Background Note
Hospital waiting lists explained
Online only 14 March 2008
Amanda Biggs
Social Policy Section
Introduction
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). [1] 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. [2] 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. [3] 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. [4] 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. [5]
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’. [6] 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.
[7]
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. [8]
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.
[9]
Triage—the systematic sorting of patients according to the urgency of
their need for care—is used to allocate treatment priorities.
[10]
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.
[11] 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. [12]
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. [13]
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).
Victoria
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.
Queensland
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.
Western Australia
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.
South Australia
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.
Tasmania
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.
Northern Territory
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.
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