By mid-August 2022, over 13,000 Australians had died from COVID-19. And yet the pandemic has caused far greater mortality and morbidity than this official death count.
The repeated suspension of elective surgery, the disruption to screening services and outpatient appointments, and a 40% drop in routine pathology testing early in the pandemic have all combined to create a cohort of Australians now presenting with more advanced disease and languishing on long waiting lists for surgery as their condition worsens.
The Australian Institute of Health and Welfare (AIHW) reports that the percentage of patients waiting over a year for their surgery has more than tripled since 2018-19. One in three patients requiring a knee replacement have waited more than a year and around 15,000 fewer patients underwent general, ophthalmological, or orthopaedic surgery, respectively in 2020-21.
Remember that ‘wait to wait’ times have also increased. Patients may wait many months to see a specialist before they are even assigned to the surgical waiting list.
When the queue gets too long at the supermarket checkout, the shop usually opens more lines to ensure shoppers don’t wait too long. This isn’t quite so straightforward for hospitals. Given chronic underfunding and capacity constraints, what can be done to address Australia’s elective surgery backlog?
Australian Medical Association (AMA) President, Dr Omar Khorshid calls for a funded plan from all levels of government to clear the elective surgery backlogs and properly support public hospitals. He argues this then ‘needs to be backed by real, long-term funding commitments that deliver permanent, expanded capacity in our public hospital system.’
Consequences of delayed care
In his ‘Advice to a young tradesman,’ Benjamin Franklin urged his reader to remember that ‘time is money’. When it comes to healthcare, time is even more important than money. Time is life – or quality of life.
Having missed their routine screening appointments or health checks during the pandemic, some patients do not yet even know they have a condition requiring surgery but symptoms will begin to show at some point. Others have been on an elective surgery waiting list for an unacceptably long time, waiting for either diagnosis or treatment with increasing anxiety.
Between 2019-20 and 2020-21, the proportion of Australian patients waiting more than a year for a total knee replacement rose from 11% to 32%. That has a significant impact on their quality of life. A Scottish study found that nearly a quarter of such patients had a EuroQol five-dimension score of less than zero, defined as a health state ‘worse than death’. And each additional month on the waiting list was independently associated with a decrease in quality of life.
A Canadian review of studies relating to surgical waiting times and mental health found that,
Most patients and caregivers reported anxiety, depression and poor quality of life, which deteriorated with increasing wait time. The impact of waiting on mental health was greater among women and new immigrants, and those of younger age, lower socioeconomic status, or with less-positive coping ability.
As Royal Australian College of Surgeons (RACS) President, Dr Sally Langley, stated in February this year,
Elective surgery is not an optional procedure that a patient or doctor elects to have – it is essential surgery. It is surgery to address often life-threatening conditions and conditions that prevent patients from living a normal life because of severe pain or dysfunction.
For many patients waiting in line in pain to have a critical operation, the delays in surgery can be devastating. Further, the lack of screening procedures has resulted in patients presenting with more advanced cancers, and in some cases, it has dramatically altered their prognosis.
How big is the elective surgery backlog?
In Victoria alone, there are an estimated 80,000 patients waiting for a procedure – almost double pre-COVID-19 numbers.
Stark as those numbers are, the AMA warns that they represent only the tip of the iceberg. Dr Khorshid notes that,
As a result of the pandemic there has also been a reduction of specialist out-patient appointments, as well as limits on access to general practitioners meaning that people may not have seen their GP for an initial referral. The longer we wait to act on essential surgery, the sicker Australians will become, and the more expensive their care will be.
It’s easy to understand how waiting lists have grown given the perfect storm of long-term underfunding, COVID-19-related suspension of activity and reduced staff availability due to isolation requirements.
Exactly how long a patient waits depends on both the surgery and the hospital in question.
Referral for surgery in a public hospital is based on catchment area. The patient’s address determines which hospital they’re referred to. Often, that’s the most convenient arrangement for patients as it reduces their travel burden. Unfortunately, it also creates a postcode lottery when it comes to waiting times.
Let’s take a closer look at one common procedure – a tonsillectomy. It’s a quick procedure but it makes a significant difference to a child’s quality of life. Surgery offers relief from painful, repeated infections, time off school (often requiring time off work for parents) and even breathing difficulties.
The Australian Institute of Health and Welfare (AIHW) reports that the median waiting time for tonsillectomy was 123 days in 2020-21, a significant increase on the previous year.
Health insurer, HBF, recently took a look at the varied waiting times around the country to highlight how a patient’s address determines their chance of receiving timely care in the public system, even within the same city. It’s an interesting picture.
|City / area||Hospital||Median wait time for tonsillectomy|
|Perth||Royal Perth Hospital||188 days|
|Fiona Stanley Hospital||358 days|
|Adelaide||Flinders Medical Centre||93 days|
|Royal Adelaide Hospital||168 days|
|Melbourne||The Alfred||127 days|
|Royal Melbourne Hospital||264 days|
|South east Queensland||Gold Coast University Hospital||82 days|
|Royal Brisbane and Women’s Hospital||349 days|
Strategies to address the elective surgery backlog
Australia needs a comprehensive and fully funded plan to tackle the backlog of elective surgeries. We highlight two key components below.
Centralised waiting lists
Given the length of the waiting list, it may be time to replace catchment-based referrals with referral to a central list. Patients would be offered the first available surgery time at any participating hospital. Patients could have the right to decline an out-of-area offer but many are keen to get their surgery done and may prove willing to travel for it, especially if it’s simply to the other side of the city.
In 2021, in response to the worst waiting list figures ever reported, the British Government committed a total £1.5 billion to create ‘surgical hubs’. These would:
- Enable greater separation of elective and emergency care
- Increase capacity
- Maximise infection control.
Success stories include:
- Moorfields Eye Hospital, which has reduced the time cataract patients spend in hospital to just 90 minutes and has performed up to 725 operations in one week
- Nottingham University NHS Trust, which has established ‘Super Saturdays’ where staff perform the same procedure all day to reduce changeover times and maximise operating time.
- St George’s University Hospitals NHS Foundation Trust, which built a stand-alone surgical hub in the car park of Queen Mary’s Hospital in Roehampton. Approximately 120 procedures per week are performed in this facility, which features 4 dedicated operating theatres and a recovery area.
The Royal College of Surgeons, England is now calling for the widespread adoption of surgical hubs, noting,
This approach builds on strategies developed by NHS leaders and surgical teams over a number of years in response to the competition for pooled elective and emergency care resources such as beds, staff and diagnostics. Such competition is particularly intense over the winter months, when elective surgery is often scaled back to free up capacity for emergency patients. The case for a clear separation of these resources became stronger during the pandemic as trusts collaborated and innovated to tackle the challenges presented by COVID-19.
Creating a surgical hub may involve:
- Reorganising teams
- Changing patient flow
- Physically separating parts of the hospital by means of separate entrances
- Treating patients from other parts of the country to help keep surgery going.
In Australia, surgical hubs now form a key part of the Victorian government’s COVID-19 catch-up plan.
Infrastructure to support surgical hubs
Flexible infrastructure provides an ideal way to establish a surgical hub in a relatively short timeframe in both rural and metro locations. Such bespoke facilities can be used for the majority of surgical procedures performed in a major hospital and include day surgery facilities, laminar flow operating theatres, outpatient clinics, decontamination and sterilisation facilities, and visiting hospitals in remote regions.
If you would like to learn more about how mobile and modular facilities could help your hospital tackle its elective surgery backlog, please contact Q-bital Healthcare Solutions.