Expert Panel Review of Elective Surgery and Emergency Access Targets under the National Partnership Agreement on Improving Public Hospital Services
Section 4: The Way Forward – Elective Surgery
Elective surgery is surgery that can safely be delayed for more than 24 hours. The term ‘elective’ is used only to distinguish it from emergency surgery, which should be provided within 24 hours. Elective surgery does not mean that the surgery is optional – elective surgery is often life saving (for example removal of a tumour) or very important to a patient’s health and well-being (such as a hip replacement). It is also known as planned or booked surgery.
For public hospitals, patients are generally placed on a waiting list prior to having their surgery, with the waiting time for elective surgery being the number of days from when the patient is placed on the waiting list until the procedure is carried out. Timely access to elective surgery is measured by the percentage of patients treated within the recommended waiting time, although we note that delays in other parts of the health system, particularly in access to specialist hospital outpatient services, can restrict access to the elective surgery waiting list.
4.1 Background and Context for Elective SurgeryIn 2009-10, the Australian Institute of Health and Welfare reported 606,305 patients admitted from public acute hospital elective surgery waiting lists, an increase of 1.9 per cent from the previous year. The proportion of public elective surgery patients who received their surgery within clinically recommended times was 85.4 per cent, up from 80.9 per cent in 2005-06.40
Unlike the provision of emergency department care, the provision of elective surgery procedures in Australia relies heavily on the private hospital system, with almost two-thirds of total elective surgery hospital procedures performed on private patients. While procedures on private patients in private hospitals will not be subject to the new performance standards discussed in this Report, we were aware of the challenges and implications of this reliance in drafting our advice.
As noted by the National Health and Hospitals Reform Commission, one immediate conclusion to be drawn from the significant role of the private hospital system is that delays and long waiting times in the public hospital system generally impact on the more disadvantaged patients, as they are unable to afford private health insurance or to self-fund private treatment.41 This highlights the importance of reducing waiting times for public elective surgery procedures, but also the risk of more patients relying on the public system if access improves.
Reasons for Elective Surgery DelaysThere are a variety of factors that contribute to delays for patients in receiving elective surgery. In its reports, the National Health and Hospitals Reform Commission noted factors such as population growth, an ageing population, advancing technology and increasing morbidity due to obesity were all putting increasing strain on the hospital system generally, including elective surgery.
For elective surgery specifically, issues such as insufficient hospital capacity, workforce shortages (particularly for some specialties in certain regions, as well as anaesthetists and nurses) and competition with emergency departments for resources contribute significantly to delays and make it more difficult for hospitals to sustain increased provision.
Delays can also result from issues affecting patients, such as patients being classified as ‘not ready for care’ (for example due to illness or co-morbidities) or declining surgery for personal reasons.
Elective Surgery Categories by UrgencyDoctors assign elective surgery patients to one of three urgency categories based on a clinical judgment about their need for surgery. While there are generally accepted definitions of the three elective surgery urgency categories, they vary in detail from jurisdiction to jurisdiction. The definitions in Table 4.1 are a reasonable representation of what is commonly used:42
Table 4.1: Elective Surgery Urgency Categories
|Cat 1||Admission within 30 days desirable for a condition that has the potential to deteriorate quickly, to the point that it may become an emergency|
|Cat 2||Admission within 90 days desirable for a condition causing some pain, dysfunction or disability, but which is not likely to deteriorate quickly or become an emergency|
|Cat 3||Admission within 365 days for a condition causing minimal or no pain, dysfunction or disability, which is unlikely to deteriorate quickly and which does not have the potential to become an emergency|
Table 4.2: Percentage of patients by urgency category (2009-10)43
Table 4.3: Clinical Priority Category44
|Cat 1||Admission within 30 days desirable for a condition that has the potential to deteriorate quickly to the point that it may become an emergency|
|Cat 2||Admission within 90 days desirable for a condition which is not likely to deteriorate quickly or become an emergency|
|Cat 3||Admission within 365 days acceptable for a condition which is unlikely to deteriorate quickly and which has little potential to become an emergency|
|Cat 4||Patients who are either clinically not ready for admission (staged) and those who have deferred admission for personal reasons (deferred) (Not Ready for Care)|
4.2 The Current National Partnership Agreement – Elective SurgeryFunding under the current National Partnership Agreement includes $800 million over five years (2010-11 to 2014-15) to improve access to elective surgery in public hospitals by providing facilitation and reward funding of $650 million and funding for capital projects of $150 million.
The current National Partnership Agreement outlines elective surgery targets, under which states and territories are required to improve their elective surgery performance so that:
- 95 per cent of Urgency Category 1 and 2 patients waiting for surgery are seen within the clinically recommended time by 31 December 2014; and
- 95 per cent of Urgency Category 3 patients waiting for surgery are seen within the clinically recommended time by 31 December 2015.
The current National Partnership Agreement includes interim targets for each state and territory, allowing for graduated improvements each year, measured from a range of baseline level of performance (calculated as at 31 March 2010), and varying from jurisdiction to jurisdiction depending on their current capacity to deliver against targets. By staging targets according to current ability, jurisdictions have a better chance of meeting their target and receiving a reward payment which can be applied to enhance their service capability to meet their next target.
We have noted the Commonwealth’s willingness to be flexible in negotiating revised interim targets with jurisdictions as required in recognition of the different circumstances and challenges that jurisdictions face.
The current National Partnership Agreement also includes a National Access Guarantee (the Guarantee) to be phased in from 1 July 2012 so that public patients will not wait significantly longer than the clinically appropriate time for their urgency category. This will mean that patients must have their surgery (if it is clinically safe to do so):
- for a Category 1 patient who has already waited 30 days – within the next 10 days (five days from 1 July 2014);
- for a Category 2 patients who has already waited 90 days – within the next 30 days (15 days from 1 July 2014); and
- for a Category 3 patient who has already waited 365 days – within the next 60 days (45 days from 1 July 2014).
4.3 The Current Situation
Current Waiting Time Trends
We have noted that there are significant differences in elective surgery performance between jurisdictions, and that there is a range of factors that may be contributing to these differences, such as geographic, socio-demographic and workforce capacity issues as well as diseconomies of scale in the smaller jurisdictions.
The current performance of states and territories and the ability of individual jurisdictions to mitigate adverse factors have been taken into account in framing our advice on implementation of the targets.
Table 4.4 shows the percentages of elective surgery patients across Australia, by urgency category, who were treated in the clinically recommended time in 2010.
Table 4.4: Percentage of patients treated in clinically recommended times, Australia, 201045
As illustrated in Figure 4.1, the proportion of Category 1 patients being treated within clinically recommended times since 2006 has generally improved or maintained steady, with all jurisdictions except Tasmania now treating over 80 per cent of patients within the recommended time frame.
Figure 4.1: Elective Surgery performed within recommended times, Urgency Category 1 2006-2010, by state46
Figure 4.2: Elective Surgery performed within recommended times, Urgency Category 2 2006-2010, by state47
As illustrated in Figure 4.2, Category 2, which represents almost 40 per cent of all elective admissions, tends to be the most problematic category due to the relative urgency of surgery and comparably longer waits, and is the source of the bulk of patient complaints. Category 2 is where greatest improvements in performance are required, particularly for the smaller jurisdictions of Tasmania, the Australian Capital Territory and the Northern Territory.
As illustrated in Figure 4.3, performance in Category 3 shows disparity between large and small jurisdictions. While Category 3 represents 31 per cent of all elective surgery admissions, waiting times as long as 12 months or more may impact less on overall patient wellbeing due to the severity of need being relatively low compared to Category 1 and Category 2 patients.
Figure 4.3: Elective Surgery performed within recommended times, Urgency Category 3 2006-2010, by state48
We have also paid close attention to those patients who are currently waiting beyond the recommended waiting time for their elective surgery. Figure 4.4 shows the national waiting time distribution of elective surgery procedures for each urgency category. Once the clinically recommended period is exceeded, for each category there is a ‘tailing off’ of procedures. All jurisdictions have a large number of patients who require surgery and have not been treated in the clinically recommended time, although the problem is most severe in three states – Queensland, Victoria and Tasmania – whose waiting lists contain close to 75 per cent of total overdue patients nationally. However, the proportion of overdue patients has been falling in recent years, from 22 per cent in March 2007 to 11.4 per cent in March 2011.49 Elective Surgery Waiting List Reduction Plan quarterly collections.
Figure 4.4: National elective surgery waiting time, 2009-10, percentage of patients receiving surgery, by days on the waiting list, by urgency category50
On a state by state basis, Figures 4.5-4.7 show the proportion of people waiting by urgency category and the number of days they had to wait for their surgery. The graphs extend to double the recommended wait time to show the tail for people who had to wait a long time for their surgery in 2009-10.
Figure 4.5: Elective surgery Category 1, 2009-10, percentage of patients receiving surgery, by days on the waiting list51
Figure 4.6: Elective surgery Category 2, 2009-10, percentage of patients receiving surgery, by days on the waiting list52
Figure 4.7: Elective surgery Category 3, 2009-10, percentage of patients receiving surgery, by days on the waiting list53
4.4 Views from the Consultation ProcessThe consultation process provided the Panel with a range of views on the elective surgery targets and the Guarantee.
Of concern to a number of stakeholders was the terminology contained within the National Partnership Agreement. There was some preference for the use of ‘planned’ rather than ‘elective’ surgery, as well as the feeling that the term ‘target’ was a bureaucratic imposition and not a measure to drive reform.
Waiting lists were also a topic of discussion, in that elective surgery lists as they are currently measured are not truly representative of the real time spent waiting for surgery - that is, the time spent from a GP referral to meeting with a specialist (which is largely unknown), then waiting for surgery. Additionally, there was recognition that improved central management of waiting lists would be vital to the success of the targets. This management could include the implementation of a system to ‘flag’ in advance those patients nearing the end of the clinically recommended waiting time, enabling them to be treated within the appropriate time.
A clear message from stakeholders was that it would be very challenging to meet the elective surgery targets in the timeframes set out in the Agreement, particularly for Category 2 patients. Furthermore, reforms made in order to meet the elective surgery targets need to be sustainable and that using the funding provided under the National Partnership Agreement to undertake additional blitzes on surgery would be problematic. The possibility of ‘gaming’ occurring in order to meet the targets, instead of making systemic changes focused on improved patient care, was also raised. It was agreed that eliminating these possibilities would lead to better patient outcomes.
Separating elective surgery and emergency surgery facilities was raised a number of times in the consultations as a strategy that would aid hospitals to meet the targets. Whether the separation was physical or time-based, it was suggested that this could help in preventing the cancellation of elective surgery to make way for emergency surgery, one of the major contributing factors to long elective surgery waiting lists.
There were strong concerns from key stakeholders that the Guarantee, as set out in the current National Partnership Agreement, would establish an unrealistic expectation for patients that would be unachievable in some circumstances. It was suggested that an alternative method of treating patients who had waited longer than the clinically recommended waiting time for surgery should be devised.
Several jurisdictions were of the view that the only way that the targets and the Guarantee would be met was by engaging with the private sector. However, some jurisdictions do not have an extensive private sector and a number of submissions identified that the private sector often runs at capacity and would not necessarily be able to treat public patients at any given time. There were also concerns about cost, perverse incentives for clinicians and inadequate capability in some private sector settings to treat complex patients.
Consumers were fundamentally more worried about their individual circumstances, having regular contact with the system and getting some degree of certainty over when they would receive their surgery, than the framework of targets. The Guarantee resonated strongly with consumers – although there was scepticism over whether it would ever be delivered. Consumers were confused by the notion of a 95 per cent target, with 100 per cent being more meaningful. Consumers were also concerned about how the Guarantee would affect them, namely, how their treatment would occur after the clinically recommended time, and how continuity of care would be managed.
4.5 Panel Considerations and RecommendationsOur consultations have confirmed that there is support for elective surgery being conducted within the recommended waiting times for each category, in order to give a degree of certainty and safety for patients undergoing elective surgery. There has, however, been some anxiety about the achievability of the targets, in the main due to capacity issues such as theatre availability, hospital bed numbers, funding and workforce.
Although there has been almost universal disagreement with the National Access Guarantee as originally constructed, it is a principle that needs to be retained. We believe it is critical to ensure there is a safety net for patients who wait longer than clinically recommended to ensure that they receive fair prioritisation for their care.
We are therefore of the view that a complementary strategy of addressing long waiting patients while also maintaining overall waiting list performance is needed, but that a more effective means of achieving it should be implemented.
Nationally Consistent Elective Surgery Category DefinitionsWe have noted with concern that there are currently significant cross-jurisdictional differences in elective surgery category definitions and waiting list policy application.
This was particularly evident when comparing New South Wales and Victoria in relation to Categories 2 and 3, where variations in the application of the definitions skew the proportion of patients within each category and therefore relative performance of jurisdictions in relation to different categories.
For the elective surgery targets to be a fair and effective means of monitoring and comparing elective surgery performance there needs to be nationally consistent definitions and approaches to measuring waiting times. A lack of consistent definitions and waiting list processes can also provide an opportunity for ‘gaming’, with potential consequences for patient safety.
We are aware that the need for work in this area has been flagged for some time and would like to add our strong support (reflecting the widespread view from our consultation process) to add impetus to this work as a matter of urgency. We were advised that the Waiting Time and Elective Patient Management Policy developed by the New South Wales Surgical Services Taskforce was being adopted by a number of jurisdictions. In the meantime, every effort should be made to improve consistency of application of urgency categories, both within and between jurisdictions.
Recommendation 10:That, in order to address the current inconsistencies in the application of elective surgery urgency categories:
I. as a matter of urgency, national definitions for elective surgery urgency categories be further developed, agreed and implemented across all states and territories. This should be led by the Australian Institute of Health and Welfare, working with the Royal Australasian College of Surgeons, and replace the planned review under the existing Clause A47 of the National Partnership Agreement on Improving Public Hospital Services:
- A47 During the transition period referred to in A47, a review will be conducted of the elective surgery categories, focusing on safety issues and practical impediments to achieving the targets that have been set under this Agreement from 2014 onwards. The review will be auspiced by Health Ministers and involve senior clinical input. (Source: the National Partnership Agreement, page 23);
III. whilst new definitions are under development, more detailed guidelines should be developed and applied to the existing urgency categories to ensure as much consistency as possible in measurement and data collection, both within and between jurisdictions.
National Elective Surgery TargetThe consultation process and performance data available confirm that current performance in relation to elective surgery requires improvement. The view from consumers was that there is little sense in striving for anything other than 100 per cent of patients treated within clinically recommended times. We support this, but accept that the achievement of such a target should not be an ‘all or nothing’ proposition. The target, and its accompanying incentives, should be structured in such a way as to reward improvement towards the target, as detailed later in this section. One condition to this is our strongly held view that 100 per cent achievement against Category 1 patients should be achieved earlier.
As we noted previously in this Report, there were serious and valid concerns raised in each jurisdiction in relation to the National Access Guarantee and its feasibility.
We also believe that the emphasis on the use of private hospital facilities to achieve the Guarantee may have unintended consequences in relation to surgical costs and perverse incentives. Furthermore, private hospital capacity does not exist in some jurisdictions such as the Northern Territory and Tasmania.
While the intent of providing certainty to individuals and the community about access to public health care services is strongly supported, it is very clear to us that the Guarantee in its proposed form is not appropriate.
In order to retain the safety net for long waiting patients there should be a specific focus on these patients that replaces the Guarantee with reward funding attached. The structure we are recommending will place specific emphasis on Category 1 patients and on those patients who have been waiting the longest.
Recommendation 11:That the current elective surgery target and the National Access Guarantee be replaced by a National Elective Surgery Target (NEST) where 100 per cent of patients are treated within clinically recommended times, across all urgency categories. It is proposed this be achieved through two complementary strategies:
I. stepped improvement in the number of patients treated within clinically recommended waiting times (Recommendation 12); and
II. a progressive reduction in the number of patients who are overdue for surgery, particularly those who have waited the longest beyond the clinically recommended time (Recommendation 13).
The reward funding will apply across both strategies proportional to achievement.
To support these changes to the final target, we are recommending that the elective surgery targets be phased in according to a new schedule (Tables 2 to 4).
We propose an initial focus on Category 1 patients in recognition of the urgency of surgery for these patients. While we understand that the differences in categorisation across jurisdictions make having different timeframes to meet targets for different categories less than ideal, we believe that, due to the urgency of their surgery, Category 1 patients should be given priority.
The recommended schedule establishes linear improvements from current performance towards the final target to encourage consistent and ongoing progress, although we maintain the option for jurisdictions to negotiate alternative implementation trajectories with the Commonwealth. The schedule also provides the smallest jurisdictions of Tasmania, the Australian Capital Territory and the Northern Territory with additional time to meet elective surgery targets, given the particular challenges these jurisdictions face.
The Panel believes reward funding should be made available in each period on the basis of proportional performance towards the interim target. This would reward jurisdictions for incremental improvements, even if they are not able to achieve the full target, and provide a balance between a financial incentive for better performance while also making some funding available to those that most need improvement.
There is also potential for achievement of targets to occur at the expense of elective surgery volume – either by prospective patients not being added to waiting lists or already overdue patients not receiving their surgery. To guard against such perverse incentives, reward funding should also be dependent on jurisdictions at least maintaining their volume of elective surgery, adjusted for population growth.
Recommendation 12:That progress to the 100 per cent target be implemented by calendar year, commencing in 2012, with the timeframe for meeting it being:
- for Category 1 patients, by 2013 for New South Wales, Victoria, Queensland, Western Australia and South Australia; and by 2014 for Tasmania, the Northern Territory and the Australian Capital Territory, according to the Implementation Schedule (Table 2); and
- for Category 2 and 3 patients, by 2015 for New South Wales, Victoria, Queensland, Western Australia and South Australia and 2016 for Tasmania, the Northern Territory and the Australian Capital Territory, according to the Implementation Schedule (Tables 3 to 4). The potential for states and territories to negotiate alternative implementation trajectories towards the final target with the Commonwealth is maintained.
The volume of surgery must be at least maintained each year.
Table 2: National Elective Surgery Target – Urgency Category 1
Table 3: Urgency Category 2
Table 4: Urgency Category 3
Overdue PatientsA clear focus of the Panel has been the need to balance elective surgery patients who are overdue for treatment with managing new patients added to waiting lists.
While the achievement of a 100 per cent target should ensure that over time there are fewer patients waiting extremely long periods to receive their surgery, we believe there is a need for a strategy to specifically target patients who have waited longer than their recommended waiting time.
We believe that, as a general principle, those patients who have waited the longest beyond their clinically recommended time should be treated first, other than for reasons of clear clinical need.
The group of patients which is overdue is often described as the ‘tail’ (see Figures 4.4 to 4.7). We are recommending a strategy to focus on overdue patients to reduce the number of patients in each category who wait beyond the clinically recommended time. This strategy will complement the 100 per cent target, so that no patients will be waiting beyond the clinically recommended time by 2015 (2016 for Tasmania, the Australian Capital Territory and the Northern Territory).
We are of the strong view that Category 1 patients should receive their surgery on time and have significant concerns that some of these patients are currently waiting longer than clinically recommended for their surgery. In recognition of the urgency of surgery for these patients, we are recommending immediate action by jurisdictions to ensure no patients in this category wait longer than the clinically recommended time for their surgery.
Figure 4.8: Concept of Management of Strategy 2, Overdue Patients.
For Category 2 and 3 patients, we aim to see no overdue patients by 31 December 2015 (31 December 2016 for Tasmania, the Australian Capital Territory and the Northern Territory) by progressively reducing the average waiting time for overdue patients (Table 5 refers).
A particular concern of ours is the patients in each category who have waited the longest for their surgery. In order to provide jurisdictions with an incentive to treat these patients, who may otherwise slip through the ‘cracks’ of the system, we recommend that a threshold be applied to reward payments for this target so that each year the ten per cent of patients who have waited the longest in each category must have their procedure.
To operationalise this, we propose that reward funding for this target be dependent on states and territories identifying this 10 per cent of overdue patients in order to set annual maximum waiting times beyond which no patients are to wait. The starting point would be calculated by the number of days waited by the patient(s) at the 90th percentile of overdue patients on 31 December 2011 for each jurisdiction, which would form the threshold for 2012. This would be reset each year in the same way to support movement towards no patients being overdue.
We acknowledge that the targets will present a difficult challenge for many jurisdictions, but consider there is an urgent need for such patients to receive the care they have been waiting for. Figure 4.8 provides a conceptual guide to how we envisage this strategy working.
Recommendation 13:That the strategy for overdue patients be implemented by calendar year, also commencing in 2012, to reduce the number of patients waiting beyond the clinically recommended time so that there are no overdue patients by:
(a) for Category 1 patients, by 31 December 2012 for New South Wales, Victoria, Queensland, Western Australia and South Australia; and by 31 December 2013 for Tasmania, the Northern Territory and the Australian Capital Territory, according to the Implementation Schedule (Table 5); and
(b) for Category 2 and 3 patients, by 31 December 2015 for New South Wales, Victoria, Queensland, Western Australia and South Australia; and by 31 December 2016 for Tasmania, the Northern Territory and the Australian Capital Territory, according to the Implementation Schedule (Table 5). The potential for states and territories to negotiate alternative implementation trajectories towards the final target with the Commonwealth is maintained.
Each year the 10 per cent of patients who have waited the longest in each category must have their procedure.
Table 5: National Elective Surgery Target – Schedule for the average overdue wait time (in days) for those who have waited beyond the recommended time
|Cat||31 Mar 11||31 Dec 12||31 Dec 13||31 Dec 14||31 Dec 15||31 Dec 16|
Monitoring Total Demand and Waiting TimeWe have been made aware that current elective surgery waiting lists and times do not reflect the true demand or waiting periods for elective surgery. We believe that a transparent recording of total demand for elective surgery procedures and waiting times across the patient journey is required to provide a clearer understanding of pressures and access issues in our health system.
Currently, entry onto elective surgery waiting lists is determined by access to an appropriate specialist or surgeon, often seen in public hospital outpatient clinics. There was a consistent message across all jurisdictions that while there is no national reporting of these waiting times, these ‘hidden’ waiting times vary between surgical specialties and geographical regions and can be twelve months or longer. We are greatly concerned that elective surgery waiting lists may significantly underestimate the demand and need for elective surgical services, as well as the true length of time patients wait for services.
To address this issue we believe a new measure of access for surgical care must be developed, monitoring the total time from a patient’s referral by their general practitioner to receiving surgical treatment. Similar measurements have been established in the United Kingdom highlighting previously hidden delays in patient care and improving access across the total patient journey. We understand that the data definitions and collection systems to enable consistent national reporting of such an access measure may take some time to develop, however we believe that it is important that this development occurs as soon as possible.
Recommendation 14:That a measure of surgical access time (‘National Elective Surgery Access Time’), that is from GP referral to patients receiving surgical care, be developed to determine the true waiting time and demand for elective surgery, and that consideration be given to utilising such a measure of elective surgery performance in future agreements.
40 Australian Institute of Health and Welfare (2011) Australian Hospital Statistics 2009-10; data are sourced from the National Elective Surgery Waiting Times Data Collection (NESWTDC).
41 National Health and Hospitals Reform Commission Interim Report December 2008 ‘A Healthier Future for All Australians’.
42 State of Our Public Hospitals June 2010 Report, Commonwealth of Australia.
43 AIHW Australian Hospital Statistics 2009-10.
44 Policy Directive: Waiting Time and Elective Patient Management Policy - Managing elective patients and waiting lists in NSW public hospitals; Department of Health, NSW; 9 April 2009.
45 Elective Surgery Waiting List Reduction Plan quarterly collections and elective surgery waiting times – Additions and Removals collection.
46 2006/2007: Australian Health Care Agreement Elective Surgery Waiting Times census collection; 2008/2010: Elective Surgery Waiting List Reduction Plan quarterly data collection.
47 2006/2007: Australian Health Care Agreement Elective Surgery Waiting Times census collection; 2008/2010: Elective Surgery Waiting List Reduction Plan quarterly data collection.
48 2006/2007: Australian Health Care Agreement Elective Surgery Waiting Times census collection; 2008/2010: Elective Surgery Waiting List Reduction Plan quarterly data collection.
49 Elective Surgery Waiting List Reduction Plan quarterly collections.
50 Elective Surgery Waiting List Reduction Plan quarterly data collection.
51 Elective Surgery Waiting List Reduction Plan quarterly data collection.
52 Elective Surgery Waiting List Reduction Plan quarterly data collection.
53 Elective Surgery Waiting List Reduction Plan quarterly data collection.
54 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. The target date is 2015 for larger states and 2016 for smaller states and territories. The targets increase linearly between 2011 and 2015 (2016 for Tas/ACT/NT). Targets are the average performance over the calendar year. Rewards apply to 2012 to 2015 (2016 for Tas/ACT/NT).