Emerging epidemics

A NEW NORMAL

The World Health Organization declared COVID-19 a pandemic on 11 March 2020, a day that became the dawn of a ‘new normal’. It has since been impossible to spare a moment without mention of this modern plague — and rightly so. Never in our lifetime has there been a public health calamity greater in magnitude or more unrelenting in its consequences. However, will our blinkered response to COVID-19 give rise to future epidemics? As a GP trainee, I am more concerned than ever about patients getting access to secondary care.

Facilitating timely access to secondary care was challenging even in the prepandemic era. By the end of 2019, there were 4.4 million patients waiting for elective care.¹ As per the NHS Constitution, patients have a legal right to consultant-led treatment within 18 weeks of a referral, a target that had not been met for 4 years.¹ Clearly, there was little capacity in the system to buffer the force of a global pandemic while maintaining ‘business as usual’. On 17 March 2020, trusts were instructed to postpone all elective surgeries to divert resources towards COVID-19, leading to further delays for patients on the waiting list.

Besides the direct impact of a halt on routine operations, our skewed response to COVID-19 caused a ripple effect that is still emerging. From January to August 2020 there were 4.7 million less referrals to secondary care compared with the corresponding period of 2019,¹ begging the question: where are our patients? There are a couple of underlying factors. First, GPs held referrals due to cessation of routine services in the first wave. Patients also failed to present, as one in five of them felt it was unsafe during the pandemic. These figures represent almost 5 million people ‘hidden’ in the community who require elective care, in addition to the 4.2 million currently waiting. In many cases, the term ‘elective’ care is a red herring as it overlooks the human suffering from relatively benign conditions. Certainly, all GPs will know a ‘sinus problem’ or a ‘joint pain’ so debilitating that it simply cannot wait, but it is still on the waiting list for elective treatment. This is reflected in statistics, for instance, 6.3% of patients from the sample with joint arthritis waiting for surgery described the symptoms as being ‘worse than death’.² With enormous volumes of patients potentially waiting for treatments now, we are facing an impending public health disaster.

FEARMONGERING

Equally concerning is the grassroots change in public perception of health. ‘Stay home, stay safe’ is in no doubt the need of the hour. However, fearmongering and intimidation have deterred people from seeking help for serious medical issues. Despite efforts to protect cancer care, 2-week wait (2ww) referrals reduced by up to 84% during lockdown.³ Macmillan estimates that there are around 50 000 people with undiagnosed cancer in the community, that is, there have been 50 000 fewer cancer diagnoses compared with the same period last year.⁴

It is regrettable that our blind response to COVID-19 is undoing decades of public health efforts to improve cancer awareness. Of course, it is also possible that the blanket use of remote consultations has failed to identify patients appropriate for 2ww referrals; but this alone is unlikely to explain the large discrepancy in numbers. Ultimately, the real challenge for GPs may come when the backlog of patients resurfaces. Hospitals may saturate and the disease burden will fall on GPs. Here are some suggestions to help prepare primary care for times to come:

• national media campaigns should educate patients on the importance of seeking medical assistance for red-flag symptoms during the pandemic;

• GPs should be provided with evidence-based guidance to triage routine referrals in order to prioritise those with the greatest need during the pandemic;

• ‘mobile GP practices’ should be established to share workload in communities disproportionately affected by COVID-19; and

• GPs should be supported in redefining patient expectations on waiting times in the pandemic era.

If trends continue, COVID-19 may be the inaugural threat in a series of public health crises. Negligence of all other healthcare needs during the pandemic will invite epidemics of cancer, heart disease, and the multitude of other illnesses that have always occupied our NHS. This is an appeal to stay mindful of the bigger picture for overall success against COVID-19.