14 March 2008
Social Policy Section
The issue of public hospital waiting lists is never far from the headlines and with major reforms to public hospital funding being proposed, it will continue to generate considerable public interest. Recently the Australian government announced $150 million in funding to the states and territories to assist them to reduce the length of elective surgery waiting lists. This Background Note provides an introduction to elective surgery waiting lists and times. It presents a brief overview of public hospitals in Australia, defines elective surgery and waiting times, explains the purpose of waiting lists/times and triage categories, and provides details of elective surgery statistics. Links and further reading are also included.
Under Australia's federal system, the states and territories have the primary responsibility for the provision of public hospital services. Funding for public hospitals is shared between the Commonwealth and the states through the mechanism of the Australian Health Care Agreements (AHCAs).  These are five year bilateral agreements between the Australian government and each state and territory government. Under the current AHCAs (covering the period 2003 2008) the Commonwealth has committed $42 billion to the states and territories for running public hospitals.  The states and territories undertake to maintain free access to public hospitals and increase their own level of hospital funding to match the rate of growth in Commonwealth funding.
The 736 public hospitals in Australia provide a wide range of acute care and out-patient services, including emergency care, intensive care, surgery, maternity and neonatal services, renal dialysis, pathology, cancer services, pharmacy and allied health services. There are also 19 public psychiatric hospitals providing mental health and psychiatric services. According to a Department of Health and Ageing (DoHA) Factsheet on public hospitals there were more than 4.5 million patient admissions to public hospitals in 2005 06; the vast majority (87 per cent) were public patients, with nine per cent of admissions for private patients.  The remainder were patients admitted under Department of Veterans Affairs or compensation arrangements.
What is elective surgery?
Elective surgery is not, as its name may imply, non-essential or cosmetic surgery. It is surgery that a doctor or health professional believes to be clinically necessary, but which can be delayed for at least 24 hours.  Much elective surgery, for example, coronary bypass surgery is therefore important to maintain health and well-being. In contrast, emergency surgery, for example, for critical cases such as a car accident, poisoning or heart attack, is undertaken when the patient s life or physical integrity is in immediate danger.
Elective surgery is booked in advance, following medical assessment of the patient. According to the DoHA Factsheet over 556 000 patients were admitted to public hospitals for elective surgery in 2005 06, which represents 71 per cent of all public hospital surgical admissions.
When a public patient s elective surgery is booked it goes on a public hospital s waiting list. Elective surgery waiting lists are used to manage access to public hospital elective surgery services and give priority to those in most urgent need of care. They have become an integral feature of our health system, and allow limited health resources to be allocated or rationed on the basis of need. Waiting lists also provide health consumers with an indication of how long they can expect to wait for their surgery. 
The length of time a patient has waited from the time their elective surgery is booked to when they are admitted for their elective surgery is known as waiting time .  Waiting times are used by health planners and administrators to measure timely access to hospital care and the efficient performance of hospitals. Waiting times assist in measuring the rate of turnover on hospital waiting lists and are considered a more reliable indicator of hospital performance than the size of the waiting list. 
Waiting times for different categories of care are often measured. Waiting times for selected high volume procedures, such as cataracts or hip replacement surgery, can be particularly useful in measuring hospital performance and efficiency. Emergency department (ED) waiting times are recorded separately. 
The majority of patients on elective surgery waiting lists do gain admission for their surgical procedure. However, in some cases the patient may be removed from a waiting list. Reasons may include that they no longer require the procedure, are instead admitted as an emergency patient, receive their treatment at a different hospital or are transferred to the waiting list of a different hospital, are uncontactable or die. 
Triage the systematic sorting of patients according to the urgency of their need for care is used to allocate treatment priorities. 
Elective surgery and emergency department patients are assigned into different triage categories based on their clinical need. There are different triage categories for elective surgery and emergency procedures; although the use of similar terminology may suggest the categories are interchangeable, they are not.
Three distinct triage categories are used in elective surgery. Category 1 is where admission is desirable within 30 days (sometimes referred to as urgent ); category 2 is where admission is desirable within 90 days (or semi-urgent ); and category 3 where admission is desirable within 12 months (or non-urgent ). The patient s surgeon decides the appropriate triage category for the patient at the time the surgery is booked.
Emergency departments in Australian hospitals employ five categories of triage: resuscitation (immediate), emergency (within 10 minutes), urgent (within 30 minutes), semi-urgent (within 60 minutes) and non-urgent (within 120 minutes). The classification of emergency department patients into triage categories is normally undertaken by a Triage Nurse upon presentation to the emergency department.
Elective surgery waiting times are reported by each jurisdiction based on agreed national standards. These standards are described in the National Health Data Dictionary. Various statistical compilations are then published on hospital waiting lists/times; the major sources are presented below. States and territories sometimes publish other elective surgery data for consumers. As well as different statistical compilations being available, methods for analysing waiting list data vary. These are explained further below.
Australian Institute of Health and Welfare data
The Australian Institute of Health and Welfare (AIHW) compiles the mandated data provided by the states and territories to produce the National Elective Surgery Waiting Times Collection. This data collection includes waiting times (as reported on a nominated census date) for public patients in most public hospitals, and public patients treated under contract in private hospitals in Victoria and Tasmania. The data collection coverage is around 87 per cent of all public hospitals that undertake elective surgery but this varies across jurisdictions. In New South Wales, Tasmania and the two territories (the ACT and NT) coverage is 100 per cent, but in South Australia it is 63 per cent.  Elective surgery waiting times are published in the annual AIHW publication Australian hospital statistics. The publication of waiting list data is slightly delayed; the latest edition was released in May 2007 and covers the period 2005 06.
Interactive data cubes on elective surgery waiting times for the period 2001 02 to 2005 06 are also available on the AIHW website. 
Some caution should be exercised when comparing waiting time data across jurisdictions or time periods, as in some instances variations in methodologies and definitions occurs.
The following figures show waiting times using median waiting times. Median is the middle value in a data group, not the average; it provides an estimate of the time taken for 50 per cent of patients to be seen. This is sometimes referred to as the 50th percentile. Waiting times are also reported for the time taken for 90 per cent of patients to be seen, (that is, the 90th percentile).
Nationally the AIHW reported that the median waiting time in 2005 06 was 32 days, that is, 50 per cent of all patients waiting for elective surgery were seen in this time. This was slightly longer than in previous reporting periods in 2001 02 the median waiting time was 27 days. Median waiting times varied across jurisdictions (see figure below); Queensland reported the lowest median time waited (25 days) and the ACT reported the highest (61 days). In 2005 06, 90 per cent of all patients were seen within 237 days, slightly longer than in 2001 02 (when it took 203 days). The proportion of patients waiting longer than a year for their surgery was 4.6 per cent, but this varied across jurisdictions; in Queensland just 2.1 per cent of patients waited more than a year, while in the ACT this figure was 10.3 per cent.
Figure1 : Median waiting times for patients admitted from waiting lists for elective surgery, states and territories, 2005 06
Source: AIHW Australian hospital statistics 2005 06
The number of additions to, and removals from, elective surgery waiting lists is another indicator of the accessibility of hospital services. However, viewing waiting list numbers in isolation from turnover gives an incomplete picture.
In 2005 06, a total of 638 904 patients were added to elective surgery waiting lists and 657 401 patients were removed from these lists. Most patients are removed from waiting lists because they are admitted for the procedure for which they were waiting (84.7 per cent in 2005 06). However, as noted previously, while a majority of patients are removed from waiting lists because they have been admitted, this is not always the case. Patients are also removed due to their being transferred to another hospital s waiting list or treated elsewhere (4.0 per cent), because the surgery was not required or declined (7.4 per cent), because they were not contactable or had died (1.5 per cent), or because they became emergency admissions (0.9 per cent). See figure 2 below.
Figure 2: Additions/removals from elective surgery waiting lists, states and territories, 2005 06
Source: AIHW Australian hospital statistics 2005 06
Waiting times for certain high volume procedures, such as cataract extractions, knee or hip replacement and coronary artery bypass graft are also reported by the AIHW. This relatively small number of procedures account for the bulk of the elective surgery workload, so waiting time statistics for these can be useful for performance monitoring, planning and resource allocation. 
According to the AIHW, the procedure with the lowest median waiting time in 2005 06 was coronary artery bypass graft (15 days); the procedure with the longest wait time was total knee replacement (178 days). There were also variations in waiting times for these procedures across jurisdictions; Queensland patients waited a median time of 41 days for cataract surgery, while those in Tasmania waited a median time of 389 days.
Under the Australian Health Care Agreements the states and territories are required to report on elective surgery waiting times for each of the triage categories. This data is then presented annually in the State of our public hospitals report. Although the waiting list data is based on the same data sets used by the AIHW, some minor differences arise from variations in methodologies.
The report includes a breakdown on the percentage of elective surgery patients seen within clinically recommended times. The performance of each of the states and territories is presented, with additional detailed tables for each jurisdiction made available on the Department of Health and Ageing s website.
Nationally 81 per cent of elective surgery admissions in all triage categories were seen within the recommended time in 2005 06, a decrease from 1998 99 when 90 per cent of patients were admitted within the recommended time. For triage category 1 patients, Victoria performed best admitting 100 per cent of patients within the recommended time, while Tasmania performed worst with 72 per cent of patients admitted within the recommended time.
Figure 3: Elective surgery Category 1 patients admitted to public hospitals within the clinically appropriate time, state and territories, 2005 06
Source: State of our public hospitals June 2007 report
The report on government services (and accompanying tables) is produced annually by the Productivity Commission (PC) Steering Committee for the Review of Government Service Provision and contains detailed analysis of waiting list and hospital data not published in other sources. For example, the PC website includes an attachment with additional tables of public hospital data based on unpublished jurisdictional data, such as percentage of patients waiting who are overdue for surgery by surgical specialty and triage category.
As well as the mandated reporting of elective surgery waiting times data by the states and territories, most also report on current waiting lists or times for elective surgery. However, the content and presentation of this data varies across jurisdictions. Sources of jurisdictional data are presented below.
New South Wales
The NSW government provides a website where patients can check the current waiting time for their surgical procedure. Comprehensive tables on waiting times are also available, including waiting times for all booked procedures (quarterly) and waiting times for each public hospital in NSW (monthly).
The Victorian government provides a website where elective surgery patients can check their likely time to treatment for their surgical procedure. However, this waiting time data is intended as a guide only, and does not reflect actual waiting times. Performance data for each public hospital is also available. Every six months the Victorian Department of Human Services reports on median waiting times for each public hospital in the Your Hospitals report.
In Queensland annual and quarterly data on elective surgery waiting lists is presented in the Queensland public hospitals performance report. The latest annual report (2006 07) includes overall waiting times, the number of patients waiting and patients treated for each public hospital, data on long waits by triage category and hospital and outpatient waiting lists. The latest quarterly report (December 2007) includes similar data as well as the number of patients removed from waiting lists for each hospital and triage category, and the number waiting by surgical specialty.
Elective surgery waiting time data for metropolitan and country hospitals in WA are provided in two separate monthly reports. The Metropolitan Elective Surgery Report provides combined waiting time data for all metropolitan public hospitals (and includes Peel and Joondalup hospitals), including total numbers on the waiting list, median waiting times, waiting times for each triage category and surgical specialty as well as historical data. The WACHS Elective Surgery Report provides similar combined waiting time data for non-metropolitan hospitals. Waiting times for individual hospitals are not included in either report.
The annual report of the WA Department of Health provides some hospital performance information, but contains no data on elective surgery waiting lists or times.
A brief overview of elective surgery waiting times is provided in the SA Department of Health s annual report. This includes percentage of patients admitted within the recommended time for each triage category. More detailed information is available on the Department s website, including an overview of hospital performance, a monthly elective surgery report, and monthly waiting time data for each Regional Health Service hospital by surgical speciality.
The state s budget papers (see Budget Paper 4: Portfolio Statement, Volume 2) also present a summary of elective surgery waiting time data.
The Tasmanian government releases a Human Services Progress Charter each quarter, which provides performance information on health and other services. Included in this is data on elective surgery waiting times, including numbers on the lists and median waiting times for each hospital. The Department of Health and Human Services annual report also provides performance information on elective surgery waiting times.
There is little current publicly available data on waiting lists in NT public hospitals. The annual report of the NT Department of Health contains a brief overview of elective surgery waiting times (see the section on acute care services). Data covers the percentage of patients in triage categories 1 and 2 seen within recommended times.
Australian Capital Territory
Elective surgery information is reported in the quarterly publication ACT Health Public Services Performance Report on the ACT Government s website. Data is reported on waiting times for each triage category and average and median waiting times by triage category. The ACT Health website also provides consumers with median waiting times for each surgical specialty and for each surgeon.
Links to the major sources of elective surgery waiting times are presented below.
A number of articles and reports have examined or discussed elective surgery waiting times. A selection of these is presented below, with links.
Stephen J Duckett, Private care and public waiting, Australian Health Review, vol. 29 (1), February 2005, pp. 87 93. Based on an analysis of public and private hospital activity in Australia following the introduction of the private health insurance rebates, this article addresses the claim that the rebates have reduced waiting times in public hospitals.
House of Representatives, Standing Committee on Health and Ageing, The blame game: report on the inquiry into health funding, the Committee, Canberra, November 2006. This Parliamentary report includes an informative chapter (chapter 7) on hospital services, which also explains funding arrangements between the Commonwealth and the states, and provides some background to the blame game debate.
John McNeil and Just Stoelwinder, Public hospital waiting lists can a necessary evil be better managed? New Matilda, 10 August 2005. A brief discussion of options for improving the management of elective surgery waiting lists.
Angela Pratt, Public versus private? An overview of the debate on
private health insurance and pressure on public hospitals , Parliamentary Library Research Note no. 54, 2004 05, Parliamentary Library, Canberra, 20 June 2005. As part of a wider ranging discussion, the paper also briefly examines how demand for elective surgery can be driven by factors other than patient need.
Luigi Siciliani and Jeremy Hurst, Explaining waiting time variations for elective surgery across OECD countries , OECD Economic Studies, no. 38, 2004, pp. 95 123. Some OECD countries report long waiting times, others do not. This article explores why some countries have longer waiting times, and highlights the difficulties of comparing waiting times across countries.
For copyright reasons some linked items are only available to members of Parliament.