National Public Hospital Performance

The most important prerequisite to receiving care in a public hospital is an available bed. Without enough beds and physical resources, hospitals frequently experience “access block”, where unwell patients must wait for others to be discharged before they can receive proper care. Despite the world-class doctors and nurses staffing our public hospitals, their ability to deliver the care sick Australians deserve relies on hospitals having sufficient capacity.

The AMA is glad to see an increase in the number of public hospital beds in 2022–23, the latest period for which the data is available. Australia saw an additional 1,607 public hospital beds become available in this period, with the bulk of these being installed in NSW (584) and Victoria (509).

However, the benefits of these increased numbers are largely offset by Australia’s changing population. Despite 1,932 new beds being made available between 2018–19 to 2022–23, the number of beds per 1,000 Australians has fallen from 2.53 to 2.50. Further investment in hospital capacity is required every year of a similar size to 2022–23 to arrest the long-term decline in beds per capita.

Not only is our current system failing to keep up with overall population growth, but it is also failing to keep up with our changing demographics. Following the trend of most Western countries, Australia’s population is getting older, as people are living longer lives and reproduction rates fall. As demonstrated in Figure 2, older Australians disproportionally use the public hospital system more often and for longer than younger Australians.

According to ABS data, Australians aged over 65 represented 17.1 per cent of Australia’s total population in 2023 (compared to 15.9 per cent in 2019), yet this portion of our population represented 40.8 per cent of total separations from public hospitals in 2022–23, and 49.7 per cent of the total patient days occupying beds within public hospitals. This highlights the inevitability that as the number of older Australians continues to rise, so will the workload of Australia’s public hospital system increase.

Despite a significant increase in public hospital beds in 2022–23, the number of beds per 1,000 Australians aged over 65 remains the lowest number on record at 14.3. Without sustained investment into the capacity of our public hospital system, this long-term decline will continue, risking the ability of hospitals to deliver care and surgeries other than in emergencies.

The public hospital system’s ability to address emergency department presentations in a timely manner is a key indicator of its health. Australians who require emergency treatment should expect to be seen within the recommended timeframe.

Under the Australian Health Performance Framework, two of the key public hospital department performance measures are:

• the length of stay for emergency department care (proportion of patients staying for four hours or less)
• the proportion of patients seen within the clinically recommended timeframes set by the Australian Triage Scale.

Our ED’s remain under intense strain across the county. Figure 4 shows that the proportion of people in all triage categories who completed their emergency presentation in less than four hours has fallen yet again, down more than 18 per cent in the past ten years, and 14 per cent in just the past four years. The visit is counted as completed within four hours if a patient is discharged or departs the emergency department within four hours of arrival.

The decline in performance for this metric is worryingly consistent across Australia. Concerningly, no jurisdiction saw more than 60 per cent of ED presentations completed within four hours. Five years ago in 2019–20, all but one jurisdiction saw more than 60 per cent of presentations completed within four hours.

Regarding the proportion of ED patients being seen within the clinically recommended time, Australia has seen its first uptick in performance since the onset of COVID in 2023–24. Overall, 67 per cent of patients were seen within the clinically recommended time, compared to 65 per cent the previous year. This is a positive, however long-term trends remain headed in the wrong direction.

Figure 5 highlights nation-wide ED performance for patients who are triaged as "emergency" and "urgent", accounting for 1,527,341 and 3,692,750 presentations respectively. The data is clear — performance has been falling since well before COVID, with an ever-increasing workload being placed on the medical and healthcare professionals in our EDs. Without increased capacity and funding, the performance outcomes, patient experiences and workforce morale within our public hospitals will continue to fall.

Planned surgery is any form of surgery considered medically necessary, but which can be delayed for at least 24 hours. The AMA uses the term “planned surgery” rather than “elective surgery” to avoid confusion about the necessity of these procedures. Planned surgeries are essential and include lifesaving procedures, diagnostic procedures and procedures which will restore basic functions for patients — they are not elective for patients, they are essential.

The Australian Health Performance Framework includes the two following performance indicators that measure the provision of timely planned surgery:

• the median waiting time for planned surgery
• the percentage of patients treated within the clinically recommended times

The median waiting time for planned surgery indicates the number of days within which 50 per cent of patients were admitted for their planned procedure. This means half of the patients had a shorter wait time than the median, and half had a longer waiting time.

After a record increase last year, the median waiting time for planned surgery fell by three days across Australia in 2023–24. Despite this improvement, Australians are waiting 58 per cent longer for planned surgery than they were 20 years ago, and 31 per cent longer than 10 years ago.

In a similar vein to most metrics, Figure 8 demonstrates a much-needed improvement in the proportion of Category 2 patients admitted within the recommended 90-day timeframe, one that comes amid a worrying long-term decline over the past 10 years. Despite this year-on-year improvement, the national proportion of individuals receiving Category 2 planned surgery on time has fallen 15 per cent in the past 10 years.

Examples of Category 2 planned surgeries include heart valve replacements, congenital cardiac defects, curettage nerve decompression, and surgery of fractures that won’t heal. These surgeries are not elective or cosmetic. They are essential, and every day of waiting can bring serious pain and increased risks to patients.

Figure 8 shows the proportion of those seen on-time. However, for the other 29 per cent not seen on time, the average wait has become extremely long and potentially dangerous. For these patients, the average wait time is more than double the recommended timeframe in Victoria (297 days), Western Australia (206 days), South Australia (184 days), Tasmania (290 days), and ACT (215 days). This means that even though Victoria has the lowest median wait time for planned surgery, patients who are not seen on time have the longest average wait in the country.

The AMA has repeatedly called for an urgent injection of funding to increase capacity and clear the additional backlog created by COVID-19. Delaying planned surgery is not only devastating for patients, it creates an inherent inefficiency within our public hospital system as treatable prognoses are left to potentially develop into advanced illnesses, leading patients with no choice but to present to the emergency department for costly and avoidable care.

The latest data demonstrates steps are being made towards clearing the backlog. However, more investment is desperately needed to reduce wait times and increase the proportion of patients seen on time back towards pre-COVID levels.

In 2022‒23 (latest data), per person funding for public hospital resources across Australia has seen a major jump in the contribution of state and territory governments, contrasted by a reduction from the federal government. While funding for public hospitals is gradually increasing, performance continues to decline, and a disproportionate funding burden continues to fall on state and territory governments. As highlighted by numerous research reports published by the AMA, funding arrangements require a refreshed approach to ensure that we are appropriately investing in the healthcare of Australia’s population.

Since the last reporting period, there has been a commitment to greater contribution to activity-based funding by the federal government, however this does not equate to a lump sum injection of funds; full utilisation of these funds will require an increase in capacity within the public hospital system, one which will be driven by state and territory government spending.

Figure 10: Per person average annual percent increase in public hospital funding by government source (constant prices)

	2012‒13 to 2022‒23	2012‒13 to 2017‒18	2017‒18 to 2022‒23
Federal	2.90%	3.61%	2.19%
All states and territories	3.59%	1.51%	5.71%