With state hospitals across the country buckling under a mounting backlog of surgeries, special interventions are being made to tackle the problem which has reached crisis levels post-Covid-19, notes MedicalBrief.
In Gauteng, with a backlog of 175 000 elective surgeries, and a long wait for radiation oncology services, the provincial Health Department has set aside R784m to deal with the crisis.
And in the Western Cape, a project initiated in May last year, the Surgical Recovery project at Groote Schuur Hospital, has reached the target of slashing its backlog by 1 500 elective surgeries – two months ahead of schedule.
Writing for Spotlight, Elri Voigt reports that Surgical Recovery project was concluded at the end of March, and while it hasn’t completely cleared the entire backlog of people awaiting surgery, it has returned the hospital to about the same waiting list level as before the pandemic, according to Professor Lydia Cairncross, head of general surgery at Groote Schuur.
The operations took place mainly in the E4 Surgical Day Ward, which generally handles surgeries where patients don’t require an overnight stay pre- or post-surgery.
E4 has 16 patient beds, four recovery beds, and two theatres, which were completed just as the pandemic hit the country. During the third wave, it was used as a Covid High Care Unit.
Dr Shrikant Peters, a public health specialist and the medical manager of theatre and ICU services at Groote Schuur, said the hospital’s CEO Dr Bhavna Patel “had the foresight to request provincial use of Covid funding to develop the space as Covid High Care, and to eventually be used long-term as an operating suite and high care ward in line with previous plans”.
The Surgical Recovery project
After the third wave of the pandemic, added Cairncross, there were discussions about how to catch up on the surgeries that had been postponed.
“The backlog comes on top of a pre-existing backlog. In November 2021, we did an audit of how many patients were just physically awaiting surgery and it was around 6 000. We don’t actually have a baseline for pre-Covid, but we knew that we lost about 50% of our operating capacity,” Cairncross said.
“The idea was really to find a way to utilise this theatre space, to catch up with some of that backlog.”
From here, the Surgical Recovery Project for Groote Schuur was born, with the ambitious target of performing 1 500 surgeries in 12 months.
Funds from the project came from three sources. Kristy Evans, head of the Groote Schuur Hospital Trust, said that fundraising for the project was jump-started by a R5m donation from Gift of the Givers. The recently established Trust focused on Surgical Recovery as its first project for which to fundraise, bringing in an additional R1m from more than 500 corporate and private donors.
The Western Cape Provincial Department of Health also donated around R6.5m to the project from its budget for surgical recovery post-Covid.
Provincial health spokesperson Mark van der Heever said this money was part of the R20m the department allocated to various surgical backlog recovery initiatives.
“Similar projects have already been successfully undertaken, such as at Karl Bremer Hospital, which also received a portion of the R20m and has performed an extra 328 procedures since August last year.”
Working around difficulties
Cairncross said with any surgical catch-up, the challenges don’t just come from needing a physical space in which to operate but also from having appropriately trained staff. Not having theatre and surgery nurses makes it hard to implement a catch-up programme, even if there is money available.
To work around these difficulties, Groote Schuur devised a centralised model for surgical recovery, where one theatre nursing team could be employed on a contract rate for the 12 months.
This team, led by Sister Melinda Davids, the nursing operations manager for the E4 theatre, would work Monday to Thursday in one of the E4 theatres and occasionally other theatres in the hospital for each of the 1 500 surgeries.
Cairncross said a number of surgeons, herself included, would go and operate on patients in addition to their normal surgeries and other duties. The funds, about R12.5m, were used to pay the staff involved in the surgeries. The 1 500 operations ranged from cataract to cardiothoracic.
Success factors
Cairncross attributes the success of the project to the existing systems at Groote Schuur, supportive management, and the dedication of the surgical team and surgeons who gave their time to the project.
Because the hospital has a relatively functional system to begin with and a supportive management team, it allowed for “enough of a regulatory environment to keep things safe and above board but not to the extent where you can’t move”.
It was also about having the right person in charge of the team, she adds, referring to Davids.
According to Davids, when the project started, several of the nurses had not worked in a theatre before so had to be trained and upskilled by her and some of the specialist nurses who make up the scrub nurse team. She also had to get creative about having the right equipment for each surgery, which sometimes meant she had to borrow equipment from other theatres.
Health system at a ‘precipice’
Peters said the shrinking health budget for tertiary services would continue to add to the backlogs countrywide.
“That’s going to be with us for multiple years and if the clinicians aren’t protecting the budget for these patients who get missed, we’re going to focus on – as we have been – the emergency patients coming through the door. But it’s always difficult for tertiary academic services because to keep up the skills of surgeons to maintain the quality of care, they need to be managing waiting lists of booked patients.”
Cairncross told Spotlight the project was just a temporary measure. In the long term, healthcare systems need to be fixed to address issues like surgical backlogs.
“Fundamentally we need to fix the health system at a core, structural level. And we can’t work in isolation from the rest of the country because we are one health system and tertiary hospitals are only a part of that ecosystem. The services at Groote Schuur, for example, cannot be sustained if the health systems – from primary care to district health facilities, in urban and rural facilities, and across provinces – are not supported and strengthened.”
The health system was at a precipice, she added, and big academic hospitals need to be anchoring elective surgical services with with emergency services.
“We know that postponed elective surgery just becomes emergency surgery over time, making cancelling elective surgery a false economy. We need to plan robust systems to ensure all types of surgical services are maintained.”
Meanwhile, in Gauteng, presenting the Health Department’s budget vote speech last week, MEC Nomantu Nkomo-Ralehoko said the surgical backlog had severely affected the healthcare system in that province, reports News24.
In January, more than 10 900 patients at Chris Hani Baragwanath Hospital were awaiting vital surgeries, and 1 777 could find themselves waiting for hip and knee replacements for more than four years.
In the same month, the South African Medical Association called for the public healthcare system to be declared a state of emergency to save people’s lives.
According to the MEC, within just 18 months, 2 218 operations had been deferred or cancelled at Charlotte Maxeke Academic Hospital for various reasons, including load shedding lack of funds, no beds for the intensive and high care units, and strikes.
In response to a question from the DA on the number of cancelled/deferred operations in 2022 and 2023, in the legislature this week Nkomo-Ralehoko said a total of 1 773 surgeries in 2022 and 445 in 2023 had been affected at the hospital.
Earlier this year, it was reported that Charlotte Maxeke was just one of many with a long waiting list for procedures, with 3 132 patients awaiting operations.
Nkomo-Ralehoko said 1.3% of surgeries were cancelled or deferred due to factors that could have been avoided with better management.
Remedial action was reinforcing procedures through workshops, on-the-spot teaching, and various clinical forums.
“There is also the need to strengthen the supply chain management system, both in-house and at the central level, to ensure that it gives dependable support to clinical and other services at an operational level. Some of the processes have to be decentralised to cut down on long lead times,” she admitted.
Gauteng DA health spokesperson Jack Bloom said he had received many complaints about surgeries being cancelled because there were either no beds in the intensive care units, or equipment wasn’t working, or there was no clean linen.
It was disappointing, he added, that more ICU beds were not planned at the facility, as this was a major cause of long waiting lists for the more complicated operations.
In defence, the MEC said while persistent equipment breakdowns at government hospitals had resulted in the huge elective surgery backlogs, as well as staff and equipment shortages, on the upside, the province had “successfully expanded our capacity to perform surgical procedures in multiple hospitals”, affirming confidence in what its “centre of excellence”.
Doctors at Sebokeng Hospital recently performed the facility’s first brain surgeries on two patients, while surgeons at Bheki Mlangeni carried out the first cardiac surgery at the district hospital, she pointed out.
The MEC added 11 242 cataract operations had been completed in the 2022/23 financial year, with 2 362 done between January and March.
While oncology services had been a challenge, they would now be expanded to cover Baragwanath and Dr George Mukhari Academic Hospitals, she said.
Bara’s paediatric haematology oncology unit had treated 5 475 children, and the newly established Soweto Comprehensive Care Centre had treated 5 656 cancer patients.
“To ensure patients requiring radiation oncology services are not disadvantaged by the reduced public health resources, … private sector providers will be appointed to supply radiation oncology services this year.”
See more from MedicalBrief archives:
Groote Schuur donors beef up resources to tackle surgery backlog
Donations plea to fund Groote Schuur’s 6,000 surgery patients’ backlog
How Groote Schuur Hospital’s ICU adapted to the pandemic