After the lockdown, we should rethink the elective surgery system
Published in The Conversation, 17 September 2020
With the number of COVID-19 cases in Victoria continuing to trend downwards, Premier Daniel Andrews yesterday announced a phased restart of elective procedures in public and private hospitals.
Regional Victoria moves to return to 75% of usual elective surgery activity from today, and 85% from September 28. In metropolitan Melbourne, hospitals can move towards 75% from September 28, and 85% from October 26. A return to full capacity across the state is slated for November 23.
But after two partial shutdowns totalling about six months, we’re left with a significant backlog of elective surgeries in Victoria.
To clear this backlog quickly and efficiently, the state government will need to make changes to the way it manages elective surgeries.
Stopping and starting
Elective procedures — particularly category 3 procedures, which are deemed non-urgent but should be done within a year of listing — were one of the early casualties of COVID-19.
Hospitals have only been undertaking category 1 (urgent elective procedures that should be completed within 30 days of listing) and some category 2 procedures (semi-urgent, within 90 days).
The aim was to ensure there was adequate personal protective equipment for staff and beds would be available for an anticipated influx of patients with COVID-19.
There was a brief restart between the first and second waves of the pandemic, but the “care debt” of needed-but-deferred procedures mounted during both slowdowns.
The number of patients waiting for elective surgeries in Victoria increased almost 14% from December 2019 to June 2020, from 49,341 to 56,039. It’s almost certainly increased even more since then. New South Wales is facing a similar problem.
That’s just the tip of the iceberg
Outpatient attendances have also slowed during the pandemic, meaning patients referred to public hospitals haven’t received the specialist assessments necessary to determine whether they need a procedure.
The number of new specialist appointments in public hospitals in Victoria dropped by more than 15% between April-June 2019 and April-June 2020. That’s equivalent to more than 2,000 fewer appointments each week in 2020 compared to the same period in 2019.
So a further hidden waiting list — of unknown proportions — is looming behind the waiting list of patients assessed as needing a procedure.
Hospitals can ramp up their work temporarily to reduce the backlog. They could contract private hospitals, although private hospitals are busy clearing their own backlogs.
When the 75/85% caps are lifted, public hospitals could introduce overtime shifts, extending operating times in the evenings or on weekends. But even adding one extra day a week, it would take a whole year to clear 50 days’ worth of backlog.
A better way
Restarting the tired, failing approach to managing elective procedures — which left thousands waiting too long for care even before the pandemic — will guarantee extended waits for those Victorians on the waiting list.
The Victorian government needs to make three immediate changes to address the problem.
1. Centralise waiting lists
Good management of lines — be it in supermarkets or for elective procedures — involves creating and managing a single queue. Multiple queues lead to inequity and long waits.
Hospital waiting lists in each specialty should be merged — potentially into three clusters in metropolitan Melbourne and three in regional Victoria. All orthopaedic patients in southeastern Melbourne, for example, should be on one list and offered a place at the first available location.
The government should provide extra funding for extra activity to help clear waiting lists — but that funding should prioritise hospitals that meet criteria of both good outcomes for patients and good efficiency.
2. Review waiting lists
Specialist clinical groups should review treatment pathways and admission criteria to ensure best contemporary practice is implemented as part of reopening elective procedures. This way, priority would go to patients most likely to benefit.
3. Modernise the system
Simply adding extra operating sessions won’t fix the extensive waiting list, let alone address the hidden backlog of people currently waiting for outpatient appointments.
Many patients having elective surgeries need to stay in hospital for several days, so the number of beds available can also limit capacity for admissions.
Hospitals should be funded to implement and evaluate changes in their approaches to treatment. For example, the current length of stay for elective hip replacements in Australia is about four to five days. But hospitals in Europe and the United States have been performing hip replacements on a same-day basis for selected patients for a decade, with comparable outcomes.
Patients on waiting lists should also be offered programs to improve the likelihood of better outcomes from their surgery, for example “prehabilitation”, a strategy that uses exercise to improve patients’ functional capacity before surgery, and quit smoking programs. Patients in better health will stay in hospital for a shorter time.
Let’s capitalise on this opportunity
The Victorian government’s announcement that elective procedures will restart is unquestionably welcome news for the tens of thousands of people waiting for a procedure. But it will be a missed opportunity if it doesn’t also involve rethinking the elective procedures system.
Fixing the backlog within a reasonable time will require major change to the way elective procedures are delivered in Victoria. This would benefit not only those currently waiting, but will have long-term effects after the pandemic has passed.