The Australian Medical Association (AMA) Public Hospital Report Card, published today, paints a grim picture: ACT public hospitals are not meeting national standards for emergency department wait times and planned surgeries, despite the “tireless efforts” of hospital staff and the largest share of public hospital funding from any state or territory government.

“ACT public hospitals are performing below the standard our community should expect,” AMA ACT president Dr Walter Abhayaratna said.

The report shows that for the fifth year in a row, the ACT had Australia’s worst performance in meeting the ‘four-hour-rule’ (National Emergency Access target, or NEAT): only 48 per cent of emergency department presentations were completed in less than four hours. 41 per cent of Category 3 (urgent, not life-threatening) patients were seen within the recommended time of 30 minutes – an improvement, for the fourth year in a row, but still 17 per cent below the national average.

The ACT was also the worst performer for planned surgery patients admitted on time: the number of Category 2 patients (procedures clinically indicated within 90 days) has fallen from 81 per cent to 49 per cent in six years.

Canberra Hospital: ‘Significant improvements’ in ED performance

However, Dr Sam Scanlan, clinical director of the Emergency Department at Canberra Hospital, reported “significant improvements” in the last nine months. The AMA report, he said, uses historical data from 2022–23, and still reflected the post-COVID state; figures from the current (2023-24) financial year, however, show that 55 to 56 per cent of emergency department presentations are now seen within four hours.

“Healthcare is a really hard industry, particularly in nursing,” Dr Scanlan said. “It has really taken until now for us to bounce back…”

Dr Abhayaratna attributes this improvement to the integration of Canberra Hospital and North Canberra Hospital, which has streamlined the admission of patients. However, he believes this improvement consumes resources.

“If you don’t turn the flow into the hospital down, those resources will be exhausted,” Dr Abhayaratna said. “We’re putting a lot of effort into that. A lot of patients are getting a lot of care for a lot of doctors and nurses and allied health 24/7 to do that. When we can, there are avoidable chronic disease admissions that we should be treating in the community.”

Nor, Dr Abhayaratna remarked, does an improvement in NEAT say whether patients are flowing through the hospital in a timely way. The length of stay in hospitals is increasing, he states, which delays patients’ discharge, and takes up empty beds needed for elective surgery.

Health minister Rachel Stephen-Smith, speaking at the national Health Ministers’ Meeting, said the quarter-on-quarter improvement in performance was “a result of the significant investments that we’ve made into our emergency departments, as well as the work that the teams have done to change and improve the models of care”.

For instance, Dr Scanlan said, the emergency department also hired 35 new graduate nurses at the same time, and introduced an ED Fundamentals program to support them, build their skills, and support them.

“The nursing staff are the backbone of the emergency department to keep the place running,” Dr Scanlan said. “And so, by investing in that group of nursing staff, we will build a team for the future. Even if they don’t all stay within the emergency department, we’re building them up with a really strong skillset to take that to all areas of the healthcare system.”

Likewise, Dr Scanlan has noticed an improvement in Canberra Hospital’s workplace culture – “tainted with some negativity” – in the last five years.

Moreover, comparing the ACT, a jurisdiction with two hospitals, to statewide services was like “comparing apples with oranges”, Dr Scanlan said.

“A lot of these smaller hospitals that make up a big part of the data in the larger states will have lower activity, lower acuity, and will have higher performance on that regard. When we compare our hospitals individually to peer base hospitals, we perform much more favourably.”

He hopes to sustain, indeed build upon, that improvement in the new emergency department, which opens in August.

AMA: ED improvement unsustainable without chronic care fix

But that improvement will only be temporary, Dr Abhayaratna fears, based on past trends. In the past 10 to 15 years, he remarked, each time the capacity of the emergency department has been increased, the NEAT improved for six to 12 months, then fell back to its baseline, where it was, and continued to worsen.

The problem, he argues, is that people with chronic disease rely on the ED, rather than on care in the community. That in turn removes beds for other patients, and affects the ED’s performance results. The problems, Dr Abhayaratna believes, must be addressed in the community.

“The issue is delivering care that could have been done elsewhere in a much better way at a much lower cost,” Dr Abhayaratna said.

“If we put more funding into the emergency department, it won’t necessarily cause the sustainable changes that we need to look after patients with chronic diseases. It’ll only just make the ‘symptoms’ better for a short period of time before things become worse…

“If we don’t look after primary care, the hospital will continue to struggle.”

Dr Abhayratna calls for a reorganisation of healthcare resources, better integration of care, and the removal of payroll taxes on GPs to alleviate pressure on hospitals and improve patient outcomes.

Besides hospitals, Canberra residents can access GP care, community care not linked to GPs, and walk-in centres – but those services are fragmented, Dr Abhayaratna said.

“All of these things do not connect. In other words, there’s no integration of care.…

“We need a system that actually is connected, that’s not just the hospital. We have to think of what’s outside the hospital, and make sure that we’re improving both types of care, acute services as well as chronic disease management in the community.”

As it is, Dr Abhayaratna said, the ACT has fewer GPs, who are doing more work, with more complex patients, but are not getting support with government-funded resources, while government-funded resources are working in isolation; they do not share patient notes, but repeat tests, questions, and examinations that increase the cost, without improving the value of care.

“That results then in we’re not getting the crux of the care of the people with chronic diseases; instead, what we’re doing is spending more money with disconnected care, or fragmented care…”

On top of that, payroll tax (introduced for GPs last year) increases the cost of care for GPs and out-of-pocket costs for patients, Dr Abhayaratna said. The ACT Government, however, has argued that GP bodies like the AMA have simply sought to minimise tax for their members; unlike other jurisdictions, it will not retrospectively access and collect payroll tax debts.

“The Chief Minister has not heeded any of our advice [on payroll tax],” Dr Abhayaratna said. “There is no intention to take the recommendation of states like Queensland and Tasmania who have said ‘There’s no chance that we’re going to be deploying an extra tax to primary care for any of our GPs, when they’re struggling already’. That just comes back to eat the patient, which then means that they have less affordability to look after themselves in the community, so they’ll rely on free publicly funded services in the emergency department.”

Due to the expense, people with chronic disease who need to see their GP more often for continuity of care end up not seeing their GP, but deferring their care, Dr Abhayaratna said; their health deteriorates over weeks in the community to the point where they need to go to hospital.

“Patients are using the emergency department at times when they can’t cope in the community,” Dr Abhayaratna said. “They’ve deteriorated because they haven’t had the timeliness of care, because there’s not enough support in the community.

“It could have been prevented from getting to that point by integrating care, high-value care, that is delivered in the community, by GPs and the non-GP providers of care who are connected to the GPs…

“We can use the resources that we’ve got in the ACT. Expenditure for the hospital is increasing; the expenditure in the community is certainly there. But how is it all connected to that patient who’s got chronic diseases, who is potentially treatable in the community with much lower-cost care than it is in the hospital? We know how expensive it is to go to the emergency department and have an occasion of service there. We also know how expensive it is per day. Imagine if we could actually look after those patients the way they should be, in the community.”

Some patients visit the emergency department to get all their needs met, if they have difficulty accessing their GP, Dr Scanlan noted.

“We provide a service that in a way encourages people to come to us, because you can get everything done there. That does mean that there becomes a bit of a grey line as to what’s a true emergency, and what’s not. We do need people to really keep the emergency department for emergencies, and look at those other health care options to meet your needs.”

(The Weston Creek walk-in centre offering radiology has improved matters, he believes: patients can be treated and X-rayed there, rather than having to visit different health centres.)

Shadow health minister Leanne Castley said: “It is time for the Minister and the Labor-Greens government to stop the self-congratulation and to start listening to the experts when it comes to the real concerns we have in the health system.

“If the Minister continues to ignore primary health care in the ACT, then Canberrans will continue to present to our emergency departments which puts further pressure on the hospital system along with the hardworking doctors and nurses.”

The hospital problem is not confined to the ACT. Nationally, the AMA stated, hospitals are “at breaking point”: the national average of emergency department patients seen on time was the lowest figure in the past decade, and the proportion of public hospital beds for every Australian over 65 was also at its nadir.

The Prime Minister announced last year that the Commonwealth will increase its share of funding for public hospitals nationwide by at least $13 billion over the next five years. (The ACT Government provides 65 per cent of public hospital funding.) Until then, the AMA has called for federal and state governments to invest $4.1 billion to address the backlog of planned surgeries.