9 January 2018
Hospitals and healthcare providers across Australia are facing an
increasing demand for services. Overall, funding for health has
increased throughout the past decade; however, the cost of
delivering care has also increased, as have public expectations
about acceptable standards and access to health services.
Australians pay a high level of income tax compared to many other
OECD countries; therefore, taxpayers expect the Commonwealth
Government to fund state and territory governments adequately to
provide timely access to high quality healthcare without additional
out of pocket costs.
RACS acknowledges that healthcare budgets are finite, and that the
Australian Parliament is directing considerable effort to improve
the sustainability of Australia's healthcare system. The College
has welcomed the opportunity to have direct involvement in the MBS
Review, and is actively working on other key challenges which
influence surgical services in Australia, including participating
in the Choosing Wisely project, taking a stand against excessive
surgical fees, and collaborating with private health insurers on
clinical variation to support surgeons' understanding of their
practice in comparison to their peers.
From 2003-04 to 2013-14, public hospital expenditure increased
each year by around 8%. This growth has not been matched by an
equivalent growth in Commonwealth funding, and is most clearly
reflected in the length of waiting lists around the country. The
funding arrangement between the Commonwealth and state/territory
governments must include equal cost sharing responsibility for
growing healthcare expenditure.
In all states and territories, waiting times for elective surgery
continue to be a concern for surgeons and patients. The longest
median wait times are for ophthalmology, ear, nose and throat
surgery, and orthopaedic surgery.
Delayed access to healthcare may lead to poorer health outcomes
and is more costly in the long term. RACS is particularly concerned
that Indigenous Australians have a longer median wait time and a
higher likelihood of waiting more than a year for elective surgery
than other Australians.
HEALTH OUTCOME DATA INCORPORATING AUDITS AND REGISTRIES
The best way to improve transparency of surgical outcomes is to
fund audits and registries, use agreed definitions for disease,
procedures and outcomes, and ensure that everyone is able to
understand, interpret and value health outcome data.
As the Grattan Institute notes, lots of hospital safety
information is collected in Australia, but not all of it is shared
with the right people. A first step in improving hospital safety in
Australia is to better use the information that is already
collected, and to put it in the hands of people who can apply
We believe a more strategic approach to health outcome data is
required and would like support from the Commonwealth Department of
Health, state and territory governments and other stakeholders to
improve interpretation of outcomes. This is already happening via
the RACS Australian and New Zealand Audit of Surgical Mortality,
however it is generally agreed that much more could be done to
improve understanding of morbidity outcomes.
Surgical audit and peer review are important strategies in
maintaining standards in surgical care at the clinical level, and
clinical quality registries have been identified as a 2016-18
Australian medical research and innovation priority.
The Australian Orthopaedic Association National Joint Replacement
Registry (AOANJRR) has demonstrated a continual decline in the
number of individuals requiring revision hip and knee replacement
procedures since its inception, and provided a major benefit to the
hospital bottom line.
Another example of audit which would improve patient outcomes and
substantially reduce hospital costs is the Australia and New
Zealand Emergency Laparotomy Audit Quality Improvement (ANZELA-QI)
initiative. Emergency surgery is a significant healthcare burden
and constitutes one third to half of all general surgery
admissions. The high mortality and variable outcomes, when compared
to similar elective operations, are well known to clinicians.
International studies have shown that emergency laparotomy quality
improvement has reduced overall hospital and intensive care length
of stay. For the equivalent of an estimated A$400 000 per year, the
UK National Emergency Laparotomy Audit (NELA) reports a cost saving
of £30 million (about A$54 million) per year. The NELA was
implemented to address inter-hospital variation, which has now been
Following initial UK Government support for three years, a further
five years funding was recently announced - a clear indication of
the value. In Australia it is estimated up to $400 million is spent
each year in Australia providing care for approximately 15,000
patients needing emergency laparotomies, making this a high volume
and high cost area of care. Independent Hospital Pricing Authority
data shows inter-hospital variation in processes and outcomes which
could be addressed by ANZELA-QI.
RACS has also highlighted its concern about the current lack of
post-operative surveillance capabilities for surgical mesh, and
believes a comprehensive mesh tracking system is required so that
patients can seek the opinion of their general practitioner,
primary surgeon or another expert if their condition is
RACS supports the public release of outcomes based data on
surgical performance at a team (larger than five), institutional or
national level. The reports need to be valid, reliable and
trustworthy so that surgeons and patients can be confident that
reports accurately reflect the standards of health care.
In the absence of systemic audit, RACS is working with Medibank
Private to produce surgical variance reports which analyse
indicators for common procedures within surgical specialities,
including general, urology, otolaryngology, vascular and
Improved health literacy is central to people's ability to enter
into an informed agreement with their clinician and we stand ready
to work with Consumers Health Forum and other groups to provide
resources and information that may assist.
To address geographic maldistribution of surgeons in regional and
rural areas, RACS supports the 'hub and spoke' model which allows
regional and rural hospitals to become involved in training
networks with larger regional and metropolitan centres.
There is evidence to show that trainees return to work in regional
settings after they qualify because they had a rewarding experience
in these centres. To ensure this level of experience, regional
hospitals need funding for training posts. This can best be
achieved by funding posts as part of the Specialist Training
Program that are aligned with workforce data to ensure specialists
are being trained and located in areas of clinical need.
We understand this is a two-way process, and while we would like
to see greater flexibility from the Commonwealth in terms of the
criteria for funding of rural training posts, we need to work with
our Training Boards to improve the efficiency of post
Supporting access to safe and affordable surgical and anaesthesia
care is important for Australia's foreign policy because it
promotes health and wellbeing, and thus economic growth.
Australia, as a co-sponsor of World Health Assembly resolution
68/15 to strengthen emergency and essential surgical care, has an
opportunity to help realise the resolution's intent through its
strategy of support for low and middle income countries (LMICs) in
RACS manages global health programs and projects in various
developing countries across the Asia-Pacific region, including
Timor Leste, the Pacific Islands, Papua New Guinea, Myanmar, Nusa
Tenggara Timur (Indonesia), and has formal linkages with several
nations including China.
Ongoing funding for these programs is critical to address the
shortage of trained and skilled national specialists in the region,
which reduces the countries' capacity to deliver surgical and
medical care to their populations.
An estimated 16.9 million lives were lost worldwide in 2010 from
conditions requiring surgical care, and at least 77.2 million
disability-adjusted life-years could be averted each year through
provision of basic surgical services. More people die each year
from lack of access to emergency and essential surgical care than
do from HIV, TB, and malaria combined.
It is estimated that by 2030, the lost financial output across the
globe (total GDP loss) from death and disability due to continued
poor access to safe and affordable surgery could total $12.3
trillion, reducing annual GDP growth in low and middle income
countries by as much as 2%. If investment is made in surgical and
anaesthesia care however, countries will be healthier, more
productive, economically active, and better trade partners.
Australia and the region will benefit.
Financing surgical expansion in a way that decreases death and
disability for patients, and maximises economic benefits for
countries in the Indo-Pacific, is both feasible and cost-effective
- amounting to at least a three-fold return on investment.
Achievement can be realised by investing in two strategic
Strategic Area 1: Surgical education, training, and workforce
- Long term support of medical personnel as educators,
clinicians, and leaders in their home countries is essential to
sustaining the local workforce.
- Fully-funded scholarships to Australia support health
professionals in the training of specific skills.
- Institutions that provide medical education such as
universities require long term support to consistently deliver
high-quality education at both undergraduate and post-graduate
- National Health Plan development needs to be supported to
incorporate surgical and anaesthesia care.
Strategic Area 2: Surgical infrastructure
- Primary Health care depends upon the support of functioning
hospitals. Distressed first line hospitals are the biggest issue in
- Health facilities need to be supported with fixed items of
equipment and consumables required to perform the three bellwether
procedures: caesarean delivery, laparotomy, treatment open
fracture, and therefore most other procedures on the WHO essential
- Strong information management is needed, including surgical
audit, to report on surgical activity and outcomes.
- Overall, investment in safe and affordable surgical and
anaesthesia care represents value for money in the context of
Australia's economic, trade, and political interests.
PREVENTATIVE HEALTHCARE MEASURES
Chronic diseases are responsible for nine out of every ten deaths
in Australia. The enduring impact of chronic disease on the
sustainability of Australia's healthcare system and overall
population health reduces the quality of life and functioning
abilities of Australians.
Dealing with these diseases costs Australia an estimated $27
billion per annum, and accounts for more than a third of the
national health budget. The Australian Institute of Health and
Welfare's latest Burden of Disease Study reported that at least 31%
of the burden of disease in 2011 was preventable, being due to
modifiable risk factors such as tobacco use, high body mass,
alcohol use, physical inactivity and high blood pressure.
Australia currently has no national strategy to address
alcohol-related harm, or the growing burden of obesity. Based on
the success of taxation in reducing tobacco use, the Commonwealth
Government should consider the use of taxes along with a suite of
other measures to divert people away from consumer choices that
negatively affect their health.
For every road fatality in Australia (>1,000 per year), there
are around 27 hospital admissions. Road trauma costs Australia
almost $30 billion per year and there is variance in outcome of
patients dependent on where they are treated. Quality of life
outcomes depends on the care patients receive in every part of
Many people and organisations involved with road safety have a
shared vision to reduce trauma from crashes on Australian roads. In
2010 all state and territory transport and infrastructure ministers
set a target to reduce both deaths and serious injuries by at least
30 per cent by 2020, through the National Road Safety Strategy
We are now more than halfway through the global decade of action
on road safety, and statistics show fatality and injury trends are
heading in the wrong direction. The 2016 road trauma summary from
the national Bureau of Infrastructure Transport and Regional
Economics showed a 7.5% increase in road fatalities, compared with
2015, while road trauma hospitalisations have been steadily
climbing since the beginning of the century.
ONGOING FUNDING FOR THE AUSTRALIAN TRAUMA REGISTRY
The value of information and investigation of injury outcomes to
improve the quality of trauma care cannot be overestimated.
Understanding the cause, place and type of injury is essential to
inform injury reduction strategies.
RACS congratulates the Commonwealth Government for providing three
years' funding to the Australian Trauma Registry, which collects
data from 27 major trauma centres across Australia, up to and
including 2018. The registry is currently the only way to measure
serious injury across Australia and benchmark quality of trauma
care, and we urge the Government to consider its longevity beyond
A VOLUMETRIC TAX ON ALCOHOL
RACS has advocated against the harmful effects of alcohol for many
years, not only for the increased risk of complication that it
poses to surgical patients, but also for the broader ramifications
it has on the sustainability of our public health system and
society as a whole.
The Commonwealth Government needs to play a leading role in
encouraging state and territory governments to adopt evidence-based
measures that will deliver consistent and nation-wide reductions in
alcohol harm, such as those that have been introduced in Newcastle,
Sydney and Queensland. The most effective strategies and biggest
priorities for action are pricing and taxation, reducing
availability, and advertising and promotion.
Economic modelling commissioned by the Foundation for Alcohol
Research and Education has shown that replacing the Wine
Equalisation Tax and rebate with a ten percent increase to all
alcohol excise and a volumetric tax on wine and cider would deliver
$2.9 billion revenue and reduce alcohol consumption by 9.4 per
However, despite its reported effectiveness, taxation as a
strategy to reduce alcohol-related harm has been under-utilised in
ALCOHOL-RELATED EMERGENCY DEPARTMENT PRESENTATIONS
Government agencies monitor and report incidents of
alcohol-related harm and some of the costs associated with alcohol
abuse. However agencies do not monitor or report the total costs to
the community, meaning we do not have a complete picture of the
harm caused by alcohol.
RACS strongly supports the addition of alcohol-related
presentations to emergency department patient data sets. Mandatory
collection of these data would provide a clearer picture of the
extent of alcohol-related presentations to hospitals, and an
evidence base to inform and evaluate policy decisions.
SUPPORTING ABORIGINAL AND TORRES STRAIT ISLANDER HEALTH
The gap in health outcomes between Aboriginal, Torres Strait
Islander and the rest of the Australian population is well
established. To help address the gap, RACS aspires to increase the
number of Aboriginal and Torres Strait Islander surgical Trainees
and Fellows to mirror those numbers in the broader population,
improve levels of cultural competence within the non-indigenous
surgical workforce and advocate for improvements in Aboriginal and
Torres Strait Islander Health.
The RACS Foundation for Surgery, in collaboration with the
Australian Indigenous Doctors' Association and other partners
including Johnson and Johnson Medical Devices, have established
$76,000 in scholarships for Aboriginal and Torres Strait Islander
medical students and doctors with an interest in surgical training.
In 2016 RACS established an Aboriginal and Torres Strait Islander
Surgical Training Initiative guaranteeing training positions for
Aboriginal and Torres Strait Islander surgical training applicants
who meet the selection standards.
RACS strongly supports the work of the Australian Indigenous
Doctors' Association (AIDA), and looks forward to its development
of a face to face cultural competency training program for
specialists. Given AIDA's important contribution to equitable
health and life outcomes and the cultural wellbeing of Aboriginal
and Torres Strait Islander people, RACS encourages the Commonwealth
Government to provide certainty through the provision of five year
funding agreements with AIDA.
The epidemic of ear disease among Aboriginal and Torres Strait
Islander people can no longer be ignored. The World Health
Organization has classified prevalence rates of chronic suppurative
otitis media at above 4% as a "massive public health problem". In
September 2017 a Parliamentary inquiry into the hearing health of
Australians revealed that at any one time up to 90 per cent of
children in remote communities will be experiencing an ear
RACS requests the Commonwealth commit to ending preventable
deafness through a two-stage process. The 2017 AMA Report Card on
Indigenous Health also supports a national strategic approach to
Stage 1 - A Ministerial Working Group or Taskforce is formed
- Establish national key performance indicators (nKPIs) and data
collection standards, as was recently endorsed by the Australian
Health Ministers' Advisory Council.
- Provide options for a national monitoring system and reporting
framework which can be used by all states and territories to better
quantify ear health status over time and identify and target areas
of geographic need.
- Investigate and provide recommendations on:
- - mainstream access to ear care for Aboriginal and Torres
Strait Islander people; and
- - referral pathways in each jurisdiction.
- Address the resolution of the May 2017 World Health Assembly on
the prevention of deafness and hearing loss, which calls on member
states to collect high quality population-based data on ear
diseases and hearing loss in order to develop evidence-based
strategies and policies.
Stage 2 - A national program is revamped/established to:
- Implement reporting on state/territory progress against the
- Improve incentives for the delivery of ear health
- Work with ACCHOs, jurisdictions, and other service providers to
evaluate ongoing efforts and alleviate barriers to primary (ear)
- Deliver appropriate training to the primary health
- Identify and support evidence-based policy and research.
- Identify and alleviate breakdowns in the continuum of
- Ensure healthcare and education are appropriately targeted and
- Guide investment.
This investment would deliver wide-ranging benefits across the
healthcare spectrum for Aboriginal and Torres Strait Islander
people, not just in the area of hearing health.
CLINICAL ACADEMIC TRAINING PATHWAYS
There has been considerable support from governments in the
translation of medical research into improved patient outcomes
including the establishment of a number of Advanced Health Research
and Translation Centres throughout Australia and the Medical
Research Future Fund. However, clinical academics, who are vital
for bridging this gap between medical research and health outcomes,
have been declining in numbers due to current training pathways
being ad hoc and few and far between.
This situation for clinical academic surgeons greatly limits the
ability to make advancements in translating health and medical
research. To overcome this challenge, potential clinical academics
including surgeons require standardised, clearly defined, and
adequately funded training pathways, such as those established in
the UK that reported an increase in clinical academic numbers
within the first few years.
This initiative is crucial to prevent Australia falling behind
other countries in introducing improvements in surgical processes
and procedures, and the consequent improvements in the quality of
patient care it can provide. RACS seeks the Commonwealth
Government's support to fund and implement training pathways for