The Doctor’s Surgery Theodore Dalrymple

More people are dying – thanks to COVID and delayed operations

When you are ill, any delay in medical attention, even if you suspect that it might be of little avail, is experienced as worse than an inconvenience. It is an insult. It confronts you with the fact that you are not as important to others as you are to yourself.

The COVID epidemic has so concentrated medical endeavour that all else, including surgical treatment, seems to have gone by the wayside.

The scale of the devastation is captured by a comparison of the number of appointments for operations in England and Wales in April 2019 with the figures for April 2020 (when the first wave was at its height).

In April 2019, there were 2,302,314 operations scheduled, of which 2.7 per cent were cancelled. In April 2020, there were 868,711 operations scheduled, of which 13.7 per cent were cancelled.

Does this translate into deaths? Look at the Nightingale diagram of total deaths (www.cebm.net/covid-19/covid-19florence-nightingales-diagrams-fordeaths). That’s the brilliant graphic method devised by Florence Nightingale during the Crimean War.

The diagram allows you to see at a glance the mortal effects of an epidemic. It shows a large excess of deaths from 29th March to 7th June 2020 compared with the previous five years. The number of deaths began to rise again, though not yet to the same extent, on 18th October. It has not yet fallen to normal – and seems unlikely to for some little while.

The Nightingale diagram, which includes all deaths, does not tell you the cause of excess deaths, of course, nor the age of the people who died in excess of the usual numbers. But generally it is assumed that the excess was caused both mainly and directly by the viral infection.

Delay in treatment of other conditions may have contributed – though, as yet, it is impossible to say to what degree.

People with potentially fatal but treatable diseases may have hesitated to go to hospital for fear of catching COVID.

Then there is the possibility that delays to surgery, particularly cancer surgery, and additional treatments for cancer (radiotherapy, chemotherapy etc), will have added to the overall mortality.

A recent meta-analysis of the effect of delay in treating seven types of cancer (44 per cent of all cancers worldwide), published in the British Medical Journal, suggested that even quite short delays in the treatment of cancer led to an increased death rate.

For example, a 12-week delay in the treatment of breast cancer would lead, according to the authors’ estimates, to an additional 1,400 deaths a year in Britain – where, incidentally, rates of survival from cancer are already notoriously lower than those in most ‘advanced’ countries.

It is a delay not only in operations but also in subsequent additional treatments that leads to increased death rates. Of course, a correlation of delay with death rates does not prove causation, but it does seem that the longer the delay, the higher the death rates.

The overall figures of delays to operations do not tell us what proportion were to treatment for cancer rather than for non-fatal conditions such as osteoarthritis of the hip.

The swift return of death rates to normal when the first wave of the epidemic was over suggests that the great majority of the excess deaths were from COVID, rather than from delayed operations or other treatments. The number of operations did not return to normal between the two waves of COVID.

One small lesson is that while the NHS proposes, it is circumstance that disposes. The handbook to the NHS constitution says:

‘All patients who have an operation cancelled … for non-clinical reasons [are] to be offered another binding date within 28 days, or the patient’s treatment [will be] funded at the time and hospital of the patient’s choice.’

This is bureaucratic hubris at its purest.