It is estimated that as many as 10m people will be waiting for surgery by the end of the year, but the suspension of services has also impacted on diagnostic test activity, leading to longer waiting times.

It is becoming clear that Covid-19 risk will continue to be a feature in hospitals for the foreseeable future. So as NHS hospitals gradually reopen for planned procedures and tests, how can activity be upscaled while maintaining critical care capacity in case of a second wave or localised outbreaks of Covid-19? And how can we prevent waiting lists escalating beyond control?

A recent paper written by Vanguard in partnership with 18 Week Support, looks at how flexible facilities and staffing options can provide a solution for safely restarting procedures, as well as the additional capacity needed to manage waiting lists.

The pandemic’s impact on diagnostic testing activity could be seen from February onwards, when activity was slightly down, followed by a more significant fall in March, and an even steeper decline in April, as all non-essential procedures were cancelled or postponed.

In endoscopy, activity levels have fallen substantially. The latest official data shows that, although activity increased slightly in May 2020, the number of endoscopies undertaken in the month fell substantially below the normal level and was over 80% lower than in May 2019.

The concern is that the fall in activity will have a significant impact on the diagnosis and treatment of gastrointestinal cancer. Delays in cancer diagnoses can reduce treatment options and can be life-threatening, given how late-stage diagnosis adversely affects mortality outcomes.

In total, 180,000 patients were waiting for an endoscopy in England in May, compared with the 120-130,000 level that has been the baseline over the last 12 months. While we have yet to see the full impact on the number of people waiting for a procedure, the impact on how long patients are waiting has been immediate.

Around 66% of all those on the waiting list, approximately 120,000 patients, had been waiting more than 6 weeks for an endoscopy in May 2020 – against a total of 9% in May 2019 and a target of 1%.  And this is before delayed referrals are taken into account.

The speed at which procedures can restart has the potential to have a huge impact, since new patients are added to the waiting list each week, and the waiting time for those already on it is increased. NHS Trusts are facing a number of major practical challenges in restarting endoscopy, including lower productivity and difficulty creating adequately separated pathways and so far, the restart has been slow.

While improvements to efficiency will be extremely difficult to achieve at this stage since productivity is much lower than normal, throughput could be increased by changes in scheduling to maximise the use of existing procedure rooms. Although the current restrictions mean downtime between cases cannot be reduced, earlier starts, later finishes, weekend or even 24-hour operation are options that could be considered. The insourcing of external staff could make this a viable solution.

In Scotland, where around 19,000 people are currently waiting for an endoscopy, the government has announced it is restarting services with the help of mobile endoscopy units. Flexible healthcare solutions are also used to provide additional capacity and safely restarting procedures at many hospital sites across England.

Mobile endoscopy suites, for example, provide separate entrance and exit points, have built-in recovery ward space and decontamination facilities, and can also be configured to house a separate reception area, staff rest areas and changing rooms. A laminar flow operating theatre, which can achieve an ever higher frequency of air changes, leading to reduced downtime between cases,  can also provide an ideal facility for performing endoscopy.

Mobile or modular endoscopy suites can be set up very quickly to provide a complete, self-contained and entirely separate ‘cold’ site. The facility can be situated on the hospital site minimising disruption and Covid-19 risk for patients and reassuring them it’s safe to attend procedures. If required, temporary units can also be supplied with experienced and adequately trained clinical staff.

It is likely that the need to care for COVID-19 patients or maintain a level of preparedness will remain for some time, possibly through the winter season and into next year. Given the fact that productivity will be reduced during this time, significantly impacting on capacity and the expected influx of new referrals expected, endoscopy waiting lists are likely to continue to grow for the foreseeable future.

Using the 2019 figures as a benchmark, the estimated backlog in referrals during the period March-May could be in the region of 270,000, with June referrals also set to remain low. This will have a substantial impact on waiting lists in the coming months, as primary care resumes and the level of referrals start to increase back up towards normal levels.

Even post Covid-19, waiting times will be substantial and it’s clear that more capacity will be needed. Flexible infrastructure and flexible staffing solutions, such as those provided by Vanguard and 18 Week Support, can be set up quickly to provide NHS hospitals with additional capacity and support, in any location.

Download our paper on restarting endoscopy here.