London Neurosurgery During the COVID-19 Pandemic
Society of British Neurological Surgeons (SBNS) Council
Consultant Neurosurgeon & Clinical Lead Neurosurgery
Kings College Hospital, London, UK
Neurosurgery services in London, like all health services in the UK, were severely affected due to the rapid advance of the COVID-19 virus. The coming “tsunami” was clear for all to see but preparations at the government level were not at first as urgent or focused as they should have been. As a result, when the epidemiology prediction models finally reversed the policy, we were faced as clinicians and departmental leads, with a rapidly evolving situation that demanded immediate changes in practice, with guidance, critical elements of which were of “questionable” validity.
As a unit (Kings), and as a network of sister units in London covering a population of approximately 15 million, with the highest incidence of COVID-19 cases nationally, we had to adapt, literally overnight, and try to balance four main challenges. First, the fact that London was facing a much more advanced and rapid peak of cases than the rest of the country. Second, our primary duty to all our non-urgent or less-urgent patients who were expecting to be treated. Third, our response to those emergencies which were expected to continue arriving. Last but not least, our duty and pastoral care to our colleagues and staff that had to continue working in completely unfamiliar and rather scary circumstances (PPE, tests, misinformation, etc) and were struggling to keep up with demand.
Of course, each unit followed their internal processes and responded to their own specific conditions. We at Kings were very proactive in setting out pathways based on carefully reviewed evidence. We worked closely with our nursing staff who went beyond anything their training had prepared them for, empowered the specialist physicians working in our department and followed their advice, took early control of the on-call process, and led from the frontline with clear protocols that allowed a significant proportion of our staff to be redeployed into the massivelyexpanded intensive care setting. At the same time, we maintained a consultant-delivered emergency rota. What proved to be very important and ultimately successful, was the fact that we managed to carry with us all, colleagues and staff, and strengthen our coherence as a department.
As everywhere, we made use of the suddenly abundant information technology (IT) that allowed us to communicate more effectively than ever before and maintain contact with some of our patients as well. Virtual groups of similarly-minded neurosurgeons formed across London and nationally, almost organically, and coordinated responses and managed the often poorly thought out central initiatives. This is a process that is ongoing and we hope it will lead to better neurosurgical services for this great metropolis.
Above all, what became very clear is the amazing resilience of the National Health Service (NHS). The dire predictions of hospitals being overwhelmed, with physicians at their wits end, were avoided. The intensive care capacity expanded immediately while the private sector made all its resources available to the NHS. In London it allowed the formation of cancer “hubs” that coordinated continuing surgery on cancer patients (including brain tumours) outside the acute hospitals with strict isolation and testing protocols. Again, the wholehearted involvement of neurosurgeons insured that the processes were equitable across all specialties and ultimately allowed the vast majority of patients to receive the care they needed.
Neurosurgery in London, as well as throughout the UK, is now recovering from the receding onslaught. The recovery phase is proving tedious and with a lot of difficulties. A proactive approach to stay ahead of the hospital challenges (COVID-19 free areas, corridors, theatres, staff etc) will ensure a successful, albeit slow, return to normality. There are a lot of planned reconfigurations of the way we deliver neurosurgical care, some out of true necessity, some as an opportunity presenting itself.
We are hopeful that the qualities and ethos of everyone working in public health care that have proven so successful in dealing with this pandemic will continue to inform the way forward. For many of us the greatest lesson learned has been that decisions need to be made by front line clinical leaders who are engaged with their multidisciplinary teams and not by health care managers and strategists who are divorced from clinical care. Continued collaboration with private health care providers, establishment of clear protocols, and provision of appropriate resources will allow London and UK Neurosurgery to continue to flourish.