It will require an enormous effort from a workforce already affected by illness and fatigue, along with continued vigilance to avoid a second wave of the virus.
9. To address pent-up demand in the system and support surgeons as they prepare to re-open services including elective care, RCS England has developed guidance on the recovery of surgical services. This includes a list of principles, recommendations and key considerations in order to facilitate elective surgery during and after COVID-19. These can be used in combination with national, specialty and local trust recovery plans.
10. RCS England believes that the government should introduce and support the following key measures in order to effectively recover surgical services and address the backlog of elective surgical procedures:
Personal Protective Equipment (PPE) and testing
11. Before resuming surgical services, hospitals should be satisfied they have adequate PPE and surgical supplies appropriate to the number and type of procedures performed, and clear policies on how and when to use them. This is a vital step, as our recent survey of 1,263 surgeons found widespread concern around the supply and adequacy of PPE. The survey found that:
12. Dental surgeons and oral health care professionals work at close proximity to their patients. Many dental treatments involve Aerosol Generating Procedures (AGPs), which are rightly deemed an infection risk. Accordingly, AGPs are currently recommended to be avoided, except where absolutely necessary. Those undertaking these procedures require appropriate PPE, which is not always available, with the result that many procedures will not go ahead. The Faculty of Dental Surgery at the Royal College of Surgeons of England surveyed dental surgeons on access to PPE. The survey found that:
13. With regard to testing, hospitals should be aware of their diagnostic testing availability and develop clear policies for addressing testing requirements and frequency for staff and patients. RCS England welcomes the recent announcement that tests will be extended to asymptomatic staff, particularly as, prior to this, 82% of surgeons and surgical trainees surveyed said tests were being reserved for staff with symptoms, and just 8% said there was testing for asymptomatic staff in their workplace. The government must therefore ensure that the rollout of asymptomatic testing is swift and effective.
Enhancing workforce capacity
14. An expansion of the workforce will be necessary to help recover surgical services. We cannot rely solely on recently retired staff to address the backlog. Also, we must be prepared for an unstable workforce, as the impact of managing COVID-19 manifests in staff (e.g. in fatigue, illness or stress). A continued supply of new, trained professionals is needed. Surgical trainees have foregone essential training and taken on new roles to help support the national effort to beat coronavirus. We need both the funding and the capacity to restore and maintain surgical training.
15. We recommend those surgeons, nurses and other healthcare workers who have returned to work should be retained for the time period necessary to manage the backlog of work, if they are willing and able to stay on. Experienced retired surgeons in particular can also support in key non-patient facing roles such as collecting and quality assuring local data, and monitoring adequate levels of facilities and equipment.
Services to support surgery
16. Steps should be taken to ensure that essential perioperative services (e.g. diagnostic imaging, anaesthesia, critical care, pathology, sterile processing) are also ready to commence operations before resuming elective surgery. Where these are not ready, hospitals may need to consider engaging with external partners, including the independent sector, for temporary support.
17. Before the resumption of surgical services, local governance teams should be put together to coordinate the recovery and provide transparent and flexible oversight. The team should have clinical input and be multidisciplinary and multi-professional, with daily meetings to deal with rapidly evolving local and national issues. The local teams should undertake the oversight and clarification of policies and guidance, make real-time governance decisions, manage the whole care pathway, communicate key messages to staff and patients, and liaise with other hospitals and related specialties as needed. Consideration must be given to the prevalence of COVID in the community that patients will return to for their rehabilitation, and availability of supportive community and primary care services to support recovery. If patients are set to be discharged into a setting where there is a high prevalence of COVID in the early post-operative phase, it should be considered, on the balance of risks, whether surgery is appropriate.
Capacity and COVID-19 positive/negative sites
18. The recovery of elective surgery depends on local capacity and availability of clinical and other services necessary for the delivery of surgery. Scheduling modifications may be required to increase hospital capacity. Extending hours of elective surgery later into the evening and operating on the weekends should be considered.
19. Although we recognise that Nightingale Hospitals are currently being mothballed, and are only likely to reopen in the event of a second wave of infections, RCS England believes that Nightingale Hospitals should remain in operation during the recovery period as dedicated COVID-19 positive sites. Further, we recommend that independent hospitals should continue to be used as COVID-19 negative facilities to deliver NHS work. Covid-19 negative areas that include operating theatres, recovery facilities and ward areas must be created in NHS hospitals and for those centres that undertake complex surgery, this should include access to dedicated critical care and interventional radiology facilities. For patients across the country to be able to access surgery, there must be a commitment to provide in every region Covid-19 negative facilities that can be used to care for patients who are COVID-negative.
20. A wider use of virtual clinics as well as virtual patient reviews and consultations should be encouraged as the default option. Integrated system facilities ensure tracking and record keeping, but mobile devices and videoconferencing can also be used as back up. Back up options and administrative support should also be on hand in the early stages of implementation.
Recording deferred cases
21. It is essential that hospitals keep a clear record of all surgery that is being deferred and the criteria used to do so, and regularly review this, so that there is an accurate estimate of deferred surgery and current waiting lists. Numbers of patients should include those who are waiting for elective surgery; on stalled care pathways; and new patients.
22. Patient population data should also be taken into account to assess population needs and potentially larger local community backlogs against available capacity.
Providing healthcare equitably, and for vulnerable groups who are shielding
23. As services recommence, a key consideration will be how to direct resource towards those with the greatest needs, in line with our surgical prioritisation outlined above. The challenge is that, depending on the structure and organisation of local resources, it can be difficult to perform complex but much-needed surgery in some areas, and easier to perform simpler but less vital procedures. A further consideration is how to provide services safely for vulnerable groups who are shielding.
24. Dental guidance and standard operating procedure states that, “Significant efforts should be made to ensure that shielded patients in particular are separated from other patient groups. These should be aligned with local systems and protocols to support shielded patients.” This remains important as non-urgent services are brought back online.
 NHS England, RTT waiting time statistics: https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2020/04/RTT-Overview-Timeseries-Feb20-XLS-128K-20005.xls
 Public Accounts Committee report into waiting times, June 2019: https://www.parliament.uk/business/committees/committees-a-z/commons-select/public-accounts-committee/news-parliament-2017/nhs-waiting-times-report-published-17-19/
 The RCS England survey fieldwork ran from 23 April 2020 to 28 April 2020. The survey was completed by 1,263 surgeons and surgical trainees. A full report of the survey findings can be found here: https://www.rcseng.ac.uk/-/media/files/rcs/coronavirus/rcs-report--ppe-and-testing-during-the-covid19-pandemic.pdf