All of us are relieved that the first wave of the coronavirus pandemic now seems to be receding in the United Kingdom. There has been an enormous cost to individual people, their families, health care workers and society as a whole.
As the world readjusts to a new normal, the NHS is quite rightly keen to restart the process of performing planned surgery on the growing number of patients on hospital waiting lists. Some patients will have urgent conditions, such as cancer, heart disease, or critically poor circulation to their limbs. A very large number of patients are looking forward to life changing surgery, such as curing chronic hip pain with a new joint. Many others are patiently queueing for routine procedures like hernia or varicose vein surgery.
The majority of people understand that each individual patient has to give consent, in order to have their operation. Many people think that this just involves signing a consent form. However, the process is far more complex than that, and includes the duty placed upon the hospital and the doctor to explain the benefits and risks of the operation. It is also important that each individual patient has time to consider this information before giving their informed consent to the operation.
In the last three months, we have sadly learned about the potential for coronavirus to make people extremely ill. Over 40,000 people have now perished in the United Kingdom as a result of this pandemic.
At the end of May, the Lancet (1) published a headline study on the effects of COVID infection on patients having emergency and planned operations. In patients having planned surgery, acquiring COVID infection during the hospital stay led to 1 in 5 (19%) of these patients dying after surgery. As a result, the authors said that “During SARS-CoV-2 outbreaks, consideration should be given to postponing non-critical procedures and promoting non-operative treatment to delay or avoid the need for surgery.”
In 2015, the landmark Montgomery legal ruling (2) clarified the law regarding the process of consent for medical treatment. This ruling stated that patients must be informed about any “material risk” regarding treatment or surgery in order to give informed consent. The risk of serious illness or death resulting from a hospital acquired COVID infection after surgery would certainly regarded as a “material risk”.
NHS England (NHSE) is aware of the high post-operative death rate with COVID. NHSE has given national advice (3) that all patients having planned surgery should ensure that they are COVID free before admission. This means that patients must self-isolate at home for 14 days prior to surgery, and that they should have a negative COVID test shortly before admission. NHSE has also provided guidance (3) to local NHS Trust managers about separating wards for planned surgical patients from wards for other COVID and emergency hospital admissions.
As each NHS Trust owes a duty of care to every patient, the hospital managers in each NHS Trust must consider the best possible separation of these patient groups, given the physical assets of each Trust. This is to reduce the risk for patients undergoing planned surgery acquiring COVID during their hospital stay with its potentially catastrophic consequences.
Some NHS Trusts have a single large hospital, in which the hospital managers will try to separate wards for patients undergoing planned surgery in so-called “Green” areas from other hospital wards designated “Red” for patients with suspected COVID and “Blue” areas for other non-COVID emergency patients. In such circumstances, there is an inherent risk of cross infection between patients, as the same specialist medical teams may care for patients in different patient categories in the same building.
Other NHS Trusts are lucky enough to have two or more separate hospitals within their organisation, and can therefore easily separate the “Green” planned surgery patients in one hospital and concentrate the “Red” COVID and “Blue” emergency patients in the other hospital. Such a strategy is more likely to reduce the risk of hospital cross infection for planned surgery patients, as medical teams are less likely to travel between different hospitals.
During the crisis, the NHS has also secured the services of the private hospitals. The private hospitals are generally very small compared to a NHS hospital, and will not be able to treat large numbers of patients.
So what does this mean for every patient, who is on the waiting list for a planned operation? We would suggest that each patient should consider the following:
- Is my operation so important to me now, that I am willing to accept the small risk of being infected by coronavirus, and the 1 in 5 (19%) chance that I might die if I get infected? Or would I alternatively consider postponing the operation until effective vaccines or treatments for COVID become widely available?
- Has the doctor explained fully the risk of acquiring coronavirus and its major implications to my health and well-being, before I attend the hospital for my operation?
- Am I satisfied that the local NHS Trust has adequately separated the facilities for planned surgery away from the facilities for emergency and suspected COVID patients?
- If I live in an area where the NHS Trust has more than one hospital, am I willing to be admitted for a planned operation in the hospital, which has been designated as the receiving hospital for suspected COVID patients, or would I insist on having my operation in the other hospital, which has been designated as being “COVID-free”?
- If I am admitted to hospital for your planned operation, and find myself in the same ward area as an emergency patient (where the COVID status is unknown), would I continue with the operation, or would I consider telling the doctors that I do not wish to proceed with my operation and that I wish to come back on another occasion?
(1) COVIDSurg Collaborative, Lancet May 29 2020 click here.
(2) Montgomery v Lanarkshire Heath Board 2015 UK Supreme Court click here.
(3) NHSE Guidance May 14 2020 click here.