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Backlog of care and treatment COVID-19 has placed the health and social care system under unprecedented pressure this year. To meet the demand created by the pandemic, a range of non COVID care and treatment was postponed at the peak of the crisis to free up capacity of the NHS. These decisions have created a long-term challenge, with a significant backlog in treatment and care.[1] Postponing all non-urgent elective operations for a period of three months is estimated as resulting in more than half a million cancelled procedures.[2] This, alongside other challenges to restoring services following the peak in the pandemic, could result in the waiting list reaching 10 million by the end of 2020.[3] Impact on patients The delays in treatment resulting from this backlog will have a significant impact of patients’ quality of life and, in some case, their survival. For those managing chronic diseases, such as arthritis, long delays in fairly common surgeries (for instance knee replacements) can reduce functional capacity gain and lead to increased pain and disability.[4] Meanwhile, a recent study looking at delayed diagnosis and cancelled treatment for cancer cases during the pandemic suggested that this could result in “anywhere between 7,000 and 35,000 additional deaths from the disease over the coming year”.[5] In addition to those waiting to be referred for treatment, there is also the issue of high numbers of patients waiting on follow-up appointment. Clinicians have expressed concerns about the clinical risk to those facing delays on their follow-up outpatient lists, particularly because the scale of this is hard to gauge due to there being “no official, verified data on follow up appointments”.[6] Addressing the backlog safely In its recent ‘Third Phase’ response guidance, the NHS identified one of its three key priorities as “accelerating the return to near-normal levels of non-COVID health services, making full use of the capacity available in the ‘window of opportunity’ between now and winter”.[7] As we do this, it is vital that patient safety considerations are placed at the heart of this process, as the NHS seeks to address the backlog of cases while also meeting regular demand for services. Key points to consider include: How are organisations tackling the treatment backlog? How is access to treatment and care being prioritised? What are the risks to patient safety, and are these being addressed? Who will ensure that patients’ needs are considered, and who will provide information to manage patients’ expectations? Should cases where surgery delays lead to significant health issues, or even death, be considered as serious incidents? Do we have adequate data about the backlog so we can quantify the problem and manage waiting lists, whether referral to treatment or follow-up appointments? Find out more - join the webinar Are you interested in hearing more about these issues? The webinar is scheduled for 11.00am (BST) on Wednesday 16 September and you can sign up here. References Patient Safety Learning, Response to the Health and Social Care Select Committee Inquiry: Delivering Core NHS and Care Services during the Pandemic and Beyond, 8 May 2020; Patient Safety Learning, The return of elective surgery and implications for patient safety, 15 June 2020. Estimates on this figure vary between around 516,000 at the lower end of the scale (University of Birmingham, COVID-19 disruption will lead to 28 million surgeries cancelled worldwide, 15 May 2020) to potentially as high as 749,248 (Alexander Fowler et al, Resource requirements for reintroducing elective surgery in England during the COVID-19 pandemic: a modelling study, medRxiv, 2020). NHS Confederation, Public reassurance needed on slow road to recovery for the NHS, 10 June 2020. Versus Arthritis, Written evidence submitted by Versus Arthritis (DEL0173), May 2020. Health Data Research UK, The Big C isn’t COVID-19 – it’s cancer, 25 August 2020. Health Service Journal, Recovery watch: the NHS' biggest restoration challenge, 2 September 2020. NHS England and NHS Improvement, Third phase of NHS response to Covid-19, 31 July 2020.

Key points Recurrent nurse workforce shortages are a global issue, also in high-income countries. Implementation of safe staffing policy measures largely varies across the world. Mandated patient-to-nurse ratios are the most straightforward policy to ensure staffing levels. Our overview of policies from various high-income countries may guide future decision-making.

The results found there were 129 unique mentions of barriers to patient safety; these barriers were categorised into five major themes. ‘Limited resources’ was the most prominent theme, followed by barriers related to health systems issues, the medical culture, provider training and patient education/awareness. Although inadequate resources are likely a substantial challenge to the improvement of patient safety in India, other patient safety barriers such as health systems changes, training, and education, could be addressed with fewer resources. While initial approaches to improving patient safety in India and other low- and middle-income countries have focused on implementing processes that represent best practices, this study suggests that multifaceted interventions to also address more structural problems (such as resource constraints, systems issues, and medical culture) may be important.

Birth choices Our pregnant women are still being offered good choices in their birth experience such as homebirth and water birth, so long as they are well. I did two lovely home births this week. We are definitely seeing a rise in people transferring to our homebirth service. I do think there is a concern nationally about high risk women choosing to homebirth unassisted, in areas where maternity services have suspended homebirth as an option. Because women in my area still have the option of a homebirth, it’s not something we’re experiencing. Birthing partners and limited visits Partners are allowed at births including cesarean sections. Also, we’ve had lots of very positive feedback from the women to say that not having their partners or visitors on the wards hadn’t been as bad as they thought, as they have talked and bonded more with other new mums and made new friends. It’s difficult for them without the support of family in the postnatal period but with encouragement they can usually see it as a positive, a time for them to bond as a family and get to know their little ones. Dads are actually very positive realising that it means they get to spend much more time with their partners and new baby. Appointments and new ways of working My Trust are doing just as many face to face antenatal visits. We do virtual appointments at booking and 16 weeks in the vast majority of cases but GPs locally are refusing to see women at 25 and 31 weeks, so we have changed the schedule to include these in midwifery care. We are using well midwives, who are isolating at home for whatever reason, to do phone clinics for booking and 16 week appointments which lifts the pressure off those of us working clinically. They also ring around all of the women due to be seen to make sure they’re well and understand that they need to attend appointments alone. I’m a case loading midwife so I know my mums to be/new mums well and do feel I’ve been able to support and reassure them effectively. I know that sadly not everyone is in this position though. Staff levels and wellbeing Annual leave has been cancelled. Nobody has complained about this though (or at least nobody that I’m aware of). We were expecting it and realise it’s vital. Lots of staff are also picking up extra shifts. If staffing levels drop though the pressure will be enormous. My trust have been very proactive regarding training and we are all being supported in terms of wellbeing. Accommodation has been provided for staff unable to go home and wellness packages and mental health support is in place. We’ve even been provided with a pop-up supermarket. Our local community are also amazing. Most staff could access a free hot meal most days if they chose to from various donations, school, restaurants and local sports teams. Hand cream, treats, snacks etc are always coming in. We feel so appreciated and loved One of our biggest issues is PPE Even for confirmed COVID-positive women we are given less protection than we are normally given when caring for women with flu. Working in community, this has its own issues. Statistically we know that the chances are that viral loads in homes are likely to be high due to the number of people present in small spaces, more soft furnishings, less stringent cleaning routines etc. The apron and mask we are given are unlikely to offer us any real protection. When we leave the houses we then have to transport the contaminated personal protective equipment (PPE) in our own vehicles, we’re wearing uniform that is likely to be contaminated and we are stood on pavements trying to clean the equipment we have used because that too will be contaminated. We’re not protected in the same way that hospital staff are. We are walking in to homes where there may be 4 or 5 people in the same room that we need to be in, as everyone is at home. We keep being told effective hand washing is key but we’re doing that in environments which are often less than clean, and in cases of COVID-confirmed women we can’t wash our hands at all as we’re unable to remove our PPE until we’ve left the house. It all feels very unsafe both in terms of staff contracting COVID-19 and cross contamination to other women, colleagues and our family. The support we are lacking comes from Public Health England and the Government. PPE guidance and availability is pitiful and dangerous and I believe is based on availability rather than need or any scientific basis. Do you work in maternity services? Or perhaps you are expecting a baby? Does this midwife's account reflect the maternity services in your area at the moment, or are you seeing different positives and challenges? We want to hear from patients and staff, so please sign up to comment below or contact us directly (content@pslhub.org) to share your story.