COVID-19: the postponement of non-urgent procedures and ensuring appropriate priority for clinically urgent treatment
COVID-19 is an unprecedented public health emergency - it is likely to be the biggest challenge the NHS and private healthcare providers have faced and has necessitated extensive reallocation of resources. NHS Trusts have introduced various emergency schemes to free-up inpatient and critical care capacity and to maximise the availability of staff to support COVID-19 patients.
This reallocation of resources, despite the NHS’s best efforts, will inevitably have implications for those patients receiving ongoing care/treatment from the NHS and other healthcare providers, for non-COVID-19 related health conditions. In recent guidance, the British Medical Association (BMA) flagged that there is a risk that more patients will die from non-COVID-19 related illness than from COVID-19 itself. The BMA has also highlighted that it is imperative a balance be struck between managing COVID-19 patients and “addressing the ongoing needs of individual patients”.
In a letter to NHS Trusts on 17 March 2020, the NHS Chief Executive confirmed that all non-urgent elective operations “from 15 April 2020 at the latest” should be postponed, for at least three months, with “full local discretion to wind down elective activity over the next 30 days”. This postponement in non-urgent elective procedures will impact patients. To mitigate against this, certain private providers are assisting the NHS in taking on many of their patients. This in turn is likely to have a knock-on effect on the resources of private healthcare providers and what they can offer their existing patients.
Sadly, the unavoidable and necessary delay is likely to disproportionately impact those patients who: (i) are deteriorating quickly; (ii) have been waiting the longest for treatment; and (iii) have a condition where earlier intervention usually results in a better outcome.
With the aim of mitigating the indirect effects of COVID-19, healthcare providers have sought to ensure that appropriate review/ monitoring is in place to recognise when a patient’s condition, which previously satisfied the non-urgent criteria, is escalated to urgent clinical input. To determine this, clinicians will need to consider patients on a case-by-case basis taking into account both clinical need and level of risk.
A challenge for healthcare providers will be ensuring a rigorous system is in place for prioritising patients once non-urgent elective procedures are able to be re-introduced.
Reassuringly, the NHS has confirmed that all emergency admissions, cancer treatment and other clinically urgent care should continue unaffected.
NHS Trusts have been advised to ensure that appropriate clinical priority is given to the diagnosis and treatment of cancer, including continuing to meet the two week wait referral policy (albeit some adjustments have been made to the policy such as first appointments can now take place over the telephone).
In the context of cancer patients, what constitutes a patient requiring urgent care will be a difficult balance for clinicians and patients to determine – factoring in both the risk posed by a delay in cancer diagnosis and treatment versus the potential implications of an immune-suppressed patient contracting COVID-19. This is equally important in the primary care sector, where appointments may be conducted remotely without the advantage of blood testing for example.
A key focus for mitigating the risk for cancer patients, will be ensuring appropriate and regular review (such as via scanning) so that the ongoing risk assessments that clinicians/ patients will be making, are fully informed.
NHS Trusts will also need to make sure, for those patients who do not progress to treatment at this time due to COVID-19, that there is appropriate safety-netting in place. Once the risk of COVID-19 has reduced, such patients will need the appropriate treatment.
For GPs, the BMA have provided guidance in the form of a RAG (red/amber/green) colour coded system delineating what care/treatment should be provided regardless of the prevalence of COVID-19, and what care/ treatment is a lower priority and can be postponed until the pandemic ends.
The guidance provides that high priority activities include dealing with acutely unwell adults/ children, patients who require chronic care (including those with Type 2 Diabetes, chronic obstructive pulmonary disease, severe asthma, severe mental health issues), cancer care (symptoms consistent with new or ongoing cancer) and palliative care.
The real risk for patients in this context, will be if resources become so stretched that there is insufficient resource to deal with those conditions deemed a priority. GPs, who are working under difficult circumstances, are mindful of the risks posed to patients by having to perform assessments remotely.
The coming months will continue to place significant strain on the NHS and private healthcare providers. Clinicians will not only have to deal with the logistical pressures of dealing with a pandemic but they will also have to grapple with the continuing demand of non-COVID-19 patients, who will need to be appropriately prioritised into those requiring urgent clinical input and those who do not.
Despite the best efforts of clinical staff it is inevitable that some patients will experience delays in receiving the appropriate care/ treatment they need.
With the opening of COVID-19 focused hospitals (such as London’s Nightingale Hospital), combined with utilising hospital resource in the private healthcare sector, there is hope that some of the challenges the NHS and private healthcare providers face may be mitigated in the future for the benefit of all patients.