Legacy of COVID‐19 – the opportunity to enhance surgical services for patients with colorectal disease

The COVID-19 crisis has undoubtedly taken a toll on the care of patients with colorectal disease. Elective services, be that face-to-face contact, endoscopy or operations, all but ceased during the pandemic [1]. As we move into the recovery phase the return to normal care is likely to be slow, with a huge backlog of patients and ongoing limitations to services. Some of the changes in care and new ways of working enforced by COVID-19 will be permanent. However, this 'legacy' of COVID-19 is not entirely negative. The pandemic has thrown into sharp relief some of the poorly thought through systems and practices that were in place previously and forced change to certain areas of practice that have proved beneficial. If we can identify, nurture and embed these positive changes there is an opportunity to improve patient care. The psychology of a crisis is well defined. The initial 'heroic' phase is followed by a honeymoon phase, both characterized by clear shared goals and a sense of urgency that energizes the workforce to be focused and productive. The disillusionment phase follows, in which uncertainty about the future reduces any sense of purpose, and productivity falls. Finally, there is the reconstruction phase, in which we begin to revise our goals, expectations and roles and to focus on moving beyond 'just getting by' [2-4]. This document aims to define the positive outcomes from the crisis and to explore how the colorectal community can reframe its future direction. It is hoped this will serve as a catalyst to move us swiftly and effectively through to the reconstructive phase and guide priorities accordingly (see Appendix). Our overarching aim is to improve care for patients. Any legacy from the COVID-19 crisis must clearly have patients' interests 'front and centre' with other factors feeding into this central theme (Fig. 1). We have, at best, only a notion of what patients really want from their health service, and welcome initiatives such as the recently described 'citizen juries' [5] to redress this knowledge gap. Nevertheless, we can make some clear suggestions, starting with the realization of the importance of high-value care during the crisis – in other words, the opportunity to make the biggest differences to patient care with the minimum resources available. With reference to colorectal diseases, pre-COVID-19 systems were typically overburdened with huge numbers of referrals of patients whose symptoms, whilst clearly troublesome to them, were not eventually associated with the finding of significant pathology. The 'old' paradigm involved invasive and expensive investigation of such patients with a near exclusive focus on the exclusion of cancer – to the extent that the primary reason the patient attended in the first place, namely management of their problem, was often neglected or forgotten. This is a grossly inefficient way of working; it puts patients at unnecessary risk of investigation and has little benefit for those who need treatment for conditions other than bowel cancer. Attempts to rectify this situation, pre-COVID-19, had been limited to small changes such as modified referral criteria to try to control the influx of patients. We now have an opportunity for major and meaningful change. Obvious examples are modifications to the 2-week-wait and straight-to-test pathways. Both are leading to an ever-increasing drain on limited endoscopy resources, a decreasing efficacy in identifying significant pathology as only cancer detection is prioritized and often inappropriate discharge of patients symptomatic from other pathologies. Rapid integration of proven adjunctive diagnostic tools such as the faecal immunochemical test (FIT) in cancer detection pathways will allow more focused high-value care [6]. Coupled with this high-value care is the concept of 'realistic' and 'personalized' medicine approaches [7]. The clinician should refocus on shared decision-making with the patient when planning investigations and treatment. The risks and benefits of testing or treating should be discussed in detail and the patient allowed to decide what is best for them. This personalized approach can deliver efficiencies that will keep the healthcare system sustainable in the face of rising costs. It requires honesty about expectations, including the description of all alternative treatment options. Patients may have accepted during the crisis that there was a virtual shutdown of services, but lack of resources is not new and even after the recovery is likely to be worse than in the pre-COVID-19 era. Given the universal backlog of patients awaiting endoscopy and surgery in the recovery period, there is an opportunity to apply the realistic medicine principle to those who, for instance, have been waiting a long time; they may not need or want the intervention planned at all (e.g. those on polyp surveillance with only a diminutive polyp burden). High-value care must be inclusive, applying to both suspected and proven malignant diagnosis and to diseases that are less common. For instance, some patients with faecal incontinence had been effectively self-isolating for years before COVID-19 came along and are now at the back of an even longer queue despite having a condition that radically reduces their quality of life. Another issue highlighted during the crisis was the obvious motivation for patients undergoing elective surgery to leave hospital rapidly. Experience from Lombardy suggests the median length of postoperative stay was reduced by over 1 day, despite a pre-COVID-19 enhanced recovery policy, with no obvious adverse sequelae [8]. Their experience implies we can push the enhanced recovery process even further provided patient motivation can be instilled and there is adequate safety netting. Over many years, and with the best of intentions, several initiatives have been introduced to streamline patient care. Many were scientifically based but political influence and greater patient expectations have not been matched by a resource-constrained National Health Service (NHS). The consequence was overwhelmed services and significantly reduced efficiency. There may be an opportunity to reset and reconfigure some services. The 2-week-wait referral pathway for suspected colorectal cancer has already been mentioned. Of all patients investigated on the colorectal cancer pathway, only 3% have bowel cancer [9] and the majority of patients with bowel cancer are still diagnosed outside of the 2-week-wait investigation pathway. Add to that the fact that referrals for colonoscopy due to symptoms exceed those through bowel cancer screening by a factor of 7:1 and it is no wonder the colonoscopy services are overwhelmed [9]. Solutions include diagnostic innovations such as the FIT already implemented in the symptomatic referral pathway in Scotland, but also other novel diagnostic tools such as the colon capsule [10]. Working closely with primary care allows the effective delivery of alternative cancer detection pathways. There may be additional ways in which assessment and rationalization of investigations can occur in primary care and reduce some urgent referrals that place pressure on secondary care with little tangible patient benefit. For instance, frailty scoring in the primary setting could identify patients who are never going to be fit enough to benefit from surgery and who would be better served with palliative input or a more routine surgical opinion. The most frail, for whom surgery is unlikely to be an option, may benefit from a virtual appraisal by the hospital colorectal team, possibly avoiding the need for hospital attendance. If investigation is deemed appropriate, it may be tailored to the individual. CT abdomen/pelvis protocols including faecal tagging alone (minimal preparation CT) in much older and frail individuals, in whom the primary aim is to exclude major pathology, may be more appropriate than subjecting them to full oral bowel preparation [11] whilst remaining mindful of not overburdening radiology services. A considerable amount of resource goes into bringing frail, elderly patients to hospital for appointments. Political pressures allied with medicolegal concerns have undoubtedly resulted in a more defensive attitude in medicine. There is fear across both primary and secondary care of missing a cancer diagnosis. These approaches will reassure primary-care clinicians and reduce the need for hospital resources and the carbon footprint of the NHS. This footprint could be further reduced by the use of virtual clinics for all age groups as it is increasingly apparent that much of secondary care can be delivered without hospital attendance. Permanent integration of virtual clinics to reduce inconvenience to the patient is an essential component of future patient-centred care [12]. Ready access for general practitioners to specialist advice will further aid stratification of patients at primary-care level. Front-of-door services such as consultant-led 'hot' clinics and telephone advice results in reduced hospital foot fall and more rapid discharge. Integration is a sensitive subject, particularly when it is taken to mean centralization of services. COVID-19 has brought a sharp focus on preexisting inequalities in quality of healthcare provision as some regions have been able to continue essential elective colorectal services, primarily due to integrated service provision [13]. In view of this, there is now more than ever a compelling argument to move beyond considering hospital walls as a boundary to clinical care and investigating models that view a waiting list by regional population, rather than hospital, to improve outcomes. In many respects, the UK has led the way with national patient registries and publication of colorectal cancer outcomes in the public domain (e.g. National Bowel Cancer Audit), multidisciplinary teams, training (total mesorectal excision, Laparoscopic Colorectal Surgery Programme, Low Rectal Cancer Programme) as well as data on screening. Both the Republic of Ireland and Denmark have copied these initiatives and further built on them by reducing the number of centres treating rectal cancer [14, 15]. Similarly, surgery for advanced pelvic malignancy is carried out in even fewer Danish centres and only five centres perform elective surgery for patients with parastomal hernias in a country of a similar population and size to Scotland. The UK still ranked bottom for colorectal cancer survival in a league table of seven high-income countries in 2019 [16] and compares poorly in terms of commitment to improving outcomes by centralizing expertise. For instance, almost all UK acute hospitals offer rectal cancer surgery but only 85 institutions in England and Wales carry out more than 25 elective rectal cancer resections each year, and just 34 have a caseload greater than 40 per year; too many also claim to carry out pelvic exenteration [17]. The data for ileoanal pouch surgery are even more stark; recent data suggest that in more than 80% of NHS Trusts less than one pouch procedure is performed each year [18]. The data-driven, evidence-based approach to rationalizing services to achieve high-quality care in Denmark has highlighted the lack of progress in the UK over the same time frame. Barriers to integration are complex and multifactorial. Some fault inevitably lies with the vested interests of healthcare professionals and managers, but political forces also exist where hospital services in any particular constituency are considered to be under threat. The COVID-19 crisis has in some regions, particularly London, removed some of these barriers, allowing a smarter and more rational use of constrained resources. The likely differing speed of recovery in different hospitals strengthens regional solutions to waiting times. Patients appear to be willing to travel to get better care [19]. The possibility of being able to deliver high-value care by a system that integrates care across hospitals is therefore appealing provided there is fair collaboration of hospital managers and healthcare boards. This may be aided further by the digital revolution that has occurred during the pandemic, allowing easier communication between specialists in different hospitals (see below). There are strong caveats to promoting such a change. It is easy to criticize conflation with COVID-19 and that such integration is the wish of self-serving opportunists. However, resistance to change may be perceived as protectionist, reactionary and blind to quality outcomes for patients. A final point is that integration of services into regional pathways offers an opportunity to provide some redress for patient groups that, pre-COVID-19, have been commonly disenfranchised from hospital care, either in terms of access to, or wait for, specialist treatment. Patients with faecal incontinence, other pelvic problems such as rectal prolapse, temporary stomas and stoma problems have already received a raw deal from the NHS in terms of long waiting times. Most will not be excited about returning to a 'normal' that treats them as a 'less profitable' inconvenience in comparison to mainstream disease pathways such as cancer. A separate initiative led by the UK Pelvic Floor Society is developing a report with particular focus on these issues, but the remarks above apply to many bowel diseases that are chronic and difficult to cure. During the COVID-19 pandemic, the number of patients attending emergency departments or seeking help from primary care fell dramatically. Within the surgical community there were widespread concerns about the risks of emergency surgery, based mainly on the Chinese and Italian experiences [20, 21]. A key theme of the advice issued by Public Health England, Joint Royal Colleges and Specialty Associations was to avoid unnecessary surgery due to the unknown (at that time) risks of COVID-19. Conservative management of emergency conditions was advised whenever possible, with increasing use of radiological drainage and antibiotics. As we return to more standard management algorithms, the effect of this change on management of conditions such as appendicitis, cholecystitis and diverticulitis is being assessed in a series of national research projects. Initial results suggest it may be safe to continue this more conservative approach in selected individuals [22] thereby potentially reducing patient harm and use of hospital resources. The culture of the workforce has in many respects changed beyond recognition. In some hospitals, the temporary freedom from bureaucratic norms led to tremendous advances in a short period of time. Examples included rapid procurement, implementation of modern IT hardware and even relocation of whole departments overnight. Remote working was possible and the 'PA counting' attitude was temporarily dropped. COVID-19 highlighted what good teamwork between management and clinical staff can achieve. Progress was built on respect, trust and overall professionalism. Both parties should reflect on this nonadversarial approach, as it was clearly productive. We need to avoid a return to a normal characterized by bureaucratic hurdles and glacial slowness; rather, mutual trust should continue so that both managers and clinicians can push things forwards. There is also need for honesty in speaking out where clinicians are unable to deliver existing standards of care (e.g. National Institute of Health and Care Excellence) due to resource constraints without fear of persecution for failing to deliver preexisting standards in a constrained environment over which they had no professional control. The positive cultural changes between clinicians and management have not been universal. In some hospitals, inadequacies have been magnified by COVID-19 with an increase in bureaucracy and paralysis of services due to both clinical and nonclinical management incompetence. There have been instances of surgeons being bullied regarding PPE and perceived risk. The surgical leadership shown by the Royal Colleges working with the speciality societies including the Association of Surgeons of Great Britain and Ireland, the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the Association of Upper Gastrointestinal Surgery of Great Britain and Ireland has been impressive in providing a joint voice for clinicians to stand behind in this respect, and future close collaboration should persist [23]. The COVID-19 crisis has highlighted the tangible benefits of working in a close surgical team, particularly when providing continuity of care. Communication has been enhanced with more efficient handovers utilizing the resources available within each department. Engagement has happened with all tiers of doctors within the surgical department and has redefined referral pathways with other hospital specialities, moving away from consultant to consultant conversations and empowering all surgical team members to have different and flexible roles. Although this structure has allowed for much needed moral support, the mental strain on surgeons should not be underestimated. Our leadership traits of organization, emotional stability and a capacity to think fast should naturally place us in a position to respond positively to a pandemic [24]. However, rapid and sustained overload as occurs in a pandemic can lead to burnout, especially if patient outcomes are poor and there has been an experience of loss of control [24]. Whilst we rely on colleagues, family and friends to support us during these times, professional bodies need to consider embedding wellness and mental health into their personnel strategies with immediate effect as the consequences from this pandemic may only just be beginning. This moral injury has still to fully play out and may cause another challenging 'wave' in healthcare. In many hospitals, of a structure the has been possible with a consultant-led service allowing and to occur with continuity of care The about such a is its and this the of which has good and In the long to In the of consultant-led practice with consultant this may not be sustainable in the long is to consider planning which for many of us happened naturally during this Whilst by no any of consultant one of could be the experience of the older consultant more and that are more likely to have decision-making and to to that can efficient patient care and outcomes. 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