Introduction: The aim of this study was to forecast the total need for elective procedures in England by 2030. Methods: We used publicly available activity data from NHS Digital to estimate procedure-level shortfalls in elective procedures performed during the pandemic period (January 2020 to March 2022) compared to what would be expected based on pre-pandemic trends. We also estimated the procedure-level composition of the NHS waiting list immediately preceding the pandemic (December 2019). The total need for elective procedures in March 2022 was calculated by summing the pandemic shortfall with the pre-pandemic NHS waiting list. We projected the need for elective procedures through to January 2030 for four scenarios: current capacity (surgical volume remains at the same level as in February-March 2022), pessimistic scenario (elective procedure volume increases to pre-pandemic levels by July 2023 followed and remains at this level until 2030), central scenario (elective procedure volume returns to pre-pandemic levels by December 2022 followed by a 2% increase per year), optimistic scenario (elective procedure volume returns to pre-pandemic levels by December 2022 followed by a 4% increase per year) Results: We estimated the total need for elective procedures in England in March 2022 was 4,347,469. Of these 4,347,469 patients, 3,304,513 (76.0%) were on a hidden waiting list. The greatest need was for General Surgery (1,522,366), Orthopaedics (976,875), and Ophthalmology (391,683). The procedures with the greatest need were sigmoidoscopy and colonoscopy (568,838), gastroscopy (447,830), cataract surgery (314,790), lower limb joint replacement (224,363), and interventional cardiology (349,300). We projected that at current capacity, the total number of elective procedures needed would increase to 14,608,195 by 2030. In the pessimistic scenario, elective procedure volume total elective procedures needed would increase to 8,507,087, in the central scenario it would increase to 5,420,999, and in the optimistic scenario it would decrease to 2,584,664 procedures. Discussion: The estimate of 4.3 million elective procedures needed in England is considerably higher than the official NHS waiting list, reflecting a large hidden waiting list. Even in the most optimistic scenarios there will be a substantially larger waiting list in 2030 than pre-pandemic.

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Background Large-scale quality improvement interventions demand robust trial designs with flexibility for delivery in different contexts, particularly during a pandemic. We describe innovative features of a batched stepped wedge trial, ESCP sAfe Anastomosis proGramme in CoLorectal SurgEry (EAGLE), intended to reduce anastomotic leak following right colectomy, and reflect on lessons learned about the implementation of quality improvement programmes on an international scale. Methods Surgical units were recruited and randomised in batches to receive a hospital-level education intervention designed to reduce anastomotic leak, either before, during, or following data collection. All consecutive patients undergoing right colectomy were included. Online learning, patient risk stratification and an in-theatre checklist constituted the intervention. The study was powered to detect an absolute risk reduction of anastomotic leak from 8.1 to 5.6%. Statistical efficiency was optimised using an incomplete stepped wedge trial design and study batches analysed separately then meta-analysed to calculate the intervention effect. An established collaborative group helped nurture strong working relationships between units/countries and a prospectively designed process evaluation will enable evaluation of both the intervention and its implementation. Results The batched trial design allowed sequential entry of clusters, targeted research training and proved to be robust to pandemic interruptions. Staggered start times in the incomplete stepped wedge design with long lead-in times can reduce motivation and engagement and require careful administration. Conclusion EAGLE’s robust but flexible study design allowed completion of the study across globally distributed geographical locations in spite of the pandemic. The primary outcome analysed in conjunction with the process evaluation will ensure a rich understanding of the intervention and the effects of the study design. Trial registration National Institute of Health Research Clinical Research Network portfolio IRAS ID: 272,250. Health Research Authority approval 18 October 2019. ClinicalTrials.gov, identifier NCT04270721, protocol ID RG_19196.

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