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Authors: Steve Robson & Rhiannon Tudor Edwards

Waiting lists for elective surgery in Australia have long been a focus of media and political scrutiny. National waiting list data are  with data released in annual reports. There already were considerable pressures on Australian State and Territory governments to deal with what were perceived as long waiting lists and waiting times for elective surgery. As has been the experience internationally, the COVID-19 pandemic has stressed the Australian health care system at all levels and led to . The Australian Medical Association (AMA) annual  for 2021 reported:

“Australia’s public hospitals are in crisis. Problems that have existed for years have only been amplified by COVID-19. The situation is even worse when it comes to elective surgery. We continue to see more people being added to the elective surgery waiting lists than are taken off the lists through provision of surgery. As this Public Hospital Report Card shows, during 2020-21 reporting period, for Category 2 elective surgery – procedures like heart valve replacements or coronary artery bypass surgery, one in three patients waited longer than the clinically indicated 90 days, a performance decline of 17 per cent since 2016-17.”

As the COVID-19 pandemic has revealed, it is impossible to have a healthy economy without a healthy population. A 2019 paper for the Australian Treasury, , states the following:

“Economists have increasingly recognised that good health across the whole population significantly contributes to labour and human capital to achieve economic growth. Through higher participation and productivity, good health contributes to economic performance and is positive for individual wellbeing. Good health enables individuals to participate in a range of activities and to engage socially with family and friends and their communities. Good health also allows individuals to be more productive physically and mentally by enabling them to learn more effectively and retain knowledge. Good health also reduces uncertainty, which allows individuals to plan for the whole of life.”

SURGERY IS IMPORTANT FOR HEALTH, WELL-BEING AND WELL-BECOMING THROUGH THE LIFE-COURSE

Surgery plays a fundamental role in healthcare, not only in developed countries but globally.  have estimated that surgery performed accounts for more than one quarter of all hospital admissions in high-income countries. At a global level, it has been  that almost a quarter of a billion major operations are performed each year, and that between 11% and 15% of the global disease burden is amenable to surgical treatment. Disruption to surgery has led to avoidable pain and disability to people who already need treatment to be healthy and productive. An  made the following observations:

“The ongoing pandemic is having a collateral health effect on delivery of surgical care to millions of patients|…|As regions with the highest volume of operations per capita are being hit, an unprecedented number of operations are being cancelled or deferred. No major stakeholder seems to have considered how a pandemic deprives patients with a surgical condition of resources, with patients disproportionally affected owing to the nature of treatment (use of anaesthesia, operating rooms, protective equipment, physical invasion and need for perioperative care). No recommendations exist regarding how to reopen surgical delivery|…|Patients are being deprived of surgical access, with uncertain loss of function and risk of adverse prognosis as a collateral effect of the pandemic. Surgical services need a contingency plan for maintaining surgical care in an ongoing or post-pandemic phase.”

Not only does delay or cancellation of surgery affect the well-being of patients today, it may have a “long-shadow” in terms of impacting on their health and well-being or well-becoming in subsequent life-course stages. This may be in terms of their mobility, ability to self-care, ability to work, ability to care for others, and enjoyment of recreational activities,

 Australia has a health system that is fundamentally different from the UK, NHS-based system. Public hospitals (run by State governments but partially financed by the Federal government) provide free at the point of contact surgery. In Australia, the Federal government provides financial incentives (both cash transfers and tax incentives) for individuals to maintain private health insurance. Usage of the different hospital systems is complex. Waiting lists act as a non-price rationing mechanism in the Australian health care system as in the UK NHS. A  found that, despite having private health insurance, 40% of people receive inpatient services exclusively in public hospitals. Only 62% of overnight hospital admissions were claimed on private health insurance. 66% of people receive services in public hospitals for surgical admissions.

Waiting lists for Australian public hospitals are prioritized according to an  with national targets for surgical access. All referrals for surgical care originate with general practitioners (GPs) in Australia, and the process for patients being referred for care in public or private hospitals is managed by those GPs as shown in the flow diagram below:

Flow diagram 1. Referral process for elective care in the Australian health care system

Once a patient has seen a surgeon and been listed for surgery, there is some choice in the way this is performed, with some patients who do not hold private health insurance opting to pay the overall costs for surgery in a private hospital. The flow diagram is shown below:

Flow diagram 2. Choice options for patients in the Australian health care system seeking surgery

The system was at capacity before the pandemic:  reported that, during the financial year 2017–18, there were 11.3 million episodes of admitted patient care in Australia’s public and private hospitals: 60% of these occurred in public hospitals. Private hospitals accounted 59% of surgical episodes of admitted patient care and of the 2.3 million episodes of admitted patient care involving elective surgery, 34% were in public hospitals and 66% in private hospitals.

As in the UK, Australia now has to deal not only with the background inflow of patients to waiting lists for planned surgery, but with an enormous backlog of patients who have been unable to access surgery during the pandemic – many of whom have experienced deteriorations in their clinical condition due to the delays. The pre-pandemic algorithm for public hospital waiting lists in Australia was like this:

Algorithm 1. Waiting list prioritization algorithm pre-pandemic

...but now looks like this:

Algorithm 2. Waiting list prioritization algorithm post-pandemic

Globally, a number of groups have reported descriptions of  of surgical patients who languish on lengthy waiting lists. How generalizable these new tools are remains to be seen.

RETHINKING PRIORITIES FOR THE MANAGEMENT OF WAITING LISTS TO SUPPORT PATIENT HEALTH, WELL-BEING AND WELL-BECOMING

In most democratic countries an important principle of providing health care is equity. Horizontal equity refers to the situation in which all people are treated equally – that those with similar needs are provided similar treatment irrespective of their capacity to pay. This was one of the founding principles of the Beveridge Plan in 1942, which led to the establishment of the NHS in 1948. Vertical equity refers to ‘unequal treatment of unequals’, where people with greater means contribute a higher proportion of the costs of care. With Australia’s parallel systems of public and private health care, how can equity be applied when dealing with waiting lists that have ballooned during the pandemic? There are : “Waiting times have been shown to be associated with patient dissatisfaction, delayed access to treatments, poorer clinical outcomes, increased costs, inequality, and patient anxiety.”

Ongoing research at the  by Steve Robson and Professor Rhiannon Tudor Edwards will explore the issue of waiting list management in Australia from multiple perspectives. These perspectives span:

• Who is being referred for surgical care and are there systematic differences in referral patterns?
• Are there systematic biases in access to surgery according to factors such as socioeconomic status?
• How large a part does geography play in access to surgery?
• Are there systematic differences in access to high- and low-value surgical procedures, where value refers to cost per QALY or cost per DALY?
• What QALY gains can be made with different approaches to surgery prioritization?

The opportunity to compare surgical access across the UK and Australian systems promises to be interesting.