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Access to elective surgery in Australia and New Zealand is a key area of concern for the Royal Australasian College of Surgeons (RACS). RACS recognises the continuing and increasing demands of the community for specialist surgical care and access to elective surgery. The capacity of health services to improve standards of living through surgery is increasing, but the allocation of resources to support this still requires improvement.1
RACS recognises that general practitioners and other non-surgical specialists require access to specialist surgical care for patients who may benefit from surgical review and treatment. To meet this requirement, patients must have access to appropriately trained surgeons for clinical management. RACS recognises that the role of the surgeon is to ascertain the benefits of surgery and other therapies and to make a recommendation to the patient and referring doctor. The urgency of need for that surgery is best assessed by the surgeon and forms part of the recommendation.
Inappropriate delays in accessing surgical assessment or treatment can be associated with increased risk of morbidity and mortality, and can prejudice the outcome of any treatment deemed necessary.2 The challenges and solutions associated with providing equity of access and minimising harmful delays are multifactorial and reliant on supportive cultural change within health services. This is particularly true in relation to the increasing burden of degenerative diseases across a number of specialist surgical disciplines and the cumulative effects of an ageing population on service demand.3
Waiting Lists & Clinical Urgency Categorisation
Waiting lists imply a demand for services that exceeds the capacity or ability to supply such services. The question of how to best manage waiting lists is a matter for governments, health services and surgeons to manage together. Only through a collaborative approach can efficient and transparent management of elective surgery waiting lists be achieved. In both Australia and New Zealand there are measures underway that seek to effectively and equitably manage waiting lists for elective surgery. In Australia, RACS has been actively involved in working together with the Australian Institute of Health and Welfare to propose reforms that address problems within the elective surgery system.4 The goals of this process were to improve the consistency and comparability of elective surgery urgency categories across all Australian states. Similarly in New Zealand there are surgical reviews and processes underway with the aim of improving categorisation of patient needs with reference to individual context and prognisis 5
RACS supports the adoption of national definitions for elective surgery urgency categories or prioritisation systems that are based on the following principles6 :
- Simplified, time based urgency categories or prioritisation criteria
- Surgeon determined categorisation
- A listing of the usual urgency categories for higher volume procedures (developed by surgical specialty groups
- Comparative information disseminated about urgency categorisation or prioritisation criteria
- Treat in turn’ by priority as a principle for elective surgery management
- Clarified approaches for patients who are not ready for surgery, because of clinical or personal reasons
In New Zealand a more finite resource base has given rise to the utilisation of detailed prioritisation systems that are used to determine the clinical needs for a particular patient with consideration given to the impact of the condition on the patient, the likely benefit of the surgery to the patient, the risk to the patient and the impact on the patient should the surgery not be undertaken. 7 RACS acknowledges the inherent problems in managing a system where those assessed as being unlikely to receive treatment within four months are not placed on a waiting list. RACS encourages the continued refinement in measuring patient needs and better reporting within the District Health Boards (DHBs) that will further ensure that the system operates in an equitable fashion and that it meets patient need in a manner appropriate to their clinical situation.8
Reporting and Reflection
RACS recognises that in order to realise ongoing improvement and refinement to the elective surgery urgency categorisation or prioritisation systems, consistent reporting of outcomes is vital. RACS encourages all surgeons in Australia and New Zealand to be using and participating in the collection and distribution of elective surgery data.9
In New Zealand, RACS is also supportive of measures for DHBs to more comprehensively record and communicate data across the elective surgery system particularly in relation to patients who are assessed as not being able to be placed on a four month waiting list and for those who drop off the list for a variety of reasons. RACS also encourages surgeons, DHBs and the Ministry of Health in New Zealand to continue to refine their capture of assessment information and procedural data that can better inform the effectiveness of prioritisation within the system.
Funding resources and leadership
Access to surgery is controlled by the allocation of funding made available by governments who are responsible for the provision of publicly funded health care. RACS urges governments to continue to invest in elective surgery as a matter of priority in view of the increasing numbers of patients who seek treatment in the public system. In Australia there will need to be consistent and focused investment in the areas of most need in order to meet the Australian National Elective Surgery Target (NEST).10 Future challenges in the area of health funding will also require careful stewardship of resources through systems reform and efficiency measures.
RACS recognises that Surgeons can actively contribute to the better management of resources and funding by eliminating waste and improving data collection and analysis in their clinical practices. Through the adoption of a more structured approach to surgical urgency categorisation and by continued and sustained investment in surgeon education and development the elective surgery system can continue to achieve improvements in patient outcomes.
- Only through a collaborative approach from governments, health services and surgeons can efficient and transparent management of elective surgery waiting lists be achieved.
- RACS encourages all surgeons in Australia and New Zealand to be using and participating in the collection and distribution of elective assessment and surgery data.
- RACS urges governments to continue to invest in elective surgery as a matter of priority in view of the increasing numbers of patients who seek treatment in the public system.
1 MacLellan DG, Smyth T, Cregan PC, Lizzio J, Watt H. Surgical services: shaping future directions. ANZ Journal of Surgery. 2012; 82: 68–72.
2 Oudhoff JP, Timmermans DRM, Knol DL, Bijnen AB, Van der Wal G. Waiting for elective surgery: Effect on physical problems and postoperative recovery. ANZ Journal of Surgery. 2007; 77: 892–98.
3 Briggs AM, Lee N, Sim M, Leys TJ, Yates PJ. Hospital discharge information after elective total hip or knee joint replacement surgery: A clinical audit of preferences among general practitioners. Australasian Medical Journal. 2012; 5 (10): 544-50. Gwynne-Jones D, Quantifying the demand for hip and knee replacement in Otago, New Zealand. New Zealand Medical Journal. 2013; 126 (1377): 7.
4 Australian Institute of Health and Welfare (AIHW). National definitions for elective surgery urgency categories. Proposal for the Standing Council on Health. 2013; Canberra, AIHW.
5 New Zealand Ministry of Health. Targeting Waiting Times. 2013; Wellington, NZMH.
6 Australian Institute of Health and Welfare (AIHW). National definitions for elective surgery urgency categories. Proposal for the Standing Council on Health. 2013; Canberra, AIHW.
7 Curtis AJ, Russell, COH, Stoelwinder J, McNeil JJ. Waiting lists and elective surgery: ordering the queue. Medical Journal of Australia. 2010; 192 (4): 217-20.
8 Ashton T, Bramley D, Armstrong D. Improving the productivity of elective surgery through a new ‘package of care’. Health Policy. 2012; 108 (1): 45-48.
9 Australian Institute of Health and Welfare (AIHW). National Elective Surgery Wait Times Data Collection (NESWTDC). Information available at: http://www.aihw.gov.au/hospitals-data/national-elective-surgery-waiting-times/ (Accessed 21/11/14).
10 Kargar ZS, Khanna, S., & A Sattar. Using prediction to improve elective surgery scheduling. Australasian Medical Journal. 2013; 6 (5): 287-89.