Expert Panel - Review of Elective Surgery and Emergency Access Targets under the National Partnership Agreement on Improving Public Hospital Services: Supplementary Annexure
2.5 Elective Surgery Targets
Elective surgery, also described as ‘booked’ or ‘planned’ surgery, is surgery that can typically be delayed for more than 24 hours. For public hospitals, patients are generally placed on a waiting list prior to having their surgery.124
Waiting lists for elective surgery result from the demand for surgical services exceeding the capacity of the public system to provide these services. Elective surgery waiting lists are a subject of media attention as delays are perceived as reflecting a lack of universal access to appropriate health care services.125
Increased demand for elective surgery has been observed in Australia and internationally over the past decade.126, 127
Problems with patient categorisationVariations have been observed in the literature in regard to the use of urgency categories across surgical specialties and between hospitals.128 Evidence suggests that patients may be placed on waiting lists for clinically unwarranted or untimely procedures. Variation is also observed according to the socioeconomic status of the patient and the remoteness of the patient from health services,129 in that patients may face a trade off between perceived quality of care and access costs (e.g. travel time to hospital).130
It has also been noted that prioritisation of patients could be made more consistent through more specific guidelines to help surgeons make decisions about patients’ need for surgery. New Zealand and Canada are examples of where effort has been made to make prioritisation for elective surgery more systematic, equitable and publicly accountable.131
Approaches to patient prioritisation for elective surgeryNew Zealand developed Clinical Priority Assessment Criteria (CPAC), which aimed to provide certainty to patients about timing of elective surgery. The tools were based on evidence-based guidelines and clinical criteria, and were condition specific. There were over 30 national CPAC tools for elective surgery prioritisation, including for coronary artery bypass graft surgery, cataract removal, joint replacement and cholecystectomy. Patients were assigned a CPAC score according to the criteria that define the urgency of need for the procedure. However, while the aim was supported by many clinicians, the effectiveness and consistency of the tools came under question.132
In Canada, methods for prioritisation are based on physician-scored point-based tools to measure patients’ priority for selected elective procedures. These are accompanied by evidence-based benchmark waiting times corresponding to different grades of urgency. The tools have been developed in consultation with community stakeholders and physicians in order to increase ownership of the approach by stakeholders.133
Impact of waiting time targets on access to elective surgeryThe most contemporary observational analyses of the impact of elective surgery performance targets on patient access are derived from the NHS, which has introduced them among a suite of interventions to reduce waiting times. Between 1997 and 2007, the NHS increased the supply of doctors, increased funding for health services, set rigid waiting time targets (including for elective surgery) and introduced market based reforms. As noted, waiting times for elective surgery decreased considerably over that time.134
In July 2000, ‘The NHS Plan: a plan for investment; a plan for reform’ was published, setting a waiting time target for inpatient treatment (elective surgery) that reduced from 18 months to six months by the end of 2005.135 In 1998 there were 67,000 patients waiting more than 12 months for surgery. By the end of March 2005, there were fewer than 1,000 patients waiting more than 12 months.136, 137 While the six month target was achieved by the end of 2005, in June 2004 the NHS Improvement Plan was released introducing a new 18 week ‘referral-to-treatment’ target for all conditions treated by a consultant, to be achieved by the end of 2008. This 18 week target took account of a patient’s entire hospital journey, from initial referral to treatment, and was credited with driving recent improvements in access to hospital treatment in the English NHS.138
To allow for unavoidable delays (whether for clinical reasons or patient choice) the new target applied to 90% of admitted patients eligible for treatment under the target, with a milestone target for completing the 18 week pathway set at 85% of admitted patients by April 2008. As at August 2009, 93% of admitted patients waited less than 18 weeks for treatment.139
It has been cited that ‘gaming’ appears to have contributed to the reduction in elective surgery waiting times in the NHS, with patients being removed from waiting lists once they had been provided with a future date for an appointment, or given an immediate appointment that they were not able to attend, then classified as refusing treatment. Furthermore, nine NHS hospital trusts had ‘inappropriately’ adjusted their waiting lists: three had deliberately misreported waiting list information to the Department; and 19 had reporting errors identified at subsequent audit.140, 141
However, some positive effects associated with the elective surgery waiting list targets have been observed in the literature. Harrison and Appleby (2009), in their analysis of NHS administrative data, found that elective surgery targets were initially achieved by prioritising long wait patients. However, as the target became more challenging, efforts began to reach patients in the middle and top end of the distribution, reducing ‘time waited’ overall.142
Dimakou (2009), in an analysis of waiting times between 2000 and 2006 demonstrated a significant reduction in waiting times after the introduction of elective surgery waiting time targets. Estimation of ‘survival functions’143 revealed considerable variations in waiting times between specialties, operative procedures and hospitals.144
Propper et al., in their analysis of provision of elective surgery services in the NHS between 1997 and 2005, found that:145
- the proportion of persons on the waiting list waiting longer than the target reduced by 13 days at the mean and 55 days at the 90th percentile;
- 30-day mortality reduced after introduction of targets, suggesting quality of care was not adversely affected; and
- the total number of admissions rose.
Cooper et al. (2009) demonstrated a reduction between 1997 and 2007 in waiting times for key high volume elective surgical procedures, including hip and knee replacements and cataract surgery.146
Data issues associated with waiting list managementIssues associated with the use of elective surgery waiting list information for performance reporting are highlighted by a case study at Melbourne’s Royal Women’s Hospital (RWH). A bonus scheme was operating in Victoria at the time, designed to reward hospitals for achieving targets. Although the RWH was not participating in the bonus scheme at the time, waiting list data was incorporated in the performance management system there. An independent audit of the waiting lists found that patients awaiting urgent or semi-urgent elective surgery whose waiting times were approaching the target for their category (30 days for Category 1 and 90 days for Category 2) were re-classified as ‘not ready for care – patient initiated’. This re-classification ensured that category waiting time targets were not exceeded and that the hospital met elective surgery key performance indicators.147
The Victorian Auditor-General and the AIHW, in ensuing reports, highlighted the limitations of waiting times and clinical urgency categories as indicators of patient access to elective surgery and hospital performance.148, 149 Issues identified included:
- because only the period from date of entry to the waiting list until provision of surgery is measured, improvements in waiting times do not reflect the entire patient journey and may be negated by increased time waiting for other aspects of care, including primary care access, diagnostic testing or outpatients appointments;
- although waiting times reflect how long it takes to receive surgery, they do not reflect the quality of care received or the appropriateness of that care; and
- the indicator is relatively insensitive and open to manipulation.
In March 2011, the media reported that at Campbelltown Hospital 28 per cent of Category 3 patients had spent less than 24 hours on the waiting list before receiving ‘non urgent’ surgery, effectively reducing the hospital’s average waiting time significantly. Data showed that less than two per cent of Category 3 patients at comparable hospitals waited a similar time for their surgery. The Campbelltown Hospital figures were explained by New South Wales Health as being attributable to some operations being performed in multiple stages. The department is now planning to develop a new waiting list policy to improve consistency of wait listing procedures across hospitals.150
Another example was in the ACT, where in January 2011 the then Auditor-General Tu Pham delivered a critical assessment of how the Territory’s elective surgery waiting lists are managed.151 The Auditor-General’s report notes arbitrary reassignment of urgency categories, questions how waiting lists are compiled and concludes that gaming may improve statistics but ultimately affects patient safety.
Curtis (2009) concluded that categorisation needs to take into account all factors that are relevant to the patient’s requirement for elective surgery as it is not just the patient’s clinical diagnosis that determines need.152
Derrett et al (2002) have described additional developments that are needed to improve the use of performance targets in measuring access to elective surgery. These include:
- developing consensus guidelines/definitions to help determine thresholds for some key surgical interventions;
- developing better tools for prioritisation;
- developing a prioritisation system that determines how the prioritisation process is best managed (e.g. by the surgeon or a ‘prioritising’ officer);
- developing evidence-based waiting time targets for specific procedures; and
- determining how prioritisation can achieve equitable provision of services to patients.153
124. Australian Government. The State of our Public Hospitals. June 2010.
125. Curtis, A., Russel, C., Stoelwinder, J. and McNeil, J., ‘Waiting lists and elective surgery: ordering the queue’. Medical Journal of Australia 2010, Vol. 192, pp. 217-220.
126. Australian Government. The State of our Public Hospitals. June 2007.
127. Dixon, T., ‘Trends in hip and knee joint replacement’. Annals of Rheumatic Diseases 2004, Vol. 63, pp. 825-830.
128. Russell, C., Roberts, M., Williamson, T. G., McKercher, J., Jolly, S. E. and McNeil, J., ‘Clinical categorisation for elective surgery in Victoria’. ANZ Journal of Surgery 2003, Vol. 73, pp. 839-842.
129. AIHW. Elective surgery in Australia. Canberra: AIHW, 2008.
130. Sharma, A., Harris, A. and Richardson, J., ‘Use of Elective Surgery in Public Hospitals: Modelling Access-Cost Quality Trade-offs in a Spatial Framework’. Monash University Centre for Health Economics, 2008.
131. Curtis, A., Russel, C., Stoelwinder, J. and McNeil, J., ‘Waiting lists and elective surgery: ordering the queue’. Medical Journal of Australia 2010, Vol. 192, pp. 217-220.
132. Curtis, A., Russel, C., Stoelwinder, J. and McNeil, J., ‘Waiting lists and elective surgery: ordering the queue’. Medical Journal of Australia 2010, Vol. 192, pp. 217-220.
133. Western Canada Waiting List Project. Moving forward. Final report. 2005.
134. Thorlby, R. and Maybin, J., (eds), ‘A High Performing NHS? A review of progress 1997-2010’, The King’s Fund, 2010.
135. UK National Audit Office (2001) Inpatient and outpatient waiting in the NHS, pp. 9-10, available on-line at: http://www.nao.org.uk/publications/0102/inpatient_and_outpatient.aspx
136. Healthcare Commission. NHS Performance Ratings 2004/05. London: Healthcare Commission, 2005.
137. Appleby, J., ‘Do English NHS waiting times targets distort treatment priorities in orthopaedics?’ Journal of Health Services Research and Policy 2005, Vol. 10, pp. 167–172.
138. Thorlby, R. and Maybin, J., (eds), ‘A High Performing NHS? A review of progress 1997-2010’, The King’s Fund, 2010.
140. Bird, S., ‘Performance indicators’. Journal of the Royal Statistical Society 2005, Vol. 168, pp. 1-27.
141. Commission for Health Improvement. What CHI has found in acute services. London: Stationery Office, 2004.
142. Harrison, A. and Appleby, J., ‘Reducing waiting times for hospital treatment’. Journal of Health Services Research and Policy 2009, Vol. 14, pp. 168-173.
143. A ‘survival function’ shows the probability of a person remaining, or surviving, on the waiting list until a given time.
144. Dimakou, S., ‘Identifying the impact of government targets on waiting times in the NHS’. Healthcare Management Science 2009, Vol. 12, pp. 1-10.
145. Propper, C., ‘Incentives and targets in hospital care: evidence from a natural experiment’. Journal of Public Economics 2010, Vol. 94, pp. 318-335.
146. Cooper, Z., ‘Equity, waiting times and NHS reforms’. British Medical Journal 2009, Vol. 339, b3264.
147. Department of Human Services. Elective surgery waiting list audit – Royal Women’s Hospital. 2009.
148. Victorian Auditor-General’s Report. Access to Public Hospitals. April 2009.
149. AIHW. Report on the evaluation of the national minimum data sets for elective surgery waiting times. Canberra: AIHW, 2009.
150. Robotham, J., ‘Waiting lists turn to statistical soup’, The Sydney Morning Herald, 24 March 2011.
151. ACT Auditor-General’s Office Performance Audit Report Waiting Lists for Elective Surgery and Medical Treatment January 2011.
152. Curtis, A., ‘Management of waiting lists needs sound data’. Medical Journal of Australia 2009, Vol. 191, pp. 423-424.
153. Derrett, S., Paul, C., Herbison, P. and Williams, H., ‘Evaluation of explicit prioritisation for elective surgery’. Journal of Health Services Research and Policy 2002, Vol. 7, s14-22.
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