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Elective Care After Covid-19 – The Long Road to Recovery

Patients have to feel confident that returning to a hospital environment and undergoing surgery is a safe option for them, says Katerina Sarafidou, Head of Standards at the Royal College of Surgeons.

It has been almost a year since the impact of COVID-19 became clear. The scale of the pandemic placed unprecedented pressure on the NHS, leading to a sustained reduction in routine surgical activity as resources were diverted to the frontline response to the crisis. As a result, COVID-19 has had an enormous impact on waiting times for planned or elective hospital treatment.

In the first wave, all planned procedures were cancelled and despite the effort to restore many services, surgery continues to be hampered by the persistent number of patients in hospital with the virus.

While the reported number of patients on a waiting list currently stands at 4.45 million, there are many more who have not yet been referred for surgery, partly because GPs have been reluctant to refer patients to suspended hospital services, and partly because many patients have chosen to stay away from the health service during the pandemic, ignoring symptoms or signs.

This foreshadows an imminent, large cohort of patients who will be placed onto elective waiting lists as soon as normal referral pathways resume.

Hip, knee and cataract surgery among the hardest hit

Recent data by NHS England show that the estimated referrals compared to 2019 have been reduced by a third, with some of the hardest-hit areas being hip, knee, and cataract surgery.

The impact of long waits for such procedures can be severe for patients’ physical and mental health, affecting their quality of life and leaving them in pain, or losing their mobility and independence.

Living alongside the virus and resuming services

The virus’s prolonged presence in society raises the question whether it is sustainable to keep treating the pandemic as an acute crisis and continue to postpone elective surgery indefinitely.

Living alongside COVID-19 seems to be “the new normal” for the next several months, and we have to find a way of moving away from crisis responses and towards identifying the circumstances that will allow surgery to resume safely for patients and clinicians.

On the service front, there are no simple solutions. Restoring staff to their specialties and freeing them up to spend more time in theatre is essential, as is a more nuanced prioritisation of patients and the local cooperation of hospitals to allow optimal use of facilities.

Crucially, patients have to feel confident that returning to a hospital environment and undergoing surgery is a safe option for them.

Available data are encouraging: Although it is not possible to entirely eliminate the risk of contracting COVID-19 while in hospital, which would likely result in worse patient outcomes, recent studies estimate the risk of contracting the virus to be 0.45% if a patient has close contact with a COVID-19 positive person while in hospital. This is a significantly low risk, similar to hospital-acquired infection levels before the pandemic.

Hospitals are taking every possible measure to minimise patients’ risk of infection. This includes training hospital staff on how to limit the spread of the virus through frequent hand-washing and social distancing within the hospital; regular deep cleaning; use of personal protective equipment; testing staff and patients for COVID-19; and treating patients who have symptoms or who have tested positive for COVID-19 in separate units or areas.

Procedures and patient choice

Patients who are referred for surgery for the first time, or are given a new date for their operation, should be encouraged to discuss with their surgeon any concerns they may have, including:

  • the benefits and risks of the procedure;
  • the risk of contracting COVID-19;
  • the risk from any pre-existing medical conditions;
  • the possible side effects of the proposed operation;
  • alternative options for treatment, including non-surgical care or no treatment;
  • advice on lifestyle patterns that may reduce risk of complications after surgery or may change the progress of the condition;
  • any further treatment after the operation that will be required (eg physiotherapy) and how it can be accessed.

If no action is taken, long waits could become the norm for years to come and for millions of people. Patients’ willingness to present at primary care and take up hospital appointments is just as essential as hospital staffing levels or theatre capacity.


March 2021


  • RCS Eng – Recovery of surgical services during and after COVID-19
  • RCS Eng – Consent: Supported Decision-Making – A Guide to Good Practice
  • RCS Eng – COVID-19: A Guide to Good Practice for Surgeons and Surgical Teams
  • The Health Foundation – Hidden backlog’ looms as NHS referrals for routine hospital care drop by a third
  • National Voices – Improving our understanding of the experience of waiting for care.
  • NHSE/NHSI and Surgical Royal Colleges – Clinical guide to surgical prioritisation during the coronavirus pandemic
  • Society of American Gastrointestinal and Endoscopic Surgeons – What is the correct risk to quote a patient undergoing urgent surgery for contracting COVID-19?
  • The Lancet – Pulmonary complications occur in half of patients with SARS-CoV-2 infection who undergo surgery, increasing mortality risk
  • Annals of Surgery – Unknown unknowns: Surgical consent during the COVID-19 pandemic
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