Resource requirements for reintroducing elective surgery in England during the COVID 19 pandemic: a modelling study

Background The COVID-19 response required the cancellation of all but the most urgent surgical procedures. The number of cancelled surgical procedures in the National Health Service (NHS) England due to COVID-19, and the reintroduction of surgical activity, was modelled. Methods Modelling study using Hospital Episode Statistics data (2014-2019). Using NHS England definitions, surgical procedures were grouped into four urgency classes. Expected numbers of surgical procedures performed between 1st March 2020 and 28th February 2021 were modelled. Procedure deficit was estimated using conservative assumptions and the gradual reintroduction of elective surgery from the 1st June 2020. Costs were calculated using NHS reference costs and are reported as millions(M) or billions(B) of Euros(€). Estimates are reported with 95% confidence intervals. Results 4 547 534 (3 318 195 – 6 250 771) patients with pooled mean age of 53.5 years were expected to undergo surgery between 1st March 2020 and 28th February 2021. By 31st May 2020, 749 247 (513 564 – 1 077 448) surgical procedures were cancelled. Assuming elective surgery is gradually reintroduced, 2 328 193 (1 483 834 – 3 450 043) patients will be awaiting surgery by 28th February 2021. The cost of delayed procedures is €5.3B (€3.1B - €8.0B). Safe delivery of surgery during the pandemic will require substantial extra resources costing €526.8M (€449.6M - €633.9M). Conclusion Reintroduction of elective surgery in NHS England will be associated with substantial treatment delays, and large cost increases. The challenges and costs of reintroducing surgical care in other healthcare settings may differ and further research to monitor the recovery of surgical care is urgently required. ### Competing Interest Statement AJF reports a grant from the National Institute for Health Research (DRF-2018-11-ST2-062). TDD reports funding from the Welsh Clinical Academic Training (WCAT) Fellowship. IW reports active grants from the American Association of Plastic Surgeons and the European Association of Plastic Surgeons; is an editor for Frontiers of Surgery, associate editor for the Annals of Plastic Surgery, editorial board of BMC Medicine and numerous other editorial board roles. RP reports grants from NIHR, during the conduct of the study; grants and personal fees from Edwards Life Sciences, grants and non-financial support from Intersurgical UK, outside the submitted work; and has given lectures and/or performed consultancy work for Nestle Health Sciences, BBraun, Intersurgical, GlaxoSmithKline and Edwards Lifesciences, and holds editorial roles with the British Journal of Anaesthesia, the British Journal of Surgery and BMJ Quality and Safety. TA is a member of the associate editorial board of the British Journal of Anaesthesia. All other authors report no relationships or activities that could appear to have influenced the submitted work. ### Clinical Trial Study using routinely collected, anonymised data only. ### Clinical Protocols ### Funding Statement NIHR (DRF-2018-11-ST2-062) to AJF ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: No ethical approval was required for this study that used pubicly available, aggregated, anonymised data. All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All data is freely available on the NHS Digital Website and the NHS England Website. The definition of surgery is available in the supplement of our publication.