ODEP chairman discusses the impact of Covid-19 on UK orthopaedic and fracture services
The Covid-19 pandemic has brought unprecedented challenges for both people and society. Writing for The Parliamentary Review, ODEP [Orthopaedic Data Evaluation Panel] chairman Keith Tucker discusses the impact that the outbreak has had on the NHS, with particular focus on the UK’s orthopaedic and fracture services.
In the piece that I wrote in the 2020 Parliamentary Review released earlier this year, I talked about how ODEP and BC [The Beyond Compliance Advisory Group] seek to ensure that the British public uses the best types of joint replacement available, while encouraging innovation. This assurance now becomes even more important taking the Covid-19 outbreak into consideration.
We simply cannot afford to use substandard implants. Since I last wrote for the Review, there has been increased interest from GIRFT [Getting It Right First Time] and NHSX in the BC and ODEP philosophy that is being introduced into the monitoring of new and legacy implants used in the cardiac, vascular, urological and gynaecological fields of medicine.
However, we all know that there are more immediate challenges facing the NHS at present. While the pandemic has been in full flow, there has not been any elective surgery or face to face “routine” outpatient appointments amid fear of patients contracting the disease in hospital. On top of that, front line hospital staff in many hospitals, including orthopaedic staff, have been re-deployed to cope with the Covid-19 admissions.
But while there can be no doubt that the government’s policy for Covid-19 has been the only obvious option, there must be ways to ameliorate its effect on the already stretched “normal” orthopaedic and fracture services now, later this year, and beyond.
If we look at one simple metric, for example, over 110,000 hips are replaced in the UK every year. With waiting lists already stretched to over six months, the mathematics are already horrendous. The number of trauma and orthopaedic outpatients seen in the UK between 2018-19 was reported as 1,231,914, and only 603,869 patients were admitted for surgery.
Just to remind us, in a recent paper by Scott, Macdonald [Bone Joint J 2019;101-B:941–950], it was found that 19 per cent and 12 per cent of pre-operative patients awaiting hip and knee replacements respectively, rated their symptoms as WTD [Worse than Death] on the internationally respected outcome scoring system EQ-5D [EuroQol five-dimension questionnaire]. There were a larger number of patients in this group than in a comparable group for any other chronic disease.
The difference for these patients, compared with those in the other groups, was that there is already a readily made solution for them in joint replacement.
Clearly, even during the pandemic, there will be a need for some surgery to happen. Surgery for certain fractures and such serious conditions as cauda equina syndrome [where delay in treatment will lead to incontinence, impotence and paralysis] will have to continue to be available. It will often be possible, but not ideal, to treat some fractures without “open” surgery during these extreme times, while accepting that many of these patients will need some sort of corrective surgery at a later date. In addition to this, their rehabilitation will often be significantly lengthened. The British Orthopaedic Association [BOA] has already published guidelines on the management of trauma including fractures, which are visible on their website.
Covid-19 has dealt a crushing blow to our normal services and our training programmes, yet there are some simple ways in which we can reduce the impact. Virtual clinics is one such way.
For instance, there is the possibility of launching post-trauma virtual follow-up clinics. Over the past few years, there has been much more contact with patients by telephone. Checking on the well-being of patients, who have been seen in an A&E department by telephoning the following day has been shown to be effective, safe and very welcome by patients, provided that the call is made by someone of significant experience and with access to the notes and x-rays. Further appointments can then be made if required. In the same way, virtual post-operative follow-up clinics can be run for patients who have recently been discharged from hospital. They can be spoken to by phone in the same way as trauma patients.
I anticipate that virtual clinics for new patients may be more challenging to launch, but by no means impossible. Clinical examination of a patients is usually essential in making a diagnosis, particularly if the availability of imaging such as x-rays and MRI [Magnetic Resonance Imaging] is limited. This is where new technology can be helpful.
Having a video-linked consultation is something that we need to consider very urgently. It is already being done in some hospitals, but it is essential to introduce it more broadly if we are to flatten the graph.
Inevitably, however, there will be hurdles that we must overcome in order to carry out these plans.
Organisation will be one major issue. Ideally, an NHS network along the lines of such technologies as Google-hangout, Zoom or Skype would be ideal. Addenbrooke’s Hospital in Cambridge already uses the EPIC e-hospital medical records system. EPIC is expensive but it allows remote access for clinicians and patients. This would be a good model to follow. In the meantime, we should use one of the safe systems that many of us already have available.
Surprisingly, in my view, we are not allowed to send an email to a patient without having written to them first, requesting their permission to do so. If a hospital was to write to a patient offering a “Virtual Appointment” with a consultant, they could then email back their decision. First, however, they would need to confirm that the hospital had permission to email them and then undertake a consultation.
Of course, there would have to be a caveat that without a clinical examination, the consultation would not be up to the standard that would be preferred. As a result, some disclaimers would need to be included. Within the confirmation email of the time and date, an online questionnaire could be sent for the patient to complete in order to help speed up the process.
Ideally, consultants would have a secretary on the call with them at the same time, in order to help with the organisation, take notes and prepare the GP’s letter. Perhaps a clock would also need to be incorporated into the screen to be sure the consultation did not overrun. It would be especially important that these appointments are kept to time.
Indeed, manpower is another matter to consider in all of this. But not all orthopaedic surgeons are being redeployed to other areas and they should be available to undertake virtual clinics, preferably from their own homes.
Orthopaedic surgeons who have retired within the past three years have been contacted by the GMC [General Medical Council] and informed that they will be allowed back onto the register to practice without any formalities once they are re-employed. The majority of these retired professionals will be quite old and within the higher risk group themselves. They will mostly be highly experienced and are more likely to have a broader knowledge of the subject than many of their junior colleagues. This would make them ideal people to conduct virtual clinics if there was not enough manpower available locally. Many of the return patients will probably remember them well, often with considerable affection.
Providing the patient gives their consent, there is no obvious reason that medical students and doctors in training should not take part in these consultations either. Teaching and training have taken a huge hit over the past few months and this could help alleviate that problem.
To make this possible, an IT platform would be needed in each hospital should a national system not be put in place.
Websites would be needed which patients would log into, in order to indicate that they would accept a virtual appointment with all the necessary disclaimers and caveats in place. Consent issues would need to be addressed and simplified.
Surgeons and doctors working from home would need a secure IT connection, and for the patient’s details to be available from a cloud system or packaged at the point of referral for their use.
Empathy and support could also be integrated into this approach by means of an app. Certainly orthopaedic patients, once they have a diagnosis, could go to an app for more advice on living with their condition. In fact, a solution in this vein is being developed by a group called My Recovery.
Then there is the issue of red tape. Over the years, my personal experience with government departments in implementing new ideas has not been good.
If these measures are to be moved on efficiently, they must be led by an enthusiastic clinician with a lot of energy, backed up by a bright enthusiast in an organisation such as NHSX. Ideally, a member of Parliament [MP] would also step forward to champion the cause.
These measures do not need to cost much if anything at all. The work will centre around re-organising what is mainly already in place in most trusts, while providing some fresh guidelines and an appropriate helpline.
What will be important here is feedback, and this will be needed early on to ensure that there are no problems in the system which would deter others from using it.
At the moment of course, it may take quite a bit of reassurance for a patient to agree to coming into a hospital for surgery when so many hospitals are thought to have been associated with the spread of the coronavirus.
Patients with potentially fatal conditions such as heart disease and cancer are likely to want to step up for treatment before patients with non-life-threatening conditions. Orthopaedic surgeons will generally step aside to allow patients with these conditions to come in first, but this does mean that orthopaedic waiting lists will become even longer.
When the time does come, it is important that the supply chain has provided hospitals with the necessary implants and other equipment.
Hopefully, surgeons and others, where possible, will have taken some of their annual leave while the lockdown has been ongoing and will therefore be ready to start again at full steam ahead.
I would perhaps suggest that this is also an opportunity to revisit the European Working Time Directive [EWTD]. The EWTD was opposed by a very large number of surgeons before it was introduced, particularly on the grounds of continuity of patient care and training.
What is for certain is that there is a massive problem on the horizon. Orthopaedics is not a luxury and we need to keep it going as best as possible until Covid-19 is no more. After that, we must find smart ways of dealing with the avalanche. Focusing on evidence-based treatments, throughout all specialities, along the lines recommended by GIRFT will be the baseline for any plan.
While we are on the back burner, we should urgently develop an online service. But to do it well, it will take some real organising and a great deal of good will. It should not require a lot of money. There is no time to waste and if necessary, the “normal processes” that would usually be cited to set up these arrangements need to be set aside or at least temporised.
Everyone accepts we will never completely replace face to face consultations for the majority of patients under the care of the NHS, but in the years to come, people will reflect on how Covid-19 helped to improve some patient services, particularly communication.