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 sick 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 that sick Australians deserve relies on hospitals having sufficient capacity.

While the number of public hospital beds in Australia has slowly been increasing over time, our population has been growing much faster. In total, 1,220 new public hospital beds became between 2017-18 to 2021-22 (from 62,224 to 63,444), yet our population grew by over a million people over the same period. Unfortunately, this means we have only installed 11.6 new beds for every 10,000 new Australians since 2017-18, far below ourcapacity of 25.3 beds for every 10,000 Australians as of 2017-18.

Not only is our current system is not keeping up with overall population growth, 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 over 65 represented 17.1 per cent of Australia’s total population in 2022 (compared to 15.9 per cent in 2019), yet this portion of our population represented over 40 per cent of total separations from public hospitals in 2021–22, and 47 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.

The most recent data show that the number of beds per 1000 Australians aged over 65 has again fallen to the lowest number on record, down to 14.3. Without immediate investment into the capacity of our public health system, this long-term decline will continue, impacting the ability of both young and old Australians to access the public hospital care they deserve.

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:

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

Unfortunately, fewer emergency department patients are being seen on time. This is particularly true in Category 2 (emergency - under 10 minutes) and category 3 (urgent - under 30 minutes), as demonstrated in Figure 4.

The data are clear, the ability of our public hospital system to treat patients on time is falling, and has been falling since well before the impact of COVID-19.

While the percentage of Category 1 (resuscitation – within two minutes) patients seen on time has remained at 100 per cent, Category 4 and 5 performance has also failed to improve over the last ten years. The 2022-23 national average of patients seen on time was the lowest figure in the past ten years across the four categories of Emergency (68 per cent seen on time), Urgent (58 per cent seen on time), Semi Urgent (68 per cent seen on time), Non-Urgent (88 per cent seen on time).

Figure 5 shows that in 2022–23, the proportion of people in all triage categories who completed their emergency presentation within four hours or less was at 56 per cent, representing a fall of 5 per cent since last year, the lowest number since 2011 and a fall of over 14 per cent since pre-pandemic levels. The visit is counted as completed within four hours if a patient departs the emergency department within four hours of arrival.

Notably, the best performing jurisdiction in 2022–23 under the four-hour rule, Northern Territory at 61 per cent, would have been the worst performing state/territory just five years prior in 2017–18, where the poorest performance was 63 per cent of visits completed within four hours, and the national average was 71 per cent.

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.

For the planned surgery that is provided in public hospitals, 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

While the detrimental effect of COVID-19 across the health system must still be acknowledged, this report card will not include a dedicated report on the pandemic’s impact as in the previous reports. Performance indicators have been falling across the board since well before 2020, and long-standing performance issues cannot be attributed to COVID-19.

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. Unfortunately, the record improvement in planned surgery wait times seen in the year to 2021-22 has been immediately negated, as the median national planned surgery wait time has increased to the highest on record. The nine day increase between 2021-22 to 2022-23 represents the equal highest jump on record, matched only by the period directly impacted by COVID-19. Australians are now waiting almost twice as long on average for planned surgery than they were 20 years ago.

Figure 7 demonstrates that the proportion of Category 2 patients admitted within the recommended 90-day timeframe has fallen yet again, while the number of Category 2 surgeries performed per person has also been falling. This means that across Australia, fewer surgeries are being performed on time, even as fewer patients receive surgery. The national proportion of individuals receiving Category 2 planned surgery on time has fallen 23 per cent in just five years. In the meantime, the number of Category 2 surgeries performed per every 80 Australians has fallen from 0.915 to 0.837 over that same period, with the two-year moving average of Cat 2 surgeries per population trending sharply downward as demonstrated in figure 7.

Examples of category 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.

In 2021-22 (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 another small increase from the Commonwealth 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. Funding arrangements require a refreshed approach to ensure that we are appropriately investing in the healthcare of Australia’s population.

Figure 9: Per person average annual percent increase in public hospital funding by government source (constant prices)

	2011-12 to 2021-22	2011-12 to 2016-17	2016-17 to 2021-22
Commonwealth	2.23%	2.03%	2.07%
All States and Territories	2.47%	-0.10%	4.67%