What elective surgery will be allowed now the coronavirus situation has improved? It’s up to your surgeon or hospital



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Stephen Duckett, Grattan Institute

Australian Prime Minister Scott Morrison has announced some elective surgery can start again in private hospitals, as it becomes clear the health system will cope with the additional coronavirus demand.

He said this week “all Category 2 or equivalent procedures in the private sector, and selected Category 3 and other procedures, which includes all IVF” can restart.

What’s this mean for you? It all depends on which category you are in – and what your surgeon has decided about how urgently your surgery is needed.

It also depends on whether you are a patient in a private hospital or public hospital. If it’s the latter, you can expect to wait a while until the hospital can tell you exactly when your surgery will happen.




Read more:
Good news on elective surgery, but dire warning on the economy


Category 1, Category 2, Category 3: what’s the difference?

Private hospitals have not had elective surgery waiting lists in the past and so have not categorised patients for elective surgery. So it’s no surprise this announcement has created enormous confusion.

States have not yet announced their plans for restarting elective surgery.

Elective procedures are categorised into three categories based on urgency:

  • Category 1, the most urgent, is where patients should be seen within 30 days
  • Category 2 patients should be seen within 90 days
  • Category 3 patients should be seen within 365 days.

Categorisation is done by the surgeon and takes into account the specific circumstances of the patient. For example, they would consider the extent of the pain and mobility loss, and the impact on the work or education if the surgery was delayed.

Different surgeons can assign patients different categories

Unfortunately, different surgeons seeing the same patient may make different assessments of what category they should be in. This policy issue needs to be addressed.




Read more:
Elective surgery’s due to restart next week so now’s the time to fix waiting lists once and for all


There is no fixed rule about whether a particular procedure is always in a specific category.

However, generally cardiac surgery, such as a heart bypass, will be classified as Category 1. More than half of all patients awaiting this procedure are treated within three weeks.

A patient waiting for a hip replacement, on the other hand, will be typically categorised as Category 2 or 3. In fact, half the patients waiting for that procedure had to wait up to four months.

Waiting times for public hospital treatment is longer in some states and others. Data for elective surgery waiting times it is published by the Australian Institute of Health and Welfare.

Categorisation is done by the surgeon and takes into account the specific circumstances of the patient.
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How do I know what category I’m in?

If you are scheduled for an operation in a private hospital, either the hospital or the surgeon will contact you.

They will let you know if your surgery is now going ahead, and discuss with you appropriate timing. Elective surgery will commence over the next week, so private hospital patients should hear from the hospital surgery within the next fortnight or so.

Because states haven’t yet revealed their strategies for restarting elective surgery, public hospital patients should not expect to hear from the public hospital until those announcements have been made.The Conversation

Stephen Duckett, Director, Health Program, Grattan Institute

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Elective surgery’s due to restart next week so now’s the time to fix waiting lists once and for all



Monkey Business Images/Shutterstock

Stephen Duckett, Grattan Institute

The near-total shutdown of elective surgery across Australia will end soon, following National Cabinet consideration on Tuesday.

The shutdown was imposed to ensure there would be enough personal protective equipment (PPE) for doctors and nurses to manage a projected tsunami of COVID-19 patients in our hospitals.

But now there is a big backlog of Australians waiting for elective procedures.




Read more:
Good news on elective surgery, but dire warning on the economy


Elective surgery waiting times are the bane of every state health minister’s life. Better ways to manage such procedures could be a major benefit from the shutdown and restart.

But we have to act quickly if we are to change how we manage these wait lists, as federal Health Minister Greg Hunt wants a staged reintroduction to begin on April 27.

Rethink priorities

Currently, elective surgery is classified as urgent (category 1), semi-urgent (category 2) and non-urgent (category 3). But different hospitals and different surgeons actually classify patients in different ways.

What’s worse is that some procedures are undoubtedly unnecessary, such as spinal fusion or removing healthy ovaries during a hysterectomy, and would provide no value for the patient, as Adam Elshaug and I have argued before.

Of course, not all of the backlog is low-value procedures. As states consider how to recommence elective surgery, they should seize this opportunity to introduce new systems, especially in metropolitan areas.

A properly managed elective procedures system should have three key elements:

  • there should be a consistent process for assessing a patient’s need for the procedure, and ranking that patient’s priority against others

  • the team performing the procedure, and caring for the patient afterwards, should be highly experienced in the procedure

  • the procedure should be performed at an efficient hospital or other facility, so the cost to the health system is as low as possible.

Unfortunately, Australia sometimes fails on all three measures.

Stop the inconsistencies

There is no consistent assessment process across hospitals. Even different surgeons in the same hospital seeing the same patient sometimes make different recommendations about the need for a procedure.

This means a patient lucky enough to be seen at hospital A may be assigned to category 2, but the same patient seen at hospital B might be assigned to category 3 and so have to wait longer.

Patient characteristics, such as gender or level of education, also seem to inappropriately affect categorisation decisions.

High-volume hospitals and other facilities generally have better outcomes for a given procedure than low-volume centres. And they are more efficient.

Yet most states ignore these facts. They have done little to rationalise services for the benefit of both the patient and the taxpayer.

Time for change

The large backlog of demand creates the opportunity for a new way of doing things. States should develop agreed assessment processes for high-volume procedures, such as knee and hip replacements and cataract operations, and reassess all patients on hospital waiting lists.

Reassessment could be done remotely using telehealth. Specialists in each area should be invited to develop evidence-based criteria for setting priorities. Where appropriate, patients should be diverted to treatment options other than surgery.

Private health insurers should be empowered to participate in funding diversion options so patients are able to have their rehabilitation at home rather than in a hospital bed.

A new, coordinated, single waiting list priority system in each state would enable all patients to know where they stand. A patient on the top of the list would be offered the first available place, regardless of whether it was closest to their home.

They could refuse the offer, without losing their place in the queue, if they wanted to wait for a closer location.

The health minister says it’s up to hospitals to decide which patients get to undergo elective surgery.
Roman Zaiets/Shutterstock

The single waiting list should include both regional and metropolitan patients, to ensure as much as possible that city patients do not get faster treatment than people in regional and remote area.

Patients with private health insurance can opt to be treated as a private patient in a public hospital. So the waiting list should include public and private patients, to prevent private patients gaining faster admission to public hospitals.

The system should be further centralised in metropolitan areas. The full range of elective procedures should not be re-established in every hospital. Some surgeons would need to be offered new appointments if elective surgery in their specialty was no longer being performed at the hospital where they previously had their main appointment.

Private hospitals can help

The private hospital system has taken a battering during the pandemic. Private hospitals have effectively been closed, and their viability may be under pressure.

States should consider signing contracts with private hospitals, at or below the public hospital efficient price, for elective procedures to be performed in these hospitals to help clear the elective surgery backlog.




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Needless treatments: spinal fusion surgery for lower back pain is costly and there’s little evidence it’ll work


As part of the new service model, states should bolster their hospital-in-the-home systems. For many patients, rehabilitation at home or as an outpatient can produce better outcomes than in-hospital rehabilitation.

The pandemic is not over yet and policymakers are right to be turning their minds to the transition back to something approaching business as usual. But the new, post-pandemic normal should be nothing like the old.

Physical distancing seems to be beating the virus, but the second victim might be health reform. Not wasting the crisis is the cliché on everyone’s lips. Australia has the chance to improve our elective surgery system. For the sake of taxpayers and patients, we should grasp it.The Conversation

Stephen Duckett, Director, Health Program, Grattan Institute

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Good news on elective surgery, but dire warning on the economy


Michelle Grattan, University of Canberra

Restrictions are to be eased on elective surgery, enabling a “gradual restart” to procedures next week.

But as national cabinet took early baby steps towards restoring normality, Reserve Bank Governor Phil Lowe warned the first half of this year would likely see the biggest contraction in Australia’s national output and income since the 1930s depression.

After Tuesday’s national cabinet meeting, Scott Morrison announced that from Monday, category 2 and some important category 3 procedures can restart in public and private hospitals. These were earlier suspended amid uncertainty about how hard COVID-19 would hit the hospital system.




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Category 2 covers cases needing treatment within 90 days; category 3 are ones that require treatment in the next year.

The easing will cover:

  • IVF

  • screening programs (cancer and other diseases)

  • post cancer reconstruction procedures (such as breast reconstruction)

  • procedures for children under 18 years of age

  • joint replacements (incl knees, hips, shoulders)

  • cataracts and eye procedures

  • endoscopy and colonoscopy procedures.

More dentistry services will also be available.

The elective surgery easing has been facilitated by the extra availability of protective equipment; also, the low number of COVID-19 cases has meant the pandemic has not placed as much demand on beds as had been feared.

It is estimated the announced easing will lead to reopening about 25% of the elective surgery activity that had been closed in private and public hospitals.

Morrison said the situation would be reviewed on May 11 to decide whether all surgeries and procedures could recommence more broadly.

Clinical decisions will determine the priority given to cases.

The Prime Minister said the easing “is an important decision because it marks another step on the way back. There is a road back”.

On aged care, national cabinet was concerned some nursing homes are being too extreme, with full lockdowns that do not allow residents to have any visitors.

People in nursing homes are particularly vulnerable to the coronavirus and there have been outbreaks and deaths in the sector.

But “there is great concern that the isolation of elderly people in residential care facilities, where they have been prevented from having any visits … is not good for their well-being, is not good for their health,” Morrison said.

The national cabinet gave a “strong reminder” that its earlier decision was “not to shut people off or to lock them away in their rooms.”

This decision was to allow a maximum of two visitors at one time a day, with the visit taking place in the resident’s room. Apart from that, residents should be able to move around the facility.




Read more:
Hospitals have stopped unnecessary elective surgeries – and shouldn’t restart them after the pandemic


Further restrictions would apply where there was an outbreak in a facility, or in the area.

On the economic front, in an indication of the devastating job losses that have already occurred, Morrison said since March 16, 517,000 JobSeeker claims had been processed. JobSeeker used to known as Newstart.

“By the end of this week we will have processed as many JobSeeker claims in six weeks [as] we would normally do in the entirety of the year,” he said.

In a speech at the Reserve Bank Lowe said it was difficult to be precise about the size of the contraction underway.

But on the bank’s current thinking:

  • national output was likely to fall by about 10% over the first half of 2020, with most of the decline in the June quarter

  • total hours worked were likely to decline by about 20% in the first half of the year

  • unemployment was likely to be about 10% by June, “although I am hopeful that it might be lower than this if businesses are able to retain their employees on lower hours.”

Lowe predicted inflation would turn negative in the June quarter, and it was likely prices would turn out to have fallen over the entirety of this financial year, the first time that had happened in 60 years

Lowe expressed confidence the economy would “bounce back”, but stressed the recovery’s timing and pace would depend on “how long we need to restrict our economic activities, which in turn depends on how effectively we contain the virus”.

“One plausible scenario is that the various restrictions begin to be progressively lessened as we get closer to the middle of the year, and are mostly removed by late in the year, except perhaps the restrictions on international travel.

“Under this scenario we could expect the economy to begin its bounce-back in the September quarter and for that bounce-back to strengthen from there.

“If this is how things play out, the economy could be expected to grow very strongly next year, with GDP growth of perhaps 6–7%, after a fall of around 6% this year,” Lowe said.

He said unemployment was likely to remain above 6% over the next couple of years.

“Whatever the timing of the recovery, when it does come, we should not be expecting that we will return quickly to business as usual.”

“It is highly probable that the severe shocks we are now experiencing will change the mindsets of some people and businesses. Even after the restrictions are lifted, it is likely that some of the precautionary behaviour will persist.

“And in the months ahead, we are likely to lose some businesses, despite best efforts, and some of these businesses will not reopen. There will also be a higher level of debt and some households might revaluate the risks of having highly leveraged balance sheets.

“It is also probable that there will be structural changes in the economy. We are all learning to work, shop and travel differently. Some of these changes will probably stay with us, requiring a rethinking of business models. So the crisis will have reverberations through our economy for some time to come.”The Conversation

Michelle Grattan, Professorial Fellow, University of Canberra

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Hospitals have stopped unnecessary elective surgeries – and shouldn’t restart them after the pandemic



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Adam Elshaug, University of Sydney and Stephen Duckett, Grattan Institute

Part of Australia’s response to the coronavirus pandemic was a severe reduction in elective surgery, and so private hospitals have stood almost empty for a month now.

People who might otherwise have had a procedure are experiencing “watchful waiting”, where their condition is monitored to assess how it develops rather than having a surgical procedure.

The big question is whether all those procedures which didn’t happen were even necessary. There has now been a steady stream of work which suggests many procedures don’t provide any benefits to patients at all – so called low- or no-value care.




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Bringing about change in health policy is usually difficult (or slow, at best) because it’s like turning a big ship around. But in the past six weeks that ship has made a sudden about-turn.

Australia’s elective procedure system after the pandemic should be different from before the pandemic. We should dramatically reduce the number of low- or no-value procedures.

What is low- or no-value health care?

Low- or no-value health care mean the intervention provides no or very little benefit to patients, or where the risk of harm exceeds the likely benefit.

Reducing such “care” will improve both health outcomes for patients and the efficiency of the health system.

Research in New South Wales public hospitals showed up to 9,000 low-value operations were performed in just one year, and these consumed almost 30,000 hospital bed days that could have been used for high-value care.

One example of low-value care is spinal fusion surgery for low back pain. This is a procedure on the small bones in the spine, essentially welding them together. The alternative is pain management, physiotherapy and exercise.

Spinal fusion for low back pain is an example of low-value care.
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The NSW analysis revealed up to 31% of all spinal fusions were inappropriate. But even this figure is likely an underestimate.




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Needless treatments: spinal fusion surgery for lower back pain is costly and there’s little evidence it’ll work


Other examples include:

  • vertebroplasty for osteoporotic spinal fractures: surgery to fill a backbone (vertebrae) with cement

  • knee arthroscopy for osteoarthritis: inserting a tube to remove tissue

  • laparoscopic uterine nerve ablation for chronic pelvic pain: surgery to destroy a ligament that contains nerve fibres

  • removing healthy ovaries during a hysterectomy

  • hyperbaric oxygen therapy (breathing pure oxygen in a pressurised room) for a range of conditions including osteomyelitis (inflammation of the bone), cancer, and non-diabetic wounds and ulcers.

Low-value care can harm patients because of the risks inherent in any procedure. If a patient having a low-value procedure gets even one complication, the time they spend in hospital doubles, on average.

For some patients, the hospital stay can be much longer. For example, a low-value knee arthroscopy with no complications consumes one bed day. If a complication occurs, that length of stay increases to 11 days, on average.




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Needless procedures: knee arthroscopy is one of the most common but least effective surgeries


For most low-value procedures, the most common complication is infection.

The situation is even worse in private hospitals, where a much greater proportion of elective procedures are low value.

Prioritise treatments that work

Most state health departments and private insurers now know the size of the low-value care problem and which hospitals are providing that “care”.

Due to the COVID-19 response, the tap for these procedures has been turned down for some and off for others. This is a risk for some patients, but others will benefit from not having the surgery. We must grasp the opportunity to learn from this enforced break.




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The coronavirus ban on elective surgeries might show us many people can avoid going under the knife


One of the challenges for policymakers in the past in controlling low-value care has been difficulty in ratcheting down supply by reducing or redirecting a hospital’s surgical capacity and staff.

In many ways, the COVID-19 response has done this for them. After the pandemic, we can reassess and reorient to high-value care.

Some people will need catch-up surgeries after the pandemic, but some won’t.
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This does not necessarily mean reducing capacity. Some people aren’t currently getting the care they need. When the tap comes back on, this unmet backlog of care must be performed.

But this needn’t detract from a focused effort to keep the low-value care from re-emerging. The last thing we need is for low-value care to take the place of high-value care that has been delayed because of the COVID-19 response.

So how do you do it?

Australia should take three immediate steps to ensure we don’t return to the bad old days of open slather.

First, states should start reporting the rates of low-value care, using established measures. This reporting should identify every relevant hospital – public and private – and it should be retrospective, showing rates for the past few years.




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Australians are undergoing unnecessary surgery – here’s what we can do about it


Second, states should require all public hospitals to take steps to limit low-value care – and hospitals that don’t comply should be called to account.

States have the insights and data necessary to do this.

Hospital strategies might include requiring a second opinion from another specialist before a procedure identified as low-value care is scheduled for surgery, or a retrospective review of decisions to perform such surgery.

Hospitals could require second opinions before scheduling low-value procedures.
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In the post-pandemic world, states should also consolidate elective surgery, so the number of centres performing elective procedures in metropolitan areas is reduced, with decision-making tools to highlight downsides of low-value care and the alternatives.

Third, private insurers know low-value care is provided in private hospitals, but currently have fewer levers at their disposal to reduce such care. The Commonwealth government should legislate to empower funds to address this issue. Given the Commonwealth government is providing financial support to the private hospitals during their downturn, perhaps a requirement should be that they work with the insurers and Medicare to police the re-emergence of low-value care.

It would be a dreadful shame to waste this unprecedented opportunity, and revert to the old status quo of low- and no-value care.The Conversation

Adam Elshaug, HCF Research Foundation Professorial Fellow, Professor in Health Policy and Co-Director, Menzies Centre for Health Policy, University of Sydney and Stephen Duckett, Director, Health Program, Grattan Institute

This article is republished from The Conversation under a Creative Commons license. Read the original article.

A coronavirus spike may put ICU beds in short supply. But that doesn’t mean the elderly shouldn’t get them



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Paul Komesaroff, Monash University; George Skowronski, and Ian Kerridge, University of Sydney

Although recent encouraging news suggests the rate of new coronavirus cases in Australia is slowing, our medical facilities could still be overwhelmed at some point.

One modelling study has suggested that, if public health measures are not observed or do not work, demand for the existing 2,200 intensive care unit (ICU) beds in Australia will be exceeded within a few weeks. More optimistic views of our achievable ICU capacity would merely delay this event for a few weeks.

Critical shortages of ICU beds and other medical resources overseas have resulted in large numbers of deaths. In these countries there have been vigorous debates about which of many eligible patients should be given access to care facilities in short supply.

This discussion is now underway in Australia.

For many clinicians, the question of who has access to limited ICU beds presents disturbing challenges, especially in view of a widely disseminated proposal that has gained particular support in Italy. This bases decisions about who is granted access to ICU beds on calculations of the future years of life that could potentially be achieved through treatment (or, in some proposals, “quality adjusted” years of life).

This would deny access to people above a certain age as well as to people with disabilities and certain medical conditions.




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What is a person worth?

This approach is deeply problematic.

It has taken many years for us to move away from judging the value or worth of a person by their age, race, sexual preference, physical ability, religion or other personal characteristics.

The worst outrages of the 20th century resulted directly from such approaches, which were often claimed at the time to be supported by “ethical” justifications.

Decisions should not be made based on calculations about how many years a person has to live.
Shutterstock

There has also never been a public discussion, and certainly there is no agreement, about whether the “ethical value” of a person can be calculated mathematically on the basis of the total number of years he or she might live.




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The alternative, which has been developed and routinely employed in hospitals around Australia for years, applies a process of rigorous discussion about the potential benefits and burdens of treatments proposed for every individual patient, taking into account all relevant clinical features and whether acute problems can be overcome.

It entails a detailed analysis of technical issues and results. It involves open discussion with the patient, medical carers, family members, and expert ICU staff, about medical, social, emotional and ethical issues.

It embraces flexibility and a readiness to adapt and change protocols with changing circumstances. It takes into account the specific circumstances of individual patients’ lives, including their personal preferences and religious and cultural beliefs.

It leaves aside personal characteristics not relevant to the medical decision at hand, such as race, gender, sexual preference and ethnicity.

Age can be relevant

This is not to say that age can never be a relevant consideration. Indeed, in some conditions, advanced age is closely linked with the likelihood of a poorer response to a treatment.

Sometimes this is because increasing age is directly linked to age-related diseases that reduce the likelihood of a successful outcome from treatment, such as certain types of cancer.

Sometimes age can be a factor but it’s more of a signifier of other considerations.
Shutterstock

At other times, for reasons that are much less clear, age itself appears to predict poor outcomes of treatment, leading to its inclusion in many scoring systems for predicting outcomes of treatment, including in intensive care and cancer care.

In both cases it is valid that age be taken into account in decision-making. It is also possible that age may be relevant to more philosophical considerations, for example, whether older people consider themselves to have already lived a “fair innings” or whether young people should be given the opportunity to live a life and gain their potential.




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While these may also be relevant considerations, and be accepted by many, including sometimes by older people themselves, they are much less clear and much more contested, and require ongoing debate.

The key point is that, even in these cases, age is never taken as a defining quality or characteristic of a person but rather as a potential signifier of other relevant characteristics or risk factors. Its relevance is linked to what it implies for the particular person, not to an assumption that old people have diminished value and are less worthy of treatment.

In extreme settings, time and resource constraints may add greatly to pressures on the decision-making process but the same principles still apply. In fact, it is exactly in these contexts that it is most important to resist resorting to criteria that are not founded on evidence or valid ethical arguments.

How do we respond?

The ethical strength of a society is revealed in how it responds to serious challenges. If we have values worth defending, this is the time to fight for them.

Most of us do not want to move to a society based on the arbitrary imposition of measures that discriminate against people on the basis of ethically or medically irrelevant personal characteristics.

Future generations will judge us on how we respond to this crisis and whether we have been able to defend our core values. This is the time, perhaps more than any other, when we have to keep our ethical nerve.




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The Conversation


Paul Komesaroff, Professor of Medicine, Monash University; George Skowronski, Research Affiliate, Sydney Health Ethics, School of Public Health, University of Sydney, and Ian Kerridge, Professor of Bioethics & Medicine, Sydney Health Ethics, Haematologist/BMT Physician, Royal North Shore Hospital and Director, Praxis Australia, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Federal government gets private hospital resources for COVID-19 fight in exchange for funding support


Michelle Grattan, University of Canberra

Private hospitals will be on the frontline in the coronavirus battle, under an arrangement with the federal government that makes available the sector’s more than 30,000 beds and 105,000 workforce, including more than 57,000 nursing staff.

The government will offer agreements to Australia’s 657 private and not-for-profit hospitals “to ensure their viability, in return for maintenance and capacity” during the COVID-19 crisis.

The agreement makes available more resources to meet the virus crisis, preserves the private hospital workforce, and is designed to allow a speedy resumption of non-urgent elective surgery and other normal activity when the crisis has passed.

The states will complete “private hospital COVID-19 partnership agreements”, with the Commonwealth paying half the cost.

“In an unprecedented move, private hospitals, including both overnight and day hospitals, will integrate with state and territory health systems in the COVID-19 response,” the government said in a Tuesday statement.

These hospitals “will be required to make infrastructure, essential equipment (including ventilators), supplies (including personal protective equipment), workforce and additional resources fully available to the state and territory hospital system or the Australian government”.

Private hospitals will support the COVID-19 response through:

  • Hospital services for public patients – both positive and negative for COVID 19

  • Category 1 (urgent) elective surgery

  • Use of wards and theatres to expand ICU capacity

  • Accommodation for quarantine and isolation cases where necessary, and safety procedures and training are in place, including:

    • Cruise and flight COVID-19 passengers
    • Quarantine of vulnerable members of the community
    • Isolation of infected vulnerable COVID-19 patients.

The cost of the move is estimated at $1.3 billion.

Last week the government announced a ban on non-urgent elective surgery. While this freed up beds and staff, it would also strip the hospitals of core income and threaten the collapse of some hospitals without government action.

Health Minister Greg Hunt said the agreement dramatically expanded the capacity of the Australian hospitals system to deal with COVID-19, at the same time as the curve of new cases showed early signs of being flattened.

The private hospitals “are available as an extension now of the public hospital system in Australia. So, whilst we’re not taking ownership, we have struck a partnership, where in return for the state agreements and the commonwealth guarantee, they will be fully integrated within the public hospital system”.

Hunt said the $1.3 billion estimated cost was not capped. “If more is required, more will be provided. If it turns out that it’s not that expensive, then those funds will be available for other activities. That takes our total additional investment to over $5.4 billion within the health sector.”

In a letter to private hospital providers, Hunt stressed: “A fundamental principle of this agreement is that it contributes towards to your ongoing viability, not profits or loan/debt repayments”.

Commonwealth deputy chief medical officer, Nick Coatsworth said intense efforts were being made to ramp up rapidly the number of ventilators.

He said there were some 2,200 ventilated intensive care beds in Australia. Currently just over 20 were being used for COVID-19 patients.

With immediate expansion, including repurposing and use of the private sector, this could be increased to 4,400.

“Our target capacity for ventilated intensive care beds in Australia currently stands at 7,500.

“We are working around the clock to procure ventilators,” he said. “Locally, we will have 500 intensive care ventilators fabricated by ResMed, backed up by 5,000 non-invasive ventilators, with full delivery expected by the end of April.”

The Australian Healthcare and Hospitals Association welcomed the “ground-breaking agreement” with private hospitals for ensuring both the best use of resources and the stability of the health system for the future.

The Australian tally of cases as of Tuesday afternoon was 4557, with 19 deaths; 244,000 tests had been completed.The Conversation

Michelle Grattan, Professorial Fellow, University of Canberra

This article is republished from The Conversation under a Creative Commons license. Read the original article.

What steps hospitals can take if coronavirus leads to a shortage of beds


Gerard Fitzgerald, Queensland University of Technology

The number of COVID-19 cases in Australian continues to grow with new cases confirmed each day.

Of those who get ill, about 20% will have moderate or severe illness that requires hospitalisation.

Based on experience in China, of those admitted, about 26% will require a stay in an intensive care unit (ICU) and 17% mechanical ventilation.




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How we’ll avoid Australia’s hospitals being crippled by coronavirus


So what happens if we run out of hospital beds for patients with COVID-19?

Overwhelmed health systems

The epidemic is currently under control in Hubei but continuing to expand rapidly in Italy which is currently overwhelmed by this disease and its health system floundering.

A report this month in the New England Journal of Medicine describes the impact of this outbreak in Italy: operating rooms turned into ICUs, patients admitted for other reasons contracting the disease and health workers falling ill.

In Australia, as of this morning there were more than 1,800 confirmed cases of COVID-19, with 344 new cases since 6am yesterday.

We have an extensive health capability in Australia with around 94,000 hospital beds (61,000 in public hospitals) including 2,200 ICU beds. We also have about 800,000 people working in health services including 350,000 nurses and 90,000 doctors.

At present in Australia, the number of cases is not at a level that would challenge our health treatment capability.

But health personnel are stretched undertaking contact tracing to understand how the infection is spreading, data collection and analysis, and implementing enhanced infection control procedures.

Similarly the laboratory system is being challenged by increased testing rates and primary care services are likely to be stretched by responding to considerable community concern.




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So, if demand continues to increase, what can our health system do to surge the response?

As the numbers grow

The surge requirements are not one-dimensional. People often speak about the capacity of the system to surge the amount of space, staff and stuff. Each of these has limitations.

The space must be appropriate to need.

The surge in staff must take into consideration the impact this event has on staff availability and the risk they are taking on.

Surging consumables and equipment depends on supply chains. The domains are complementary. Increasing ventilators alone without having sufficient staff to operate them is futile.

In addition, people will continue to get sick from other causes. Indeed, there is often a danger in disaster response in which all of the attention is focused on those with the disease and other patients including some who are serious and critically ill are relatively ignored.

A four tier response

Health system responses will escalate as demands increase and may be broadly categorised into four tiers.

The first tier is when there is a relatively small epidemic. Health systems will seek to concentrate the care into a small number of facilities, thus concentrating the expertise and maximising the infection control. This is what is happening now.

The second level of response occurs when health facilities need to create additional internal capacity or to refocus existing capacity. Common strategies involve cancelling elective surgery, early discharge and relocation of patients to other facilities.

The third tier of response occurs when additional capacity has to be created. Options include recommissioning purpose-built facilities (closed hospitals) or by taking over suitable alternatives such as hotels.

Hotels can be useful for recuperating patients who require mainly observation and support. They are facilities that can be easily and rapidly converted to include appropriate levels of infection control.

Victoria has announced funding for an extra 269 hospital beds, including 84 at Melbourne’s old Peter Mac Hospital, and the former Baxter House Hospital in Geelong will be recommissioned.

In South Australia, new facilities will be set up at the recently decommissioned ECH College Grove and Wakefield hospitals providing an extra 188 beds.

Additional space and equipment is one thing, but not helpful as we need people to care for the patients and run the ventilators. We need to protect the existing staff wherever possible.

Additional staff can be found among recently retired practitioners and students, and by redirecting personnel from other (particularly non-clinical) areas.

But a word of caution. This is not a time to learn new skills. Familiarity leads to efficiency and so unfamiliar staff can be best used to help and support and to undertake non-technical roles.

Hard decisions at tier four

The fourth tier occurs when a system is overwhelmed, as in Italy and other European countries at present. This is when the demand for care exceeds any possibility of providing that care equally to all.

In this case, very difficult decisions have to be made involving triage of patients and the allocation of resources.

We have not had to implement such responses in this country since perhaps the Spanish Flu pandemic of 1918/1919. But such decisions based on risk and possible benefit are not unusual.




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Decisions about whether to resuscitate or operate are made commonly but mostly focused on the likely benefit to the individual and are made in partnership with the patient and their carers.

In this circumstance, very hard decisions will have to made about relative benefit to preserve the health system’s capacity for people who are more likely to survive.

To support this, we would need to identify and communicate what is known as “Crisis standards of care” so that there is a consistent, system-wide approach. The legal and ethical aspects of this will need agreement not only by medical authorities but more broadly in the community.




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The Conversation


Gerard Fitzgerald, Emeritus Professor, School of Public Health, Queensland University of Technology

This article is republished from The Conversation under a Creative Commons license. Read the original article.

How we’ll avoid Australia’s hospitals being crippled by coronavirus



Shutterstock

Caleb Ferguson, Western Sydney University; Rochelle Wynne, Western Sydney University, and Scott Newton, Johns Hopkins University

Australians should now be practising social distancing to slow the spread of SARS-CoV-2, the virus that causes COVID-19.

By creating more space between yourself and others you decrease the risk of person-to-person spread.




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It’s also essential that confirmed cases, those awaiting test results and people who have recently returned from overseas self-isolate for a minimum of 14 days.

The purpose of these public health measures, and others such as practising good hand hygiene and cough etiquette, is to “flatten the curve” or mitigate the spread of COVID-19.

Flattening the curve is another way of saying slowing the spread. The epidemic is lengthened, but we reduce the number of severe cases, causing less burden on public health systems. The Conversation/CC BY ND

If we don’t slow the spread of the virus and decrease the number of people with it at any given time, our health-care system – and intensive care units in particular – will struggle to cope.

What would uncontrolled spread look like?

As Australian mathematician Joel Miller, from La Trobe University, wrote on The Conversation, without public health interventions, the virus could spread quickly and infect a large proportion of the population:

COVID-19’s observed doubling time has been about four days. That means every four days the number of cases has been roughly double what it was four days prior.

We would calculate it takes about three months for one infection doubling every four days to cause 15 million infections.

After the peak, we expect the total time to drop to be about the same as it took to rise. This gives a crude prediction of six months.




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According to data from China, around 5% of people who test positive to COVID-19 will experience severe symptoms and require admission to an intensive care unit (ICU) for around four weeks.

So, three months into the pandemic, without public health measures to control the spread, we could have expected to see 750,000 severe cases requiring admission to ICU in the first three months.

What can our ICUs cope with?

We currently have just over 2,200 ICU beds.



Assuming all ICU beds will be reserved for coronavirus patients, statistician Megan Higgie from James Cook University has estimated that when Australia has 44,580 infected patients, all our ICU beds will be full.

Based on these estimates, Higgie suggests we could run out of ICU beds in early April.

And, of course, chronic conditions and traumatic injuries will persist and people without coronavirus will continue to need intensive care.

What impact can public health measures have?

Modelling published this week by Imperial College London suggests that implementing all available mitigation options, including social distancing and home isolation, could dramatically reduce pressure on ICUs.

The researchers estimate that over a three-month period, these measures could reduce demand for ICU beds by 69%.

Washing your hands and social distancing means you’re doing your part to reduce the spread of COVID-19.
Shutterstock

But even with the public health measures we have in place to control the spread of COVID-19, the Australian and New Zealand Intensive Care Society suggest the number of ICU beds may have to double to cope with the increased demand.

We don’t just need more beds, we need nurses to staff them

Nurses will need to be mobilised to provide this additional ICU care.

In Australian ICUs, the nurse to patient ratio is 1:1, so one nurse looks after one patient. This is due to the highly complex care needs of these patients who require constant observation, assessment and treatment to remain stable.




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We need to identify nurses with critical care qualifications or experience who can be redeployed to address this increased demand.

Nurses who specialise in medical and surgical fields could also be deployed to work in ICUs under supervision.

Recently retired nurses could be called on to rejoin the workforce, as well as those with registration but not practising.

Current leave and future leave from work may need to be limited or cancelled and other health professionals, including defence personnel and student nurses, working under supervision, could be called on to boost the overall nursing workforce.

What else can hospitals do to cope with the increased demand?

As the pandemic evolves, hospitals will experience a triple threat of more patients, reduced numbers of clinical staff as some become infected, and increased illness intensity.

We need to protect front-line health workers from contracting COVID-19 or becoming exhausted, which will also reduce absenteeism.

Hospitals may also need to:

  • discharge patients from hospital more quickly than previously

  • postpone admissions for all non-critical procedures

  • increase the remote and virtual care capabilities, such as telehealth and care hotlines, to treat patients at home

  • activate alternate care sites such as hotels or small private hospitals for patients requiring low levels of care so we can save large tertiary hospitals for those with greatest need.

This is an unprecedented global public health crisis. Our health systems will be under tremendous pressure over the next several weeks and months, requiring rapid adaptation to meet the needs.

The social distancing measures we adopt now will help us to deliver the best care to patients and each other when we need it.




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The Conversation


Caleb Ferguson, Senior Research Fellow, Western Sydney Nursing & Midwifery Research Centre, Western Sydney Local Health District &, Western Sydney University; Rochelle Wynne, Director, Western Sydney Nursing & Midwifery Research Centre, Western Sydney University, and Scott Newton, Lecturer, Johns Hopkins University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

As Mediscare 2.0 takes centre stage, here’s what you need to know about hospital ‘cuts’ and cancer funding


Stephen Duckett, Grattan Institute

Health is proving a bone of contention in the 2019 election campaign. Labor has positioned health as a key point of difference, and the Coalition is arguing that Labor’s promises are untrue in one case and underfunded in another.

This cheat sheet will help you sort fact from fiction in two key health policy areas: public hospital funding and cancer care.

Public hospitals

In his budget reply, Opposition Leader Bill Shorten promised that Labor would restore every dollar the government had “cut” from public hospital funding.

The government counter-claimed that hospital funding has increased. So who is right?

The short answer is both.

In 2011, the then Labor government negotiated a funding agreement with the states for the Commonwealth to share 45% of the growth in the cost of public hospital care, funded at the “national efficient price”. This price is based on the average cost of the procedure, test or treatment.

The funding share was to increase to 50% of growth from July 1, 2017.




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At the 2013 election, the then Liberal opposition agreed to match that promise and, indeed, claimed they were the only ones who could be trusted to keep the promise:

A Coalition government will support the transition to the Commonwealth providing 50% growth funding of the efficient price are hospital services as proposed. But only the Coalition has the economic record to be able to deliver.

However, in the 2014 budget the Coalition scrapped its promise. The 2014 budget papers list the savings that were made by the decision. It was a clear and documented cut that the Coalition was proud to claim at the time.

The green line represents the Gillard hospital funding agreement; the blue line is the revised projection from the 2014 budget.
Budget 2014-15

Since then, the Turnbull government has backtracked on the 2014 cuts to health but only to restore sharing to 45% of the costs of growth.

Labor has estimated the impact of the gap between 45% and 50% on every public hospital in the country, and spruiks the difference at every opportunity.

Hospital costs increase faster than inflation because of growth and ageing population, the introduction of new technologies, and new approaches to treatment.

As a result, the Commonwealth’s existing 45% sharing policy drives increased spending, and so Commonwealth spending is now at record levels, albeit not at the even higher levels that Labor had promised.

Labor’s promise is, appropriately, phrased as an additional quantum of money to the states, sufficient to restore the 50% share in the cost of growth.

The public hospital funding gap comes down to how much of the growth in hospital funding each party has committed to.
Shutterstock

The details of how this funding should be operationalised to the states should be left to detailed negotiations after the election as it is not good practice for all the details of your negotiating position to be aired in the heat of a campaign.

So Labor is right to say hospital funding is lower than it would have been if the 50% growth share commitment had been maintained. But the Coalition is right to say the Commonwealth is spending more on hospital care than when it came to office.

Cancer care

The second major element of the Labor campaign was a high-profile A$2.3 billion package to address high out-of-pocket costs for Australians with cancer. The package has three key components:

  • additional public hospital outpatient funding to reduce waiting times
  • a new bulk-billing item for consultations
  • more funding for MRI machines for cancer diagnosis.



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Labor did not promise to eliminate out-of-pocket costs for cancer, not even for consultations. It claimed bulk-billing would increase from 40% to 80% of consultations.

This promise has led to another showdown between Labor and the Coalition. Health Minister Greg Hunt claims to have found a A$6 billion black hole in Labor’s cancer policy.

The Coalition has produced a list of 421 Medicare items used for cancer treatment – including treatment in private hospitals – and noted Labor has not allocated funds to cover the fees specialists charge for these items.

But Labor rightly claims the 421-item list is not what it promised. Labor’s promise was about increasing the rate of bulk-billing for consultations and is based on a new item which is only available if the specialist bulk-bills.

Expect more claims and counter-claims in the weeks ahead.The Conversation

Stephen Duckett, Director, Health Program, Grattan Institute

This article is republished from The Conversation under a Creative Commons license. Read the original article.

More hospitals will not cure Australia’s ailing health-care system. There’s a more efficient way



File 20190409 2912 1s6hmzz.jpg?ixlib=rb 1.1
There needs to be more focus on treating people before they need a hospital.
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Steven Bond-Smith, Curtin University; Alan Duncan, Curtin University; Astghik Mavisakalyan, Curtin University, and Yashar Tarverdi, Curtin University

The federal government has just promised to increase spending on public hospitals from A$21.7 billion in 2018 to A$26.2 billion by 2023. Expect more hospital promises in coming weeks. There is a long history of parties at both state and federal level pledging new hospitals during election campaigns.

Building new hospitals may at first seem sensible, especially as the population grows. But it will not cure the health system’s most pressing ailment. Instead, our research shows it’s more effective to focus health policy on people and prevention.

A problem of demand

It is true that hospitals in Australia aren’t keeping up with demand. Though supply of beds has increased, the population is growing while also ageing. This is increasing demand for all health-care services, including hospital beds.

The following graph shows the change in the number of beds per 1,000 people in all states and territories since 2006. Only in the Australian Capital Territory has the ratio improved.


Available hospital beds per 1000 population, by region, public hospitals (including psychiatric).
Bankwest Curtin Economic Centre | AIHA (various years), Australian hospital statistics, Health Services Series; AIHW (various years), hospital resources’ Australian hospital statistics, Health services series.

State and federal governments thus feel a lot of pressure to spend more on hospitals. In 2016-2017 it was $69 billion Australia-wide – $2 billion more than the previous year. The following graph shows expenditure on public hospitals by state over the past two decades.

Public hospital spending in each state since 1996.
Australian Institute of Health and Welfare, CC BY

Queensland shows the greatest growth over the past two decades. In Western Australia, where we did our research, the proportion of government health budgets spent on public hospitals rose from 26% to 31%.

Preventive measures

We looked at why the hospital care is growing faster than the overall health sector, and what can be done about this.

Our conclusion: there needs to be more focus on the “unsexy” parts of the health-care system that treat people before they get sick enough to need a hospital. Prevention is cheaper and more effective than cure.




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For example, it is estimated that A$9 million invested in anti-smoking campaigns between 1997 and 2007 saved A$740 million on smoking-related illnesses like lung cancer.

Yet our breakdown of health spending in Western Australia shows just 1.7% is spent on preventive measures – called “public health spending”. Australia-wide the average percentage is even less, according to research from La Trobe University and the Australian Preventative Partnership Centre.


Breakdown of health care spending in WA.
Bankwest Curtin Economics Centre | Authors’ calculations from AIHW health expenditure database.

Early medical attention is another way to reduce the need for hospitals. In analysing data from around Western Australia between 2009 and 2016, we generally found that increasing visits to general practitioners reduced the incidence of avoidable deaths (deaths that could have been avoided with better treatment or prevention).

People-centred approach

Limited prevention and early detection comes back to the way we fund health care.
Australia’s health system is funded using a “hospital-centred” rather than “people-centred” approach.

This means hospitals are funded by the number of patients cared for and the type of procedures done. Hospital and GPs are funded separately. There is no incentive to cooperate and keep people out of hospitals.

A people-centred approach, on the other hand, would give funds based on patients’ health outcomes, rather than their particular treatments. GPs would be paid to manage patients, with the goal of keeping them out of hospital.

This system would particularly help people living in remote and rural regions, including Indigenous Australians, who are disadvantaged by the relative lack of resources being spent on local and preventive health.

The Canterbury model

The Canterbury region in New Zealand.
English Wiki

The best example of such a people-centred system is New Zealand’s Canterbury model – named after the Canterbury region on New Zealand’s South Island (which includes Christchurch).

Instead of separate budgets for GPs and hospitals, Canterbury created a “one system, one budget” approach. This led to new programs that weren’t possible under the old system. An example is Healthpathways, which brought together GPs and specialists to decide on treatement programs for individual patients.

In working to make hospitals the last resort, more time and resources have gone to GPs. There are now more 24-hour clinics, for example, making it easier to get treated by a local doctor when needed.




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A study of the Canterbury system showed that between 2007 and 2014 the number of people being hospitalised declined from 6.59 to 5.83 per 1,000. While an 11% decline may not seem huge, it represents a significant financial saving, given the high cost of hospitalisation.

Canterbury shows what can be achieved by rethinking how health care funding works. Australia has the opportunity to reimagine its health care system in a similar way.

New hospitals get a lot of attention. Politicians can point to them as concrete evidence they’re doing something to help. But emphasising hospitals as the most important part of the health system comes at a cost, and will only get more so as the population ages.

It’s time to discuss alternatives. Putting more resources into prevention and people is the right medicine for our future health needs.The Conversation

Steven Bond-Smith, Research Fellow, Bankwest-Curtin Economics Centre, Curtin University; Alan Duncan, Director, Bankwest Curtin Economics Centre and Bankwest Research Chair in Economic Policy, Curtin University; Astghik Mavisakalyan, Associate professor, Curtin University, and Yashar Tarverdi, Research fellow, Bankwest Curtin Economics Centre, Curtin University

This article is republished from The Conversation under a Creative Commons license. Read the original article.