Now is the time to fix hospital waiting lists once and for all

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Stephen Duckett, Grattan Institute

The near-total shutdown of elective surgery across Australia will end soon, following National Cabinet consideration on Tuesday.

The shutdown was imposed to ensure there would be enough personal protective equipment (PPE) for doctors and nurses to manage a projected tsunami of COVID-19 patients in our hospitals.

But now there is a big backlog of Australians waiting for elective procedures.

Elective surgery waiting times are the bane of every state health minister’s life. Better ways to manage such procedures could be a major benefit from the shutdown and restart.

But we have to act quickly if we are to change how we manage these wait lists, as federal health minister Greg Hunt wants a staged reintroduction to begin on 27 April.

Rethink priorities
Currently, elective surgery is classified as urgent (category 1), semi-urgent (category 2) and non-urgent (category 3). But different hospitals and different surgeons actually classify patients in different ways.

What’s worse is that some procedures are undoubtedly unnecessary, such as spinal fusion or removing healthy ovaries during a hysterectomy, and would provide no value for the patient, as Adam Elshaug and I have argued before.

Of course, not all of the backlog is low-value procedures. As states consider how to recommence elective surgery, they should seize this opportunity to introduce new systems, especially in metropolitan areas.

A properly managed elective procedures system should have three key elements:

– there should be a consistent process for assessing a patient’s need for the procedure, and ranking that patient’s priority against others

– the team performing the procedure, and caring for the patient afterwards, should be highly experienced in the procedure

– the procedure should be performed at an efficient hospital or other facility, so the cost to the health system is as low as possible.

Unfortunately, Australia sometimes fails on all three measures.

Stop the inconsistencies
There is no consistent assessment process across hospitals. Even different surgeons in the same hospital seeing the same patient sometimes make different recommendations about the need for a procedure.

This means a patient lucky enough to be seen at hospital A may be assigned to category 2, but the same patient seen at hospital B might be assigned to category 3 and so have to wait longer.

Patient characteristics, such as gender or level of education, also seem to inappropriately affect categorisation decisions.

High-volume hospitals and other facilities generally have better outcomes for a given procedure than low-volume centres. And they are more efficient.

Yet most states ignore these facts. They have done little to rationalise services for the benefit of both the patient and the taxpayer.

Time for change
The large backlog of demand creates the opportunity for a new way of doing things. States should develop agreed assessment processes for high-volume procedures, such as knee and hip replacements and cataract operations, and reassess all patients on hospital waiting lists.

Reassessment could be done remotely using telehealth. Specialists in each area should be invited to develop evidence-based criteria for setting priorities. Where appropriate, patients should be diverted to treatment options other than surgery.

Private health insurers should be empowered to participate in funding diversion options so patients are able to have their rehabilitation at home rather than in a hospital bed.

A new, coordinated, single waiting list priority system in each state would enable all patients to know where they stand. A patient on the top of the list would be offered the first available place, regardless of whether it was closest to their home.

They could refuse the offer, without losing their place in the queue, if they wanted to wait for a closer location.

The health minister says it’s up to hospitals to decide which patients get to undergo elective surgery. Roman Zaiets/Shutterstock

The single waiting list should include both regional and metropolitan patients, to ensure as much as possible that city patients do not get faster treatment than people in regional and remote areas.

Patients with private health insurance can opt to be treated as a private patient in a public hospital. So the waiting list should include public and private patients, to prevent private patients gaining faster admission to public hospitals.

The system should be further centralised in metropolitan areas. The full range of elective procedures should not be re-established in every hospital. Some surgeons would need to be offered new appointments if elective surgery in their specialty was no longer being performed at the hospital where they previously had their main appointment.

Private hospitals can help
The private hospital system has taken a battering during the pandemic. Private hospitals have effectively been closed, and their viability may be under pressure.

States should consider signing contracts with private hospitals, at or below the public hospital efficient price, for elective procedures to be performed in these hospitals to help clear the elective surgery backlog.

As part of the new service model, states should bolster their hospital-in-the-home systems. For many patients, rehabilitation at home or as an outpatient can produce better outcomes than in-hospital rehabilitation.

The pandemic is not over yet and policymakers are right to be turning their minds to the transition back to something approaching business as usual. But the new, post-pandemic normal should be nothing like the old.

Physical distancing seems to be beating the virus, but the second victim might be health reform. Not wasting the crisis is the cliché on everyone’s lips. Australia has the chance to improve our elective surgery system. For the sake of taxpayers and patients, we should grasp it.The Conversation

Stephen Duckett, Director, Health Program, Grattan Institute

This article is republished from The Conversation under a Creative Commons licence. Read the original article.

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Total Comments: 12
  1. 0

    I have been paying large amounts over the past 60 years for private health insurance so that if I need surgery I do not have to wait in a line as would be needed in a public hospital. I certainly do not want patients who have never contributed to private health insurance to be able to have surgery in a private hospital meaning that I would need to wait.

    • 0

      DogLover, or we pay excesses when someone else who is wealthy can get it free in the private hospital. We save from our pension to keep our private cover yet I know wealthy people who use the free hospitals. It is a different time now and I realise that but some consideration needs to be given to poor people who do sacrifice to keep their cover. Maybe go by priority and everyone pays no excess this year. Just bulk bill or swipe the private health card. Some do not place an excess on and they should all adhere to that this year.

  2. 0

    I have been on the Public waiting list for 2 years now for gall stone issues. Prior to the virus, I was going to escalate the issue myself and go private(no health Insurance) I need to have another ultrasound just to see how my gallbladder is going. When I was placed on the waiting list 2 years ago, I was poorish and could not readily afford to go private. Now my finances have changed and I can.

  3. 0

    I to have been paying for private health for 55 years. In 2018 I had right knee replacement surgery. At that time the surgeon indicated that I would need the left knee replaced in 2-3 years. The surgeon was spot on. The left knee is now giving me a great deal of pain and is restricting my ability to walk and complete simple house hold chores. I’m keen to have elective surgery ASAP. However, it was announced that private health paying patients-to-be requiring elective surgery will be sent “to the back of the queue”. That is a stupid statement when I outlay $2500 per year to have surgery when I require it. It is not my problem that there are so many people waiting for surgery in the public health system. Some might say “Stiff”, but I’ve paid for the right to be medically helped. I haven’t wasted my money on the un-necessary things in life, like boozing, smoking, over eating and long expensive holidays to name some of the “luxuries” that some people indulge themselves in. Private health has cost me plenty and I don’t want some up-start politician or State Premier to tell me I’m now “at the back of the queue”.

  4. 0

    I used to pay private health insurance, it was a struggle out of an Age Pension, but when time came for a knee replacement, I could not afford the huge gap payment needed as my health fund would pay only two thirds of the cost. So have been in the public health system since then. I waited 4 years for bilateral foot reconstruction, and over three years for a second knee replacement, The surgeons said my feet and knee were some of the worst he’d seen, and yet I was a category 3 according to the system. Now I am waiting for cataract surgery, and have been waiting well over 12 months. My sight has deteriorated badly, and I can no longer drive at night. I also have double vision in my left eye. Perhaps its because of my age (76) that it’s not seen as a priority. But I am fit and healthy apart from that. I believe the public health system is ageist, and unable to prioritise effectively. That’s the price we pay for not being wealthy, I guess.

  5. 0

    Good article…highlights the transfer pricing, and fiddling which goes on between the federal and States Health Departments , and between the operators of public and private hospitals and the Health Funds? It is disgraceful that Health Funds can sell “Private single rooms” as part of their top cover, with very small type saying “if available”, when they know that such accommodation is not usually available. In fact the ratio may be 1 single: 3 shared. Surely every new or modernised hospital should build only single rooms.
    Recently my wife aged 86 had to share a ward with three younger gentlemen for four days following a Coronavirus test at Monash Hosp here in Melbourne. When did we as patients ever agree to this in Victoria? Even youth hostels or backpackers accommodation segregate the sexes.
    May I suggest that any review of the health service or the hospitals, starts with the PATIENTS.
    Who wants to be wakened at 5.30 ,just because the ward handover is fixed at 7.00,
    Why not wake at 6.30 and hand over at 8.00
    Who wants to walk 150 m to physio, when the gym could be integral to the wards it serves

    If we can’t agree on how to define the categories of Elective surgery, how do we expect nations to define the results of coronavirus testing, and the definition of a virus death!”

  6. 0

    In general, we’re at the mercy of those who have qualifications in medicine when it comes to individual health. Like any other organisation out for profit, it’s maximize the opportunities presented for the most benefit.

    This may not apply so much in the public system because the government attempts to bring some sense into the mix by establishing a procedural cost based upon a fair days work for a fair days pay, but we all know in the real world most people with qualifications charge whatever the market can bare – not what might be considered fair. The higher the qualification, the higher the cost.

    It’s the reason why there is a difference between what you receive from Medicare as a rebate and what medical specialists actually charge. And what can you do about it – nothing!? They have you over a barrel when it comes to working the system, and they’re very good at doing just that.

    In so far as elective surgery is concerned, there is a case for people having to wait in a line for procedures, but I suspect there are many specialists who’ve found a way to make this work for them to obtain some kind of extra benefits.

    But as for helping out the public hospital system to become more efficient; I’m lined up at some stage in the future to have a procedure performed which will likely take approximately 45 minutes to complete. Once this is done, my regular six weekly visits to the hospital for the last 18 months will no longer be required. In the meantime, each of these current 6 weekly visits to hospital for ‘procedural maintenance’ usually involves at least one nurse and takes approx. 15 to 20 mins to do.

    Notwithstanding the time and cost concerning my own involvement in this, the extra involvement by nurses and cost of equipment used to perform my ‘procedural maintenance’ every six weeks, would together, not be insignificant. Surely, in the interests of saving time and money, it would be far more prudent to get my elective procedure finalised ASAP thereby saving everybody a considerable amount of everything!

  7. 0

    Those waiting lists are obscene. I have said all along that elective surgeries never needed to be put on hold cos of the corona virus. Most elective surgeries are short in duration with patients in and out quick time. They only needed to monitor the virus situation and act accordingly without shutting down electives prematurely.

  8. 0

    OK I admit that this morning I have shed a few tears. At how I have been treated, definitely second class.
    Recently arrived back in Australia from several years overseas, we stopped our health cover before we left and have not rejoined. even with the lifetime health cover exemption that we can get if we rejoin soon it is too expensive to justify.
    I saw a specialist for 10 mins last week on a little health issue. He recommends a 15 minute investigative procedure under local anaesthetic only. I paid his fee of $210 and have subsequently asked what it will cost me. His fee is close to 500, of which I get back $180 ish from medicare. Hospital fees (half day only) are $1200 to 1400.
    I said I am sorry but I cannot justify paying that for this procedure, please take me off the list.
    Secretary has replied. If you want to go public, get your GP to refer you to public and go on their wait list. Maybe imaginary but there was a degree of snottiness in her email.
    I will do that.
    Am I being oversensitive? Should I just toughen up and get used to being treated like this unless I pay up for private health?
    Is $1200 to 1400 hospital charge for a procedure which should take less than an hour really justifiable? Thoughts? (but go easy on me today!)

    • 0

      Agree; those sorts of fees are obscene, price gouging and those charging them should be very ashamed. In regard to the little health issue. Is there any alternative like physio, exercise etc ??

    • 0

      Thanks John. I am a wimp today and you stayed kind.

      Yes will be investigating alternatives. It was a nasty procedure anyway, but more embarrassing for me than really unpleasant!

      It is no surprise that health cover keeps going up if prices are like that!



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