Covid-19 Elective Guidance Issue 5: The Good the Bad and the Ugly

Good

What’s been suggested to date in the media as a positive change, brings with it increased risk. In a hospital context what we’ve seen so far that has been lauded as good practice actually isn’t.

The most significant area reported has been about redesigning outpatient care away from face to face clinic appointments in a hospital to non-face-to-face via technology. On paper, social media and flashy product videos, it looks great. However, in reality, all we see is chaos on top of chaos. Let’s explain:

Previously, patients came to an outpatient clinic. A visit was recorded on the computer and in theory an outcome of the visit produced (clinic outcomes are notoriously poorly recorded in the NHS). A clinical letter is produced (often through dictation but not always) and a copy sent to both the GP and the patient. Even in this process, often mistakes are made.

Now, we see doctors calling patients on normal calls, Skype calls, WhatsApp calls, Attend Anywhere and various other applications. Nothing is recorded in the central hospital system. No clinic outcomes. Maybe a dictated letter. 

To us, this fragmentation of patient visits is a major risk to both patient care and financial tracking for hospitals moving forward.

Bad

Attempts to resume elective care have been severely hampered by various issues but the biggest has been estates and PPE.

Think about it – if you need to come in for a surgical procedure today a lot of new measures need to be considered, for example: 14 days quarantine pre-operation. On the day of the procedure itself, you will need to be tested before being allowed into a clean facility to have an operation. Even if you pass that test, the PPE requirements are significant depending on the type of surgery you need. Add all of this to an NHS estate that was widely accepted to be crumbling in the face of the lack of capital investment over the last 10 years and we have the perfect storm. It is currently almost impossible to social distance within the vast majority of theatre, outpatient and diagnostic departments in hospitals. 

All of these factors combined mean that the capacity of the NHS to resume elective surgery is severely hampered, with little options available other than “do what we can”.

Solutions to date have included pooling resources and redirecting patients to “clean” sites as well as the creation of waiting lists at locality rather than hospital level. 

There are two major flaws with these solutions:

• Firstly, patients have traditionally been VERY resistant to move from the clinician they have been seeing up to now.

• Secondly, waiting lists within hospitals are notoriously inaccurate – imagine trying to come up with a single list across 10, 20 or 30 hospitals which is the current unicorn being suggested by NHSE.

Ugly

Taking all of the above into account leads us to the ugliest conclusion of all:

Internationally, it has been recognised for years that the key to managing clinical risk is to diagnose as fast as possible. In England, a new national standard of time to diagnosis for cancer patients was introduced in 2019 in an attempt to improve cancer survival rates. In a post-Covid world, this should be extended to all patients. Faster diagnosis will tell us what patients need, what estates are required, what PPE is required and what money is required to treat them.

Conclusion

The problem is twofold: 

1. A drive to record outpatient attendances (in-person, Skype WhatsApp, Attend Anywhere, FaceTime or whatever else) needs to be more coordinated so that we can track everyone on one platform. 

2. Diagnostics are currently highly geared to hospitals. MRI, CT & Endoscopy are the largest diagnostic tests performed in the world. In the UK, these machines are 95% hospital based. And they aren’t running. That’s not to mention ECGs, heart monitoring and lots of other diagnostic tests that allow clinicians to treat patients effectively. 

Unless these two areas are addressed urgently, elective care resumption will be at best a mess and at worst a catastrophy. Already the Financial Times are reporting Excess Deaths in the UK as the highest in the world. Whilst international comparisons are notoriously difficult, there is no doubt that the UK has not done well in this regard. But the challenge is how to do better.

Outpatient recording. Moving diagnostics out of hospitals. Relentless focus on these two areas. Let hospitals focus on increasing ED attendances and resumption of complex surgery.