COVID-19: What are the challenges for NHS surgery?

Abstract

In December, 2019 while COVID-19 was unfolding in China, surgeons in the United Kingdom were enjoying some of their last few months of normality. By April, 2020 all National Health Service (NHS) trusts in the United Kingdom had halted their nonurgent elective operating,1 and much of the surgical community had been redistributed to roles far from their specialized career trajectories. The first UK identified case of COVID-19 was recorded in February, 2020.2 By March 11, 2020, the World Health Organization (WHO) had declared a global pandemic.3 It became rapidly apparent that despite the NHS being a highly revered healthcare system, it was sorely underprepared. With some of the lowest ratios in Europe of beds per population (2.5 per 1000) and doctors per population (2.8 per 1000), combined with the lack of experience of recent epidemics (Severe Acute Respiratory Syndrome-1, Middle Eastern Respiratory Syndrome, Ebola), which were successfully contained by other continents, COVID-19 presented an emergent humanitarian crisis for the United Kingdom. The risk of nosocomial infection to the surgical workforce through both direct contact with surfaces, droplet or aerosol spray, or through intraoperative generation of fomites have led to abrupt changes in surgical practice during this unprecedented period. In the face of COVID-19, the risk profile of surgery to both patients and the operative team has dramatically increased. Routine procedural activities such as open suctioning, smoke generation (monopolar, bipolar diathermy, LASER), and the opening of pressurized cavities or orifices, are now considered high-risk.4 To mitigate these risks, surgical services (across all surgical specialties) have made pandemic-response changes to their practice as guided by their specialist organizations, the Department of Health, Public Health England, and input from the Royal Surgical Colleges. This monograph focuses on the challenges facing surgical practice within the NHS during the COVID-19 crisis, acknowledging the state of fluidity. As the global pandemic unfolds, there has been a corresponding increase in the COVID-19 literature, informing practice across all fields of surgery. In light of the rapidity of pandemic spread, the majority provides low level evidence and is not directly translatable into NHS practice; however, these articles have provided important insights during these unprecedented times. A significant volume of UK national guidance has been produced in response to the pandemic, with frequent updates on the published recommendations. Remaining current, for the individual, is a challenge in itself. Most surgeons have been navigating through the unchartered territory of their surgical specialty en-pandemic, employing adaptive working by drawing on, and implementing, relevant national guidance. Given the number of active occupational challenges, surgeons are either embroiled in managing their local responses to COVID-19 or adjusting to redeployment. By reviewing the published literature and national guidance (including literature from public health organizations, specialty groups, the Royal Surgical Colleges and affiliated groups) combined with our own on-the-floor experiences of the COVID-19 response, we have produced a review of current surgical challenges in the NHS. This manuscript consolidates the current challenges into 3 key areas: surgical patients, surgical workforce, and surgical process. Each limb of the current challenges and their component parts (Table 1 ) will be discussed. On account of the broad scope of this manuscript, we have elected not to discuss the specifics of anesthesia. Table 1 Current challenges, by category.