key: cord-0982478-noepw5cn
authors: Barker, T.; Barker, P.; Sokalsky, L.; McNamara, I.
title: The use of the Independent Sector in providing NHS services during the Covid-19 outbreak; two hospitals experience
date: 2020-10-13
journal: Surgeon
DOI: 10.1016/j.surge.2020.09.009
sha: 1f7f397dc32734e87b29bdc7a6feb79ba70be914
doc_id: 982478
cord_uid: noepw5cn

This paper reviews the activity undertaken between a teaching hospital and its adjacent Independent Hospital and its implementation under the Independent Sector Provider Contract between NHSE and the Independent Sector. Results From the instigation of the NHSE contract with the Independent Sector up until 28th June 2020 The Norfolk and Norwich University NHS Trust (NNUH) delivered 9016 episodes of care including 576 surgical episodes at its nearby Independent Hospital. During the time that a seven day household isolation period was required, no patients from the 31 tested postoperatively were recorded as testing positive for Covid-19. In the month after moving to a mandatory 14 day period of household isolation, 29 patients had their surgery postponed as they were unable to comply with the required period of isolation. Conclusion Working cooperatively with the independent sector can deliver significant additional capacity for the NHS. Fourteen days household isolation may impact on a patient’s decision to have surgery, despite, in some cases, that surgery being time-sensitive. The recommendation from NICE reducing the length of isolation largely reversed this impact.

In early 2020, Coronavirus became a public health crisis in the UK and lead to the cessation of all elective surgery, resulting in ever longer waiting lists for urgent and elective surgery, and subsequent potential for patient harm to individual patients.

During March, National Health Service England (NHSE) negotiated with the Independent Sector Providers (ISP) to utilize some of their capacity for time-sensitive elective surgery, primarily to provide care for those patients needing urgent elective and cancer surgery.

Whilst these negotiations were progressing, the Norfolk and Norwich University Hospital (NNUH) Surgical Division began negotiations with the nearby Spire Hospital in preparation for the admission of NHS patients once the national contract was agreed. The national contract was subsequently agreed on the 23 rd March 2020 for an initial period of 14 weeks 1 .

This contract covered all the inpatient facilities and the existing staff working for the independent provider. In Norfolk, the principle aim was to utilize the Norwich Spire inpatient beds and operating theatres for urgent, time-sensitive NHS elective care services along with utilization of their outpatient services and diagnostic capacity. A number of early decisions were made; it was decided that whilst patients requiring major cancer surgery and needing critical care on site would be operated upon at the main University Hospital, the ISP could be used for other priority one and two cases. This was made possible by accommodating the patients in a single ward of 32 beds.

The rest of the ISP was utilized to allow the provision of the whole of the cancer and haematology chemotherapy service from a separate clean ward. Other services moved to the ISP in part or total included cardiology outpatients and echocardiography, the whole dermatology service and some midwifery services, as well as blood testing for renal J o u r n a l P r e -p r o o f transplant patients. Radiology utilised the vacant CT and MRI scanners to offset the scanning capacity at NNUH that was allocated for the sole use of Covid-19 patients.

In the initial period, patients undergoing surgery, self-isolated for seven days prior to admission, with Covid-19 PCR throat swabs taken within 48 hours prior to admission. When NHSE changed its advice to 14 days household isolation on the 15 th May 2 these arrangements changed in line with the updated guidance. However, for those patients who had been already told to self isolate for seven days before surgery, the previous time frame for self-isolation remained. This advice was changed again by the National Institute for Health Care and Excellence (NICE) on July 27 th ; moving to 14 days social distancing with a culmination of 3 days isolation after a Covid-19 nasal and throat swab 3 preceeding surgery.

Following institutional approval, patient admission data stored within a secure Excel spreadsheet were reviewed to obtain date of admission, hospital number, specialty and procedure. The outcome of the patients' screening Covid-19 swab was obtained from the hospital electronic results system. The results of any further patient Covid-19 specimens were also recorded and reported.

Prior to admission to the ISP, all surgical cases had a nurse telephone assessment with both an experienced preoperative assessment clinic nurse and anaesthetist. All preoperative blood tests and other investigations were performed when the patient attended for Covid-19 swabs thereby limiting their contact with health care providers and the hospital.

Following the change from seven to fourteen days of household isolation before surgery, it became apparent that filling the operating sessions was becoming increasingly difficult. A J o u r n a l P r e -p r o o f further review of the scheduling spreadsheets for the month of June was undertaken to ascertain the reasons for cancellation or reallocation of operating slots. The NICE conducted a review of admission arrangements for elective surgery released during July 2020 3 . This review recommended that patients should socially distance, have enhanced hand washing for a 14 day period and then isolate after a Covid-19 nasal and throat swab taken 3 days prior to their admission for surgery. Clinicians retained the option to recommend 14 days household isolation if the severity of the surgery or risk of infection with Covid-19 warranted it. We implemented this change gradually, not altering a patients existing pathway, and from 10 th August all the admissions followed this new guidance. We reviewed the scheduling spreadsheets for the three weeks commencing 10 th August to ascertain if the numbers of patients declining surgery had altered. The specialties involved are shown in Table 1 . Surgery accounted for just a proportion of the care episodes provided by the ISP. Table 2 shows the total number of care episodes provided up to the end of June J o u r n a l P r e -p r o o f

The scheduling review of the month of June revealed 23 patients who had the surgery cancelled or postponed after their anaesthetic pre-operative assessment, of which 13 were unfit and required medical optimization before their surgery could proceed and 10 had their surgical episode transferred to the base hospital as a result of comorbidities rendering them unsuitable for the ISP. A further 34 patients could not be listed for admission to the ISP. Of these 5 wanted to 'wait until Covid is over completely' and 29 reported that they could not comply with 14 day household isolation and so were unable to be admitted to the ISP.

The scheduling review for three weeks subsequent to the recommendations by NICE in July had 215 patients potentially scheduled for surgery; five were found to be unfit at their preoperative assessment, four had holidays planned for their scheduled time, four patient symptoms had resolved and no longer needed surgery. Just two were unable to self isolate.

The NHS was facing a crisis during the height of the C-19 pandemic and needed to find innovative ways to maintain the service, be that Nightingale Hospitals, expansions in Critical

Care capacity and reallocation of beds and staff within the hospital. Maintenance of timesensitive surgery was an important consideration which was partly managed via the contract with the ISPs. However, the implementation of this contract was not without difficulties. Staffing proved difficult, surgical and anaesthetic staff were reallocated with agreement from direct clinical care sessions from within NNUH to staff sessions within the ISP theatres. This was possible as some inpatient operating theatres had been converted to three bedded ITUs, but fortunately these were never required. Some of the surgical and J o u r n a l P r e -p r o o f anaesthetic consultants at the NNUH were not registered with the ISP and were granted temporary admitting rights there; the base hospital human resources department provided the ISP with assurance with regards to hepatitis B testing, currency of appraisal and Disclosure and Barring Service certification. These colleagues were welcomed by those practicing at the ISP who helped familiarize them with the theatres and wards, also offering to act as surgical assistants if needed. All consultant anaesthetists were co-located whilst surgeons were co-located according to their specialty and service requirement. No colleagues asked to co-locate declined. All consultants with admitting privileges at the ISP also held contracts with the base hospitals. Theatre staff from the NNUH supplemented the staff at the ISP where particular skills were needed. Reciprocally, staff from the ISP who had critical care experience were transferred to the base hospital trust to supplement the staff on its critical care complex. Whole services were moved with the medical staff and nursing staff from NNUH to enable uninterrupted service provision in a Covid-19 secure manner, which was welcomed by the at risk patient population.

NNUH provided managerial support for the process from within its service directors along with a divisional matron and a consultant anaesthetist who was working from home as clinical lead (author PB). In addition, specialist equipment was loaned as necessary from the base trust.

Although the numbers are small it is reassuring that none of the initial tranche of patients tested positive for Covid-19.

The move from 7 to 14 days household isolation proved to be problematic with some patients declining appointments for surgery. This was more noticeable after 'lock down' measures were relaxed and patients were returning to employment after a prolonged spell J o u r n a l P r e -p r o o f away from work or furloughed. This has had two effects; operating lists were harder to fill, with more patients having to be contacted to fill each theatre session, and increased anxiety amongst clinicians regarding potential harm caused by further delays in surgery. In addition, any patients found to be unfit at assessment or declining surgery later resulted in a lost operating opportunity, as the replacement patients could not meet the 14 day requirement. J o u r n a l P r e -p r o o f

Operating Framework for urgent and planned services in hospital settings during Covid-19

COVID-19 rapid guideline: arranging planned care in hospitals and diagnostic services. NICE guideline

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection; an international cohort study