The COVID-19 pandemic has undoubtedly posed many challenges to individuals, families and societies over the past 18 months. Indeed, the National Health Service (NHS) has not escaped these pressures and like all health services around the world, it is now struggling to maintain its normal throughput, whilst still planning for the next possible COVID-19 surge.
NHS surgical waiting lists (WL) have always been a challenge for clinicians. Over the years their management has become subject to both managerial and political scrutiny, and to address it, workforce expansion, waiting list initiatives, an extended working week and outsourcing to Treatment Centres and private providers have all been used. However, the pandemic has significantly increased these challenges, and with NHS surgical waiting lists currently estimated to include five million procedures, and with this set to potentially double within six months, the pressures on the NHS and its workforce are only set to increase.
So how does one prioritise such a huge number of patients, all of whom deserve, and indeed, expect to be treated in a timely fashion? Historically, clinically urgent cases and the length of time on the WL were the most easily applied criteria for prioritisation. However, with many shoulder and elbow conditions being degenerative in nature, an increase in waiting time could very easily translate to both changes in treatment plans and possibly even worsening outcomes. The complexity and nature of the condition must therefore now be reviewed along with other factors such as one’s ability to work whilst waiting for treatment, as well as any mental health issues that are caused or possibly aggravated by undue delay.
The pandemic also demonstrated that its effect on societies varied amongst demographic groups, regions and even nations. Special care must therefore also be made to avoid pre-existing health inequalities from being further amplified by maintaining the status quo with respect to pre-existing WL's. Our waiting lists must therefore not only be managed better than previously, but also differently.
In February of this year, the British Orthopaedic Association (BOA), along with the specialist orthopaedic societies, including the British Elbow and Shoulder Society (BESS), formed a working party to discuss these very concerns. At the core of these discussions was the knowledge that during the height of the pandemic, the priority had understandably been to maintain the delivery of surgical care to those patients suffering from trauma and with a cancer related diagnosis. However, as normal services return, the priority must be to provide an equitable service for all surgical specialities. A document was therefore produced to provide a framework regarding prioritisation that members could follow until normal services are reinstated.
The main goal must be to return the provision of orthopaedic services to as normal a footprint as possible, whilst also enabling shoulder and elbow surgery to retain proportionate theatre exposure compared to other sub-specialities. To ensure the appropriate prioritisation of patients, the Federation of Surgical Specialities has stipulated the use of prioritisation groupings 1 to 5. Although the clinical urgency of Priority Groups 1 and 2 are straight forward, the remaining groups represent a considerable concern, especially when they are considered in the context of increasing waiting list numbers and the recommended time constraints assigned to each group; P3 < 3 months and P4 > 3 months.
Therefore, due to the anticipated increased waiting times, the following recommendations have been suggested:
Clinical urgency should be based on the priority category.
The priority of P3/P4 groups is based on clinical need and time spent on the WL.
P3 cases should be reviewed every 10−12 weeks.
P4 cases should be reviewed at 6 months.
Patients should be informed that their case will be reviewed on a regular basis.
Patient initiated review is possible.
The review process is to be considered a Direct Clinical Care (DCC) for job planning purposes.
Patients of concern can be re-prioritised with the validation of one other clinician.
P5 patients can elect to return to the P3 or P4 categories if they feel that their perceived risk from the Pandemic has eased.
As all clinicians continue to have a duty of care to their patients whilst they remain on a waiting list, hopefully this overview can provide a framework for surgeons to actively manage their patients whilst also protecting them from harm in what is likely to continue to be challenging times.
The complete document can be found on both the BOA and BESS websites.
Footnotes
Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship and/or publication of this article.