“Perfect,” says Seana Ruddick. Her single word tells the surgeon Sam Oussedik that the robot-assisted knee replacement he is performing is going well. He is removing the joint using a combination of old-school tools – a hammer and chisel – and cutting-edge technology – the saw blade of a Mako robot. It is a noisy and smelly process. Viewing is not for the weak of stomach.
Ruddick, a Mako specialist, is Oussedik’s guide as he works in an operating theatre in one of the five below-ground levels of the Grafton Way Building, a 13-storey new extension to University College hospital in central London.
She constantly monitors a screen on the robotto track the progress of the surgery on their patient Patricia Pavey’s painful knee. It tells Oussedik exactly how much bone he needs to remove, down to the last millimetre, to accommodate the prosthetic. If he sought to take out even a fraction more, the robot, having analysed a 3D image detailing the joint’s topography, would stop him.
It will take 80 minutes for Pavey, a retired antiques dealer, to receive her new joint. With luck it will end her longstanding knee pain and help her walk normally again.
The trays of surgical equipment brought by the scrub nurses from the “prep room” to the foot of the operating table include a power saw that looks like a DIY tool bought in a hardware shop.
Today it will take off the back of Pavey’s kneecap – “just like the top of a boiled egg coming off,” says Oussedik, a consultant orthopaedic surgeon. Oussedik and his colleague Simon Walgrave will then hammer into place a new permanent knee and secure it using bone cement.
Songs from a team member’s playlist, including She Loves You by the Beatles and Sit Down by James, keep things relaxed.
The operation is a success, but afterwards Oussedik is unhappy. “Patricia was first referred to me 18 months ago,” he says. In an ideal world he would have operated on her in May or June last year. “That’s fairly typical at the moment as we are treating now patients who have been waiting since before the first Covid surge, though the average wait is less than that. Eighteen months is a long time to wait for a new knee.”
Looking back to before the pandemic, he adds: “Our promise pre-Covid was that people would have had their surgery as far as possible within 18 weeks from referral. [But] because of Covid it’s 18 months. Waiting times like that take me back to when I was a junior doctor more than 20 years ago, back in the late 1990s. Long waits are bad for the patients because their life goes on hold. They are in daily if not constant pain.”
The number of people in England on the waiting list for care such as a hernia repair, cataract removal or hip or knee replacement has ballooned to the once unimaginable total of nearly 5.5 million, the highest it has ever been.
The numbers having to wait six months, a year, 18 months or even two years for an operation have also reached record levels. This week the Guardian revealed a stark postcode lottery when it comes to the NHS backlog, with some areas having 25 times more patients awaiting certain types of surgery than others.
About 7 million people who needed help over the last 18 months are thought not to have got it, so the potential for the waiting list to grow much longer is obvious. The health secretary, Sajid Javid, has made clear he expects many of the 7 million to come forward in the months ahead and create a further “huge increase in demand”, which will inevitably lead to even more people waiting. Doctors, hospital bosses and health charities fear the delay will lead in some cases to diseases that took longer than usual to spot becoming untreatable, and thus avoidable deaths.
Even if Covid recedes, it will cast a long shadow over the NHS for years to come, through long Covid and an increase in mental illness but especially through the backlog. Experts have warned that what NHS bosses refer to as “recovery” – getting back to previous levels of surgical activity and reducing delays – will take three to five years.
Despite Pavey’s experience and the national picture, University College London hospitals trust (UCLH) is one of the few trusts to have fewer patients waiting now than before the pandemic. It gave the Guardian access to its new facility and some of its top doctors to demonstrate what it is doing to tackle its pile of undone surgery.
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With its blue and green soft chairs and long multicoloured drapes, the Grafton Way building’s reception could easily be mistaken for a hotel. While there is no A&E it does have a 32-bed surgical ward, a critical care unit, 36 beds for patients to recover in after surgery, eight operating theatres and four new robots, though these were funded by UCLH’s charity and not the NHS trust itself – a reminder of the Treasury’s squeeze in recent years. By the end of the year it will also contain what trust bosses say will be Europe’s largest treatment centre for blood cancer.
Below ground it is home to one of the NHS’s two new proton beam radiotherapy centres, which is opening soon. The centres – the other is at Manchester’s Christie hospital – will mean the NHS no longer has to pay for cancer patients whose survival may depend on proton beam treatment to go abroad, as it has done for years.
“This building is at the heart of what UCLH, [the NHS’s] north central London [region] and London in a bigger way is doing to help catch up on the increased numbers that have arisen as a result of backlogs caused by Covid,” says Prof Fares Haddad, the trust’s divisional director of surgery.
Haddad points out that Grafton Way was planned long before coronavirus appeared. UCLH conceived the new facility to tackle what was already a problem across the NHS – patients having to wait in pain and uncertainty. The virus has merely exacerbated the problem.
“There has always been a backlog of surgery in the NHS. It’s just that it’s reached a staggeringly large size,” says Haddad, an orthopaedic surgeon. He recalls how in March last year “I literally just switched off my waiting list. A colleague rang all the patients on my waiting list and said: ‘Just to let you know you’ve been cancelled, we’re sorry and we’re thinking of you.’”
Prof Geoff Bellingan, UCLH’s medical director for surgery and cancer, recalls how it had no choice in the second Covid wave last winter but to stop doing non-urgent surgery. “We went from 35 intensive care unit beds to 117 but we didn’t have staff for 117. We needed all the anaesthetists, theatre scrub staff and recovery staff to help run all the extra ICU beds.”
While the England-wide waiting list has risen inexorably because of Covid, UCLH has bucked the trend. It had 42,383 people on its waiting list in March 2018. By February 2020, as the pandemic was unfolding, the number had risen to 52,972. But by April this year it had been reduced to 44,550 – still higher than trust bosses would like.
It is not all good news, though. More than a third of its patients still have to wait more than 18 weeks, four times the 8% allowed for in the target. And the number of people awaiting orthopaedic surgery is still much higher than pre-pandemic. However, given the chaos and disruption from Covid, it is a major accomplishment in the circumstances.
How has it managed to shrink its waiting list? UCLH has taken advantage of NHS England’s contract with the independent healthcare sector to send patients it cannot operate on quickly enough, including those needing cancer surgery, to private hospitals in London such as the Wellington and Princess Grace. The Treasury has picked up the tab for NHS patients treated that way, who have thus avoided an extended delay and only paid NHS rates.
The trust also ran extra surgical lists on six “super Saturdays” in May and June, when 124 patients underwent operations for which they would otherwise have had to wait even longer. All were done as day surgery cases, involving no overnight stay.
Grafton Way’s eight operating theatres are also helping. Fortuitously, they have come on stream at the same time as Covid has sent waiting lists rocketing. The main advantage of the robots being used there in hip and knee replacements and ear, nose and throat procedures is greater precision.
There are several constraints on UCLH going faster in its “recovery” drive. They include staff shortages, especially of anaesthetists and nurses. But the biggest limit on progress is the need for staff to have proper time off to protect their wellbeing. One UCLH official says: “Staff have been through an horrific period. They have worked hard, experienced more death, felt helpless at times and wanted to do more than they were physically able to do for [Covid] patients. We should not be asking too much of staff bearing in mind what they have been through.”
Flo Panel-Coates, the trust’s chief nurse, says many personnel are “weary”. UCLH has expanded its programme of help and support, such as through a 24/7 counselling service, improved rest areas, provision of virtual reality goggles to let staff switch off after a busy shift, and online origami sessions. There is also free massage, walking and running clubs and more flexible working.
Covid has left UCLH “a broken workforce”, says Haddad. “There’s this tension between looking after our staff, who frankly have done an amazing job over the last 18 months, and allowing them to take leave, but at the same time increasing activity.”
Staff are told that extra hours and additional shifts are available and that they will be paid extra for doing them, but they are not pushed to sign up. “The reality is that we all feel we owe something to this group of patients we’ve met and put on a waiting list and now we’ve got to catch up,” Haddad adds.
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Like all health professionals, Haddad and Bellingan worry about the backlog’s impact. “I feel sorry for the patients out there. Waiting is a real hit on their anxiety. We want to do everything we can but we have limited resources,” says Bellingan.
Does the backlog keep him awake at night? Bellingan pauses. “Yes,but it’s more than that. It has a draining effect.”
Haddad admits doctors will need to take difficult decisions about whose medical need is greatest. “Every patient on that list needs their surgery, and elective surgery is not optional surgery. We are pushing as hard as we can.”