What to do about SA’s chronic surgical delays

Based on figures from the national department of health, a staggering number of more than 107,000 non-emergency or elective surgeries were put on the back burner during the Covid-19 pandemic. However, challenges to address surgical backlogs were there long before the coronavirus.

Prof Kathryn Chu, director of the Centre for Global Surgery at Stellenbosch University’s Faculty of Medicine and Health Sciences, said compared to infectious diseases such as HIV, TB and Covid-19, surgical conditions and care are not a priority in the public health system.

“Surgery as a whole has not had a national strategy or plan, and I think that is a problem,” she said.

“Our government and province do not have a co-ordinated surgical plan. There’s nothing in the National Health Plan about surgery. It’s not even mentioned.”

Makings of a plan but no funding

Chu said in 2019 a technical working group on national safe surgical care was formed to write a national surgical plan. This is now an official ministerial advisory committee and Chu is a member of the core team.

“Now that National Health Insurance (NHI) is coming, the idea is to have a surgical benefits package defined through this and there will be different factors to consider to identify surgical best buys, which conditions should be covered, how much should it cost the system, what is the burden of disease of that surgical condition and so on.”

The plan, a National Surgical Obstetric and Anaesthesia Plan (NSOAP) for SA, is described as a “blueprint to define a national surgical package of care” and focuses on key areas including human resources, service delivery, infrastructure, supply chain, governance, finance and informatics. Among the main objectives of the plan is to ensure the “implementation of an equitable, accessible and comprehensive surgical, obstetric and anaesthesia care system” for the country.

The initial start date for the plan to be implemented was January 2022. However, according to Chu, there have been many delays and the research is still under way. She said there are a lot of challenges and there has been no money forthcoming from government to fund this.

“It’s planned but there are delays,” Chu said.

“It is very necessary but is taking a lot longer than we thought. It’s going to cost millions to even do the work. Government will have to put in the money if they want to prioritise this.”

Spotlight asked health spokesperson Foster Mohale about progress and resources for this plan but had not received a response by the time of publication.

Shortages in the surgical workforce and the maldistribution of surgical capacity have been a challenge over the years, said Chu. Many specialists are in the private sector and those who are working in the public sector are often working in bigger tertiary hospitals in urban centres.

Referring to cases like the Brooks family’s experience of multiple cancelled procedures, she said this happens to many people and even before Covid-19.

“Patients would drive in for elective surgeries for gall bladder removal, for example, but there are no beds or there will be another emergency and they will get bumped from the list. Even then it was frustrating.”

Chu said for 12 to 18 months almost no elective surgeries were done. Presently hospitals across the country have different strategies to deal with surgical backlogs and some direction from provinces or national government could be helpful.

Devolving surgical care

One possible way to better co-ordinate surgical care is to devolve some surgical care procedures to smaller district hospitals nearer to healthcare users.

According to Chu, however, district hospitals are hamstrung by resource and capacity constraints. Many district hospitals, for example, do not have the necessary ICUs and CT scanners and there are things surgical care needs postoperatively that are not there. The surgical care package they can provide is limited, she said.

“The regional hospitals do what we call ‘bread and butter’ surgery and mostly have some good capacity. However, there are many district hospitals that are smaller and in rural areas that should (based on international practice) be providing basic surgical care but what that surgical package of care should look like is not that well defined, specifically in SA.”

Also weighing in on possible solutions to improve the co-ordination of surgical care, associate professor Lydia Cairncross, University of Cape Town Global Surgery Oncology Lead at Groote Schuur Hospital, said from a cost efficiency point of view it is much better to treat patients at a district rather than central hospital level.

“But a lot of relatively minor surgery that could be done at district level hospitals is being done at central or regional hospitals,” said Cairncross.

This adds to the service pressures at these hospitals.

“We need to focus on the district hospitals and ensure they have the capacity to provide a package of surgical procedures. At present it’s very patchy.”

Beefing up the surgical workforce

Both Chu and Cairncross flagged staff shortages, especially theatre nurses, as a huge challenge.

According to Cairncross, the more immediate priority for government is to unfreeze all posts so surgical teams can be capacitated.

“I don’t know how to emphasise this enough,” she said.

“There’s doublespeak happening when we talk about capacity. We need human resources but at the same time we have a growing unemployment crisis among junior doctors. There are people who can do the work but funded posts are not available.”

According to figures from the national health department, by May this year there was a 15.47% vacancy rate of critical skills personnel in the nursing category, which meant 22,655 vacant posts.

“When someone resigns or retires, the post is often left unfilled for six to 12 months and the whole system spirals into chaos while that person isn’t in place. This obviously has knock-on effects with other people who get burnt out and also leave,” said Cairncross.

“The first step in a national co-ordinated response would be to fill all theatre-related vacant posts as a matter of urgency.”

Chu echoed this and said there’s a shortage of nurses and many are already working maximum time shifts, so opening up theatres on weekends will not properly address the backlogs.

The health department has cited budget constraints as the reason posts in the public health sector are not filled immediately.

Many health budgets, including in the Western Cape, took a knock with Covid-19.

Chu said in the Western Cape the government put money into a recovery plan, “but that was a one-off and most of the time they want you to do more without necessarily increasing the resources”.

She said district hospitals often have theatres that are empty most days because they don’t have the staff to run them, while tertiary hospitals, due to different surgical specialities, are almost always full.

“If you’re looking for more theatres, one solution is to go to the smaller hospitals but surgeons need theatre nurses.”

We need to train more theatre nurses, she said.

“One way to do this would be to have spent the money for Covid-19 surgical recovery on training more nurses, but the province was thinking more about a quick fix.”

Cairncross said there is a tremendous amount of red tape and bureaucracy around getting specialist nurses trained.

“It doesn’t really help to train up GPs, which we can do. To do these operations you need to have a theatre team and the core of the theatre team is the nursing team. We absolutely need to invest in training theatre nurses.”

What makes SA unique, Chu said, is that you don’t have to be a specialist to perform surgery or anaesthesia.

“There are many GPs and medical officers who do some operations and who give anaesthesia who never qualified as a specialist per se. On the other hand, their training is variable and not that well-regulated and there isn’t a standard of care on what procedures they should know how to do. It’s a bit hit or miss and personalised depending on where the person is working and who their mentor is.”

Cairncross said the country needs to have a national plan for developing the human resources for surgery.

“That is not only the theatre team but also builds into the nursing teams in the ward as well as the post-operative rehabilitation which includes physiotherapy and occupational therapy . All this needs to be part of this planning,” she said.

“For example, you can do a beautiful hand operation but if you don’t have physio and OT postoperatively it’s almost as though you didn’t do it. Your rehabilitation is a critical step in surgical care, which we can’t forget.”

Health minister Joe Phaahla, in response to a written parliamentary question, recently said the SA Nursing Council’s figures show there were 52,887 specialist nurses who completed their studies and registered as nursing specialists over the past 10 years. The figures, however, show that despite this number of qualified specialist nurses, the number of appointments in the public sector remains low. This is, Phaahla said, among other reasons, due to the private sector absorbing some nurse specialists, and some nursing specialists, such as ICU-trained nurses, “prefer to work for agencies, as proven during the height of the Covid-19 pandemic”.

Co-opting private sector resources

Another way to beef up surgical capacity is to lean on the private sector. During Covid-19 there was a small taster of what this relationship could look like when the government bought private sector beds for Covid-19 patients and paid specific amounts of money per day per patient.

However, there are some considerations to keep in mind.

According to Cairncross, there are many levels at which there can be support between the two systems, for example, with theatre space. This will mean private hospital theatres are used for public sector patients.

“The question then arises: who’s the theatre team that does that?” Cairncross asked.

“Is that the theatre team in the private hospital or are they coming from the public hospital? It sounds like a good solution on paper but in terms of impacting with hundreds of operations, it can be quite difficult to do.”

She said there are already some public/private programmes running, such as Saturday (surgery) lists done in private hospitals. That helps, she said, and should be encouraged.

“But the true impact comes from investing in building capacity in the public sector. If you compare a once in a while Saturday list, maybe once a month or every two months in a private hospital to what we are trying to do and are doing without recovery, which is eight lists a week, it’s incomparable.”

Cairncross said another way the private sector can help is through sharing surgical expertise, especially in smaller district hospitals where there is a theatre and nursing staff but no anaesthetist or surgical expertise.

“These skills can be volunteered,  contracted in or paid locum fees to support lists in the smaller hospitals, but you still need to have a surgeon in the public sector who is screening and ensuring it’s the correct operation and so on.”

This article was first published by Spotlight