Dr Philip Matley

In response to a number of refusals to
authorise surgery during the COVID-19 pandemic, Surgicom Chairperson, Dr Philip
Matley was asked to write a position statement by SAPPF. Members may wish to
use this to resolve any difficulties they may be experiencing with
authorisations during this time.

 
The question of balancing risk versus benefit speaks to the very foundations of
medicine. Surgeons recognize that the skills required to get this right are
more important than any particular technical skill they may have acquired and
are based on years of training, experience, and the evaluation of evidence. It
is only within the individual doctor – patient interaction that such an
assessment can be made.
 
Medical funders and managed health organisations have responsibilities to their
members, clients and trustees to ensure that patient well-being is paramount
and that the particular fund is protected from wasteful, irrational or
fraudulent expenditure. However, the ultimate responsibility for surgical
decisions lies with the surgeon who remains accountable to his patient, his
professional societies, his peers and the law. Only in the most exceptional of
circumstances would one expect a funder to interfere in a decision arrived at jointly
between a surgeon and his or her adequately informed patient. This has always
been the case. The current complexities of the Covid-19 pandemic are certainly
not a reason to deviate from this principle.
 
A national understanding of the need for on-going surgical services is
developing for 2020. Initial calls by the surgical societies themselves to halt
scheduled surgery well ahead of the promulgation of any disaster regulations
were based on the predictions that the pandemic would peak in April 2020 following
which there would be at least some sort of return to normality. It is clear
that the crisis will continue well into 2021 and will in fact deteriorate
considerably in the coming months, therefore patients requiring necessary
surgery must be offered this now.
 
In terms of regulation 16(2)(a) of the Disaster Management Act of 2020,
essential medical services are permissible and a recent senior legal opinion
has stated that ‘virtually any “medical service” can be rendered, provided that
the legal compliance criteria in regulation 16(6), Annexure E and the
Occupational Health and Safety Act can be adhered to’. There is no legal
impediment to scheduled surgical procedures being undertaken.
 
Timing in surgery is everything with a price to be paid when necessary surgery
is delayed. The fact that a procedure can be scheduled in no way indicates that
it is unnecessary or can be postponed indefinitely. Surgery for cancer as well
as conditions associated with intractable pain or severe loss of quality of life
simply cannot be delayed by months and months. Many conditions will almost
certainly require emergency treatment later, if not managed correctly now. The
list is innumerable and these preventable emergency procedures tend to be
associated with high medical risk as well as considerable cost.
 
The risk of patients or healthcare workers contracting Covid-19 in hospital
cannot be under-estimated, even if reduced by adherence to guidelines including
effective use of PPE. Routine testing of in-patients or patients scheduled for
surgery will certainly be helpful (in spite of the risk of false negatives) and
all major hospital groups are requiring this as a routine.  It is clear
that this increased risk will continue beyond 2020. Patients need to be carefully
informed of the risks and both surgeons and patients must balance this risk
against the risk of denying surgical treatment. This they must do together and
should reflect the decision in a specific Covid-19 consent form.
 
Measures to “flatten the curve” have almost certainly created a window of
opportunity to provide necessary surgical treatment. As the anticipated surge
arrives it is likely that for a period, hospitals will only be able to provide
resources for surgery that is immediately necessary to save life or limb, but
this is simply not the case at present and accumulating large backlogs will not
help anyone. This situation is quite unlike that experienced in the USA or
Europe and therefore a requirement that there be a sustained fall in new
Covid-19 cases before continuing with necessary surgery cannot be supported.
 
The ability of a hospital to provide such necessary surgical services will, in
the context of the current pandemic, vary from location to location depending
on Covid-19 case load, available resources, and the possibility of sub-dividing
the hospital into Covid-19 and non-Covid-19 areas. Private hospitals may be in
a better position to achieve this than state institutions and therefore the
services offered by the two should not be compared. As the anticipated surge
arrives it is likely that for a period, hospitals will only be able to provide
resources for surgery that is immediately necessary to save life or limb, but
this is simply not the case at present.
 
Priority at this time should be given to day-case procedures, particularly
those that do not require general anaesthesia or intensive care and patients
who because of low age and lack of co-morbidities are relatively low risk for
serious Covid-19 infections. Several scoring systems have been proposed to aid
decision making. Day clinics in particular do not have overnight facilities and
therefore will not be treating or admitting Covid-19 patients, enabling
procedures to go ahead there according to the relevant specialist group
guidelines.
 
Many interventions can and will be postponed beyond 2020 but those that cannot,
should not. Lists of procedures are completely unhelpful as it is not the
procedure code that is key but the clinical indication for doing the procedure.
It is the surgeon and the patient who should be making this call as long as
practice conforms to available specialty-specific guidelines. South African
surgeons should be working, prioritising patients appropriately, and consulting
closely with local hospital management, anaesthesiologists and nurses to ensure
that local resources are adequate and properly managed, and that all safety
guidelines are rigidly adhered to. This approach has been endorsed by the
Federation of South African Surgical Societies (FOSAS) representing 19 surgical
societies and associations in this country.
 
Funders at this time should be assisting surgeons wherever possible given the
unique difficulties that the pandemic presents. Many surgeons continue to
operate with their support staff working from home. Laborious pre-authorisation
and requests for letters of motivation should be suspended during the crisis.
In the majority of instances, the need for the procedure should be evident
simply by noting the ICD10 code, most of which will reflect a PMB condition.
Surgeons are simply not going to be performing unnecessary procedures whilst
exposing both their patients and themselves to risk and to suggest that such
practices are widespread at this time is to fundamentally misunderstand the
nature of the doctor-patient relationship and the commitment of surgeons to
firstly, do no harm.