Almost five months ago elective surgeries came to a standstill. This was reflected in claiming patterns in the private healthcare sector during lockdown – a disruption of the norm globally. In South Africa, elective surgery in both the private and public healthcare space and specialists’ visits are just two of the areas which have been affected by Covid-19. The link between the two is clear: Fewer specialists’ visits mean fewer referrals for surgery.

So what exactly is elective surgery?
The term can be ambiguous. It does not mean, as the name implies, that the surgery is optional but rather that it doesn’t need to be performed immediately. It can be scheduled at the patient’s and surgeon’s convenience. Some of these surgeries are necessary to prolong life, for example an angioplasty or, as in most cases, improve the quality of life. In brief, elective surgery is ‘A planned, non-emergency surgical procedure’.

Elective surgeries dropped by over half
According to Lee Callakoppen, principal officer of Bonitas Medical Fund, “there has been a 60% reduction in hospital authorisation requests compared to 2019. A study release in March predicted that an estimated 28.4 million elective surgeries worldwide, would be cancelled during the 12 weeks of peak disruption due to the global pandemic. This has been a similar experience to other industry role players and is predominantly due to a combination of member fears related to Covid-19, lockdown and provider caution.”

Surgeries delayed not cancelled
The postponement of surgeries was done to prevent patients taking up hospital beds and to avoid unnecessarily exposure to the virus – a strategy that worked well to flatten the curve. Surgeries were delayed based on provider discretion and subsequent patient engagement. Callakoppen says: “Providers are best placed to make these clinical decisions in the interests of their patients. If the procedures were emergencies or urgently required to enable member quality of life, those would have proceeded.”

The public sector too experienced backlogs in terms of elective surgeries. Examples are procedures including but not limited to, cataracts, orthopaedic surgeries, scopes, caesarean sections, tonsillectomies and adenoidectomies.

BHF cautioned funders
In July, The Board of Healthcare Funders (BHF) and its members in the healthcare funding space requested members of medical schemes to proceed with caution in scheduling elective surgical procedures. Dr Rajesh Patel, head of benefit and risk at the BHF, said: “While the relaxation of the lockdown restrictions is good news for people, the country and the economy at large, we are still in the eye of the storm.”

The way forward?
“As we move toward Level one, elective surgeries are almost back to normal,” says Callakoppen. “It’s time to address the backlog of surgeries not considered emergencies during lockdown. These include slow-growing cancers, orthopaedic and spine surgeries, airway surgeries, surgeries for non-cancerous tumours as well heart surgeries. We caution against a rush of elective surgeries though. Any surgery has an impact on the immune system, which means the patient has a greater risk of contracting Covid-19 and developing complications from it.

“It must further be noted that in some instances surgery is often recommended by specialists as one of the key courses of action. But we have noted that managed care protocols, in many instances, improve clinical outcomes with lower risk to the patient. One such example of this is spinal surgery, which is often unsuccessful. From a Bonitas perspective, we have noted that in the back and neck programme, which enforces functional rehabilitation has been far more effective for our members. In addition, the risk to the member is significantly lower.”

Bonitas recommends the following is taken into account:

• That elective surgeries should only be resumed in instances where not having the procedure will severely impact the members’ health and quality of life
• That the current state of a patient’s healthcare is assessed – individuals with chronic conditions such as diabetes, asthma HIV/Aids and hypertension, are at high-risk of developing Covid-19 complications
• The patient’s age is taken into consideration (older individuals are identified as one of the most vulnerable groups)
• The impact of waiting on the patient’s healthcare outcomes (for example, is it essential that the surgery takes place now or can it safely be deferred for a few months)
• Alternative care protocols – in some cases surgery, which should be a last resort, is prescribed without considering other treatment protocols such as rehabilitation. The most common examples of this include back and spine procedures, elective c-sections as well hip and knee replacements
• The use of day hospitals and clinics, where possible, to limit the possible chance of infection

We may have flattened the curve but we are by no means out of the woods. Current Covid-19 cases in South Africa prove that.

What is happening in hospitals?
“Surgeries are being resumed responsibly with due collaboration and consideration exercised between the surgeon, the patient and hospital staff,” says Callakoppen. Where there are capacity constraints, surgeries will be classified in terms of priority at the various hospitals. Pre-operative screening will continue. Facilities will continue to utilise separate zones for Covid-19 positive patients, Persons Under Investigation (PUI) and those for whom the status is unknown at the point of admission. Surgeries will be carefully planned and scheduled.

Specialist visits on the up
“Consultations are starting to increase once again but providers in general are likely to remain prudent. However, we urge people who have not had their necessary annual check-ups, particularly our high risk members, to consult with their doctors. There may be members who have put these consultations on hold and are now more comfortable to visit a specialist. But care coordination is essential. Your GP should be your first point of contact – particularly in cases where you are not already under specialist care.”

Callakoppen says that members may also need to be physically examined if they are no longer as responsive to their medication, are concerned about general matters relating to their health or have received a specialist referral from their GP.

“The healthcare of our members is critical, particularly as we want to prevent them from developing unnecessary and preventable complications further down the line. It is important that we don’t have tunnel vision and only focus on Covid-19. We need to consider the overall healthcare needs of our members. Healthcare professionals are best positioned to decide if surgery should go ahead or not but it is ultimately the patient’s decision on how to proceed.

“We strongly urge patients to make informed decisions and weigh up the pros and cons. During the pandemic we all need to act responsibly and make informed decisions that won’t place patients, healthcare providers and the healthcare system under more pressure than necessary.”