Much of South Africa's public health sector is plagued by long waiting times for surgery, a situation that was made much worse by the COVID-19 pandemic. Now, an inspiring project at Groote Schuur Hospital in Cape Town has reached the target of slashing its backlog by 1 500 elective surgeries - two months ahead of target.
At the end of March, a small team of healthcare workers completed the project called 'Surgical Recovery'. The project ran from May 2022 and was originally planned to conclude 12 months later.
While this hasn't cleared the entire backlog of people waiting for surgery at Groote Schuur, it has helped the hospital return to about the same waiting list level as it had before the COVID-19 pandemic, according to Professor Lydia Cairncross, the head of general surgery at Groote Schuur. (Spotlight previously reported on the human cost of surgical waiting lists and on what could be done about it.)
The surgeries took place mainly in the E4 Surgical Day Ward at Groote Schuur. Cairncross explains that ward E4 was built as a Day Ward - meaning it handles surgeries where patients don't require an overnight stay pre- or post-surgery - with the aim of increasing daycare surgery capacity for the hospital. And for the last 12 months, it has been the host of the Surgical Recovery Project.
E4 has 16 patient beds, four recovery beds, and two theatres, which were completed just as the COVID-19 pandemic hit the country. During the third wave of the pandemic, it was used as a COVID High Care Unit.
According to Dr Shrikant Peters, a public health specialist and the medical manager of theatre and ICU services at Groote Schuur, 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 eventually to be used long-term as an Operating Suite and High Care Ward in line with prior hospital plans".
The Surgical Recovery Project
By the end of the third wave of the COVID-19 pandemic, according to Cairncross, there were discussions about how to catch up on the surgeries that had to be postponed because of COVID-19.
"The backlog in surgery comes on top of a pre-existing backlog. So, it's not that the backlog was created by COVID, but it made it much, much, much worse," she says, "In November 2021, we did an audit of how many patients were just physically waiting for surgery at the hospital. It was around 6 000 plus. We don't actually have a baseline for pre-COVID, but we knew that we lost about 50% of our operating capacity," Cairncross says.
From here, the Surgical Recovery Project for Groote Schuur was born with the ambitious target of performing 1 500 surgeries in 12 months.
"So, the idea was really to find a way to utilise this theatre space so that we could 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, tells Spotlight that fundraising for the project was kick-started by a R5 million donation from Gift of the Givers. The recently established Groote Schuur Hospital Trust focused on Surgical Recovery as their first project to fundraise for. An additional R1 million was raised by the Trust from over 500 corporate and private donors.
"People are always willing... [they] give what they can. We had donations from people who would transfer R10 into the account, sometimes people transfer R180 000," Evans says.
She adds that the Project will continue into its second year, but the details regarding targets had not yet been finalised by the time of publication.
The Western Cape Provincial Department of Health also donated around R6.5 million to the project from their budget for surgical recovery post-COVID-19. According to Mark van der Heever, the provincial health spokesperson, this money was part of the R20 million that the department allocated to various surgical backlog recovery initiatives.
People are always willing... [they] give what they can. We had donations from people who would transfer R10 into the account, sometimes people transfer R180 000. - Kristy Evans
"[The] COVID-19 pandemic meant that elective surgical services had to be significantly de-escalated, as staff were deployed to COVID services, and this resulted in an increase in the backlog of operations. Hence, a specific practi[cal] plan to address this backlog in the short and long term has been developed," says van der Heever. "Similar projects and initiatives across hospitals have already taken shape and also yielded success, such as at Karl Bremer Hospital, which also received a portion of the R20 million from the department. The hospital was able to perform an extra 328 procedures since August last year."
Working around difficulties
At Groote Schuur, the project had to find a way to work around the difficulties of surgical catch-up. According to Cairncross, with any surgical catch-up, the challenges don't just come from needing a physical space to operate in but also from having the appropriately trained staff. Not having enough trained staff in the public health sector, like theatre and surgery nurses, makes it hard to implement a surgical catch-up programme, even if there is money to do so.
To work around these difficulties, they came up with a centralised model for surgical recovery, where one theatre team of nurses 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.
According to Cairncross, many surgeons, herself included, would come and operate on patients in addition to their normal surgeries and other duties. The funds, a total of about R 12.5 million, were used to pay the staff involved in the surgeries. The day-to-day operations were run by Davids and Peters.
According to Peters, the 1 500 operations occurred across all surgical specialities, ranging 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 that gave their time to the project.
She says that because the hospital has a relatively functional system to start off 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, gesturing to Davids.
Davids, who started her nursing career in 1989 and qualified as a theatre nurse in 2009, started working at Groote Schuur six years ago. She explains that the surgical team at E4 consisted of about 18 people. This includes herself, five scrub nurses, three anaesthetic nurses, three floor nurses, a registered nurse who assists in recovery, and a clerk. Peters adds that there are also two surgical medical officers and two anaesthetic registrars.
I mean, the ability to trust junior staff to upskill themselves to become scrub nurses, to hand surgeons the right instrument when they asked for it. That's been really heart-warming. - Melinda 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.
"It's been a challenge, but it's a good challenge that's kept me going," she says. "We're a good team."
"Trust [in staff] has been fundamental to this," says Peters, "I mean, the ability to trust junior staff to upskill themselves to become scrub nurses, to hand surgeons the right instrument when they asked for it. That's been really heart-warming."
'Behind every number on the list is a patient'
When asked why it was so important to do this kind of catch-up, Cairncross says the surgeries that were postponed during the COVID-19 pandemic were ones that weren't urgent or emergent, but those patients who were bumped still struggled physically because of the delays.
"Behind every number on the list is a patient with a story of either progressive blindness, invasive skull tumours, or tumours around the auditory canal that result in hearing loss, chronic pain from joint problems and urinary retention with recurrent infections and admissions or having a stoma bag [a colostomy bag] with them for months longer than needed," Cairncross says. "Heart-breaking stories and often these were the patients who kept getting cancelled [on]. They would come in and if something urgent would come up, they would be cancelled or the COVID wave would come."
She adds that at the time when the idea for Surgical Recovery came about, the morale amongst the surgical teams was at a real low. Patients would be coming to the outpatient clinics and asking, for the umpteenth time, "when am I going to have my operation?" to which the healthcare workers had to keep responding that they don't know.
"It's just a terrible thing and so people [staff] started to feel disempowered and disillusioned and I really think that the project helped them to at least see some progress. That there were some changes or some shift in what they were dealing with," Cairncross says. "It hasn't cleared our entire backlog, and a once-off project will not do that, but it has reset us pretty close to where we were pre-COVID-19."
Peters adds that while the backlogs haven't been fully cleared, "for every case that we've done in the project, it's someone off of a waiting list".
Health system at a 'precipice'
While the COVID-19 pandemic caused many surgeries to be postponed and added tremendously to surgical waiting lists, it isn't the only factor contributing to backlogs. According to Peters, the issue of a shrinking health budget for tertiary services is and will continue to add to the existing backlogs across the country.
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"There's this building backlog coming up against the shrinking budget. And that's going to be with us for multiple years going into the future and if the clinicians aren't protecting the budget for these patients that get missed, we're going to focus on as we have been the emergency patients that come through the door," he says. "But it's always difficult for tertiary academic services because to keep up the skills of surgeons to maintain the quality of care, they do need to be managing waiting lists of booked patients. And so, I think across the country we're going to be struggling with that across all tertiary services."
Cairncross tells Spotlight that the project is just a temporary measure. In the long term, healthcare systems need to be fixed in order to address issues like surgical backlogs.
"The lesson, I suppose, is that these are temporising measures. We can do them, but 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," she says. "The services at Groote Schuur Hospital, 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 project is just a temporary measure. In the long term, healthcare systems need to be fixed in order to address issues like surgical backlogs. - Lydia Cairncross
The health system is at a precipice, according to Cairncross, and big academic hospitals need to be anchoring elective surgical services together with emergency services, as the problem with emergency services will only get bigger down the line if electives aren't dealt with now.
"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 that ensure all types of surgical services are maintained," she says.
"The strongest voice [in defence of the health system] is a conscious and motivated health workforce. So, where the nurses and doctors and managers are standing and defending patient services, they are supporting the health system," she says. "I think this is an example of health workers standing up and saying, we can't allow this deterioration in services. We've got to do more. We really want to tell the story, so that people can see it can be done."
