Feature, Report

Elective surgery post-COVID

An elective surgery shutdown as part of the COVID-19 response wreaked havoc on an already-stretched hospital system last year. Insight checks in on how each state is faring one year on.

This month marks one year since the Federal Government took the unprecedented step to suspend non-urgent elective surgeries in public and private health systems across Australia due to the COVID-19 pandemic.

The National Cabinet’s directive affecting all states and territories was designed to free up bed space to manage COVID-19 hospitalisations, preserve personal protective equipment (PPE) for the most urgent use and to protect patients from infection.

Twelve months on, Insight reviews the ophthalmic surgery landscape and the lingering impact of the shutdown. Leading figures also discuss the merit of elective surgery ‘blitzes’ announced in certain states, and the role of the private sector in helping whittle down public waiting lists.

QUEENSLAND

Queensland’s Dr Bill Glasson believes treating public ophthalmology patients in the private system to improve efficiency and outcomes is the way of the future.

Dr Bill Glasson

After the initial shutdown, Queensland Health started re-introducing non-urgent procedures across its hospitals from late-April and May, with private hospitals able to return to 100% of normal activity, subject to availability of PPE.

With modelling indicating Queensland could have more than 7,000 people waiting longer than clinically recommended by 1 July 2020, the state government swiftly announced $250 million in new spending for hospitals to provide non-urgent procedures outside of regular hours.

Six months later, the Queensland Government claimed the ‘blitz’ had been a “resounding success in managing waiting lists”, according to the latest health data.

Glasson, former president of the Australian Medical Association (AMA) and the Australian Society of Ophthalmologists (ASO), said Queensland hospitals were “in a pretty good position”.

“There is no difference in waiting lists between pre and post COVID,” he said. “Waiting lists are never-ending, and it’s hard to measure ‘hidden’ waiting lists – those waiting to be seen to then go on to an elective surgery waiting list – but most hospitals keep to targets.”

The median waiting times for ophthalmology patients from July to September 2019 was 0 days for Category 1, 129 days for Category 2, and 333 days for Category 3.

Compared with the 2020 figures over the same period, Category 2 patients are now waiting 100 days longer on average, and Category 3 38 days longer.

At 1 October 2020, the percentage of ophthalmology patients waiting within the clinically recommended time was 65% (Category 1), 33% (Category 2), and 67% (Category 3).

Several years ago, the Queensland Department of Health introduced Surgery Connect, a program to ease elective surgery waiting lists in public hospitals.

The patient-centred program coordinates and contracts with the private sector to deliver elective surgical services for patients where there is insufficient capacity to provide treatment within clinically recommended timeframes within Queensland public hospitals.

Glasson said the Queensland Government’s decision to treat public patients in the private system, to reduce backlog, was “the way of the future”.

“Surgery Connect utilises efficiencies of the private system. It’s far cheaper to have cataract surgery in the private system, than the public system,” he said.

“The public system has a limited budget but unlimited demand. Ophthalmology is a highly sought-after type of surgery, and it’s an expanding field of medicine, supported by good technology and good patient outcomes. Its success rate is putting huge pressure on the public purse. Waiting lists control demand in the public system, whereas price controls demand in the private system,” he said.

Glasson, who sits on Cancer Australia’s Advisory Council, said patients with cancers and tumours often face adverse implications from elective surgery, but cataract patients, by comparison, have some of the best access to intraocular implants, are often able to have “walk-in, walk-out” day surgery, and achieve consistently good visual outcomes.

“There is always going to be a waiting time for ophthalmic elective surgery. Public patients will be diverted to private hospitals more in the future, but we don’t want to undermine the value of private health insurance and the benefit of choice for patients paying to be treated in the private system. How we do this is important,” Glasson said.

“State Governments want to ‘bundle’ elective surgery services, such as the costs associated with theatre, anaesthetist and so on – but we need to be very careful that they don’t screw down the price so it’s unsustainable. The state government needs to be mindful of not affecting quality.”

Glasson warns that if public patients are going to be treated in the private system as a means to reduce the public backlog, then registrars must follow. “We need a mechanism which registrars can operate in private settings.

We need to teach future generations to operate in private facilities, in addition to the public system,” he said.

NEW SOUTH WALES

Associate Professor Ashish Agar is concerned about what impact the outsourcing of elective surgery to the private sector is having on teaching the next generation of specialists in NSW.

A/Prof Ashish Agar

After the initial shutdown in March, hospitals in New South Wales were given the green light in April to increase elective surgery from 25% of pre-pandemic levels to 50% by May 31, then 75% by June 30, 2020.

Agar, glaucoma specialist at the Prince of Wales Hospital and Sydney Eye Hospital and partner at Marsden Eye Specialists, said the elective surgery scene in New South Wales has not changed since November, when the latest healthcare data revealed ophthalmic patients were waiting 330 days on average – a 98 day increase on the same period in 2019 and the largest rise among all medical specialties.

Despite the lengthy wait, Agar commended the nation’s healthcare leaders, acknowledging the restrictions and gradual return to capacity had proven to be a successful strategy compared to the failures evident in healthcare systems overseas.

“Australia has demonstrated good leadership, and healthcare providers and patients have complied for the common good, and now we’re reaping the benefits. Our elective surgery capacity is a pipedream for those overseas, and in that context, it’s important to acknowledge Australia’s leadership and successful campaign to manage the pandemic,” Agar, who is also president of the Australian Society of Ophthalmologists (ASO), said.

“A year down the track [since elective surgery restrictions were introduced], Australia is in one of the best positions of developed nations, and there’s an expectation in our health system that things are heading back to normal. The private sector is going ahead as usual, but the public sector is a mixed bag.”

Agar said there was a minimum three-month wait for ophthalmic patients, and up to one year maximum, which is having a severe impact on outpatient clinics in public hospitals.

The latest Bureau of Health Information Healthcare Quarterly report reveals from July to September last year in NSW, ophthalmologists performed 10,298 procedures in the public system, with just 66% of those on time. This is a 32% drop from the same quarter in 2019 when 98% were delivered within the recommended timeframe.

Of the 8,426 cataract procedures performed in the September quarter, the median wait time was 343 days – 71 days longer than in 2019.

“The data reflect who has come through the system, but it doesn’t capture the backlog of patients who remain unseen,” Agar said.

“The unknown patients are a bigger concern. As Dr Bill Glasson was saying, there has been some outsourcing to the private sector – which can work well in terms of efficiencies and the like – but our concern is that outsourcing has a significant impact on teaching hospitals. If cataract surgery is done in private hospitals, what impact does that have on teaching?”

Agar said his colleagues who taught in public hospitals have told him how registrar’s caseloads are impacted by public patients being siphoned into the private system.

“The temptation for public hospitals is for a cost-saving aim, rather than a patient-outcome aim,” he said.

“The established infrastructure and staff in the public system is rundown. In NSW, there are some major teaching hospitals where ophthalmic surgery has not resumed to pre-COVID levels. This means a loss of training and a loss of skills in the public sector. Ophthalmic surgery is not being done.”

Agar said his colleagues are raising concerns that COVID may be used as an argument to cut costs and services in public ophthalmology surgery, thereby cutting patient’s visual prospects.

SOUTH AUSTRALIA

Dr Mark Chehade says South Australia was fortunate to suffer no adverse eye health outcomes for patients as a result of COVID-related surgical suspensions.

Dr Mark Chehade

Following the elective surgery suspension in March, South Australia was the first state to fully restore all elective procedure capacity by early-to-mid-June 2020.

Chehade, who commenced in the role of head of the ophthalmic surgery unit at the Royal Adelaide Hospital in January 2021, said the state was fortunate to be only shutdown for three months.

“COVID’s effect on elective surgery waiting times in South Australia were minimal,” he said. “I’d estimate it increased the number of Category 3 patients who reached the target 12-month wait by 15%.”

He said surgeons did not fall too far behind. “South Australia did very well with respect to COVID. We had immediate cessation of all surgery except Category 1 [in March] and returned to Category 2 and urgent Category 3 by mid-year. The problem is waiting lists are endemic, not from the pandemic.”

According to SA Health’s Elective Surgery Dashboard [last updated 5 April 2020], 3,475 ophthalmology patients statewide were on the waiting list and ready for surgery at the first opportunity, with 201 patients overdue.

At the Royal Adelaide Hospital, 520 patients were on the waiting list, with 45 overdue; 306 were waiting for a lens extraction, with 18 overdue. For those classed Category 3, 109 patients were waiting between 121 and 240 days.

When Insight spoke with Chehade in January, he estimated there were 546 patients on the ophthalmology waiting list for surgery at the Royal Adelaide Hospital.

“I’d estimate 95% would be Category 3. After 12 months, they’re targeted. A few dozen have gone beyond the target of a 12-month wait for surgery.”

Chehade said three specialists volunteered to treat public patients in private hospitals as part of South Australia’s blitz.

“We had a blitz at Royal Adelaide Hospital, but we have had them intermittently over the years. Fortunately, there have been no adverse eye health outcomes for patients as a result of COVID-related surgical suspensions, but as I said, we were only shutdown for three months.”

VICTORIA

Dr Anton van Heerden believes overall wait times have not been catastrophic, but there remains an unknown number of people whose pathology has not been assessed in Victoria.

Dr Anton van Heerden

Before elective surgery could gain any meaningful momentum in Victoria, the state was plunged into a second lockdown in July that led to a second shutdown of non-urgent surgery.

By September, Premier Daniel Andrews announced a phased restart of elective procedures in public and private hospitals. Regional Victoria eventually returned to 85% of usual elective surgery activity from September 28, while for metropolitan Melbourne this occurred from October 26. A return to full capacity across the state was slated for November 23, 2020.

Insight recently spoke with van Heerden, head of surgical ophthalmology services at Royal Victorian Eye and Ear Hospital (RVEEH), about the elective surgery landscape in Victoria.

He said the RVEEH was still only operating at about 80% of usual elective surgery activity.

“We’ve gradually increased our activity as per the Department of Health and Human Services guidelines. Waiting times between an appointment and surgery are about the same as pre-COVID,” van Heerden said.

Elective surgery rates at RVEEH were “not going backwards” and while he had received a number of new patients through referrals from optometrists, there “hasn’t been a mad rush”.

“There hasn’t been a massive deluge of patients, contrary to expectations,” he said.

The median waiting time for ophthalmology patients in Victoria from July to September last year was 30 days (compared to 330 days in NSW), and similar to 32 days for the same period in 2019.

The median waiting time for ophthalmology patients in Victoria peaked at 87 days from April to June 2020. From July to September, ophthalmologists treated 2,240 patients in the public system statewide, compared to 6,463 patients from the same quarter in 2019.

In Victoria in 2020, the median waiting time for cataract patients nearly doubled from 56 days (January to March quarter), to 101 days (April to June quarter), then fell back to 54 days (July to September quarter).

Van Heerden said he noticed that patient’s pathology was much worse because of lockdown.

“I’ve seen quite a few cataract patients who had treatment deferred for six months due to lockdown, and their vision has suffered as a result of that,” he said. “Overall, there hasn’t been a catastrophic wait, but there is an unknown number of people whose pathology has not been assessed.”

In December, the state government – having driven COVID cases numbers down – announced a $300 million elective surgery blitz to ensure Victorians can access surgery.

“The Victorian government has been threatening a blitz for a while – it was on the radar even before COVID started. But there’s no real point until we’re at 100% capacity. Based on our [RVEEH] waiting list, there is no urgency for a blitz at the moment,” van Heerden said.

However, he is concerned about a third wave outbreak, especially after the NSW Northern Beaches cluster in late December and Greater Brisbane’s three-day snap lockdown in January to stop the spread of the UK COVID-19 variant.

“When Victoria had a few confirmed cases in early January, it prompted discussion at RVEEH of re-introducing COVID testing for each patient, as per in the lockdown.”

According to van Heerden, one of the main issues of re-introducing COVID testing for each patient is the administrative burden.

“It takes a lot of work to book and un-book patients. It’s a very inefficient use of time and it can be frustrating, but we anticipate there’ll be another lockdown and must be cautious,” he said.

“The boat turns a lot slower in the public system than the private system, and that poses a real challenge, but the RVEEH has done a remarkable job of managing patients and staff during the pandemic. I was expecting progress to be a lot slower, and more difficult, but the communication between the Department of Health and Human Services and the RVEEH has been exceptional, especially given there are a lot of cogs in the wheel.”

WESTERN AUSTRALIA

Dr Tom Cunneen says Western Australia should be commended for eliminating COVID from the community which has allowed minimal interruption to ophthalmic care.

Dr Tom Cunneen

A Perth-based surgeon, Cunneen specialises in cataract, laser, and eyelid surgery. He operates privately at St John of God Subiaco Hospital and the Perth Eye Hospital and holds a consultant position at Sir Charles Gairdner Hospital.

When he spoke to Insight in May last year, ophthalmologists in Western Australia were restricted to operating at 50% of all normal elective surgical activity, despite only two active COVID cases at the time.

As a result, they were consulting at full capacity but operating surgically at just 50% of their previous through-put. This created friction because patients were being diagnosed but unable to have surgery in a timely manner.

Surgical capacity was reinstated 100% in WA on 15 June and in January 2021 – six-months later – Cunneen said elective surgery, in both the public and private system, has been “back to normal” for several months.

“WA has been fortunate not to have community spread of COVID for several months and as such our elective surgery has been running at full capacity for the majority of 2020,” he said.

Last year, amid the frustration of reduced elective surgical activity, Cunneen said he felt that, based on the number of positive COVID cases, the state government could use their discretion and lift the capacity restrictions. His initial frustration has since subsided.

“The state government, and the people of WA, should be commended for eliminating COVID from the community which has allowed very little interruption to ophthalmic care,” Cunneen said.

At the end of November 2020, Sir Charles Gairdner Hospital, where Cunneen holds a consultant position, had eight Category 1 cases with five days median waiting time, 68 Category 2 cases with 27 days median waiting time, and 304 Category 3 cases with 83 days median waiting time.

TASMANIA

Professor Nitin Verma says waitlist numbers differ across Tasmania and are the result of many, often complex, interrelated factors.

Professor Nitin Verma

Tasmania deployed a gradual and progressive restart to elective surgery at the discretion of medical professionals, following the National Cabinet’s recommended suspension last year.

Current RANZCO president, Verma practises privately at Hobart Eye Surgeons and publicly at the Royal Hobart Hospital.

“Tasmania has had around 230 cases who tested positive to the COVID virus since early 2020,” he said. “During the initial restrictions that resulted from the COVID pandemic, we followed the directives of the Federal and Tasmanian health departments as well as those of the local hospitals in our management of patients with eye problems.

“In particular, the guidelines specifically developed by RANZCO for this period were used to triage and prioritise treatment for patients with new and pre-existing eye problems.”

Verma said the surgical treatment of Category 1 and urgent Category 2 cases, in general, continued uninterrupted during the pandemic.

According to Tasmanian Health Service outpatient clinic data, as at 28 October 2020 in the Southern Region (which includes Royal Hobart Hospital), ophthalmology patients were waiting 71 days in urgent cases, 147 days in semi-urgent cases, and 383 days in non-urgent cases.

“As the leaders in collaborative care, we continue to work with the Tasmanian Government, our local hospitals and health facilities to ensure that eye patients on waiting lists are seen as soon as feasible,” Verma said.

“Overall waitlist numbers differ across Tasmania and are the result of many, often complex, interrelated factors. Although COVID-19 has affected waiting lists in some areas, as long as there are no major problems around the corner, we anticipate a speedy return to normal in the delivery of eyecare.”