Current BOA position regarding elective activity, waiting lists and restart

11 Dec 2020

Facts and figures on reduced operating and increasing waiting times during 2020

In late-March 2020, all non-urgent elective operations and most outpatient clinic appointments were cancelled. Elective operating resumed gradually over the late spring and summer, but the progress in restarting elective orthopaedics has been slower than most other specialties. There is wide geographical variation in operating capacity, and many units have suspended surgery again in the second wave, which will further increase waiting times.

Latest T&O data for England was published 10 December and is as follows (data for devolved nations - see appendix below):

  • In total, between April and September 212,000 (73%) fewer operations occurred this year than in the same period last year.
  • In October 2020 in England, the number of patients admitted was 63% of normal (compared to October 2019). This was the lowest percentage of any surgical specialty.
  • Consequently there have been huge rises in the number of people on the waiting list for extended periods. Patients waiting 18+ weeks at the end of October stood at 244,536 (had been 100K at start of 2020). The number of patients waiting over a year was 436 in January and has now reached over 34,978 (Oct).

This situation is intolerable for many patients, as they await their surgery in enormous pain and increasing levels of disability.

Patients suffer major effects on their physical and mental health as their bones crumble and deteriorate and they struggle to undertake everyday activities. These delays really matter. Patients suffer before and after treatment. There is clear evidence that when we allow arthritis patients to deteriorate to lower functional levels, they can still be improved by joint replacements but achieve lower post-operative function. There are serious wider societal and economic effects, e.g. where they are unable to work, or become reliant on the state for care and/or family/carer support for day to day life.

Why this scale of impact for orthopaedic patients and how delays affect them

Orthopaedic patients have been disproportionately affected by the pandemic.

A large number of the orthopaedic patients start in the lowest Priority 4 category which is defined as “Procedures do not need to be performed within 3 months”1. This includes most of those awaiting life-changing hip and knee replacement, which are two of the largest volume procedures in orthopaedics (over 200,000 procedures per year in total).  The ability to wait more than 3 months is reasonable on day 1 but arthritis is a chronic deteriorating condition punctuated by severe inflammatory flare ups of pain and increasing disability. Waiting beyond 12 months lacks humanity and breaches NHS obligations to patients.

The following is extracted from the ARMA position statement on “Access to Joint Replacement Surgery and Impact on People with Arthritis and Musculoskeletal Conditions”2:

“For any surgery, it is important that patients can access the intervention at an appropriate time. The delays in treatment mean that people with severe arthritis are living in pain for longer. Delays to surgery can have multiple consequences for the patient: it can mean they don’t have such a good outcome from the surgery, as well the extended wait resulting in muscle wasting due to immobility, reduced cardiovascular fitness, osteoporosis due to immobility and adverse effects on the patient’s mental health and motivation caused by chronic pain; the delay may result in permanent impaired mobility in some cases. In certain patient groups, especially those with rapidly progressive hip osteoarthritis, a delay in surgery can result in the need for more complex surgery (at increased cost).”

Delays to surgery also have wider societal and economic effects. Younger patients become unable to work, or become reliant on the state for care and support for activities of daily living. Older patients require more community support, GP resource and increased pain relief with concomitant problems associated with the side effects and dependence on strong and opioid pain killers. Patients fear loss of independence and becoming a burden on family, friends and even their healthcare providers.

During the first wave the BOA supported the principle that non-urgent services needed to be suspended in order to deal with the pandemic as it emerged. The limited capacity for NHS surgery was prioritised for life- and limb- saving surgery. Essentially all T&O procedures for chronic conditions were delayed – in April just 3.3% of normal numbers of operations occurred – these were urgent and emergency cases only. This was the lowest percentage of any speciality and represented the fact that so many of the orthopaedic procedures performed were placed in the lower priority categories during this initial prioritisation period.

Since restarting surgery, average national operating capacity has remained low and in some areas has been scaled back again during the second wave. Throughout this time, surgery has continued to be prioritised in the same way as during the acute surge phase, with low priority for long-term musculoskeletal conditions: this cannot continue. We strongly believe there is a need to prioritise surgical delivery.

Other wider pandemic impacts on patients and trainees

Reduced referrals and likelihood of future explosion in referrals: Many people avoided healthcare settings during the pandemic. Referral rates have not returned to their pre-pandemic levels and currently stand at 65-70% of normal rates. From March to August 2020 there have been 614,000 fewer referrals to orthopaedics than the same period last year in England (of whom usually a quarter would have gone on to have surgery). While some may be managed effectively within primary/community care without referral, it is likely that there will be a delayed surge of patients presenting to primary care with more advanced musculoskeletal disease, causing a further increase in orthopaedic workload in the months and years ahead.

Training the future generation of orthopaedic surgeons: It is not just our ability to operate today that is at risk from the consequence of the pandemic. The vast reduction in operations means far fewer training opportunities for trainee surgeons. There are serious educational and service consequences of this. The NHS relies on the continuous availability of newly trained surgeons, and disruption of that career pathway may lead to delays in qualification and career progression.  This will put further pressure on the provision of future services and ability to catch up on lost time, and will create a training bottleneck at junior doctor level.

Appendix: Scotland, Wales and Northern Ireland key statistics3:

Scotland, Wales and Northern Ireland have all published their latest waiting times data covering the period up to the end of September.

Scotland does not breakdown its data by speciality. The overall picture across all specialties is:

•             The number of patients seen (excluding NHS Borders, Grampian and Lothian whose data is not included as yet) has gradually increased from the reported low of 22,252 in April to 52,624 in September. The comparable figure for September 2019 is 79,942.

•             Of the fully measurable patient journeys which were completed in September 2020, 66.9% (excluding NHS Borders, Grampian and Lothian) of patients were reported as being treated within 18 weeks of referral, compared with 78.6% in September 2019.

In Northern Ireland, the total number of people on the T&O waiting list (either for day case or inpatient care), is 19,309. Of these, 11,705 (60.6%) had been waiting over a year, and 5,362 (27.7%) had been waiting for between 6 and 12 months. Regarding resumption of services, T&O specific data is not available, but across surgery, provisional figures indicate that 25,654 inpatients and day cases were treated in Northern Ireland in July-Sept this year, this compares with 10,978 patients treated in the quarter ending June 2020, and 42,496 in the quarter ending September 2020.

NHS Wales/GIG Cymru data for ‘Trauma and Orthopaedics’ in September 2020 reveal that 75,131 patients are on T&O referral to treatment waiting lists. Of these, 41,202 have been waiting for 36 weeks or more - a 372% increase since January.

  1. https://fssa.org.uk/covid-19_documents.aspx.
  2. http://arma.uk.net/wp-content/uploads/2017/08/Policy-Position-Paper-Surgery_v5_Interactive.pdf.
  3. For more see the following links: Wales, Scotland and Northern Ireland.
 
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