Surgery waiting lists: ‘Emergency department patients will always win over elective patients’

Since mid-July, Prof Kevin Barry has been back working to a full schedule of surgery. “My weekly timetable is not hampered by Covid now, but there is an element of catch-up which is affecting the whole of the country, and we don’t know what will happen this winter with flu and Covid,” Barry, a consultant general surgeon at Mayo University Hospital and Galway University Hospital.

Virtual outpatient clinics (where patients speak to their consultant on the phone rather than go to the hospital), targeted weekend waiting list initiatives for endoscopic surgery (investigative procedures for stomach and bowel conditions) and weekend symptomatic breast outpatients clinics are some of the ways surgeons are trying to make up ground lost during the Covid pandemic.

The backlog in surgeries for hip and knee replacements and other routine surgeries following the pandemic has emphasised more than ever the importance of having specific hospitals dedicated to elective surgery, according to Prof Deborah McNamara, colorectal surgeon at Beaumont Hospital and vice-president of the Royal College of Surgeons of Ireland (RCSI).

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Reflecting on the impact of the pandemic on surgical procedures, Prof McNamara says patients needing operations were the “net losers” in hospitals because so much capacity was given over to treating Covid. “In the big hospitals, we never stopped operating and we were dealing with the most complex patients with cancer and other conditions, but operations took more time and the waiting lists increased even more,” she explains. “The only way we will ever cope with waiting lists is to ring-fence surgery beds for elective patients.”

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Eighty per cent of patients on waiting lists in Ireland are awaiting a surgical procedure, according to Prof McNamara. “Two-thirds of these are waiting for a short intervention which doesn’t require the patient to stay overnight.”

Respiratory infections

As we face into the winter season, Prof McNamara says that during the expected increase in respiratory infections – whether flu or Covid – the first patients whose procedures will be postponed will be elective patients. “These patients are not as visible as others [waiting on trolleys] because they are at home. Emergency department patients will always win over elective patients,” she claims.

The Sláintecare report proposes new hospitals in Dublin, Cork and Galway specifically for elective surgeries, day cases, overnight cases and surgical procedures including scopes on the bladder, stomach, bowel and ear, nose and throat.

Prof McNamara doesn’t believe the National Treatment Purchase Fund is a suitable long-term mechanism to solve waiting lists because it constrains capacity in the original hospitals, thus never allowing them to maintain their staff capacity and expertise to treat enough patients in the future. “Surgical care pathways, surgical training opportunities and career progression for surgical nurses are all disturbed by a system that takes patients out of hospitals so resources aren’t built up to cope with future demand,” she argues.

Prof Barry says that, in the long term, demand for surgery in Ireland is on the increase both due to overall population increase and our population getting older. “The National Doctors Training and Planning unit in the HSE projects that we will need 35-40 per cent more consultant surgeons by 2030,” says Prof Barry, who is also the director of national surgical training at the RCSI.

Currently, there are just over 700 consultant surgeons working in public and private hospitals in Ireland, 30 per cent of whom are over 55. And while the RCSI has increased the number of trainees on its eight-year-long postgraduate surgical training programmes by about one-third to 80 intakes per year (alongside another 600 non-consultant doctors working directly under the supervision of consultant surgeons), it will be a challenge to ratchet up consultant surgeon numbers to adequate levels as older surgeons retire and some trained surgeons choose to work abroad.

Robotic surgery

In October 2022, the RCSI began introducing robotic surgical training. “The introduction of laparoscopic [keyhole] surgery in the late 1980s/early 1990s was a revolution in minimally invasive surgery and robotic surgery is the next revolution. It offers significant benefits to patients in terms of precision, technical refinement and the protection of normal tissue,” explains Prof Barry.

“It is particularly apt for urological, gynaecological, colorectal and neurosurgery,” adds Prof Barry who suggests robotic surgery works best for elective surgeries with dedicated teams trained specifically in its techniques. “My job is about coping with the demands of elective and emergency surgery on any given day but, ideally, as we move towards the introduction of these new technologies, elective and emergency surgery should have their own operating theatres.”

The high level of bed occupancy in Irish hospitals is another concern. “Hospital bed occupancy is very high in Ireland – around 95 per cent. When patients are waiting for a bed in the emergency department it’s hard for best practice – 90 per cent bed occupancy at any one time – to be maintained,” says Prof McNamara.

Leaving beds in hospital wards empty for a certain period of time is the best way to prevent hospital-acquired infections. “In the Netherlands, when a patient leaves the hospital, the bed is taken out for an industrial cleaning process and a new bed is put in its place,” she explains.

Speaking in general about how patients can best prepare themselves for surgery, Prof McNamara says that all the simple advice applies. “Stay healthy, stay fit, eat well and stop smoking. Even someone who stops smoking two weeks before surgery, reduces the risk of surgery, increases blood flow and wound healing,” she explains. She also advises patients to know and understand the medications they are on before coming to hospital for a surgical procedure.

She believes that patients should have the option to be treated by a male or female surgeon if they have a preference – especially for surgery on intimate parts of the body. “Older men with prostate cancer might not be as comfortable with a female surgeon and, for Muslim women, having access to a female surgeon might mean that they will get healthcare that otherwise they might not seek help for.”