Listen to Mr Andrew Duckworth interview Mr Ben Ollivere about the impact COVID-19 has had on the challenges faced every day, particularly in terms of trauma service delivery and training.
Click here to view our COVID-19 content
Listen to Mr Andrew Duckworth interview Mr Ben Ollivere about the impact COVID-19 has had on the challenges faced every day, particularly in terms of trauma service delivery and training.
Click here to view our COVID-19 content
[00:00:00] Welcome everyone. I am Andrew Duckworth. And I would like to thank you for joining us for our special series of BJJ Podcasts on the COVID 19 pandemic. As we've already discussed in our first overview podcast with our Editor-in-Chief Professor Fares Haddad, the impact of the COVID-19 pandemic is being felt throughout the world and without doubt will have affected every facet of our professional and personal lives.
Through these podcasts we hope to reflect on the main issues that have arisen as a consequence of the pandemic for us in orthopaedic and trauma surgery, as well as our profession as a whole. First we'll include the impact of our day to day state clinical practices, as well as the effects on research now and moving forward in the future. You'll be hearing from colleagues throughout the UK, as well as from across the globe, including hearing from surgeons working in some of the worst affected areas. We also feel it's an opportunity to discuss the future in terms of both the recovery phase following this and what we can anticipate moving forward.
So today I have the pleasure of being joined by one of my editorial colleagues and the Editor-in-Chief of BJ360, Ben Ollivere, from Nottingham, who without doubt will be able to give us some great insight into the impact of the pandemic on the challenges we are facing each [00:01:00] day, particularly in terms of trauma service delivery, the effects on training for our junior colleagues and finally what's in store for us moving forward.
Many thanks for joining us today, Ben.
No problem at all. Always a pleasure Andrew.
So Ben if we could start off by looking at trauma & orthopaedic surgery services in particular, if we could just discuss the consequences you've seen and the changes that have occurred in particularly sort of focusing on our subspecialty interest in trauma.
Yeah. So, I mean, it's a different world, isn't it? The whole world changed about three weeks ago, not necessarily on the day that we were told there was going to be a lockdown but in the NHS you know, a few weeks before. Certainly in our institution, we started planning for this within orthopaedics around about four or five weeks ago, which I think has made a good step actually. We've been one step ahead of what the hospitals asked us to do. And we've been able to engage with our colleagues, as you probably know, at the Queens we're split site into two hospitals. [00:02:00] So the Queens Medical Centre is essentially an acute hospital where the trauma services are housed along with Hands and Feet.The children's hospitals there and at the elective centre, at Nottingham City Hospital, we have our elective colleagues. I think the biggest change actually most positive change is the way everything has pulled together. So as a group, about four weeks ago, we met. We've had some of the best attended director meetings that I've ever seen in the 10 years I've been a consultant there and we've all just become trauma and orthopaedic surgeons, rather than splitting into trauma & elevtive. And I think that's been a key consequence and key positive consequence, of the problem, I guess is that I've been very proud of how our department is pulled together as a department.
In terms of what's happened to our services, which was essentially, I think what you're getting at is, the elective services essentially stopped. Um, We , uh, made decisions as a trust , uh, [00:03:00] around about , uh, three weeks ago that we would draw to a close all elective services um, and that actually includes cancer. Um, So our trust is a big cancer centre ntree er er er , um, and all non-urgent - how on earth you can describe cancer as non-urgent, um , uh, services stopped um, and we , uh, expect at the same time with trauma, we expect to be working on a skeleton trauma service. Um, I was involved quite heavily , uh, along with Dan Deakin in the , uh, rearranging for that of our trauma service.
Um, What was felt by our trust and the representations that we made , um, was that the talking to colleagues in Italy, and I have some collaborators in Italy and also colleagues in other countries who are sort of a little bit ahead of us in terms of , uh, in terms of the COVID wave, as it is /. , um, we felt that we would see likely , um, a massive reduction in minor injuries , um, and that we would see initially a reduction in fragility fractures, and then as , um, the pandemic moves on and people start to lose their social support we're expecting to see an increase in frailty fractures.
And of course in , uh, trauma & orthopaedics, we're also , uh, fortunate to care for some elderly [00:04:00] patients. And then that means that we are caring for patients who have , um, COVID, as every other institution is. And probably uniquely in trauma & orthopaedics we are faced with the acute operating on patients with COVID , um, which obviously is the hip fracture population.
So I think, I think , um, I think that's the biggest change change in working. Do you want me to run into specifics or...
I think that's good, Ben. I think, I think actually I would agree. I would echo that. I think that what we found here, as you know, we have a similar setup in terms of , uh, trauma and elective or arthroplasty-type surgeons. And then actually the way that the collaborative and everybody's got together to move forward is, I think one of the big positives that's come out of it, actually. I agree.
In terms of , um, if we look at just talking about a bit about trauma management, there are two things I want to talk about would just be your, how your trauma pathways have changed. Both the major trauma and sort of day-to-day trauma. And then we could maybe talk about neck of femur fractures in particular.
Yeah. No, absolutely.
So , um, so just talking about the major trauma pathway. Um, Nottingham is slightly unusual in so far as 1. It's very busy service. So we manage about [00:05:00] 1600 , uh, ISS 16 plus patients a year , um, which makes us a huge MTC. And so we have a separate MTC service, whereas in a lot of places uh, the MTC service is housed by a specific specialty. We have our own specialty of major trauma, which includes consultants from various different disciplines. So I act on that rota, as do a couple of orthopaedic colleagues um, and we have intensivists , uh, plastic surgeon, vascular surgeons to run an acute 24/7 consultant-led trauma service. Um,
So one of the sort of the differences, I guess, between having a larger service that is therefore better funded and has more people involved than the smallest services is we're able to offer consultant led resuscitation 24/7.
, um, One of , uh, the key advantages is when we were planning for this is that we therefore have a consultant major trauma surgeon available 24/7. And so one of the first things that we've done is changed our triage pathways. So our triage pathways to reduce the burden on the ambulance service and also , uh, to try and offload the MTC, which is [00:06:00] essentially the hospital last resort, whether that's for a respiritive patient or whether it's for a , um, it's for cancer patient or whatever, was that we, rather than , uh, doing our standard pathway, which is, you know, send them home.
So, because we're a big centre, we have an open door policy for referrals um, so the phone call happens after the sends... Um, we've gone to the phone and sent. . , um, So each patient that's transferred is run past the major trauma consultant prior to their transfer. Um, We anticipated a significant drop in trauma call s and we've had a significant drop in trauma calls going from kind of 10 to 14 every 24 hours to probably 6 or 7 for 24 hours. Um, We didn't anticipate as much of a drop as we see. Um, You know, if you look outside your window, you can see the roads are empty. And the two people who either have to go to work or breaking the lockdown , um, haven't got anybody to run into as far as I can see, cause no one else is on the road.
So there's been a dramatic reduction in , um, , uh, trauma calls um, and that obviously wasn't something we anticipated and perhaps going back and revisiting it again , , um, we might have acted [00:07:00] slightly differently in that way. So that's the major trauma service. Um, The , um, sorry the second part of your question was?
So the day-to-day fracture management, particularly in terms of I suppose fracture clinics and...
Yes so day-to-day fracture management - we did a couple of strategic things early on. Um, We , uh, moved , um, and I managed this move actually, up the ... we moved our orthopaedic trauma services out of fracture clinics and co-located with A&E. And we moved into our independent treatment centre, which is on site.
Okay.
Um, And we made that a COVID-free pathway, COVID symptom-free pathway. And at the same time we moved the minor injuries pathway from A&E and we took the minor injuries pathway with us, which has essentially doubled the size of A&E because , uh, the GP s , uh, and, you know, absolute credit to our local GP s , um, took the minor illness pathway. So , uh, A&E doctors are no longer dealing with minor injuries or minor illness. Um, They are just dealing with , um, major injury supported by our on call , uh, and , um, major illness, i.e. COVID. And they've got twice the space to do it.
So we set up. .P . , um, We said that the minor injuries pathway *inaudible*. , um, We , uh, were able to requisition a few [00:08:00] nurse practitioners who we've upskille and what we've done with the assessment pathways is I've put all the pathways together. Um, So , uh, instead of multiple trips around the hospital, multiple x-rays , , uh, multiple follow-up appointments and consultations, the nurse practitioners , uh, essentially act as triage service. The patient comes in, they're seen by the nurse practitioner, they are then triaged to one of eight different pathways. So I think it's eight from pathways. So we've got a , um, we've got an EMP led pathway for things like , uh, cuts and stuff around the face, removing foreign bodies from the ear and that sort of stuff that we don't do essentially. Um, We've got a limb injury pathway , um, where the patient is then triaged directly to x-ray. This is a significant treatment injury pathway then sees a consultant or orthopaedic surgeon immediately afterwards as their , uh, treatment instigated. No requirements for a virtual fracture clinic because the decision is made now and then.
Yeah. Um,
We've taken over the QP plastics pathway. So for significant , uh, plastics injuries , uh, they see a plastic surgeon , uh, right away , um, similar, similar approach [00:09:00] . , uh, . We have done the same with a hand pathway. So hand injuries, instead of , um, you know, doing the typical thing of coming backwards and forwards many times they get a consultant opinion right away. Um, And we've done the same for *inaudible* pathway and also for the , um, elective orthopaedic problems, because one of the difficulties with just turning off elective surgery is if you don't turn off elective surgery six weeks before you have still got large cohorts of patients going through coming back and needing their elective , uh, their elective followups. Um, And , um, we , uh, felt we wanted to provide a reasonable pathway to those patients. And in fact, because our elective orthopaedic colleagues are acting as the consultant for the minor injuries pathway, they're able to deal with those things um, almost right away. We haven't yet had to turn that pathway on because we're still able to staff the city hospital a little. And so the , um, elective problems are still being managed as they were before, but we expect within the next week or two to turn that pathway on , um, and to deal with things like infected joint replacements and stuff that may not be post-operative problems, but are acute orthopaedic problems that need to be dealt [00:10:00] with , , , um, .
At the same time we opened a warded treatment centr e and we did two things , uh, with regards to theaters. We decamped our ambulated trauma pathway , uh, to , uh, the treatment centre um, and because anaethetists are , uh, in hot demand at the moment. And we reckoned we could do a lot more with consultant led , um, local anaesthetics and, or regional stuff.
Um, We also start the theatre without an anaesthetist.
Right. Um,
So on the hand pathway, for example, you will get your tendon repair done by the consultant hand surgeon that sees you an hour after they see you um, because that sort of thing can be done under regional. Um, So that's improved our efficiency , um, .
A couple of mistakes that we made. We introduced the virtual fracture clinic, and, you know, we've always known in Nottingham Notting, um, that the Scotts are entirely wrong about virtual fracture clinics. We've been, we've been pretty clear throughout that you guys are, you know, not doing what you should do. Um, And so we thought we'd follow the crowd and started a virtual practice clinic , um, about five, four or five weeks ago.
Um, That's morphed into a virtual triage service because the virtual fracture clinic , uh, essentially by taking control of the minor injuries pathway the virtual fracture clinic [00:11:00] has got no one in it.
Right. Um,
Because essentially all those decisions that take a little while you have to phone the patients and what have you. So you can eyeball the patient for 2 minutes as they come through in the plaster room. It takes two minutes and you go ankle fracture, stable, dont have a plaster, have a boot. Here's your information sheet. You dont need to come back.
Yeah.
That's it. And all done. All done at the same , um, ... the same thing.
We do have a triage pathway, which we're running like a minor injuries pathway between 8:00 PM and 8:00 AM when there's no consultant there, but there's a registrar there. Um, And those patients are , um, triaged to a number of specific pathways, like soft tissue shoulder pathway. And so on. That again, we instigated since we started.
We have done a huge amount of work on our pathways and actually a lot of it we're going to keep, because we think our patients are getting, without doubt, better care than they had prior to this. They can't keep it all because essentially, you know, in order to achieve that our elective services entirely shut down, but we're hopeful we'll be able to , um, continue to provide better care because one stop [00:12:00] shop is much better.
Yeah. So like you say, it's much better for the patients. What, just moving on though, what is your, how have you been managing your, I mean, you say, I think in our specialty, it's unique in terms of the neck of femur fracture patients, you know, that COVID-positive patients, elderly patients pretty unique in terms of, I suppose, that we are still trying to operate on those. What's your sort of, how have you dealt with it in Nottingham in relation to the guidelines that have been put out there.
So there's a couple of things in terms of operating. One of them is we started off , um, and there was a bit of descent amongst the group, which is unusual. We're pretty, we're normally pretty , um, we're normally pretty , uh, pretty cohesive as a group of consultants. And some of us felt that we should be , um, we should be much more conservative because of the coming tidal wave of , um, of , uh, COVID patients. Um,
I wasn't in that group as you can probably tell by my facial expression. Um, I felt that, you know, there's a window for most , uh, orthopaedic surgery of around about two weeks for most orthopaedic trauma surgery. And what we should do is be as efficient as we can, operate as much as possible, anticipating there'd be two or three weeks when we couldn't operate and some patients would suffer. [00:13:00] Um,
As a group, we decided to go down the conservative option. We reversed that decision about seven days in. Um, And went back and operated on everything that we decided to treat conservatively because we're conservative to start with. We don't operate on much that we see. Um, And we relearned some of the reasons why we dont operate on some of these things, because we have lots of early stepsof plaster and so on.
And we also discovered with the ambulatory patients, you know, the thing that I guess we all know, but don't , um, necessarily need to be reminded. We need to be reminded of, in order to remember, is that, you know, non-operative management is not seeing the patient.
Yeah.
And if you try to keep the patients out of hospital, putting them in a plaster when they need to come back reviewed every week, as opposed to putting two K wires across their distal radius fracture, you are better with the K-wires. Especially if you do it under regional.
Yeah.
You know, they get it right away. They get the manipulation, the K-wires and their plasters and don't come back for five weeks. Um, So that's the sort of ambulatory stuff.
The neck of femur stuff, we went through a similar sort of route, although we never, we never ended up non-opping any of them, but we talked about what we might do if we have no access to theater.
Um, We've up-skilled [00:14:00] a little bit in terms of , um, reviewing traction, teaching our nurses, that sort of stuff, you know, things that things that we haven't been doing for a long time , um, .We, we were sort of lucky, although we perhaps thought we weren't lucky to start with, which is we first made the decision that one of the first COVID cohort was that we would have would be one of our orthopaedic boards , um, which is how we managed to get a COVID-free ward at the treatment centre.
Um, And actually, that's worked out really, really well. And anybody who's listening to this and you know, more to expanding that, then I would thoroughly recommend that that's a good method because , um, the reason they did it actually was because they saw that we had some, we had some clinicians, you know, the ortho-geriatricians that weren't really, as far as the trusts were concerned, were kind of redundant because they never really understood why you need two consultants to look after the neck of femur patients. And the only reason they do it is because of the uplift of tarrif. Um,
But what we found of course is we've got really good relationships with our *inaudible* colleagues. of what was our wards, but is now COVID ward. We've got somewhere to put our patients who, you know, had a patient just the other day, came in with bilateral wrist fractures. You know, you can't leave that patient [00:15:00] in plaster, especially as she was 75 on her own. And she had COVID. And she was diagnosed with COVID on her admission. Um, So she needs somewhere to go postoperatively. She has not got bad case of COVID, but nobody's going to let her into a clear ward. And so that was perfect. You know, she came in and she came into the COVID cohort ward. She had her uh, wrists sorted out, she was sent home same day , uh, and she's now a bit more able to care for herself than she would have been if she was , um, if she was just managing plasters. Um,
So yeah, so we've been living pretty aggressive about neck of femure patients. One thing we're not allowed to do , um, because of how the trust , uh, views , uh, COVID as , uh, as a , uh, as an, as a risk factor is we're not allowed to operate in orthopaedics theaters. So we have COVID specific theaters. And again, we're a big trust. We're quite lucky. I don't know how many theatres we've got, but it's pushing 70, I think.
Um, You know, so a lot of those theaters are going to be used to ventilate for patients if we end up with a surge rgeu , um, but we were quite fortunate to operate in cancer theaters and stuff that we wouldn't normally operate in. Um, So there [00:16:00] are, I think three, two or three COVID theatres on the Queen site and there's two on the city site. So you just list the patient and the COVID theater and off you go. I think the idea of leaving somebody with a viral pneumonia in bed, and it's no different to anything else, you treat them as you would any other patient. You fix them so they can sit upright. And you get them going as quickly as you can.
Absolutely. No, I totally agree. That's a pretty good overview of the trauma services, I think it's interesting. I think certainly a lot of, a lot of what you've done is very similar as well.
So if we move on to training, which I know you have a big interest in, and I think it's obviously there's been a lot of changes for the trainees as well. And , um, what do you feel is. Well, first of all, I suppose the major impact has been on them. And, and how would you think, you know, how is this period going to be sort of, I suppose, recognized for, for their training? Certainly that's, what's worrying a lot of them , uh, moving forward.
So, I mean, there's a... that is a complex question, but , um, as first speaking as program director, I guess , um, you know, the truth is that we are all just doctors at the [00:17:00] moment, whether you are a consultant or whether you , uh, whether you're an F2 or whether you're a registrar. And, you know, my trainees have been absolutely fantastic. They've all gone and done the necessary. Same as consultant colleagues have. You know, everybody from the F1 to the consultants is acting as a SHR on the medical ward at times when it's your turn on the rota.
, um, I don't think we can recognize this period for training. I think it would be unfair on our trainees to do so. My personal view, and, you know, the terms like training pause have been bandied around and so on, but I actually don't think we need to think about it in that way. We now have a competency-based curriculum. We're able to sign people off early or late, depending on how competent they are. And as such, you know, if somebody is an ST8 and clearly is ready to sign off, then they should be signed off.
Um, If somebody is in, you know, ST5 and was scheduled to do their hand surgical job, and they've spent it on the respiratory wards then clearly they need to have that, have that opportunity again.
So personally what I've done is I've paused my rotation. Um, So, you know, everybody stayed in their own, their own slots. [00:18:00] So the first rotation has become a year rotation , um, and everything else has moved forwards. Um,
I've done. Uh, I've done a few things. We set up a whole rotation WhatsApp groups which we didn't have which I'm on. So I'm able to answer questions and it has all been very clear. I don't want to be on the email list and stuff. So the trainees feel they've got somewhere that they can complain about me, complain about everybody else, but equally there needs to be a forum where they could ask a quick question. So that's the first thing.
Second thing we've done is we've instituted evening teaching using zoom. Um, So once a week they get teaching , um, and they love that as far as I can see.
Uh, And again, I've given some, colleagues have given some , uh, ,people are happy to teach by zoom at eight o'clock at night, which means most people are able to make it. Um, It's been some of the best attended teaching I've given in our program because nobody's on call. Nobody's doing this, nobody's doing that. And they're desperate to get a bit of orthopaedics in . , um, .
I think , um, I think actually one of the things that people are learning. I think there are learning opportunities. And I think it's important to recognize that. You know , um, is that people are learning how to be adaptable. They're learning how to work in teams. They're learning , um, how to manage disasters and, [00:19:00] you know, the truth is, although we're facing a national disaster, most of us at some points in our career are involved in a *inaudible* and the principles are pretty much the same.
Yeah.
You know, and, and , um, it's , um, it's about, I think it's 18 ... no longer than that. It's about 25 years since there was the *inaudible* disaster in our own patch. You know there was an air disaster, not so far from where you work. There's train crashes and so on, up and down the country and actually learning how to work in a hospital that is overwhelmed is , uh, an important skill. And learning how to be good to each other and how to put aside differences with those specialties is an important skill. And you know, one of the things I'm quite proud of is all of my trainees have done a fantastic job of that. I've had no complaints about , uh, them. Uh, And in fact, I've only had one inquiry out of a group of 40 as to whether or not they really had to go and be respiratory doctors. And could I do anything about it? Everybody else has just been fantastic.
I would certainly echo that for our trainees here. And I think everybody's just really like you to say mucked in and like, we're all saying, like you said, we're all doctors and we've, we've [00:20:00] likewise found that the zoom teaching sessions have been really, really productive and people, like you say, attend it and they really enjoy it.
If we move on then in terms of, before we go on to the future and discuss that, in terms of research, obviously you have a strong research interes Ben.
What sort of happened from your point of view in terms of, you know, obviously the main, like you've just said, we're all doctors now the main focus is on clinical work, which it should be, what has happened with, in terms of your research, in terms of the trials , um, you know, have been paused and things like that.
So, so most trials are paused, so that's down to the CI. Um, So I , um, I've paused , um, most of my randomized trials, I've got two still running at the moment. Important thing to remember is that when you cause a trial though, I mean, it's like pausing elective surgery. You pause renew recruitment, but you still got people going through that cycle. You still need to be able to send out their follow-up questionaires, you still need to have a trial office open so that maybe there's any problems they can phone up. You still need to be able to deal with *inaudible* and that sort of stuff that comes in. Um,
So I have kept one day a week, academic time. I'm [00:21:00] normally 50:50. And I also run our division so I've got 120 odd staff, academic staff, not clinical staff working from home, so I need to provide them with some support. Um,
I think we're just trying to even things out from that perspective. You know, the NIHR is going to offer suspensions and so on. I think it's important to remember that if you have staff or a nonclinical , um, you know, there are things that they can do, but many of them, you know, may choose to furlough so their training, their funding doesn't run out and that's something that that's important , um, because the funders wont pay extra salary, cause they just don't have the money. Um,
The second second part is, you know, there's a huge opportunity and people should be thinking about how they can study what's going on.
Um, We started a big tissue study. We were recruiting starting on Monday. We managed to get all that through in 10 days. So we're going to be looking at frailty patients and , um, how they do , um, and doing some of genomics and so on. Um, So there are some opportunities there. Um, I think , um, I think it's important , um, to keep things ticking over. And I think it's important to keep touching base with your staff who are at [00:22:00] home or have not much do.
Most hospitals have research associates. Most hospitals now have , , uh, you know, research nurses. Most hospitals have , uh, some form of audit department and all of these people are 1. Very frightened and 2. many of them are being redeployed to clinical areas in which they've never worked.
And I think that's another side to it is that there's the sort of, there's the support side to those staff being redeployed because essentially those are academic. You know, like *inaudible* you, you, you, you're their line manager. You're the person that they'll turn to. And you're not necessarily, it's not top of your mind is what's happening to my research nurse because you are worried about what is happening with your doctors. And I think that that's something just to remember.
No, that's a very good point, Ben, I totally agree. I think so if we move on, finally, I think sort of all those topics we've talked about, and it's very difficult, you know, you dont have a crystal ball, but what do you anticipate the future holds for us in terms of our specialty training research sort of immediately, but also how do you think we're going to sort of come out the end of this when hopefully [00:23:00] things calm down.
So I think , um, I mean, so, so from that, from a trauma perspective, you know, I think , um, I think things would just turn back on won't they? ? , um, I think, I think one of the things that we haven't touched on, which I think is a, is a hugely important thing to remember is we need to be planning now for a second wave of neglected older patients. You know, you saw those heartbreaking stories , uh, in Spain, which I hope will never happen here, of all the nursing members and staff linked to .
One thing that definitely will happen is isolated older people who rely on social services support. Many of them will fall over because their carer won't turn up and they'll try and get themselves out of bed. Um, We know from just icy weather, there's about two weeks delay on that so we should start seeing that fairly shortly.
Um, You know, older people will venture out to get food. You know, and those sorts of things. And so we're going to start seeing an increase. And in fact, we have started seeing that. We normally run four day trauma theaters a day at the Queens, um, plus an evening theater list and went down to two. And initially we had not much to do, and now we're starting to outstrip that capacity with frailty.
Um, And I suspect next week, things are going to be pretty bad and I suspect the week after [00:24:00] we will be having to prioritize things , um, and really struggling. Um, And, and I think that's something people need to bear in mind, you know, in, in many hospitals, I think talking to colleagues and interested to hear what it's like in the Royal, you know, things aren't as bad on the ground as is expected. You know, we had, we had a bit more time to plan, I think NHS central, although there's been, you know, terrible stories on Twitter, which are clearly untrue of, you know, inappropriate, PP equipment being unavailable. That's just not true. What's been available is what we're told we need. And people may or may not agree that's what they want. But the NHS central has done, I think a really good job with the supply chain, with making sure people are where they need to be and get what they need.
What it hasn't done is it hasn't thought about that second wave for ortho & trauma. And I think we just need to, as an, as a profession, take that forwards.
I think in terms of, in terms of our trainees and our colleagues, you know we're going to have a slightly de-skilled workforce. We're going to have , uh, we're going to have to think very carefully about people who have done things like being out on *inaudible*, come back for three [00:25:00] months and now have nothing to do surgically. We're going to have to think about part-time trainees , um, who, you know, keep their skills up. But uh, now are not able to do any surgery and maybe weren't didn't have as much under their belt over the last couple of years. Um, And, and I think we're going to also have to think about our patients because there's going to be a huge burden of pathology. People don't stop getting arthritis. They don't stop. They don't stop getting cuff tears. They don't stop getting ACL injuries and we're going to be swapped. Um, You know, the first question, every patient, I say needs surgery uh, asks me now, which they never used to is, you know , uh, can I have it non-op? Every patient is thinking, do I need to be in hospital?
Um, And consequently, lots of patients at home just haven't come.
Yeah.
And I think we need to think about ramping up our services and how we do that.
Yeah, no, I think that's right. I think, like you say, I think that the time is to prepare now for all that. I totally agree. Well, Ben, I think that's all we have time for, but thank you again so much for your really interesting [00:26:00] comments and insights today, we really do appreciate it and we send our best wishes to you and your colleagues and their families in these difficult times.
Thanks for joining us, Ben.
Thanks so much, Andrew. Bye.
Finally, as always, we'd also like to acknowledge and thank our many colleagues around the UK and across the world for their ongoing tireless efforts and the delivery of care to our patients during this pandemic. We at the journal thank you and we'll always endeavor to support you in all the ways we can.
Stay safe and thanks for listening.