Elective Restoration: when to re-start

As Covid levels continue to decrease in most areas of the country the NHS is looking forward to restoring elective services for the second time. Given waiting lists are at a 10-year high there is a pressing need to re-start elective services as safely and effectively as possible, in particular for high priority patients.

Ensuring this can be done whilst pressures on ICUs remain and the potential for a 3rd wave still exists will require Trusts and ICSs to balance multiple considerations when planning service restoration.  Based on our experience, some key areas to consider are:

Workforce

Staff across healthcare have been working tirelessly through the first and second waves of Covid, sacrificing leave to ensure patient care is maintained.  Balancing staff wellbeing alongside the need to re-start services will be key to sustainable restoration.

The key workforce metrics we believe should be considered include:

  • Absence – Improved covid testing and tracing has led to increased levels of staff absence due to positive tests or contacts. Ensuring that there is a clear trend in decreasing staff absence will be key in planning when staff will be available to return to their normal services.
  • Re-deployment – During the second wave staff have again been re-deployed to support other parts of the organization or increase capacity in ICU or the general bed base.  Trusts will need to consider which areas need to be de-escalated or where staff will be re-patriated from to restore each service.
  • Shielding – The national guidelines remain that staff who would normally shielding remain unable to provide direct patient care within high covid risk areas, but could be used to open up capacity that the private sector is unable to staff consistently.

ICU Surge Capacity

A significant change from the first wave was the super surge of ICU capacity, even in areas of the country with lower incidence of Covid to ensure that those hardest hit did not have to limit access.

This will restrict the types of surgery that can be undertaken across cold and hot sites, therefore planning to re-start services with the lowest risk patients may allow some activity to re-commence whilst ICU continues to de-escalate.

Trusts will also have to review their own internal surge areas, such as the use of theatre recovery for additional ICU capacity, which will have an impact on throughput. There will also be surge capacity outside of ICU for additional beds, and a clear trigger of areas being de-escalated will be required to support service restoration.

Falling numbers in local ICU’s may not reflect the true level of ICU patients, with some centres having transferred patients to other hospitals who will need to be re-patriated.  This will need to be closely monitored to understand the true level of demand on ICUs as elective services are restored.

Clinical Prioritisation

Maintaining surgical pathways for higher priority (P1/P2) patients, whether on an acute site or in partnership with the independent sector, was a key message from NHSE during the second wave.

As Trusts plan to re-start activity for lower priority patients (P3 / P4) they will need to consider the balance between further delay to surgery against any risk of contracting covid whilst in hospital.  Adopting a collaborative approach with primary care to ensure waiting lists are updated with patients’ vaccination status will help Trusts to manage this balance in line with the Royal College of Surgeons’ guidance.

Restoring Services

Building a model that takes these factors into account, along with any that are trust or system dependent (such as hot and cold sites, surgical hubs and independent sector provision) will provide a planning framework with clear triggers for the restart, and if necessary the de-escalation, of elective services.

Once these triggers are agreed Trusts can prioritise which services they can re-start at each level, this will need to consider:

  • The mix of day case and inpatient work
  • The speciality waiting list size, and ability to undertake additional activity.
  • The clinical priority of cases by speciality.

Developing this into a matrix can help provide transparency around the decision making process, providing a roadmap of the sequencing of services and specialties to be restored and allowing clinical teams to contribute to and understand the rationale for restart priorities.

Attain are proud to be supporting the NHS and its partners throughout Covid and have worked closely with Trusts and systems to develop their elective recovery plans from the second wave.

To find out how we can help you plan for your elective re-start please get in touch with Gareth Hartley at Gareth.hartley@attain.co.uk or Dan Pearce at dan.pearce@attain.co.uk.

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