Hospitals ‘buffing’ surgery wait times to hit KPIs, doctors warn

NSW hospitals are refusing to accept patients for cancer surgery and other time-critical procedures, pressuring surgeons to downgrade the seriousness of urgent cases to meet their publicly reported targets.

The tactics used to manipulate surgery waitlist data, revealed by senior public hospital surgeons, conceal the true extent of delays for patients with serious medical conditions in overstretched hospitals, where administrators are under immense pressure to meet state government-enforced benchmarks.

Surgeons report hospitals are refusing to accept patients onto wait lists who risk breaching KPIs. Credit: Getty Images

Several senior specialists report RPA and Westmead are among the public hospitals refusing to add urgent “category 1” patients to waitlists unless their surgeon can guarantee an available operating theatre session within the clinically recommended 30-day wait time.

“The doctors have the capacity to perform the procedure, but if the hospital doesn’t have the theatre time or resources to get them done [in time], they won’t accept a patient’s booking form,” said general surgeon and Australian Medical Association NSW vice president Dr Fred Betros.

“That way, they won’t breach the publicly reported KPI. Everything looks like it’s under control, so we don’t get the resources and future funding we need to keep up with demand.”

One senior surgeon prohibited from speaking publicly by their employment contract characterised the practice as “buffing the numbers”.

The Bureau of Health Information (BHI), a state government agency, collects and publishes elective surgery data for every NSW public hospital. Its latest quarterly report shows that 99.1 per cent of essential surgeries were performed on time in NSW.

According to the report, no RPA patient has waited longer than clinically recommended for surgery in the last two years.

One senior specialist not authorised to speak publicly said RPA’s administration was “obsessed with its surgery KPIs”.

“Hospitals are not allowed to refuse a recommendation for admission [the form specialists complete to admit a patient for surgery], but they do it all the time,” they said.

NSW Health’s surgery policy states urgency categories must be “based on the patient’s clinical need … and not influenced by the availability of hospital or surgeon resources”.

Another senior clinician not authorised to speak said: “I always thought that the focus of an individual hospital’s executive would be, ‘Okay, we’ve got patients breaching. That means we should tell the ministry we’ve got patients breaching, so we need more resources,’ and the ministry would go, ‘Okay, there’s your resources because your KPIs show that you’re breaching’, but they don’t. They get told to make the problem go away.

“The burden of disease is still there. The people [who need care] are still out there. The problem won’t go away with jiggery pokery.”

NSW Health’s surgery access policy

If a patient is likely to breach the recommended wait time, the clinical director of surgery must consider, in conjunction with the surgeon, patient and senior management:

- Additional theatre time at the same or another facility

- Pooled surgery lists, where patients may be treated by any doctor of the same specialty 

- Transfer patients to another doctor with a shorter surgery list (if available)

- Paying for the patient to be transferred to a private hospital

Dr Jenny King, chair of Westmead Hospital’s Medical Staff Executive Council, described scheduling patients for urgent surgery within a couple of weeks due to the severity of their condition only to have booking staff push the date closer to the 30-day cut-off to bring forward a less urgent patient about to become overdue.

King said one “seriously unethical” strategy involved cancelling overdue paediatric dental surgery lists to prioritise patients breaching wait times that are KPIs, for instance, head and neck cases.

“These paediatric dental patients often have special needs or serious medical issues, but it doesn’t matter if they breach because their wait times are not a KPI, so no one looks at them,” King said.

“Their parents are at their wits’ end, and they have no option but to pay a fortune in the private sector. Often, the private hospitals won’t take difficult kids with behavioural issues.”

A spokesperson for Western Sydney Local Health District (WSLHD) – which oversees Westmead – said a small number of paediatric dental procedures were rescheduled to alternative theatre lists to prioritise more clinically urgent cases.

King said Westmead surgeons had not been pressured to change urgency categories since the appointment of a new associate director of operations for surgery two months ago to oversee efforts to get the hospital to the “magic triple zero” (zero patients overdue in categories one, two and three).

“Our response has always been that if you can’t fit patients on lists in the appropriate time for the condition, then there simply aren’t enough lists,” King said.

In 2022, WSLHD unsuccessfully attempted to contractually bar doctors from adding patients to surgery wait lists unless they could guarantee they had time to perform the procedure within the recommended timeframe.

Health Minister Ryan Park said he expected surgery management to be consistent with health policies, “and if there’s any evidence to suggest otherwise, I’d seek a please explain”. Park ordered an independent review of recategorisation of surgery at Orange Hospital after the ABC reported on similar issues.

The WSLHD spokesperson rejected that surgeons had been asked to prioritise waiting list targets over patient care, saying all RFAs were accepted and waitlisted in line with NSW Health policy.

“WSLHD maintains its commitment to ensuring the efficient and safe management of surgery to deliver the best possible outcomes for patients,” they said.

Risky delays for colonoscopies

Meanwhile, patients with suspected bowel cancer are waiting for months for colonoscopies, which should be performed within 30 days of a positive screening result.

“There are gastroenterologists whose patients have gone well beyond that timeframe because colonoscopy wait times aren’t measured as a KPI reported to the ministry or published publicly,” Betros said.

Professor Nick Talley, gastroenterologist and chair of the luminal faculty at the Gastroenterology Society of Australia, said category 1 patients could wait two or three times longer than they should for a colonoscopy in the public system.

“That’s just not good enough,” Talley said. “Colon cancer will progress from a curable stage to an incurable stage within several months, and that is the kind of time period some people are waiting.”

The WSLHD spokesperson said there are some delays accessing gastroenterology procedures as demand is increasing, and work was underway to address this by implementing a networked approach across the LHD.

‘The tip of a very big iceberg’

Surgeons also reported being asked to re-categorise urgent patients to category 2 “semi-urgent” (recommended within 90 days) if about to breach the 30-day timeframe.

Betros said the tactic was not endemic, but tended to arise at times of overwhelming demand for individual hospitals.

“[Hospital clerical staff] will say: ’We can’t do it within 30 days, but if we can guarantee they will get their surgery five days late, can we change them to category 2?” he said.

Betros said a five-day delay was highly unlikely to affect a patient’s clinical outcome, but the approach obscured the lack of appropriate funding to keep up with demand for surgical services.

“This is the tip of a very large iceberg,” he said. “Our patients are more overweight, they’re more cirrhotic [liver damage] because they’ve got more emphysema [a type of lung disease] than they’ve ever had, and it’s because our public health measures aren’t pushing the tidal wave back.”

The final report from the Special Commission of Inquiry into NSW’s health funding warned the system risked being overwhelmed by ageing and chronically ill patients, characterising the failure to embed prevention into the system as “beyond comprehension”.

“It all gets kicked down the road to become an even bigger problem, and it just compounds with every year,” Betros said.

A NSW Health spokesperson said all LHDs were expected to adhere to the elective surgery access policy.

“Every endeavour is made to ensure patients are treated within the timeframes required for their level of urgency as assigned by their treating doctor,” they said.

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