Despite efforts to catch up on elective surgery activity, a backlog remains for certain specialisms, orthopaedic procedures have some of the longest waiting times.

Non-urgent orthopaedic operations, such as hip and knee replacements, are often considered low priority and as such, waiting times can be very long. And although the backlog pre-dates Covid-19, the pandemic has not helped matters.

Substantial efforts have been made to catch up on the backlog, but a year from the decision to suspend non-urgent elective surgeries in both the public and private health sectors across Australia to free up bedspaces, preserve PPE and protect patients from infection, waiting lists remain high in many areas.

In particular, hip and knee surgery waiting lists are a long-standing issue, not just in Australia but worldwide.

Have we caught up?

Waiting lists are a hot topic, especially around election time, and the state of elective surgery depends on who you ask. If you ask health officials or senior management, Covid-related elective surgery backlogs have been cleared and targets are being met, but when talking to staff or patients, the answer is often different. It is still seen as an issue.

Most agree though, that while Australia is in a good position compared to other developed nations in terms of Covid-19 recovery, there is pressure caused by demand increasing over a longer period of time without the corresponding increase in capacity. There is also consensus that a hidden waiting list of people waiting to be seen by a GP could cause further pressure on elective surgery lists.

The perspective matters when looking at waiting times data, and it is useful to have a wider perspective, as well as consider trends over a longer period.

We are still waiting for comparative post-pandemic data across states so that we can assess the impact of Covid-19 on waiting lists, but both the Covid-19 and the longer term situation differs between states, and between individual hospitals.

In terms of the impact of Covid-19, South Australia has not seen a huge impact, while Victoria went through a second lockdown and another period of suspended non-urgent surgery in July. A phased restart of elective procedures meant the state did not return to full capacity until November 2020.

In NSW, elective surgery resumed in July. Surgical activity between October and December 2020 was higher than ever, increasing by almost 8% compared with the same period in 2019. Although it was a significant improvement on the previous reporting period, almost 6,000 patients had been waiting longer than clinically recommended for elective procedures at the end of 2020.

The NSW government has committed $458.5 million to fast track elective surgeries since March 2020, with Tasmania also seeing recent funding announcements aimed at increasing future capacity for elective surgery, but most of that new capacity is not available yet.

In Tasmania, which has some of the longest waiting times in the country for hip and knee replacements, the average waiting time for a hip replacement in December 2020 was 286 days, having increased from 180 in 2019; and 462 days for a knee, up from 319 in 2019.

But overall, it appears the health system is recovering well from the effects of Covid-19. The high waiting lists are a result of a hospital departments being under-resourced over a longer period of time.

A long term demand increase

Before Covid-19 hit, Victoria and Western Australia had the shortest waiting times in the country for orthopaedic surgery while Tasmania had the longest waiting times. In Victoria the median waiting time over the 2019-20 period was 55 days, while at the 90th percentile, the wait was 253 days. Tasmania on the other hand, had a median wait of 140 days, which rose to 491 days at the 90th percentile.

It is interesting to look at those that have waited the longest. In Western Australia, only 1.9% of patients had waited more than 365 days for surgery, while in Tasmania the share was 21.5%, according to the AIHW statistics. Nationally, the share of patients waiting over a year for surgery has risen over time, as shown in the chart below.

The ageing population is driving an inevitable increase in demand over time, particularly for procedures commonly sought by older people, such as knee and hip replacements and cataract surgery. Further waiting list increases can be expected for orthopaedic procedures, especially given the non-urgent status of this type of procedure.

The longer term trend can be seen within data from the NSW Bureau of Health Information. This shows annual changes since 2010, with more granular data for 2020 showing how Covid-19 impacted on waiting lists over each quarter. It’s clear that the waiting list is gradually increasing; though not at an alarming rate, the rate of growth has accelerated since 2017 as can be seen in the chart below.

Aside from the fact our population is ageing, another reason for elective surgery demand rising in public hospitals is the falling take-up of private health insurance.

It’s true that many patients have dropped or downgraded their insurance premiums during the pandemic. But there has also been a longer term trend that has seen younger, healthier members dropping out amid concerns about the value and the affordability of premiums. Already at the lowest level in more than a decade, private health insurance membership fell to 43.9% of the Australian population by the end of December 2020.

Where are the bottlenecks?

One of the biggest reasons for elective surgery waiting lists building up is a shortage of bedspaces and operating theatre space in the hospital, meaning that operating at full capacity is not possible. Classed as non-urgent, patients waiting for hip and knee surgery often have to give way to more urgent cases.

Although funding has been allocated to increasing the rate of elective surgery, that does not always translate into additional capacity in the short to medium term. Elective surgery blitzes, which is one way that Tasmania has dealt with the issue, may help in the short term but do not address the underlying demand for elective surgery in public hospitals and the shortage of bedspaces.

Staffing levels have been a major concern since long before Covid-19. A national shortage of surgeons has impacted the ability of health service organisations to attract and hire staff, particularly in rural areas. This is leading to higher than average waiting times in these areas – and the division has deepened since the start of the pandemic.

According to the Royal Australasian College of Surgeons, Covid-19 has meant recruitment of more surgeons and surgical nurses has become more challenging – as has the retention of staff. Recruitment of overseas healthcare workers has been affected by international border closures, which has also led to a shortage of PPE in some cases.

Other reports say staffing levels are at historical lows. In Tasmania, the nursing union recently said surgeries were being cancelled, as here were 900 unfilled shifts at the state’s largest hospital in April. A government spokesperson said this is despite the fact that there are more than 750 additional nurses in the Tasmanian health system now compared to seven years ago, which shows to what extent demand is outpacing capacity.

The impact of longer waits

Older orthopaedic patients are often encouraged to manage as long as possible without hip or knee surgery, with the help of aids such as exercise, physiotherapy and assistive devices. One of the reasons is that prosthetics have limited lifespans, so operating too early could lead to a need for additional surgery. However, living with hip- or knee pain long term is debilitating and can reduce the patient’s quality of life substantially.

While these procedures may not be life threatening, evidence has showed that long waiting times can have negative effects on health outcomes for patients in various ways. A patients’ condition may deteriorate during the wait, especially if the wait is extended or the patient de-prioritised. But as well as the physical impact, waiting for procedures delayed by Covid-19 or other factors could also have mental health consequences for both patients and caregivers.

A new study, published at the end of March, looked into the psychological burden of waiting for procedures. It found that, as well as being associated with disease progression and mortality, delayed procedures often cause anxiety, depression or poor quality of life, which can manifest physically, prompt or worsen other aspects of mental health and escalate if untreated. This may mean already strained healthcare systems may face added pressure to manage mental health needs in future.

If you ask patients, their ‘elective surgery’ isn’t elective at all, it is essential in order to maintain quality of life. The latest instalment of the survey ‘Patient Experiences in Australia’ found that 22.7% of people were waiting longer than they felt acceptable for a medical specialist appointment.

A regional gap is evident, not just between states but also between rural and metropolitan areas. People living in areas of most socio-economic disadvantage and those living in outer regional, remote or very remote areas were more likely to report waiting longer than they felt acceptable for an appointment than other groups.

In NSW, waits of more than a year were reported at some country hospitals, while being just seven days at city hospitals. A recent report on the detailed data available showed regional residents wait far longer for knee and hip replacements than most inner-city Sydney residents. This is partly because rural communities were struggling to attract a local doctor, much less specialist surgeons, causing the local variations.

The bigger picture

It can be useful to widen the perspective ,and look at the longer term trends and the international context for elective orthopaedic procedures. A recently published OECD report reviews waiting times across 17 countries, as well as the effect of a range of policies implemented to deal with the issue, using data up to and including 2018-19.

The chart below shows the median waiting times for some selected OECD countries with comparable data for different types of surgery.

On average across these countries, the OECD average median waiting times were shorter for more minor surgery and longer for more major surgery like hip replacement (113 days) and knee replacement (189 days) – but there are huge variations across countries. Overall, waiting times for hip and knee surgery in 2018 were the lowest in Denmark, the Netherlands, Italy and Hungary, while they were the highest in Estonia, Poland and Chile.

For hip replacements, the median waiting time in Australia was slightly higher than the OECD average, and significantly above the New Zealand median, although it was not alone – many countries recorded long waits for hip replacements. Median waiting times ranged from 35 to 50 days in Denmark, Hungary and Italy, to 180 days in Poland and 250 days in Estonia.

Australia’s median wait for knee replacements was one of the highest out of all OECD countries at 209 days, more than 6 months. Although the OECD average is high for this type of procedure, the average was brought up by relatively few countries with very high waiting times, such as Chile, which has a median wait of 840 days, and Estonia with 460 days.

The figures also show that, as in Australia, waiting times in many countries had started to rise following a period of stability in many countries even before the Covid-19 outbreak. However, changes to the median waiting time in countries such as United Kingdom and Australia have been relatively small from an international perspective compared to, for example, Estonia and Portugal.

What is needed?

The shortages of staff and bedspaces are not just an issue in particular regions in Australia, they represent one the most common reasons for cancelling elective surgery worldwide.

Even permanent increases in supply are not a guarantee of success. In some cases additional supply can be offset by an increase in demand, through an increase in referrals, tests and procedures – or even just natural growth in the population. For example, waiting times for some elective surgery in both Canada and Australia have increased in recent years despite additional funding and an increase in activity.

As the population ages, there is no doubt demand for both urgent and non-urgent knee and hip operations will increase further. Given how long it takes to train a surgeon or to build a new hospital, a significant amount of additional space and additional staff will need to be included into planning immediately to ensure they can cope with the future healthcare needs of our country’s population.