23 February 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.
RACS is concerned about this rising cost. We acknowledge that
healthcare budgets are finite, and that governments are directing
considerable effort to improve the sustainability of Australia's
healthcare system. We have welcomed the opportunity to have direct
involvement in the MBS Review, Choosing Wisely and other
initiatives aimed at improving the efficiency and quality of
healthcare at the state and territory level, such as this
Efficiency of current health financing
The average cost per admitted acute weighted separation in the
ACT ($6,347) is significantly higher than the Australian average
($5,199). This is also the case for emergency department
presentations where the average cost in the ACT ($1,461) is the
highest in Australia. Although
the ACT health system is adequately resourced, these figures
indicate service outputs do not reflect efficient use of funding.
For example, the ACT has the second lowest proportion of emergency
department patients seen within triage category timeframes in
Australia (62% compared with the Australian average of
With the National Efficient Price per National Weighted Activity
Unit for 2017-18 set at $4,910,4 RACS believes further
investigation is needed into the efficiency of the ACT health
system and areas for improvement.
There is a perception among some that the high proportion of
non-clinical staff compared to staff providing direct patient care
may be one reason for the inefficiency of the ACT system compared
to other jurisdictions. There is a small number of practising
clinicians at the executive level of ACT Health, and a disconnect
resulting from poor communication between senior administrators and
those delivering clinical services.
During the ACT Budget Estimates in June 2017 the Member for
Ginninderra made reference to efficiencies and how these could be
achieved with a large increase in ACT Health executive staff and
salaries. Further investigation of the clinician to administrator
ratio in the ACT compared to other jurisdictions may be useful.
Engaging all areas of ACT Health (including surgeons) to be part
of the solution will deliver greater efficiencies in health
funding. To do this, clinicians need to be educated about health
financing, involved in decision making - particularly where
administrative decisions may impact workflow - and provided with
detailed information about how their costs compare with other
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
Health funding and patient outcomes
In all states and territories, waiting times for elective
surgery continue to be a concern. In the ACT the average wait time
for all types of surgery was 45 days for patients at the 50th
percentile and 279 at the 90th percentile compared to the national
average of 38 and 258 days respectively.
Without efficient use of theatre time and sufficient staffing,
surgery gets pushed into the private system as governments strive
to meet their elective surgery targets. While the private system
provides greater flexibility in terms of working hours, its use may
erode the long-term sustainability of the public health system and
reduce training opportunities.
Furthermore, emergency surgery and trauma constitute more than
60% of the surgical workload at The Canberra Hospital. The
government monitors elective surgery wait times; however resources
are rarely reallocated from elective cases to emergency cases. This
means treatment is delayed for the most seriously injured patients,
leading to increased length of stay, poorer patient outcomes and
adding to the inefficiencies and cost of the system.
Inappropriate delays in accessing either elective or emergency
treatment can be associated with increased risk of morbidity and
mortality. This is particularly true in relation to degenerative
diseases and the cumulative effects of an ageing population. In the
emergency setting we know that preventable deaths have occurred in
the ACT as a result of the current Trauma Service model of
Changes need to be made so that resources are focussed on
patients' needs rather than statistical targets. The current
funding model does not encourage patient-focused service delivery.
Keeping patients at the centre of funding decisions will encourage
development of more efficient models of care. Giving hospital
service units more autonomy will allow them to be more responsive
to changes in healthcare requirements, and to engineer efficiencies
more quickly and effectively.
RACS supports the public release of outcomes-based data on
surgical performance at a team, institutional or national level. It
is appropriate that clinicians have access to reports on
performance that are valid and reliable, leading to greater
uniformity of practice. This information also helps establish trust
so that clinicians and their patients can be confident in the
quality of medical care being provided. RACS is consulting
its Fellows on the status of morbidity audit in the ACT to see
if improvements can be made.
Sources and interaction of health financing
While the Commonwealth supports public private partnerships as
vital to the development of infrastructure in Australia, they are
not without problems. The partnership may bring about issues with
accreditation, employee entitlements, lack of accountability and
The ACT operates under a public private partnership arrangement,
with government funding provided to Calvary Public Hospital under
the Calvary Network Agreement. A 2016 report prepared by the ACT
Auditor-General examined the hospital's financial and performance
reporting and found inappropriate financial practices and
manipulation of data to present a better financial result than was
There are a growing number of public patients being treated in
private settings in the ACT, and while this may be more efficient
in the short term, training opportunities are lost which could
impact the workforce in the future. Consideration should be given
to better integrating the private and public workforce in the ACT,
and remuneration options which will incentivise doctors without
restricting their trade.
In the private setting, RACS is concerned about rising out of
pocket costs for patients and has committed to challenging surgeons
who charge manifestly excessive fees. We are collaborating with
private health insurers on clinical variation to support surgeons'
understanding of their practice in comparison to their peers. The
results of this work provide important insights into the way health
services are delivered which can be used to inform more efficient
RACS affirms the rights and necessity for patients to be
actively engaged in their own healthcare and to be provided with
all relevant information in a manner that they can readily
understand. At the national level we are working with the Chief
Medical Officer to improve transparency of fees and outcomes for
RACS notes that unpaid patient bills in the ACT, largely owed by
patients without a Medicare card or non-citizens, have risen into
the millions, and that this must be an ongoing concern for the
Impact of health financing on population growth and
With rapid increases in medical knowledge, technological
advancements and the development of highly individualised packets
of care available to meet specific patient requirements, being
appropriately informed on these aspects of continuing education is
the responsibility of clinicians.
The introduction of new technologies and treatments is dependent
on publication of supportive peer-reviewed literature demonstrating
efficacy without undue risk, and practitioners ensuring they have
acquired the appropriate levels of knowledge and skill. This is
most satisfactorily monitored through the robust credentialing of
practitioners and their work environment, expected as part of each
practitioner's employment or right to access medical
Other key strategies to ensure continuous quality improvements in
healthcare are stricter pre-market scrutiny of devices and
equipment, clinical quality registries and post-operative
Hospital financing and primary, secondary and community
Health literacy is an important component in improving
transparency of health financing, efficiency and outcomes for the
public. The role of groups such as the ACT Health Care Consumers'
Association and Consumers Health Forum is central to patients'
ability to access, understand and use information in ways which
promote and maintain good health.
Decisions about hospital financing and patient flow systems and
processes must be done in consultation with clinicians. In 2017
changes to the Outpatient Department at The Canberra Hospital led
to an increased administrative burden for clinicians which resulted
in less time spent with patients.
The Government's efforts to reduce unnecessary presentations to
emergency departments by funding walk-in centres is to be commended
although we are aware the Royal Australian College of General
Practitioners has concerns about this.
We also welcome the Government's cross-portfolio focus on
preventative health to help reduce the burden of chronic health
conditions such as obesity, heart disease and diabetes.
RACS has offered its input to the Territory-Wide Health Services
planning process and we look forward to participating in
consultations as the new Surgical Procedures, Interventional
Radiology and Emergency Centre is developed.
A general outpatient procedure room would allow minor procedures
such as removal of skin lesions to be performed safely and
efficiently in the outpatient setting, rather than adding to demand
for operating theatres where elective and emergency surgery is
Relevant learnings from other jurisdictions
Health sector investment in Australia in 2015-16 represented
10.3% of GDP. According to the Victorian Government public
healthcare services generated some 42,000 tonnes of solid waste and
the cost of disposing this waste was close to $17 million. They
estimate that by 2021-22 Victorian public healthcare services could
be generating as much as 52,000 tonnes of solid waste per
Intravenous (IV) bags, face masks and oxygen tubing are all
items commonly used in hospitals, which will have a long term
impact on the environment and on costs. Over 50 million IV bags are
used annually in Australia, yet recycling and landfill diversion is
not a common feature of hospital waste management plans. RACS
encourages the ACT Government to consider ways to reduce, reuse,
recycle and rethink medical waste.