‘A stitch in time saves nine,’ is an old piece of sewing advice dating back to the 1720s. The encouragement to act quickly before a problem worsens applies to healthcare too. Timely access to screening or elective surgery can improve health outcomes and quality of life.

Every clinician knows that. Yet many are now unable to provide timely investigations or treatment due to capacity constraints in the health system.

Long-term underfunding and COVID-related delays mean hospitals are now grappling with lengthy waiting lists for life-changing and life-saving procedures. That trend must be reversed if Australia is to maintain high standards of patient care.

Deferring care

Deferred care is usually due to the system rather than the patient.

Yes, sometimes patients defer their own care due to time constraints, financial pressures or a desire to minimise COVID exposure. And sometimes they don’t perceive their situation as serious enough to require more immediate attention.

But most patients want their health needs addressed as promptly as possible because waiting means pain and anxiety. They’re worried about bowel cancer symptoms but can’t get a colonoscopy. Their vision is clouded by cataracts, increasing their fall risk and compromising their independence. They’re living with painfully limited mobility as they wait and wait for a hip or knee replacement.

As the Federal AMA President explains, ‘Non-urgent elective surgery is still necessary surgery that may now have become more urgent. There will be a big and growing volume of these patients.’

The number of patients waiting over a year for elective surgery has nearly tripled, according to the Australian Institute of Health and Welfare. In 2020-21, 7.6% of patients waited over 365 days to be admitted, up from 2.8% in 2019-20. There was also a 40% increase in the number of patients being transferred to another hospital’s waiting list.

Waiting times for cataract surgery range from 4 months to over 2 years and have lengthened during COVID-19. Yet reducing these waiting times from 12 to 3 months could save $6.6 million by preventing over 50,000 falls.

Patients waiting for a colonoscopy, either due to a positive screening test or symptoms of bowel cancer, are also facing delays as services try to clear the backlog of 78,048 fewer procedures performed across Australia in 2020, in addition to the waiting lists that existed prior to the COVID-19 pandemic.

In short, there are now system-wide pressures that require increased capacity.

‘We will need to build the long-term capacity of our public hospital system so that it is fit for purpose as it faces a vastly different environment that the pandemic has created. The human cost of delayed treatment is real and patients were already waiting, in some cases, years to access care well before this pandemic started. This situation was intolerable and in the absence of additional funding and deep system reform, it will only get worse.’

Dr Omar Khorshid Federal AMA President

Re-engaging patients

Hospitals need to employ creative solutions to re-engage patients in order to cut waiting lists and deliver timely access to healthcare.

Patients who have spent many months on a waiting list are likely to feel frustrated and neglected. In some patients, that can translate into feelings of apathy about their health (it seems unimportant to the hospital, after all) or hostility towards a system that keeps them waiting.

When they’re finally offered a date for their procedure, some may not prioritise booking the time off work to attend their appointment as their motivation has now dissipated. They’ve turned into a no-show.

It doesn’t have to be like that. Hospitals can keep patients engaged by staying in touch while the patient works their way up the waiting list.

Regular telehealth consultations enable you to provide support and, if necessary, reassess the urgency of the patient’s need, moving them up or down the list as required. Telehealth is convenient, socially distanced and easy to slot into the working day, unlike a trip to a clinician’s rooms or a hospital outpatient clinic which may involve a morning off work and many hours of waiting in line.

Depending on their condition, you could also encourage the patient to access some prehabilitation treatment such as physiotherapy, dietetics or psychological support. Prehabilitation aims to enhance a patient’s capacity to better equip them to withstand and recover from surgery. Evidence suggests that patients who have engaged in a prehabilitation program may have less postoperative pain, fewer postoperative complications and a reduced length of stay in hospital. Those outcomes benefit both the patient and the healthcare system.

Building capacity

Heightened pressures on infection control have created a need for more enhanced cleaning and disinfection protocols within healthcare environments, increasing the amount of downtime required and creating increased pressure on capacity.

It’s a very tricky situation. Hospitals must comply with stricter cleaning protocols, which takes time and so reduces the number of procedures that can be performed per day. Yet there is also a mounting need to complete more procedures due to burgeoning waiting lists.

Clearly, more capacity is needed. Yet the need is urgent and immediate – there is no time to commission major building work that will not deliver usable operating theatres for several years.

The way forward is to use a mobile or modular solution, which enables your hospital to enjoy additional capacity for elective surgeries or endoscopy procedures in less than 3 months.

The standalone nature of facilities ensures that patients do not have to enter the main hospital site prior to their appointment. Flexible infrastructure enables healthcare providers to prioritise infection control measures, increasing patient confidence in turning up to their appointment.

Flexible mobile and modular facilities are a key part of a new model of care adopted by the UK in response to the COVID-19 pandemic.

As in Australia, elective surgery was halted during the first wave of the pandemic, both to ease capacity pressures and to protect surgical patients from the risk of catching the virus during their hospital stay. Once elective surgery resumed, the UK’s goal was to maintain access for COVID-negative patients while reducing their risk of contracting the virus during or immediately after surgery when they would be particularly vulnerable.

And so ‘green zones’ were created. These are self-contained healthcare facilities or ‘surgical hubs’ that only admit COVID-negative patients.

The Royal College of Surgeons, England notes that,

Over the course of the pandemic, hospital trusts and surgeons have collaborated remarkably, providing ‘mutual aid’ at times of extreme pressure to ensure urgent surgery continues. Through this collaboration, trusts have also been able to put agreements in place to designate certain hospitals as ‘surgical hubs’. These hubs have helped to expand capacity and improve efficiency for specified types of elective procedures by bringing skills and resources together under one roof in COVID-secure environments.

For staff, this can mean they do not work at the hospital they previously worked at, but instead follow the surgical patients to the hub. For patients, this may mean that they do not get their operation in their nearest hospital, but in a nearby ‘surgical hub’ hospital. The pandemic has resulted in huge behavioural changes in how patients use the NHS…

At the hospital level, such a model may mean that elective surgery happens in new, standalone facilities away from the main building with no crossover of staff or visitors. At the health service level, it may mean that some hospitals are designated as ‘green zones’ that do not accept emergency admissions or treat COVID-positive patients but simply provide a safe(r) space for elective surgery to continue and so benefit the many patients waiting for their procedure.

The Victorian government recently announced similar plans as part of its COVID catch-up plan. It will create Rapid Access Hubs across metropolitan hospitals. These will exclusively perform specific surgeries to tackle the waiting list backlog.

Case study: The Prince Charles Hospital, Brisbane

The Prince Charles Hospital was feeling the pressure of a lengthening colonoscopy waiting list and created the necessary additional capacity by installing a mobile endoscopy suite.

The new facilities were up and running in a matter of months and will enable the hospital to perform an additional 450-500 procedures each month. That’s wonderful news for patients waiting anxiously for a colonoscopy after a positive screening test or because they’re experiencing symptoms of bowel cancer.

Addressing your waiting list

Waiting times matter. They affect a patient’s mental well-being and their long-term recovery. Delayed care means a patient’s condition may worsen, limiting their treatment options and compromising their life.

Australia’s hospital system is not keeping pace with patient demand, particularly in the public sector. There is an urgent need to increase capacity in order to provide timely access to treatment.

What do you feel is the solution to ease your hospital’s day-surgery capacity pressures and restore patient flow?