National Health Reform

Expert Panel Review of Elective Surgery and Emergency Access Targets under the National Partnership Agreement on Improving Public Hospital Services

Section 1: Introduction from the Expert Panel

At the 13 February 2011 meeting of the Council of Australian Governments, the Commonwealth and all state and territory governments signed a Heads of Agreement on National Health Reform and the National Partnership Agreement on Improving Public Hospital Services (the National Partnership Agreement)² Under these agreements, the Expert Panel (the Panel) was established to provide advice on the implementation of elective surgery and emergency access targets and incentives.

The Panel was announced by Minister Roxon on 10 May 2011.

Our membership has extensive experience in the fields of elective surgery, emergency medicine and hospital administration, and comprises:

• Professor Chris Baggoley (Chair) – A/g Chief Medical Officer of the Commonwealth Department of Health and Ageing
• Professor Michael Grigg – Member of the Victorian Quality Council and the Council Executive of the Royal Australasian College of Surgeons
• Associate Professor Brian Owler – Neurosurgeon based at Westmead Hospital and Children’s Hospital at Westmead, and Associate Professor of Neurosurgery at the University of Sydney
• Dr Mark Monaghan – Emergency department physician at Fremantle Hospital and the Clinical Lead in the implementation of the Four Hour Rule there
• Ms Julie Hartley-Jones CBE – Chief Executive of Cairns and Hinterland Health Service District
• Dr Heather Wellington – Former member of the Australian Commission on Safety and Quality in Health Care, with wide health system experience in a number of roles

In fulfilling our role, we have been tasked with providing advice according to the Terms of Reference outlined in the National Partnership Agreement. As part of our review, we have given consideration to system capacity, the circumstances of each state and territory, feedback from our consultation sessions, and international and Australian experiences. At all times our focus has been to ensure the targets deliver improved outcomes for the Commonwealth, states and territories, clinicians and, most importantly, patients.

We have welcomed the involvement of a broad range of stakeholders including state and territory governments, clinicians, hospital managers, consumers and key interest groups.
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Figure 1.1: Expert Panel Terms of Reference³

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1.1 The Need for Reform

Elective surgery and emergency department care are key pressure points in public hospitals, and waiting times relating to these two service areas are a major cause of public commentary and concern about our hospital and health system.

This concern has been borne out through our consultation process and research on the public’s view of the health system. For example, we note feedback from our consumer consultation forums that public hospital waiting times are a principle concern for consumers.
For close to a decade, almost one in six elective surgery patients and one in three people attending emergency departments have been waiting longer than the clinically recommended time for treatment. ⁴

The public is as familiar with the stories as we are. Some patients wait for hours in ambulances queued outside emergency departments, or on chairs and makeshift beds inside emergency departments. Some patients wait too long to receive surgery that will significantly boost their well-being and quality of life, returning them to a healthy and productive lifestyle.

This is not to dismiss or undervalue the excellent, high quality care that is currently provided to patients, the majority in a timely fashion, or the hard work and effort that is being put in across the board by health professionals and administrators to make improvements. However, it must be recognised that challenges are ongoing, and we need to make even more changes to better meet these challenges.

Total elective surgery admissions have increased at 3.6 per cent per year over the past four years, although much of this increase has been in the private hospital system. ⁵ Meanwhile, despite more public elective surgery procedures being provided, the number of patients on public elective surgery waiting lists has increased.⁶ We were also advised of a significant increase in emergency surgery in recent years.

The number of presentations to emergency departments has grown even more, increasing over the past five years by more than four per cent annually, well in excess of population growth. Although the proportion of emergency department patients being seen within clinically recommended times has remained steady, patients are spending longer total periods in emergency departments waiting for their episode of care to be completed, including nearly a third of patients subsequently admitted to hospital who spend longer than eight hours in the emergency department. ⁷

The reasons for increasing demand on health services have been well established in a number of other reports, including the reports of the National Health and Hospitals Reform Commission and the report supporting the National Primary Health Care Strategy. ^8,9 We will not repeat these discussions in this Report, except to note the two major drivers of demand are an ageing population and higher rates of chronic disease, and that we can expect these demand drivers to accelerate over time, adding pressure across the entire health system.

For its part, the Council of Australian Governments has previously agreed on investments and reforms to both of these areas as a priority including up to $600 million to states and territories for elective surgery under the Elective Surgery Waiting List Reduction Plan, the first stage of which was originally announced in December 2007. For emergency departments, $750 million was provided in 2008-09 under the ‘Taking the Pressure Off Public Hospitals’ initiative, with the Commonwealth also announcing in 2010 funding of $96 million to deliver more and better qualified emergency doctors, nurses and support staff.

Under the latest National Partnership Agreement $1.55 billion will be provided to assist meeting elective surgery and emergency department targets with $1.6 billion for new subacute beds and a $200 million flexible funding pool for capital and recurrent projects across elective surgery, emergency department and subacute care.

However, while action so far at a national and jurisdictional level has enabled capacity building and seen more patients treated to a high standard, pressures on our hospital system, and on these two areas in particular, continue to grow.
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1.2 The Role of Targets and Incentives in Driving Change

In its 2009 Final Report, the National Health and Hospitals Reform Commission recommended introducing National Access Targets, linked to bonus payments, across a range of health services to improve timely access to care, leading potentially to National Access Guarantees. ¹⁰ We understand that the emergency access and elective surgery targets agreed by the Council of Australian Governments build on this recommendation.

Targets can be an important tool to drive process and system improvements in health care delivery. They focus attention on identified priority areas, encouraging necessary reforms to take place, with regular monitoring and public reporting of performance allowing progress to be measured. For emergency access and elective surgery targets, they seek to improve patient safety and quality of care by removing obstacles that contribute to emergency department overcrowding and patients waiting too long for surgery. Combined with appropriate facilitation and reward funding to enable changes and support ongoing improvement, they can create a powerful mechanism to achieve better patient health care.

For patients, the new initiatives are intended to complement existing targets in these areas, setting new, higher standards of care. The goal is to stop patients spending too long, even indefinitely, on elective surgery waiting lists, while patients presenting to emergency departments should be confident of both being seen and progressed through the emergency department in a timely manner to an appropriate destination for treatment and care, be that in hospital or elsewhere in the health system.

However, we also understand from our consumer consultation sessions that access targets are not easily understood by the public or recognised as a driver of improved performance. Governments will need to convey the value and use of the new targets as a means of encouraging better care. We address this in Section Five of the Report.
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1.3 Challenges and Opportunities

The targets represent both a challenge and an opportunity for health administrators and clinicians.

Hospitals and clinicians will have to adopt new ways of operating and providing services, establishing more efficient processes to improve patient flow through the hospital system. These changes are not just about emergency departments and surgical theatres, they will involve every aspect of hospital operation.

We recognise there will be many challenges to achieving the targets. Not least of these will be the difficulties of driving significant improvements in elective surgery and emergency access at the same time, as both areas compete for finite resources such as staff and surgical theatres.

We note that the Final Report of the National Health and Hospitals Reform Commission raised this issue and recommended greater separation of elective and emergency surgery, something that is also supported by the Royal Australasian College of Surgeons. We will not go so far as to recommend how hospitals redesign their services to meet the targets, but note that significant redesign of hospital processes is not only desirable, but necessary. This redesign will need to take place on a hospital-by-hospital basis according to local circumstances, not be mandated at a national level.

We are aware of the possible dangers of hospitals focusing too intently on meeting the targets, such as ‘gaming’ and risks to safety and quality of services, and of potentially greater reporting burdens on hospitals and clinicians. These issues need to be managed in the implementation phase and we have addressed them in Section Two of this Report.

However, regardless of the approaches taken, one thing is clear – to achieve these targets we will need a culture supportive of change, involving health professionals, administrators and patients. This will require people to take ownership of the changes and work together, demonstrate strong and supportive leadership and be aware of the potential for unintended consequences of changes. For these reforms to be successful, strategies to manage these changes and encourage ground level support will be needed. This is an issue we have been aware of in framing our advice.
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1.4 Informing the Expert Panel: the Consultation Process

As part of preparing our advice on implementation of the targets, we undertook a public consultation process involving written submissions, consumer research and visits to each state and territory to meet with departmental officials, clinicians and other key stakeholders.

The public written submission process ran from 5 May to 10 June 2011, with details of the process, including an information paper, posted on the yourhealth.gov.au health reform website. Invitations to make submissions were also sent to a number of key stakeholders. Eighteen consumer group discussions were also undertaken between 5 June and 11 June 2011 so that we could receive consumer feedback on the initiatives across several metropolitan, regional and rural areas.

Face-to-face consultation sessions were held between 24 May to 8 June 2011 in each state and territory capital city. Attendees at the sessions included representatives of state and territory governments, hospital administrators, emergency department specialists, surgeons and other senior specialists, nursing and allied health clinicians, with a session for peak stakeholder bodies held in Canberra on 8 June 2011. Lists of all written submissions and all consultation sessions are at Appendices A and B.

Key themes raised throughout the consultation process included:

• questions about the practicality of the proposed targets;
• the risks of targets, including ‘gaming’ and increased demand for services;
• issues with the need for and quality of nationally consistent data; and
• the need for substantial redesign or reorganisation of hospitals and service delivery practices.

More information on the comments received through the consultation process as they relate to the proposed emergency access and elective surgery targets can be found in Sections Three and Four of this Report. There will be analysis of the submissions in the Supplementary Annexure.
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1.5 Data used by the Panel

The Panel has sought to use the latest available data to inform its deliberations and recommended approach to implementing the targets.

As the emergency department data published by the Australian Institute of Health and Welfare (AIHW) does not include information on four hour length of stay performance, this information has been calculated from the unit record data that states and territories provide to the AIHW.

The data used for considering elective surgery is sourced from the Elective Surgery Waiting List Reduction Plan (ESWLRP). This data is provided to the Department of Health and Ageing, which obtains state and territory sign-off before providing a report to the Australian Health Ministers’ Conference (AHMC) for approval and release. Given the most recent publicly released ESWLRP data is for the March quarter 2010, the Panel has used unreleased ESWLRP data up until March 2011. Data collection under the ESWLRP commenced from the March quarter 2008. Elective surgery data prior to the introduction of the ESWLRP is sourced from the elective surgery National Minimum Data Sets collected by the AIHW.
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1.6 Structure of this Report

In Section Two we look at how we can accomplish sustainable change to realise the benefits of these reforms for patients in the short and long term, as well as some of the risks and challenges of implementing the targets and achieving this sustainable change.

Sections Three and Four consider the specifics of the targets agreed by the Council of Australian Governments for emergency access and elective surgery respectively. We discuss current state and territory performance, views from the consultation process and our recommendations on implementation.

In Section Five we examine the next stage of the Panel’s work, focusing on the development of a communication framework to support implementation of the targets, and recommend an ongoing role for the Expert Panel.

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²All subsequent references to the National Partnership Agreement refer to the agreement signed on 13 February 2011 by Australia’s First Ministers.
³National Partnership Agreement on Improving Public Hospital Services, C44, p. 11.
⁴Australian Institute of Health and Welfare (2011) Australian Hospital Statistics series, 1999-2000 to 2009-10.
⁵Australian Institute of Health and Welfare (2011) Australian Hospital Statistics 2009-10.
⁶Elective Surgery Waiting List Reduction Plan quarterly collections and elective surgery waiting times .
⁷Unpublished data from NNAPEDCD, 2009-10.
⁸National Health and Hospitals Reform Commission (2009) Final Report: A Healthier Future for All Australians.
⁹Commonwealth Department of Health and Ageing (2009) Primary Health Care Reform in Australia: Report Supporting the National Primary Health Care Strategy.
¹⁰National Health and Hospitals Reform Commission (June 2009) Final Report: A Healthier Future for All Australians.