Legacy of COVID‐19 – the opportunity to enhance surgical services for patients with colorectal disease

摘要

The COVID-19 crisis has undoubtedly taken a toll on the care of patients with colorectal disease. Elective services, be that face-to-face contact, endoscopy or operations, all but ceased during the pandemic [1]. As we move into the recovery phase the return to normal care is likely to be slow, with a huge backlog of patients and ongoing limitations to services. Some of the changes in care and new ways of working enforced by COVID-19 will be permanent. However, this ‘legacy’ of COVID-19 is not entirely negative. The pandemic has thrown into sharp relief some of the poorly thought through systems and practices that were in place previously and forced change to certain areas of practice that have proved beneficial. If we can identify, nurture and embed these positive changes there is an opportunity to improve patient care. The psychology of a crisis is well defined. The initial ‘heroic’ phase is followed by a honeymoon phase, both characterized by clear shared goals and a sense of urgency that energizes the workforce to be focused and productive. The disillusionment phase follows, in which uncertainty about the future reduces any sense of purpose, and productivity falls. Finally, there is the reconstruction phase, in which we begin to revise our goals, expectations and roles and to focus on moving beyond ‘just getting by’ [2-4]. This document aims to define the positive outcomes from the crisis and to explore how the colorectal community can reframe its future direction. It is hoped this will serve as a catalyst to move us swiftly and effectively through to the reconstructive phase and guide priorities accordingly (see Appendix). Our overarching aim is to improve care for patients. Any legacy from the COVID-19 crisis must clearly have patients’ interests ‘front and centre’ with other factors feeding into this central theme (Fig. 1). We have, at best, only a notion of what patients really want from their health service, and welcome initiatives such as the recently described ‘citizen juries’ [5] to redress this knowledge gap. Nevertheless, we can make some clear suggestions, starting with the realization of the importance of high-value care during the crisis – in other words, the opportunity to make the biggest differences to patient care with the minimum resources available. With reference to colorectal diseases, pre-COVID-19 systems were typically overburdened with huge numbers of referrals of patients whose symptoms, whilst clearly troublesome to them, were not eventually associated with the finding of significant pathology. The ‘old’ paradigm involved invasive and expensive investigation of such patients with a near exclusive focus on the exclusion of cancer – to the extent that the primary reason the patient attended in the first place, namely management of their problem, was often neglected or forgotten. This is a grossly inefficient way of working; it puts patients at unnecessary risk of investigation and has little benefit for those who need treatment for conditions other than bowel cancer. Attempts to rectify this situation, pre-COVID-19, had been limited to small changes such as modified referral criteria to try to control the influx of patients. We now have an opportunity for major and meaningful change. Obvious examples are modifications to the 2-week-wait and straight-to-test pathways. Both are leading to an ever-increasing drain on limited endoscopy resources, a decreasing efficacy in identifying significant pathology as only cancer detection is prioritized and often inappropriate discharge of patients symptomatic from other pathologies. Rapid integration of proven adjunctive diagnostic tools such as the faecal immunochemical test (FIT) in cancer detection pathways will allow more focused high-value care [6]. Coupled with this high-value care is the concept of ‘realistic’ and ‘personalized’ medicine approaches [7]. The clinician should refocus on shared decision-making with the patient when planning investigations and