AMA submission on Elective surgery urgency categories - national definitions
Submission to the AIHW and RACS on national definitions for elective surgery urgency categories
The AMA fully supports efforts to ensure there is nationally consistent data definition, collection of high quality comparable data and regular transparent reporting of that data.
While ever there is inconsistency in the data collected for public hospital services, there can be no transparency of the real impact on public patients waiting for medical care across Australia.
All patients who have been assessed by a medical practitioner as requiring surgery to address a health condition should have their operation as soon as possible.
Patients wait for medical care because the public hospital system does not have the capacity to treat them at the time a medical practitioner first identifies the clinical need for surgery.
Consequently, governments use elective surgery urgency categories as a means of rationing the treatment provided by public hospitals. The AMA notes that no such system of allocating patients to categories exists in the private hospital sector.
The system of allocating patients to elective surgery categories and monitoring and reporting on the time people wait from being allocated a category until their surgery simply highlights the inadequacy of public hospitals to meet the demands being placed on them.
The AMA recognises that the scope of the task the Standing Council on Health has given to the AIHW and RACS is limited to developing national definitions for elective surgery categories – the result of which will not improve access to elective surgery. However, there are other steps that are needed to provide a clear and accurate picture of public elective surgery.
Definitions for elective surgery categories
Given that elective surgery categories are used to ration patient care in public hospitals, it is important for good patient care that national definitions for elective surgery categories facilitate patients being prioritised for surgery fairly and equitably. Public patients must be able to access elective surgery within clinically appropriate timeframes and before their clinical situation worsens.
Medical practitioners make decisions about what elective surgery category a patient should be placed in based on an assessment of the patient as a whole. Category definitions should take into account all the factors relevant to a patient’s requirement for elective surgery, and not be limited to the type of procedure the patient requires or the volume of procedures.
The particular condition is one aspect. Co-morbidities and other patient factors such as chronic diseases, disabilities, and, where appropriate, non-clinical factors, such as social/economic issues are factors that determine the clinical urgency of the surgery.
For example, hysterectomy for cancer may be more urgent that for menorrhagia which may be more urgent than for fibroids. However, menorrhagia in the face of refractory anaemia would change the urgency. Similarly, an elderly patient living alone will require surgery sooner to maintain independence. In assessing patients for surgery, surgeons are guided by information provided by referring general practitioners regarding patient circumstances.
We are aware that in certain states/territories or in certain regions, medical practitioners know that if a patient’s elective surgery is defined as the lowest category, it will almost never be done. This situation is unacceptable for the patient, places medical practitioners in an ethical and clinical dilemma, and may account for some of the differences in elective surgery data across jurisdictions.
The primary driver for surgeons to categorise elective surgery patients will always be clinical urgency. This autonomous decision making by medical practitioners can be justified and supported by guidelines or tools to take into account the variability between patients with the same condition. These tools, which could be developed by the medical colleges and specialty societies, would assist in the categories being applied consistently across the country. The AMA notes that in 2009 the Australian Health Ministers Advisory Council (AHMAC) commissioned a project to develop a model for nationally consistent elective surgery listing practises, data collection and reporting. The outcomes of this project may provide a basis for the development of these tools.
Further, there should be clear protocols for placing patients in the ‘not ready for care’ category (which should always be for a medical reason) or removing them from a waiting list. There must be clear documentation of the reason a patient is in the ‘not ready for care’ category or removed from a waiting list. There should also be a mandatory review period.
The truest measure of the length of time public patients wait for surgery is from when they are referred by their general practitioners to specialists for assessment. While ever this period of time is not counted, the elective surgery waiting time data grossly understates the real time people wait for surgery. The true picture of the demand on the public hospital sector and the impact on public patients is hidden.
The Council of Australian Governments does not consider the hidden waiting list a priority – consideration will only be given to developing a measure of surgical access from general practitioner referral to surgical care for future agreements (National Partnership Agreement for Improving Public Hospital Services, 2011, pg 25, clause A54(c)).
Nevertheless, this project presents an opportunity to implement arrangements to count the waiting time from the GP referral.
Public hospital capacity
The reality is that insufficient public hospital capacity is the cause of people waiting too long for elective surgery. Fiscal pressures in jurisdictions combined with performance reporting leads to strong incentives for inconsistent application (i.e. data manipulation) of national definitions to paint a better picture of the capacity of hospitals to meet demand. Financial rewards or penalties for ‘good’ or ‘bad’ performance can have a similar effect.
Introducing national definitions will not (of themselves) overcome these situations. Clearly articulated elective surgery waiting list practises, data collection and reporting is needed. The AMA points again to the work commissioned by AHMAC in 2009, but apparently not completed.
Taking all these steps – introducing national definitions, counting the full waiting time for elective surgery, and applying them consistently across the country – will require a strong commitment from governments, hospital administrators and medical practitioners responsible for assigning patients to elective surgery urgency categories.
Only when we have a commitment to these activities will there be a true picture of the demands on the public hospital sector and the ability to make fully informed decisions about public hospital service planning, delivery and resourcing.
Senior Policy Advisor
Medical Practice and eHealth
Australian Medical Association
Ph: (02) 6270 5466