Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services

Report for the Department of Human Services,

Project Team (on behalf of The Australian Health Workforce Institute)

Catherine Jones and Fiona Landgren – Project Health and Vin Massaro and Lorraine Perry – Massaro Consulting

June 2009

Contact: Mr. Brendan Moloney The Australian Health Workforce Institute Level 3, 766 Elizabeth Street University of Melbourne Parkville 3010 Tel: + 61 3 8344 9659 Fax: + 61 3 9347 8939 Email: [email protected]

This study was funded by the Department of Human Services. The opinions presented in this document are those of the authors and not the Department of Human Services and have been provided for general information to guide discussions of future policy initiatives.

The Australian Health Workforce Institute is a joint initiative between The University of Melbourne and The University of Queensland Contents

1. Executive Summary...... 5 2. Introduction...... 10 2.1 Background...... 10 2.2 Project purpose ...... 11 2.3 Methodology...... 11 2.3.1 Phase 1 – Literature Review ...... 11 2.3.2 Phase 2 – Mapping of Current Service ...... 13 2.3.3 Phase 3 – Key stakeholder consultations: exploring solutions...... 18 2.3 4 Limitations of the Report ...... 23 2.4 Context...... 23 2.4.1 Surgical services in Victoria ...... 23 2.4.2 Other workforce initiatives...... 24 2.4.3 Providers of foot and ankle elective surgery ...... 24 3. Demand for foot and ankle surgery...... 26 3.1 Foot and ankle surgery in Australia – procedure profile and trends...... 27 3.2 Foot and ankle surgery in Victorian – procedure profile and trends...... 30 3.3 Waiting times for foot and ankle elective surgery...... 37 3.4 Number of people waiting for elective foot and ankle surgery ...... 42 3.5 Waiting times for an outpatient appointment...... 42 3.6 Factors influencing demand for foot and ankle elective surgery ...... 43 3.6.1 Increasing patient expectations...... 43 3.6.2 Availability of and access to conservative management options ...... 44 3.6.3 Population level influences...... 45 4. Supply of foot and ankle surgery – current service model and workforce...... 46 4.1 Current service delivery in Victorian public hospitals – an overview...... 46 4.2 Current workforce...... 49 4.3 Other factors influencing the supply of foot and ankle surgical services...... 51 4.3.1 Theatre availability and competing priorities ...... 52 4.3.2 Other system factors ...... 53 5. Initiatives to address demand for foot and ankle surgery ...... 54 5.1 Outpatient workforce reform initiatives...... 55 5.2 System redesign initiatives...... 59 6. The role of podiatric surgeons ...... 60 6.1 Background...... 61

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (May 2009) 2 6.2 Current podiatric surgeon workforce and service model...... 61 6.3 Qualifications...... 63 6.4 Scope of practice and funding...... 65 6.5 Safety and effectiveness of podiatric surgeons...... 66 6.6 Cost effectiveness of podiatric surgeons ...... 66 6.7 A possible workforce initiative - creating a multidisciplinary team (employing podiatric surgeons in public hospitals) ...... 67 7. Roadmap for implementation of possible solutions...... 69 8. Conclusion ...... 72 9. Bibliography...... 73 Appendices ...... 75 Appendix 1. Literature Review ...... 75 Appendix 2. Membership and Terms of Reference of the Reference Group ...... 76 Appendix 3. Data request sent to Victorian public hospitals for data pertaining to foot and ankle elective surgery and outpatient services...... 78 Appendix 4. Foot and ankle procedures Victorian hospitals 2007 /2008 ...... 80 Appendix 5. The economic impact of podiatric surgery - Access Economics Report, September 2008 – an analysis ...... 87

Figures Figure 1. Drivers of supply and demand for elective foot and ankle surgery in Victorian public hospitals ...... 14 Figure 2. Number of emergency* and non-emergency^ foot and ankle procedures for Victorian private and public hospitals by financial year (July 03 - June 08)...... 31 Figure 3. Average time to treatment for elective orthopaedic surgery in Victorian public hospitals, July 2007 to June 2008 ...... 38 Figure 4. Median time to treatment for category 2 elective orthopaedic surgery in Victorian public hospitals, July 2003 to June 2008 ...... 39 Figure 5. Median time to treatment for category 3 elective orthopaedic surgery in Victorian public hospitals, July 2003 to June 2008 ...... 40 Figure 6. Average waiting time for category 2 elective orthopaedic surgery. Snap shot of Victorian public hospitals* ...... 41 Figure 7. Average waiting time for category 3 elective orthopaedic surgery. Snapshot of Victorian public hospitals*...... 41 Figure 8. Number of cases waiting for elective orthopaedic surgery and elective foot and ankle surgery. Snap shot of Victorian public hospitals* ...... 42 Figure 9. Victorian population and numbers of patients on elective surgery waiting lists by age group (Surgical Services Strategy, DHS) ...... 45 Figure 10. Common public service delivery model...... 47

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (May 2009) 3 Figure 11. Factors influencing the demand for and supply of elective foot and ankle surgery in Victorian public hospitals ...... 52 Figure 12. Workforce innovation – Allied health foot and ankle clinic (Barwon Health)...56 Figure 13. Service model – Podiatric surgery, Repatriation General Hospital, Daw Park, South Australia ...... 63

Tables Table 1. Summary of proposed solutions and implementation strategies ...... 8 Table 2. Breakdown of literature included in the review ...... 13 Table 3. Hospitals consulted during mapping exercise ...... 16 Table 4. Summary of data collected ...... 17 Table 5. Consultation strategy ...... 19 Table 6. Projected number and percentage of foot and ankle surgery procedures, showing hospital breakdown (public / private) by procedure type, Australia, 2008...... 28 Table 7. Projected number and percentage of foot and ankle surgery procedures, showing procedure breakdown by hospital type (public / private), Australia, 2008...... 29 Table 8. Number and percentage of foot and ankle procedure categories, showing hospital breakdown (public / private) by procedure type July 2007 – June 2008...... 32 Table 9. Number and percentage of foot and ankle procedure categories showing procedure category breakdown by hospital type (public / private) July 2007 – June 2008 ...... 33 Table 10. Number and percentage of foot and ankle procedures in order of frequency for Victorian private hospitals, July 2007 – June 2008...... 34 Table 11. Number and percentage of foot and ankle procedures in order of frequency for Victorian public hospitals, July 2007 – June 2008...... 35 Table 12. Top five foot and ankle procedure categories undertaken at Victorian private and public hospitals in 2007/08...... 36 Table 13. Time to treatment for patients admitted for surgery for excision of bunion and other toe deformities in Victorian public hospitals, July 2007 - June 2008...... 38 Table 14. Profile of foot and ankle elective surgery related workforce, surgical and outpatient services at 12 Victorian hospitals 2008...... 48 Table 15. Profile of the workforce related to provision of foot and ankle services at 12 Victorian public hospitals - 2008 ...... 50 Table 16. Workforce profile for orthopaedic surgeons in Australia, 2008 ...... 51 Table 17. Workforce profile for podiatric surgeons in Australia, 2008 ...... 62 Table 18. Summary of proposed solutions and implementation strategies ...... 70

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (May 2009) 4 1. Executive Summary

This project has sought to describe the current delivery of foot and ankle surgery in Victoria and to identify the level of unmet need in this area. It has also sought to explore options for enhancing access to foot and ankle elective surgery and improving the management of people with foot and ankle conditions. The project has a particular emphasis on workforce- based solutions, whilst acknowledging the broader influences on the supply of surgical services, such as theatre availability, local priorities and inpatient capacity.

The project involved a review of the literature; a mapping exercise; and stakeholder interviews. The findings of these activities provide an evidence base to assist decision- making regarding possible alternatives to address the demand for foot and ankle surgery.

1. Foot and ankle surgery - current delivery and problems identified A total of 12,938 surgical procedures of the foot or ankle were performed in Victorian hospitals during 2007/08. Forty seven per cent (6,052) of these procedures were performed in public hospitals and 53% (6,886) in private hospitals. Procedures relating to fractured ankle or toe were the most commonly performed procedures in the public sector (25.7%), while procedures performed for hallux valgus (bunion) or hallux rigidus (stiff big toe) were the most commonly performed procedures in the private sector (17.3%).

In Victorian public hospitals, foot and ankle surgery is performed predominantly by orthopaedic surgeons, some of whom have a special interest in foot and ankle surgery. Podiatric surgeons undertake foot and ankle surgery only within the private sector.

There is a trend of increasing numbers of foot and ankle surgical procedures being performed in Victorian hospitals, both public and private. Nationally, the number of foot and ankle surgical procedures undertaken is expected to increase by around 62% by 20505, largely due to population level influences such as population growth, the ageing population and the increasing incidence of ‘lifestyle’ conditions such as osteoarthritis, obesity and diabetes.

Foot and ankle cases are variously represented on public hospital orthopaedic waiting lists, ranging from 7% to 24% of the total elective orthopaedic cases on waiting lists in the hospitals providing data for this project.

Findings of this project point to a level of unmet need, with waiting times for bunion and toe surgery, on average, exceeding the national standard. There is however, considerable variability between hospitals, and many hospitals have not identified foot and ankle surgery as a particular problem or priority.

In terms of waiting time, foot and ankle surgery is similar to other high demand orthopaedic surgery, such as hip and knee arthroplasty; thus foot and ankle does not stand out as a particular priority over other elective surgical procedures.

Waiting time data were generally not available for foot and ankle surgery other than bunion and toe surgery, although at one hospital waiting times for more complex foot and ankle surgery were up to 4 years. Thus the unmet need may be highest for complex foot and ankle surgery undertaken by more specialised surgeons, but more specific data are required to confirm this.

Waiting time for consultation at orthopaedic outpatients clinics was also investigated as part of the project in order to gauge the overall picture for patients waiting for surgical

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 5 management. Data were limited but indicated waiting times of up to 2 years for an appointment with an orthopaedic consultant. Findings also suggested that a high proportion of patients presenting to orthopaedic outpatients do not require or do not want surgery, thus placing unnecessary demand on limited specialist services, and potentially delaying the conservative management of these patients (conservative management includes all treatment of a non-surgical nature). Some hospitals have addressed this demand through the introduction of early assessment allied health clinics, which provide conservative management and may assess the need for surgical management.

A number of factors are known to influence the supply of elective surgery services, including theatre capacity, competing surgical priorities and inpatient capacity, as well as workforce factors. These factors vary considerably at a local level and interact in a complex way.

The project confirmed that theatre availability and competition for theatre time with emergency cases and other surgical specialties were significant barriers in some hospitals. While additional theatre availability would still be subject to clinical judgements about the comparative urgency of individual cases, expanded capacity would provide greater opportunities for the performance of more elective foot and ankle surgery.

Surgical skill shortage was also an issue at some hospitals. Limited data in terms of very long waiting times for complex foot and ankle surgery at one hospital, and consultations with orthopaedic surgeons, point to a relative shortage of foot and ankle surgeons in the public sector. At the same time there is evidence of some spare capacity among foot and ankle surgeons in the private sector. The reasons for this imbalance appear to be related to insufficient operating theatre priority; inadequate outpatient facilities; remuneration opportunities for orthopaedic surgeons in the public sector being less than in the private sector and the current exclusion of podiatric surgeons from practice in the public sector.

While surgical workforce did not appear to be a major issue amongst the hospitals consulted during the project, a number of hospitals have sought to implement workforce solutions to meet demand at an outpatient level, where waiting times for specialist consultation may be prolonged and where there is scope to identify patients who may benefit from conservative management.

2. Possible solutions The project sought to identify existing initiatives that had been established to address the demand for foot and ankle surgery and to explore additional ideas with stakeholders. Existing initiatives focus mainly at the outpatient level and include: • a multidisciplinary foot and ankle clinic at Barwon Health; • an advanced practice podiatry clinic at Northern Health; and • a multidisciplinary “super clinic” at Western Health.

The Barwon and Northern experiences suggest that long waiting times for an outpatient appointment with an orthopaedic surgeon can be reduced through early and accurate identification of the need for conservative management. It is not known whether these services have had an impact on waiting times for surgery, but in the case of Barwon Health, there is evidence that the services have transferred patients who do not require or are not suitable for surgery from the surgeon, leading to more efficient use of specialist surgeon services.

Western Health used the availability of additional Commonwealth funds to create a multidisciplinary “super clinic” that was used to assess and treat all patients on its foot and ankle waiting list. This is more of an episodic solution to deal with a current problem but is a strategy that could be used in other facilities.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 6 These models have demonstrated increases in efficiency through decreased waiting times for an outpatient appointment and a resultant increase in patient throughput. The consultations identified a general consensus for the creation of multidisciplinary clinics to manage demand for foot and ankle elective surgery.

One further proposal was to create a specialist centre for foot and ankle surgery to bring together a dedicated and specialised pool of clinicians that is able to deal efficiently with a large number of cases. Establishing the facility would require a significant injection of development funds.

The Barwon Health model has particular benefits as it incorporates workforce model redesign and restructure to: • improve access to foot and ankle related services; and • increase the efficiency and effectiveness of the available health workforce through the optimal utilisation of skills.

The role of podiatric surgeons was also explored. In Victoria, two podiatric surgeons practise in the private health system; none practise in the public hospital system. Only one podiatric surgeon practises in the public health system in Australia (in South Australia). The scope of practice of podiatric surgeons includes any surgical procedure of the foot and ankle, but the actual scope of practice is commonly self-limited to procedures involving the forefoot. There are several examples overseas of significantly greater involvement of podiatric surgeons in providing public surgical services.

Employing podiatric surgeons as part of multidisciplinary teams in public hospitals was argued strongly by podiatric surgeons as their preferred solution to meeting the current and future demand for foot and ankle surgery. They envisage a team in which podiatric surgeons, orthopaedic surgeons, podiatrists, physiotherapists and other suitably skilled health professionals, work to optimise surgical and conservative management, to ensure appropriate use of surgical skill and to ensure appropriate medical input. The consultations confirmed that the inclusion of podiatric surgeons as part of such teams would be a logical and optimal strategy.

However, there are presently a number of impediments to this solution: • orthopaedic foot and ankle surgeons, general orthopaedic surgeons, other medical specialists and some podiatrists have concerns about the quality of the current podiatric surgery training program; • while hospital CEOs have the power to engage suitably credentialed professionals, it is highly unlikely that any would be prepared to pursue this path given the current views of medical personnel; • there is an insufficient number of podiatric surgeons in the system at the moment to make significant impact; and • podiatric surgeons would be competing for already limited operating theatre time.

While employing podiatric surgeons in public hospitals may form part of an optimal long term solution, there are a number of potential short and mid term options to address foot and ankle surgery waiting lists: • establishing multidisciplinary foot and ankle clinics (as at Barwon Health); • establishing “super clinics” (as at Western Health); and • increasing operating theatre time.

These solutions are not equally applicable to all clinical settings, but they provide effective options for meeting foot and ankle surgical needs. Table 1 overleaf summarises the proposed solutions and implementation strategies.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 7 Table 1. Summary of proposed solutions and implementation strategies

Option Option Attributes Implementation Strategies

Description Benefits Limitations Short term Medium term Long term

Establishing A regular clinic Reduced waiting times Limiting exposure of Recruit appropriately Build up an evidence Build up an evidence multidisciplinary clinics assessing all foot and and access to a range orthopaedic and qualified staff. base to support base to support ankle problems in of conservative and podiatric surgical implementation. sustainability. order to triage patients surgical solutions. trainees to non- for the most effective operative cases. Identify facilities and timely treatment. preferably co-located Workforce may involve with orthopaedics. podiatrists, physiotherapists, podiatric surgeons, GPs; ideally collocated with orthopaedic clinics to provide access to surgical review as required.

Introducing advanced Providing capacity for Increasing the number Recruiting Identify the main Train staff in role Develop and support practice roles different members of of health professionals appropriately qualified clinical groups in foot extension while also extended practice the clinical team to able to assess and staff and ensuring and ankle surgery, engaging the clinical multidisciplinary work to the capacity of treat patients, thus that all team including podiatrists specialists to accept teams. their skills and clinical reducing waiting times. members recognise and podiatric the advanced practice abilities. and accept the surgeons, to concept as part of the clinical capacities and determine the degree clinical environment, Workforce may involve limitations of each to which their scope including the capacity advanced practice team member. of practice could be of different members podiatrists or, extended. of the team to make physiotherapists. effective clinical judgements.

Increasing theatre Availability of theatre Reducing waiting Requires additional Secure funding to Attract surgeons and capacity to cope with a greater times for surgery funding and the ready staff theatres. anaesthetists to the range of cases, generally and for availability of surgical public sector. including elective elective surgery more staff and

surgery. specifically. anaesthetists, nurses and related theatre staff.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 8 Option Option Attributes Implementation Strategies

Description Benefits Limitations Short term Medium term Long term

Increasing theatre Collect sufficient Provide additional capacity (cont) accurate data to funding to support the justify the use of engagement of theatre additional theatre staff. capacity for foot and ankle surgery.

Increasing the Attract more Increased surgical Funding constraints Inject funds to Build sufficient available orthopaedic orthopaedic surgeons capacity. may impede public support orthopaedic workforce numbers workforce for foot and to work in the public sector competing with appointments. for sustainability. ankle surgery sector. Broader clinical team private sector salaries so that less complex and conditions. cases can be performed by less specialised surgeons.

Establishing a podiatric Engage podiatric Increased surgical Although scope of Podiatric surgeons Podiatric surgeons Build sufficient surgeon workforce for surgeons as full capacity. practice would need prepare for national apply and gain (?) workforce numbers foot and ankle surgery members of the to be defined and registration and national registration, for sustainability. clinical team to work acknowledged, the accreditation. accreditation and S4 within established and Broader clinical team training of podiatric prescribing rights. accredited scope of surgeons would need so that less complex practice. cases can be to be accredited at a performed by less national level and the Address cultural specialised surgeons registration of such barriers/ resistance surgeons and their from medical scope of practice profession. defined.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 9 2. Introduction

2.1 Background

Foot problems are reported by nearly one in five people in the general population1 and one in three people over the age of 652. The prevalence of foot problems is greater amongst females; people aged over 50 years; people who are obese; and people who also report knee, hip or back pain2. Foot pain is associated with self-reported disability3 and reduced health-quality of life2.

Although many common foot problems can be effectively managed by conservative methods, major structural or long-standing conditions often require surgical intervention4. In Australia, almost 129,000 foot and ankle surgical procedures were undertaken in 2007. It has been estimated that this number will increase to around 211,000 procedures by 2050 – an increase of 61.9%5.

The factors responsible for this increased demand for elective foot and ankle surgery have not been identified but it is likely that they are the same factors that are driving demand for elective surgery in general namely: • the ageing population; • overall population growth; • increasing community awareness, knowledge and expectations of health care; and • increasing prevalence of certain ‘lifestyle’ conditions such as obesity and associated comorbidities, in particular osteoarthritis and diabetes6.

There is a suggestion that waiting a long time for foot and ankle surgery results in adverse health outcomes. Waiting list data reveal that people waiting for one of the more common foot and ankle procedures – an excision of bunion and/or digital deformity – are waiting longer than is clinically recommended.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 10 2.2 Project purpose

The purpose of the project was to explore solutions to better meet demand for foot and ankle elective surgery from a service and workforce planning perspective. In particular the project aimed to: • describe the current delivery of foot and ankle elective surgical services; • define the problems associated with the current delivery of foot and ankle surgical services; • identify and analyse a range of possible alternative solutions to enhance access to foot and ankle elective surgery, ensuring that current and potential workforce options are fully explored; and • provide an evidence base to assist decision-making regarding possible alternatives to address the demand for foot and ankle surgery.

2.3 Methodology

The project was undertaken in three phases.

2.3.1 Phase 1 – Literature Review Aims The literature review provided a basis for the project in terms of: • establishing existing data with respect to the burden of disease associated with foot and ankle problems; • identifying current best practice guidelines relating to the management of foot and ankle problems, including both conservative management and surgical management; • identifying evidence for models of care to support improved management of foot and ankle problems; and • exploring issues likely to be relevant to designing models of care for Victoria.

Search strategy A pragmatic strategy was used to search the academic and grey literature and key websites. In addition advice was sought from experts in the field to assist in identifying the most recent/relevant literature.

A search of the peer review literature was undertaken primarily using the Medicine, Dentistry and Health Sciences database available at The University of Melbourne. This database contains the following: • University of Melbourne Library Catalogue • Web of Science (ISI) • SCOPUS (Elsevier) • MD Consult • Access Medicine • MEDLINE (ISI) • CINAHL PLUS (EBSCO) • PsycINFO (CSA) • PubMed • University of Melbourne Digital Repository (DigiTool)

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 11 Keywords included: • foot and ankle surgery • bunion surgery • metatarsalgia • podiatric surgery • randomised controlled trials • orthopaedic vs podiatric surgeons • surgery waiting lists

A search of the grey literature was undertaken with a focus on the following organisations: • Australian College of Podiatric Surgeons • Australian Podiatry Associations • Australian Podiatric Registration Boards • Australian Research Council • Australian Institute of Health and Welfare • State Health Departments • National Health and Medicine Research Council • Society of Chiropodists and Podiatrists (UK) • American Podiatric Medical Association (US) • American Board of Podiatric Surgery (US)

The grey literature was also searched for information relating to best practice guidelines and the management of foot and ankle problems. Key websites included: • Joanna Briggs Institute • The Cochrane Library • National Health Service and affiliated websites (UK) • National Institute for Clinical Excellence (UK) • National Guideline Clearinghouse (US)

Further literature was also obtained from Mark Gilheany, Podiatric Surgeon and President of the Australasian College of Podiatric Surgeons.

Review limitations Although an attempt was made to limit articles published since 1996, some important and relevant papers were dated prior to 1996.

The literature contained in this review was not appraised for methodological quality using instruments such as those developed by the AGREE Collaboration and NHMRC. However, an attempt was made to provide commentary regarding the quality and limitations of studies cited if relevant.

An important input into this literature review and into the project in general is the recent Access Economics report commissioned by the Australasian College of Podiatric Surgeons. This report was released on 26 September 2008.

Results A total of 50 articles were included in the literature review as described in Table 2. In addition, nine clinical practice guidelines were included in the review.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 12 Table 2. Breakdown of literature included in the review

Description Number Randomised or pseudo randomised controlled trial 3 Observational study 5 Descriptive study 8 Sociological or qualitative analysis 6 Literature review 9 Economic analysis 1 Editorial / opinion piece/ expert commentary 11 Legislation or government or professional body report 7 Total 50

A report of the literature review was submitted to the Department of Human Services in December 2008 and appears in Appendix 1.

2.3.2 Phase 2 – Mapping of Current Service Aims and objectives The mapping exercise sought to inform the development of suitable strategies to address the demand for foot and ankle surgery in Victoria.

The specific objectives of the mapping exercise were to: • describe the size and extent of the current demand for elective foot and ankle surgical services including unmet; • describe existing service delivery models; • describe issues relating to current service provision and opportunities for improvement; • identify alternative service models currently being trialled or implemented at Victorian public hospitals; • identify barriers and drivers for change including the role of workforce redesign; and • provide a baseline against which potential reforms can be measured.

Scope In order to meet the above objectives, the mapping exercise sought information about foot and ankle elective surgery and related outpatient services currently provided in Victorian public hospitals.

In addition, workforce issues and other factors that influence the delivery of foot and ankle elective surgical services were explored (Figure 1). These factors have been divided into those that influence the supply of foot and ankle elective surgery services and those that influence demand. On the supply side, factors such as workforce are given particular attention as well as other factors such as theatre availability, competing priorities for surgery and system factors. On the demand side, factors such as patient expectations, access to conservative management and clinical decision-making have been considered as part of the mapping exercise. Population growth, the ageing population and the increasing incidence of chronic disease are important drivers of demand for elective surgery, but they are influenced largely by social, political and cultural factors and, as such, are beyond the scope of this project.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 13

While the focus has been on services provided in public hospitals, private health system services have also been explored where they are relevant, particularly in relation to podiatric surgery. Similarly, because of the dynamic relationship between emergency and elective surgery, unplanned (emergency) surgery has also been considered where relevant.

Figure 1. Drivers of supply and demand for elective foot and ankle surgery in Victorian public hospitals

SUPPLY DEMAND

Influenced by: Influenced by: • workforce – surgeons and other • population growth theatre staff • ageing population

• theatre availability • increasing incidence of chronic

disease i.e. OA, obesity • competing priorities for surgery including unplanned • patient expectations (emergency) surgery • access to conservative • System factors such as day management surgery models or systems of • clinical decision-making patient prioritisation practices

Data collected A range of sources were used to collect relevant data.

• Victorian (Department of Human Services) Admitted Episodes Dataset Morbidity data is collected on all admitted patients from Victorian public and private acute hospitals, including rehabilitation centres, extended care facilities and day procedure centres. These data form the Victorian Admitted Episodes Dataset (VAED, formerly VIMD).

Data were extracted to describe all elective and emergency surgical procedures for foot and ankle conditions in Victorian public and private hospitals.

• Elective Surgery Information System (Victorian Department of Human Services) Information about waiting lists was obtained from the Elective Surgery Information System (ESIS). This is the central collection of elective surgery waiting list data for the 29 Victorian hospitals which have more than 3,000 elective surgery WEIS per year. The ESIS also allows for monitoring of a patient’s waiting list history, including any changes in their status.

The key performance data relating to elective surgery include: • time to treatment for foot and ankle elective surgery by hospital (by urgency category); and • time to treatment for other major orthopaedic conditions (by urgency category).

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 14 Box 1. Measuring waiting times for surgery

Waiting times for surgery are measured in two different ways6. Both measures are important indicators of performance but they differ significantly: 1. Time to treatment for admitted patients: this measures the waiting time for admitted patients i.e. the time patients who have had their surgery had to wait. This measure may be relatively low because of preferential treatment for patients who have waited less than average time. This measure is used to report on health system performance. 2. Waiting time for elective surgery: this measures the waiting time for patients who are still waiting for their surgery. This measure may be relatively high because it includes the waits of those patients still on the list who have waited extended periods. This measure is used to monitor individual health service waiting list management.

• Victorian public hospital data The mapping exercise also sought information directly from a sample of metropolitan and regional public hospitals in Victoria where orthopaedic surgery is performed (Table 3). Analysis of data from Victorian public hospitals has aimed to describe current service models including: • the nature of the surgery undertaken at various sites; • the range of health personnel involved in providing foot and ankle surgery; • the capacity of outpatient and surgical services in relation to foot and ankle conditions; and • waiting times for outpatient consultation and elective surgery.

Data relating to surgical and related outpatient services have been collected through data requests to hospitals asking them to provide data about the outpatient department (outpatient waiting times and number of outpatient consultations) and the elective surgery waiting list (numbers of patients waiting, waiting times, urgency categories and types of conditions) (Table 4). Of the 13 data requests made, seven hospitals provided data within the project time period. Hospital data have been de-identified.

Data and other information were also collected through site visits, and interviews with a range of personnel, including orthopaedic surgeons, surgical liaison staff, outpatient managers, podiatrists, department heads, nurse unit managers and elective surgery managers. The issues explored included those related to patients, workforce, waiting list management, theatre availability, outpatient department capacity and waiting times, service integration, coordination between service providers, funding and resources.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 15 Table 3. Hospitals consulted during mapping exercise

Telephone Data request Site visits Hospitals consulted consultations completed and completed completed returned Metropolitan Dandenong Hospital Moorabbin Hospital Northern Hospital St Vincent’s Hospital Western Health Austin Health Regional Base Hospital Geelong Hospital Goulburn Valley Hospital Latrobe Regional Hospital Wangaratta Base Hospital West Gippsland Hospital

• Medicare Benefits Schedule data The Medicare Benefits Schedule (MBS) database records all services in Australia performed by registered providers that qualify for a Medicare benefit with the exception of: • services provided by hospital doctors to public patients in public hospitals; and • services that qualify for a benefit under the Department of Veteran’s Affairs, Work Cover or the Transport Accident Commission.

The MBS does not record services provided by podiatric surgeons. Relevant (foot and ankle) MBS item numbers were accessed from Medicare Australia MBS Group Statistics Report – www.medicareaustralia.gov.au/statistics/mbs_group.shtml > Category 3 – Therapeutic procedures > T8 Surgical Operations > 15 Orthopaedic.

Age / gender breakdown for relevant MBS item numbers were also accessed from Medicare Australia MBS Item Statistics Reports – (www.medicareaustralia.gov.au/statistics/mbs_item.shtml).

These data were not specifically analysed for this report because other authors have undertaken more in depth analyses (see Menz et al, 2008 and Access Economics, 2008).

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 16 • Data from professional bodies The Australasian College of Podiatric Surgery and the Australian Orthopaedic Foot and Ankle Society were consulted as part of the mapping exercise. Issues discussed included workforce, training, models of service delivery and funding arrangements.

Table 4 summarises the data sources and the nature of the data collected during the mapping exercise.

Table 4. Summary of data collected

Data source Aggregate Type of data Data collected level

Victorian Admitted State Elective and Information about elective and emergency foot and Episodes emergency ankle procedures for all separations from Victorian Dataset(VEAD) surgery public and private hospitals 2002-2007.

Elective Surgery State Elective Elective surgery waiting list data for people waiting Information System surgery for foot and ankle surgery by urgency category (ESIS) 2003 – 2008.

Site specific Hospital Elective Information about: Victorian public surgery • outpatient department; waiting times and hospital data Workforce number of outpatient consultations; • the elective surgery waiting list; numbers of patients waiting, waiting times, urgency categories and types of conditions; and • qualitative data regarding delivery of foot and ankle surgery including workforce data.

Medicare Benefits National Elective Relevant (foot and ankle) MBS item numbers were Schedule (MBS) surgery accessed from Medicare Australia MBS Group Statistics Report to provide detail of the range of procedures undertaken. > Category 3 – Therapeutic procedures > T8 Surgical Operations > 15 Orthopaedic.

DHS Workforce National Workforce Data on orthopaedic surgeon workforce nationally innovation, service and at state level and changes in workforce 1998- and workforce 2008. planning branch

Australian National Workforce Data on the orthopaedic surgeon workforce were Orthopaedic collected from the Australian Orthopaedic Association Association website including the number and distribution of surgeons by state.

Department of National Workforce Data on the podiatric surgeon workforce were Health and Ageing collected from the website including the number and distribution of podiatric surgeons by state.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 17 2.3.3 Phase 3 – Key stakeholder consultations: exploring solutions Aim and objectives Discussions with key stakeholder groups were conducted to explore the findings arising from Phases 1 and 2 including the range of feasibility issues raised. The consultation also attempted to investigate further suitable strategies to address the demand for and management of foot and ankle surgery in Victoria.

The objectives of the stakeholder consultation were: • To identify current and potential workforce options for the delivery of foot and ankle surgical services. Particular areas of focus included staffing profiles, location of facility and personnel, role redefinition, agreed management and decision-making protocols, accessibility to and capacity of conservative management services in the community, infrastructure support and change management. Attention also focussed on surgical workforce reform initiatives such as the role of podiatric surgeons and covering areas such as the regulatory environment, role possessiveness, access to surgical rights in public hospitals, suitable professional indemnity, recognition of private health insurers, workforce numbers; • To identify barriers and drivers for change including the role of workforce redesign; and • To explore other factors influencing the delivery of foot and ankle elective surgery services, such as - o theatre availability and competing priorities, o system factors such as the introduction of State-wide elective surgery centre and multidisciplinary or super clinics, o increasing patient expectations, o availability of and access to conservative management options, and o clinical decision-making practices.

Twenty-nine stakeholders were interviewed face-to-face or over the telephone during February to April, 2009 including: • two general orthopaedic surgeons / heads of public orthopaedic units • four foot and ankle surgeons; • three podiatric surgeons, including one currently operating in the public sector in South Australia; • three podiatrists working in private clinics; • four podiatrists working in public hospital services; • three hospital CEOs/managers of surgical services; • allied health staff working in hospitals/clinics; and • academic podiatrists.

The stakeholders were selected on the advice of the Project Reference Group, the results of the Mapping Exercise and the consultants’ own research.

Table 5 lists those who were consulted and a brief summary of the topics discussed.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 18 Table 5. Consultation strategy

Stakeholder group Name and position Method of interview Main themes / questions discussed (telephone or face to face) Orthopaedic surgeons Dr David Bainbridge, orthopaedic face to face • Is there a problem with the demand for foot ankle surgeon, Barwon Health surgery at Barwon Health? • Effectiveness of the multidisciplinary foot and ankle clinic – issues to be considered • Possible other solutions Dr Susan Liew, Director of Orthopaedics, face to face • Does Alfred Health have a problem with the demand for Alfred Health foot ankle surgery? • The “Alfred solution” and others - issues to be considered Orthopaedic foot and Dr Andrew Beischer, orthopaedic foot face to face • Is there a problem with the demand for foot ankle ankle surgeons and ankle surgeon practising at Royal surgery? Melbourne Hospital and the Epworth • Differences in working in the public and private health Centre sectors Dr William Edwards, orthopaedic foot face to face • Reactions to existing initiatives and ankle surgeon, Prahran Sports • Attitudes about working with allied health professionals Medicine Clinic • Possible solutions to the problem Dr John Negrine, Chairman, Australian telephone Orthopaedic Foot and Ankle Society and orthopaedic foot and ankle surgeon practising in the private sector (Orthosports) in Sydney Dr Alison Taylor, Secretary, Australian face to face Orthopaedic Foot and Ankle Society and orthopaedic foot and ankle surgeon practising at Maroondah Hospital and Knox Consulting Suites

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 19 Table 5 (continued)

Stakeholder group Name and position Method of interview Main themes / questions discussed (telephone or face to face) Podiatric surgeons Mark F Gilheany, podiatric surgeon, East face to face and telephone • Is there a problem with the demand for foot ankle Melbourne Podiatry; President, surgery? Australasian College Podiatric Surgeons; • Advantages and disadvantages of working in the public and President, Podiatrists Registration and private health sectors Board of Victoria • Extent of scope of practice Andrew Kingsford, podiatric surgeon, face to face • Effectiveness of the South Australian situation, and Kingsford Podiatry Group overseas Andrew van Essen, podiatric surgeon, telephone • Preferred solution and other possible solutions to the Repatriation General Hospital, South problem Australia Academic podiatrists Dr Adam Bird, Head, Department of face to face • Explanation of the podiatrist and podiatric surgeon Podiatry, education and training programmes in Australia and overseas Associate Professor Alan Bryant, Head telephone of Podiatric Medicine, Faculty of • Possible strategies for involving a more multidisciplinary Medicine, The University of Western approach in the provision of foot and ankle services Australia • Possible other solutions Podiatrists Andrew Cook, President, Australian face to face • Is there a problem with the demand for foot ankle Podiatry Association (Vic); podiatrist, surgery? Peninsula Foot Clinic • Reactions to existing initiatives Matthew Dilnot, podiatrist, Melbourne face to face • Advantages and disadvantages of recommending Foot Clinic patients to podiatric surgeon versus orthopaedic foot Christopher Wheeler, podiatrist, face to face and ankle surgeon Brunswick Foot Clinic • Possible solutions to the problem • Position of the APA (A Cook)

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 20 Table 5 (continued)

Stakeholder group Name and position Method of interview Main themes / questions discussed (telephone or face to face) Hospital administration Claire Culley, Divisional Director Surgery face to face • Is there a problem with the demand for foot ankle surgery at Western Health? Karen Rossitto, Manager, Day Surgery face to face Unit, Western Health • Effectiveness of the foot and ankle “super clinic” – issues to be considered • Possible other solutions Alan Kinkade, Group Chief Executive face to face • Exploration of capital development plans and organisational structure initiatives Christine Balfour, Acting Director of face to face Surgical Services • Preparedness to establish a foot and ankle surgery centre of excellence in partnership with the Department Donna Watters, Manager of Business face to face Development, Epworth HealthCare Dr Brendan Murphy, Chief Executive face to face • Is there a problem with the demand for foot ankle Officer, Austin Health surgery at Austin Health? • Preparedness to trial surgical workforce reform involving podiatric surgeons or other multidisciplinary workforce solutions Hospital allied health Julie Miller, Manager, Podiatry Services face to face • Effectiveness of the high risk foot clinic – lessons to be staff learnt for the establishment of other multidisciplinary Jane Tenant, podiatrist face to face clinic solutions Merilee McClelland, podiatrist, Austin face to face • Advantages and disadvantages of referring patients to Health orthopaedic foot and ankle surgeons and allied health professionals Peter Schoch, Manager, Orthopaedic face to face • Effectiveness of the multidisciplinary foot and ankle Access Service clinic – issues to be considered Lisa Adair, Nurse Unit Manager, face to face Outpatient Clinics, Barwon Health

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 21 Table 5 (continued)

Stakeholder group Name and position Method of interview Main themes / questions discussed (telephone or face to face) Hospital allied health Paul Butterworth, podiatrist, Northern face to face • Effectiveness of the advanced practice podiatry clinic – staff (cont) Health and podiatric surgical registrar progress to date Anita Spring, Health Service Manager face to face (Dietetics, Podiatry, Speech Pathology Audiology, Orthoptics & Orthotics), Northern Health Other medical specialists Dr Scott Ferris, Director, Victorian Plastic telephone • Investigation of the operation of the Victorian Unit Surgery Unit and its suitability as a model for the establishment of a foot and ankle centre of excellence Professor Geoff McColl, practising face to face • Is there a problem with the demand for foot ankle rheumatologist, President of the surgery? Australian Rheumatology Association; • Advantages and disadvantages of referring patients to Director of the Medical Education Unit in orthopaedic foot and ankle surgeons and allied health the Melbourne Medical School and professionals Professor of Medical Education and Training at the University of Melbourne; • Possible curriculum reform to encourage role extension and member of the Pharmaceutical Benefits Advisory Committee

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 22

2.3 4 Limitations of the Report There are a number of limitations of this report, which should be considered in making decisions based on the findings.

In particular, data were limited with respect to measures of unmet need. For example, data relating to waiting times for foot and ankle procedures other than bunions and toe procedures were generally not widely available. Specific information about the waiting times for outpatient consultations for foot and ankle conditions was also not available, and has been extrapolated from general orthopaedic outpatient waiting times.

Consultations with stakeholders identified and confirmed the advantages and disadvantages of possible solutions but there was limited documentary evidence and analysis to support the purported positive outcomes of the existing initiatives. In part this can be explained by the relative youth or work in progress of several of the initiatives.

Consultations were in part limited by the scope of the Project as determined by its budget. It was decided not to arrange consultations with consumers; it was felt that given the complexity of the issues surrounding the project there would be little benefit gained from seeking views about consumer experiences with particular professional groups and facilities. A robust survey instrument would have been the preferred means of collecting data but was again constrained by the project scope. Valuable consumer insight was however provided through membership of the Project Reference Group (refer Appendix 2, Membership and Terms of Reference).

2.4 Context

2.4.1 Surgical services in Victoria Surgical services in Victorian public hospitals are overseen by the State-wide Surgical Services Program of the Department of Human Services. The Ministerial Advisory Committee on Access to Elective Surgery was established in 2000 to advise the Minister for Health and the Department on priority issues relating to public hospital patients’ access to elective surgery.

A surgical services strategy, currently under development, will set future directions to enable the Victorian public health system to best meet the community’s surgery needs (http://www.health.vic.gov.au/surgery/sss-backgroundpaper0408.pdf). The strategy is proposed to encompass both elective and emergency surgery. The strategy will consider how provision of surgical services is affected by elements of care at all stages in the patient journey, from initial referral through to discharge, rehabilitation and follow-up. The strategy will also link with a separate strategy being prepared for the delivery of outpatient services.

Development of the surgical strategy will be guided by a number of key principles (Box 2), including supply of an appropriately skilled workforce - thus this current project interfaces closely with the surgical services strategy.

Workforce planning is just one aspect of the surgical services strategy, which will build on a number of existing initiatives implemented in recent years to build system capacity, improve service quality and achieve better patient outcomes. These initiatives reflect the complex issues affecting demand and supply of surgical services (Box 3).

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 23 Box 2. Draft key principles for the Victorian surgical services strategy

As key principles, surgical services in Victoria’s public hospitals should: • deliver care that focuses on the needs of patients; • deliver care in a way that encourages patient and carer involvement; • deliver timely and accessible care that is prioritised on the basis of clinical need; • deliver safe and evidence-based care; • support continuous improvement, collaboration, innovation and research; • support integration of surgical services with broader hospital services; • support coordination of surgical services with relevant providers and agencies in the community; • ensure the supply of an appropriately skilled workforce; and • ensure efficient and effective use of available resources.

2.4.2 Other workforce initiatives In terms of health workforce, the Department’s Strengthening Medical Specialist Training Program is undertaking a range of initiatives to improve training opportunities for doctors, targeting areas forecast for high growth such as surgery (http://www.health.vic.gov.au/workforce/medical.htm).

In addition, the strategy will consider how other health care staff, including nurses, allied health workers and technicians, could be used more effectively to support surgery related activity.

2.4.3 Providers of foot and ankle elective surgery Surgical procedures on the foot and ankle are carried out predominantly by orthopaedic surgeons, some of whom are specialised in foot and ankle surgery. Surgery related to the foot and ankle is also performed by general practitioners and podiatrists (e.g. toenail surgery), vascular surgeons (e.g. amputations), paediatric orthopaedic surgeons (e.g. surgery for club foot) and general surgeons. In the private hospital system a small proportion of foot and ankle surgery (approximately 1.9%) is undertaken by podiatric surgeons5 who tend to concentrate on forefoot surgery. Podiatric surgery is also performed in private practice, community health centres, day surgical centres and one public hospital7.

Defining the scope of practice among these professionals poses problems because it is self- regulating. On the other hand, it seems that orthopaedic surgeons undertake the majority of ankle surgery.

There has been ongoing debate about the role of podiatric surgeons in the Australian health system. In a submission to The National Health and Hospital Reform Commission, the Australasian College of Podiatric Surgeons argues that health system reform should include increased utilisation of podiatric surgeons as part of broad based health workforce reform and that podiatric surgeons represent an example of an existing workforce with skills which can contribute to addressing the current issues facing the health system8. A recent report by Access Economics has assessed the economic impact of increasing the utilisation of podiatric surgeons in Australia5. These issues are discussed in Section 6.3.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 24 Box 3. Key surgical services initiatives to build system capacity, improve service quality and achieve better patient outcomes.

Targeted additional funding for elective surgery including: • The Victorian Government’s Elective Surgery Initiative which provided $15 million in 2007-08 for additional elective surgery. Over five years, the Victorian Government has committed $77 million to provide additional elective surgery and reduce waiting times at Victoria’s public hospitals. • The Commonwealth Government’s Elective Surgery Waiting List Reduction Plan which will provide $600 million over four years from 2007-08 to States and Territories to reduce the number of elective surgery patients waiting for longer than recommended. As part of Stage One, the Commonwealth and State Governments combined to contribute an additional $60 million into Victorian public hospitals in 2008-09 to treat elective surgery patients. A range of major capital works and innovation projects funded through Stage Two of the plan are currently underway. Once completed, these improved facilities will increase elective surgery capacity and improve efficiency in meeting demand for elective surgery. • The Victorian Government provided $10.8 million to fund equipment and minor capital works at Victorian public hospitals to support the implementation of the additional elective surgery activity in 2007-08. Infrastructure initiatives including: • a purpose built freestanding state-wide elective surgery centre at ; • two designated surgery centres at St Vincent’s Health and Austin Health; • new day surgery theatres at the Yarra Ranges Day Hospital; and • theatre re-development at Peninsula Health including two new theatres.

Waiting list management and prioritisation initiatives including: • the Elective Surgery Access Service (ESAS) which assists semi-urgent (category two) and non-urgent (category three) elective surgery patients to receive more rapid treatment at another hospital that has the capacity to treat their condition; • dedicated clinical resources such as elective surgery access coordinators to manage patients waiting for surgery; • specialty-specific prioritisation models such as the orthopaedic waiting list (OWL) project which includes an evidence-based tool for prioritising people waiting for joint replacement surgery, and a service model for coordinating conservative treatment and care for patients while they wait for surgery; • the Elective Surgery Waiting Time website www.health.vic.gov.au/yourhospitals for patients and referring practitioners which provides information about waiting times for individual procedures and health services; and • reviews of the range of surgery that will be offered to public patients e.g. aesthetic surgery and non-medical circumcision.

New models of care including: • 23-hour procedure units which have been developed for surgical patients whose expected episode of care can be delivered within 23 hours; • streamlined models of care for particular conditions e.g. the Cranbourne cataract model which has reduced the number of appointments required by each patient; • guidelines to support best practice in caring for particular patient groups e.g. bariatric surgery programs; • non-surgical alternatives where appropriate e.g. varicose vein clinics; and • using private sector capacity to target patients who have waited longer than the clinically recommended time.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 25 3. Demand for foot and ankle surgery

Summary of Findings

The project sought to describe the current demand for foot and ankle surgery in Victorian public hospitals. Demand is reflected in: • the number of procedures undertaken; • number of people on a waiting list waiting for a procedure; and • length of time patients are waiting, both for surgery and for outpatient appointments.

In Victorian hospitals a total of 12,938 surgical procedures of the foot or ankle were performed during 2007/08. Forty seven per cent (6,052) of these procedures were performed in public hospitals and 53% (6,886) in private hospitals. Procedures relating to fractured ankle or toe were the most commonly performed procedures in the public sector (25.7%), while procedures performed for hallux valgus (bunion) or hallux rigidus (stiff big toe) were the most commonly performed procedures in the private sector (17.3%).

There is a trend of increasing numbers of foot and ankle surgical procedures being performed in Victorian hospitals, both public and private. Nationally, the number of foot and ankle surgical procedures undertaken in Australia is expected to increase by around 62% by 2050, largely due to population level influences such as population growth, the ageing population and the increasing incidence of ‘lifestyle’ conditions such as osteoarthritis (OA), obesity and diabetes.

Victorian waiting list data for foot and ankle surgery reveal considerable variability between hospitals, but on average, the time to treatment for patients with bunion and other toe deformities is in excess of the clinically recommended waiting times. Waiting times for these conditions are however comparable to other orthopaedic procedures such as total hip joint replacement, total knee joint replacement and shoulder surgery. Data was generally not available for other foot and ankle surgery, however at one hospital waiting times for more complex foot and ankle surgery were up to 4 years.

Foot and ankle cases are also variously represented on public hospital orthopaedic waiting lists, ranging from 7% to 24% of the total elective orthopaedic cases on waiting lists in the hospitals providing data for this project.

Data on waiting lists for an outpatient appointment were limited, however available data suggest considerable variability across sites, ranging from 10 months to 2 years. Limited data also suggests that a considerable proportion of patients referred for surgical consultation do not require or do not want surgery, thus contributing unnecessarily to patient waiting times and to inefficient use of specialist services. New initiatives such as the multidisciplinary foot and ankle clinic at Barwon Health have been introduced to support early conservative management and ensure those in need of surgery are directed to surgical consultation. These clinics are discussed in Section 5.

Whilst the measures of demand for foot and ankle surgery are highly variable, there are indications of a level of unmet need, and indications that the demand will continue to increase. The unmet need may be highest for complex foot and ankle surgery undertaken by more specialised surgeons but more specific data is required in this regard. These trends are not unique to foot and ankle surgery, but are shared by other elective orthopaedic surgery and elective surgery in general.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 26

Demand for foot and ankle elective surgery is reflected not only in the number of procedures undertaken but also the number of people on a waiting list waiting for a procedure and the length of time they are waiting, which could be considered a proxy measure of unmet need. These aspects and the general profile of foot and ankle surgery performed nationally and in Victorian hospitals are discussed below.

3.1 Foot and ankle surgery in Australia – procedure profile and trends

In Australia, almost 129,000 foot and ankle surgical procedures were undertaken in 2007 – this includes procedures performed by surgeons (orthopaedic, vascular and other surgeons), podiatric surgeons and general practitioners. According to an analysis by Access Economics this is likely to increase to over 130,000 in 2008 and to an estimated 211,000 procedures by 2050 – an increase of 61.9%5. This increase is consistent with trends in foot and ankle surgical procedures being performed in Victorian hospitals over the past five years (see Section 3.4.2) and with increasing numbers of other orthopaedic procedures such as hip and knee joint replacement procedures (Box 4).

Box 4. Joint replacement surgery in Australia

The Australian Orthopaedic Association’s Joint Replacement Registry has reported data on ankle joint replacement surgery for the first time in 2008. The report indicates that there were a total of 138 ankle joint replacement procedures (including total, partial and revision joint replacements) performed in Australia between July 2006 and June 2008. In comparison there were 2,651 shoulder replacement procedures, 153 elbow joint replacement procedures and 15 wrist joint replacement procedures9.

In comparison, for the 12 months to June 2004 there were 59,064 hip and knee joint replacement procedures in Australia. Data for the 10 years to June 2004 indicate that nationally, hip and knee joint replacement surgery has increased by 84.5% (hip replacement procedures by 56.5% and knee replacement procedures by 123.6%). In Victoria, hip and knee joint replacement surgery has increased by 79.4% over the same period10.

Note: data collection periods varied for each type of procedure and comparative figures are presented as a guide only9.

The incidence of all foot and ankle procedures performed in Australia during 2008 has been estimated by Access Economics (September 2008) (Table 6 and Table 7). Three data sources were used to estimate incidence: • data for all foot and ankle procedures from the Medicare Benefits Schedule (MBS) database for the financial year 2004-05 and calendar year 2007; • casemix data for corresponding foot and ankle procedures performed in public hospitals for the financial year 2004-05; and • an estimate of procedures performed by podiatric surgeons in 2007 using data from an audit by Butterworth et. al. (2008).

Access Economics applied age specific incidence rates by procedure to Australian Bureau of Statistics (ABS) population projections to obtain calculations of the projected incidence of foot and ankle procedures for the year 2008, as well as projections for future years. The data include procedures performed by general practitioners as well as surgeons (including general, vascular and orthopaedic surgeons) and podiatric surgeons. The analysis does not reflect foot and ankle elective surgery trends in Victorian hospitals but is presented as an overview of foot and ankle surgery in Australia.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 27 Table 6. Projected number and percentage of foot and ankle surgery procedures, showing hospital breakdown (public / private) by procedure type, Australia, 2008 Procedure Surgical Procedure Private Public Total # category Description procedures procedures N* N N (%) (%) (%) 1. Toenail Wedge resection, partial 52,641 5,097 57,739 resection and total removal of (91.2) (8.8) (100) toenails 2. Foot and Treatment of dislocations and 14,687 12,763 27,450 ankle trauma fractures of the ankle, tarsals, (53.5) (46.5) (100) metatarsals and phalanges 3. Lesser toes Primary and secondary repair of 10,002 3,914 13,916 flexor and extensor tendons, (71.9) (28.1) (100) tenotomy, correction of clawtoes, hammertoes and hyperextension deformity 4. Ankle Diagnostic arthroscopy, 8,941 3,882 12,822 arthroscopic surgery, (69.7) (30.3) (100) ligamentous stabilisation, arthrodesis, total joint replacement and Achilles tendon procedures 5. First Excisional arthroplasty, 6,618 2,130 8,748 metatarso- osteotomy, adductor hallucis (75.7) (24.3) (100) phalangeal tendon transfer, prosthetic joint arthroplasty and arthrodesis for either hallux valgus or hallux rigidus 6. Amputations Digital, transmetatarsal, Syme 994 4,194 5,188 (19.2) (80.8) (100) 7. Neuroma Neurectomy for plantar digital 1,488 381 1,869 neuritis (79.6) (20.4) (100) 8. Heel Excision of calcaneal spur and 517 337 854 plantar fasciotomy (60.5) (39.5) (100) 9. Rear foot Triple arthrodesis and subtalar 529 192 721 joint arthrodesis (73.4) (26.6) (100) 10. Clubfoot Posterior release, medial release 152 418 570 or combined postero-medial (26.7) (73.3) (100) release 11. Lesser Synovectomy of 501 0 501 metatarso- metatarsophalangeal joints (100) (0) (100) phalangeal joints 12. Tarsal Tarsal coalition and congenital 103 100 204 coalition and vertical talus (50.5) (49.7) (100) congenital vertical talus TOTAL 97,173 33,409 130,581 (74.4) (25.6) (100)

* Procedures performed by podiatric surgeons have been added to those performed in the private sector. # These data relate to surgical episodes so the same person may have had more than one episode. Source: MBS database, Casemix, Butterworth et al (2008) as cited in Access Economics, 2008. Note, figures are projected as they were published prior to the end of the 2008 year.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 28 Table 7. Projected number and percentage of foot and ankle surgery procedures, showing procedure breakdown by hospital type (public / private), Australia, 2008 Procedure Surgical Procedure Private Public Total # category Description procedures procedures n=97,173 n=33,409 n=130,581 N* N N (%) (%) (%) 1. Toenail Wedge resection, partial 52,641 5,097 57,739 resection and total removal of (54.2) (15.3) (44.2) toenails 2. Foot and ankle Treatment of dislocations and 14,687 12,763 27,450 trauma fractures of the ankle, tarsals, (15.1) (38.2) (21.0) metatarsals and phalanges 3. Lesser toes Primary and secondary repair 10,002 3,914 13,916 of flexor and extensor (10.3) (11.7) (10.7) tendons, tenotomy, correction of clawtoes, hammertoes and hyperextension deformity 4. Ankle Diagnostic arthroscopy, 8,941 3,882 12,822 arthroscopic surgery, (9.2) (11.6) (9.8) ligamentous stabilisation, arthrodesis, total joint replacement and Achilles tendon procedures 5. First metatarso- Excisional arthroplasty, 6,618 2,130 8,748 phalangeal joint osteotomy, adductor hallucis (6.8) (6.4) (6.7) tendon transfer, prosthetic arthroplasty and arthrodesis for either hallux valgus or hallux rigidus 6. Amputations Digital, transmetatarsal, Syme 994 4,194 5,188 (1.0) (12.6) (4.0) 7. Neuroma Neurectomy for plantar digital 1,488 381 1,869 neuritis (1.5) (1.1) (1.4) 8. Heel Excision of calcaneal spur and 517 337 854 plantar fasciotomy (0.5) (1.0) (0.7) 9. Rear foot Triple arthrodesis and subtalar 529 192 721 joint arthrodesis (0.5) (0.6) (0.6) 10. Clubfoot Posterior release, medial 152 418 570 release or combined postero- (0.2) (1.3) (0.4) medial release 11. Lesser Synovectomy of 501 0 501 metatarso- metatarsophalangeal joints (0.5) (0) (0.4) phalangeal joints 12. Tarsal coalition Tarsal coalition and congenital 103 100 204 and congenital vertical talus (0.1) (0.3) (0.2) vertical talus TOTAL 97,173 33,409 130,581 (100) (100) (100)

* Procedures performed by podiatric surgeons have been added to those performed in the private sector. # These data relate to surgical episodes so the same person may have had more than one episode. Source: MBS database, Casemix, Butterworth et al (2008) as cited in Access Economics, 2008. Note, figures are projected as they were published prior to the end of the 2008 year.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 29 The analysis shows that approximately three quarters (74%) of foot and ankle surgery is performed in the private sector (Table 6) however, it should be noted that private sector activity includes procedures performed out of hospitals for example by GPs or other service providers for which a Medicare rebate is applicable.

Overall, the most common procedures are those performed on the toenail (44.2%), 91.2% of which are performed in the private sector. Toenail procedures account for 54.2% of procedures in the private sector but only 15.3% of procedures in the public sector. Because these data were in part derived from MBS data, which do not distinguish between service providers, it is likely that a significant proportion of the reported toenail procedures were performed outside the hospital system by general practitioners or other service providers for which a Medicare rebate is applicable.

Procedures relating to foot and ankle trauma, such as dislocations and fractures account for 21% of all foot and ankle procedures, with 53% being performed in the private sector and 47% in the public sector. Procedures associated with trauma are the most common procedures in the public sector, accounting for 38.2% of procedures in that sector, compared with only 15.1% of procedures in the private sector.

The third and fourth most common procedures overall are those for the lesser toes (10.7%) and the ankle (9.8%). Approximately 70% of these procedures are performed in the private sector. One of the most commonly performed elective procedures - treatment of a bunion (also known as hallux valgus) - is included in procedures for the first metatarso-phalangeal joint which account for 6.7% of total procedures. Three quarters of procedures for the first metatarso-phalangeal joint are undertaken in the private sector.

The majority of all amputations associated with the foot or ankle are undertaken in the public sector (80.8%). These procedures represent the third most common procedure category in the public sector, after foot and ankle trauma and procedures of the toenail.

Box 5. The demographics of foot and ankle surgery

A report by Access Economics indicates that the total number of foot and ankle surgical procedures is split evenly between males and females. However, in males the majority of surgery is performed on those less than 44 years of age (61.1%) while in females, the majority of surgery is performed on those 45 years and older (64.1%)5.

The age distribution for surgical procedures for foot and ankle trauma demonstrated a peak in the 15- 24 year age group (with an over representation of males) and a peak in the over 55 year age group (with an over representation of females). The authors hypothesised that the first peak was likely to primarily represent sporting injuries and occupational foot and ankle trauma in young men, while the second peak may be related to osteoporotic fractures associated with accidental falls in older women5.

3.2 Foot and ankle surgery in Victorian hospitals – procedure profile and trends

A profile of foot and ankle procedures performed in Victorian hospitals was established through analysis of data from the Victorian Admitted Episodes Database (VAED). The database includes information about 150 foot and ankle procedures. Data was examined for the five years from 2003/2004 to 2007/2008. Table 8 shows a trend of increasing numbers of foot and ankle surgical procedures being performed in Victorian hospitals. The private hospital sector has consistently performed more foot and ankle procedures than the public hospital sector over the past five years, however, the differential between the number of procedures performed in the private compared with the public sector has increased

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 30 significantly in the last two years from a 3% difference in 2003/04 to a 14% difference in 2007/08.

The reason for the significant increase in the number of procedures undertaken in the private sector compared with the public sector could be related to Commonwealth government initiatives that have seen public patients being treated in the private sector as a means of reducing public sector elective surgery waiting times. It may also be because consumers, faced with a long wait for relatively minor and straight-forward surgery, choose to bear the cost themselves and have their operation conducted privately.

Figure 2 also shows the proportion of emergency versus non-emergency procedures. The majority of procedures performed in private hospitals are non-emergency procedures (97% in 07/08). In the public sector around 60% of all procedures are non-emergency procedures.

Figure 2. Number of emergency* and non-emergency^ foot and ankle procedures for Victorian private and public hospitals by financial year (July 03 - June 08)

8000 e e e e e t t t t c t c c c c i i i i i l a a a a l l l a l b v v v v b b b v b i i i i i Pu Pr Pu Pr Pu Pr Pu Pr Pu 7000 Pr

6000 s e dur e 5000 oc pr e l k

n Non-emergency

a 4000 Emergency & oot f 3000 of r e b m u

N 2000

1000

0 2003 - 04 2004 - 05 2005 - 06 2006 - 07 2007 - 08 Financial year

* Includes all “emergency admissions through emergency dept” and “other emergency admissions”. ^ Includes all “planned admission from waiting list”, “statistical admissions (change in care type within hospital)” and “other admissions”. Source: VAED

As already evident from the national data, the nature of foot and ankle surgery varies considerably between public and private hospitals. Appendix 4 includes data extracted from the VAED database for all procedures performed in both public and private hospitals for the 2007/2008 financial year. These data are summarised and discussed in the following tables. Table 8 and Table 9 show a breakdown of the seven main categories (and their sub categories) of foot and ankle procedures performed in public and private hospitals in Victoria. Within each sub-category there are a number of specific procedures which are listed in full in Appendix 4. The seven main categories of foot and ankle procedures are: application, insertion, removal; incision; excision; reduction; repair; reconstruction; and other procedures.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 31 Table 8. Number and percentage of foot and ankle procedure categories, showing hospital breakdown (public / private) by procedure type July 2007 – June 2008

Procedure category Procedures Procedures Private Public hospital hospital Total N (%) N (%) N (%) (n=6,886) (n=6,052) (n=12,938) APPLICATION, INSERTION, REMOVAL Other application, insertion or removal 0 (0) 0 (0) 0 (100) procedures on ankle or foot INCISION Osteotomy of ankle or foot 412 (75.1) 136 (24.9) 548 (100) Other incision procedure on ankle 299 (76.7) 91 (23.3) 390 (100) Other incision procedure on foot 200 (65.1) 107 (34.9) 307 (100) EXCISION Arthroscopic excision procedure on ankle 250 (81.4) 57 (18.6) 307 (100) Excision of bone of foot 455 (72.6) 172 (37.4) 627 (100) Amputation of ankle or foot 283 (30.5) 645 (69.5) 928 (100) Other excision procedure on ankle or foot 271 (75.1) 90 (24.9) 361 (100) REDUCTION Closed reduction of fracture of calcaneum, talus 13 (28.3) 33 (71.7) 46 (100) or metatarsus Closed reduction of fracture of ankle or toe 98 (20.6) 378 (79.4) 476 (100) Open reduction of fracture of calcaneum, talus 198 (46.0) 232 (54.0) 430 (100) or metatarsus Open reduction of fracture of ankle or toe 461 (22.9) 1,555 (77.1) 2,016 (100) Closed reduction of dislocations of ankle or foot 5 (4.9) 96 (95.1) 101 (100) Open reduction of dislocations of ankle or foot 10 (26.3) 28 (73.7) 38 (100) REPAIR Repair of tendon, ligament of ankle or foot 486 (70.5) 203 (29.5) 689 (100) Arthrodesis of ankle, foot or toe 618 (70.9) 254 (29.1) 872 (100) Other repair procedure on ankle or foot 272 (71.2) 110 (28.8) 382 (100) RECONSTRUCTION Reconstruction procedure on ankle or foot 50 (78.1) 14 (21.9) 64 (100) OTHER PROCEDURES Procedures for club foot 9 (33.3) 18 (66.7) 27 (100) Procedures for hallux valgus or hallux rigidus 1,191 (73.6) 427 (26.4) 1,618 (100) Procedures for other toe deformities 351 (66.7) 175 (33.3) 526 (100) Toenail procedures 735 (41.8) 1,022 (58.2) 1,757 (100) Tumours of the foot & ankle 219 (51.0) 210 (49.0) 429 (100) TOTAL 6,886 (53.2) 6,052 (46.8) 12,938 (100)

Source: VAED 2007/2008

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 32 Table 9. Number and percentage of foot and ankle procedure categories showing procedure category breakdown by hospital type (public / private) July 2007 – June 2008

Procedure category Procedures Procedures Private Public hospital hospital Total N (%) N (%) N (%) (n=6,886) (n=6,052) (n=12,938) APPLICATION, INSERTION, REMOVAL Other application, insertion or removal 0 (0) 0 (0) 0 (0) procedures on ankle or foot INCISION Osteotomy of ankle or foot 412 (6.0) 136 (2.2) 548 (4.2) Other incision procedure on ankle 299 (4.3) 91 (1.5) 390 (3.0) Other incision procedure on foot 200 (2.9) 107 (1.8) 307 (2.4) EXCISION Arthroscopic excision procedure on ankle 250 (3.6) 57 (0.9) 307 (2.4) Excision of bone of foot 455 (6.6) 172 (2.8) 627 (4.8) Amputation of ankle or foot 283 (4.1) 645 (10.7) 928 (7.2) Other excision procedure on ankle or foot 271 (3.9) 90 (1.5) 361 (2.8) REDUCTION Closed reduction of fracture of calcaneum, talus 13 (0.2) 33 (0.5) 46 (0.4) or metatarsus Closed reduction of fracture of ankle or toe 98 (1.4) 378 (6.2) 476 (3.7) Open reduction of fracture of calcaneum, talus 198 (2.9) 232 (3.8) 430 (3.3) or metatarsus Open reduction of fracture of ankle or toe 461 (6.7) 1,555 (25.7) 2,016 (15.6) Closed reduction of dislocations of ankle or foot 5 (0.1) 96 (1.6) 101 (0.8) Open reduction of dislocations of ankle or foot 10 (0.1) 28 (0.5) 38 (0.3) REPAIR Repair of tendon, ligament of ankle or foot 486 (7.1) 203 (3.4) 689 (5.3) Arthrodesis of ankle, foot or toe 618 (9.0) 254 (4.2) 872 (6.7) Other repair procedure on ankle or foot 272 (4.0) 110 (1.8) 382 (2.9) RECONSTRUCTION Reconstruction procedure on ankle or foot 50 (0.7) 14 (0.2) 64 (0.5) OTHER PROCEDURES Procedures for club foot 9 (0.1) 18 (0.3) 27 (0.2) Procedures for hallux valgus or hallux rigidus 1,191 (17.3) 427 (7.1) 1,618 (12.5) Procedures for other toe deformities 351 (5.1) 175 (2.9) 526 (4.1) Toenail procedures 735 (10.7) 1,022 (16.9) 1,757 (13.4) Tumours of the foot & ankle 219 (3.2) 210 (3.5) 429 (3.3) TOTAL 6,886 (100) 6,052 (100) 12,938(100)

Source: VAED 2007/2008

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 33 Table 10 and Table 11 show the number of foot and ankle procedures (according to sub category) in order of frequency for private and public hospitals respectively in 2007/2008.

Table 12 summarises the five most common procedure categories for private and public hospitals in 2007/2008.

Table 10. Number and percentage of foot and ankle procedures in order of frequency for Victorian private hospitals, July 2007 – June 2008.

Procedure category Procedures Private hospitals (n=6,886) N (%) Procedures for hallux valgus or hallux rigidus 1,191 (17.3) Toenail procedures 735 (10.7) Arthrodesis of ankle, foot or toe 618 (9.0) Repair of tendon, ligament of ankle or foot 486 (7.1) Open reduction of fracture of ankle or toe 461 (6.7) Excision of bone of foot 455 (6.6) Osteotomy of ankle or foot 412 (6.0) Procedures for other toe deformities 351 (5.1) Other incision procedure on ankle 299 (4.3) Amputation of ankle or foot 283 (4.1) Other repair procedure on ankle or foot 272 (4.0) Other excision procedure on ankle or foot 271 (3.9) Arthroscopic excision procedure on ankle 250 (3.6) Tumours of the foot & ankle 219 (3.2) Other incision procedure on foot 200 (2.9) Open reduction of fracture of calcaneum, talus or metatarsus 198 (2.9) Closed reduction of fracture of ankle or toe 98 (1.4) Reconstruction procedure on ankle or foot 50 (0.7) Closed reduction of fracture of calcaneum, talus or metatarsus 13 (0.2) Open reduction of dislocations of ankle or foot 10 (0.1) Procedures for club foot 9 (0.1) Closed reduction of dislocations of ankle or foot 5 (0.1) Other application, insertion or removal procedures on ankle or foot 0 (0)

Source: VAED 2007/2008

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 34 Table 11. Number and percentage of foot and ankle procedures in order of frequency for Victorian public hospitals, July 2007 – June 2008.

Procedure category Procedures Public hospitals (n=6,053) N (%) Open reduction of fracture of ankle or toe 1,555 (25.7) Toenail procedures 1,022 (16.9) Amputation of ankle or foot 645 (10.7) Procedures for hallux valgus or hallux rigidus 427 (7.1) Closed reduction of fracture of ankle or toe 378 (6.2) Arthrodesis of ankle, foot or toe 254 (4.2) Open reduction of fracture of calcaneum, talus or metatarsus 232 (3.8) Tumours of the foot & ankle 210 (3.5) Repair of tendon, ligament of ankle or foot 203 (3.4) Procedures for other toe deformities 175 (2.9) Excision of bone of foot 172 (2.8) Osteotomy of ankle or foot 136 (2.2) Other repair procedure on ankle or foot 110 (1.8) Other incision procedure on foot 107 (1.8) Closed reduction of dislocations of ankle or foot 96 (1.6) Other incision procedure on ankle 91 (1.5) Other excision procedure on ankle or foot 90 (1.5) Arthroscopic excision procedure on ankle 57 (0.9) Closed reduction of fracture of calcaneum, talus or metatarsus 33 (0.5) Open reduction of dislocations of ankle or foot 28 (0.5) Procedures for club foot 18 (0.3) Reconstruction procedure on ankle or foot 14 (0.2) Other application, insertion or removal procedures on ankle or foot 0 (0)

Source: VAED 2007/2008

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 35 Table 12. Top five foot and ankle procedure categories undertaken at Victorian private and public hospitals in 2007/08

PRIVATE PUBLIC (n=6,886) (n=6,052) Procedure category N (%) Procedure category N (%) 1. Procedures for hallux 1,191 (17.3) 1. Open reduction of fracture 1,555 (25.7) valgus (bunion) or of ankle or toe hallux rigidus (stiff big toe) 2. Toenail procedures 735 (10.7) 2. Toenail procedures 1,022 (16.9) 3. Arthrodesis (fixation of 618 (9.0) 3. Amputation of foot or ankle 645 (10.7) joint) of ankle, foot or toe 4. Repair of tendon, 486 (7.1) 4. Procedures for hallux 427 (7.1) ligament of ankle or foot valgus (bunion) or hallux rigidus (stiff big toe) 5. Open reduction of 461 (6.7) 5. Closed reduction of 378 (6.2) fracture of ankle or toe fracture of ankle or toe

Source: VAED 2007/2008

During 2007/08, a total of 12,938 surgical procedures of the foot or ankle were performed in Victorian hospitals. Forty seven per cent (6,052) of these procedures were performed in public hospitals and 53% (6,886) in private hospitals.

The most common procedures overall were those involving open reduction of fracture of ankle or toe, accounting for 15.6% of foot and ankle procedures undertaken in hospitals in Victoria in 2007/2008 (Table 9). The majority of these procedures (77.1%) were undertaken in public hospitals (Table 8). They account for 25.7% of all foot and ankle procedures in public hospitals and 6.7% of all foot and ankle procedures in private hospitals (Table 9).

Toenail procedures were the second most common procedure category overall, accounting for 13.4% of foot and ankle procedures across Victorian hospitals (Table 9). These were more evenly spread between public and private hospitals, with 58.2% being performed in public hospitals and 41.8% in private hospitals (Table 8).

Procedures for hallux valgus (bunion) or hallux rigidus (stiff big toe) represented the third most common procedure category overall, and the most common foot and ankle procedure performed in private hospitals. These procedures accounted for 12.5% of total procedures, 17.3% of private hospital procedures and 7.1% of public hospital procedures (Table 9).

The majority (69.5%) of amputations were undertaken in public hospitals with amputations representing the third most common procedure category in public hospitals (Table 8).

As described above, the most common procedures performed in the public sector relate to trauma and/or emergency treatment (ankle fractures) or complex patients (amputation of toe), while the most common procedures in the private sector include elective procedures such as bunions, joint fixation and tendon and ligament repairs.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 36 3.3 Waiting times for foot and ankle elective surgery

Further reflecting the demand for foot and ankle surgery is the waiting time for elective surgery. Currently in Australian public hospitals there are long waiting times for orthopaedic surgery in general. In 2006-07, orthopaedic surgery (compared with all other surgical specialties), had the highest proportion of patients who had waited longer than a year (6.0%)11. The health impacts associated with waiting for foot and ankle elective surgery have not been well established.

Health impacts associated with delayed access to foot and ankle elective surgery There is a dearth of evidence relating to the health impacts associated with waiting for foot and ankle elective surgery. The report by Access Economics states that long waiting periods for surgery increase the time that individuals spend with pain, suffering and reduced quality of life5. While it is probable that increased waiting results in reduced quality of life, there is no evidence to support this in relation to foot and ankle surgery. The evidence cited in the Access Economics report relates to patients awaiting surgery for hip joint replacement or diabetic foot complications.

Currently, there is no validated method of prioritising foot and ankle surgery according to impact on quality of life. Through the consultation phase, it was found that some orthopaedic surgeons report that the impact on quality of life of foot and ankle conditions is in general less than that of osteoarthritis of the hip or knee requiring joint replacement surgery, however, quality of life impacts can be highly variable. One example is the impact of a condition such as a bunion on a patient’s quality of life. A bunion can be a complicated long- standing structural problem which can lead to pain, ulcers, infections, callouses and difficulty getting footwear to fit. These impacts can have a debilitating impact on a patient’s quality of life. In other instances the impact on quality of life of a bunion is no more than cosmetic.

Victorian waiting list data for foot and ankle surgery reveal that the average time to treatment for patients with bunion and other toe deformities is in excess of the clinically recommended waiting times. For patients assessed as category 2 (Table 13), waiting times for surgery were in excess of the recommended 90 days in 89% of Victorian hospitals. For patients assessed as category 3, waiting times for surgery were in excess of the recommended 365 days in 33% of Victorian hospitals (refers only to hospitals for which data were available (Table 13).

Box 6. An explanation of urgency categories used in Victorian public hospitals

All patients on the elective surgery waiting list have been assessed by a surgeon and categorised according to the urgency of their condition. In Victorian public hospitals, there are three levels of clinical urgency which currently guide scheduling of patients for elective surgery as follows: Category 1: Admission within 30 days desirable for a condition that has the potential to deteriorate quickly to the point that it may become an emergency. Category 2: Admission within 90 days desirable for a condition causing some pain, dysfunction or disability but which is not likely to deteriorate quickly or become an emergency. Category 3: Admission at some time in the future acceptable for a condition causing minimal or no pain, dysfunction or disability, which is unlikely to deteriorate quickly and which does not have the potential to become an emergency.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 37 Table 13. Time to treatment for patients admitted for surgery for excision of bunion and other toe deformities in Victorian public hospitals, July 2007 - June 2008 Hospital Category 1 Category 2 Category 3 Austin Hospital * 187 days 385 days * 242 days * Dandenong Hospital * 269 days 422 days * 292 days * Goulburn Valley Health * 104 days * Maroondah Hospital * 134 days 464 days Northeast Health Wangaratta * * 329 days Northern Hospital * 84 days 349 days Royal Children’s Hospital * * 63 days Royal Melbourne Hospital * * 68 days Sandringham Hospital * 111 days 144 days St Vincent’s Hospital * 91 days 255 days Average N/A 168 days 275 days National Standard 30 days 90 days 365 days

*This hospital has treated less than 10 patients in this category during the period. Results of less than 10 are not reported due to statistical unreliability. Source: DHS Your Hospitals report website

Waiting for foot and ankle surgery compared with other orthopaedic surgery Whilst waiting times for one of the most commonly performed elective foot and ankle procedure (excision of bunion or other toe deformity) are in excess of the clinically recommended waiting times, they are comparable to other orthopaedic conditions such as total hip joint replacement, total knee joint replacement and shoulder surgery (Figure 3).

Figure 3. Average time to treatment for elective orthopaedic surgery in Victorian public hospitals, July 2007 to June 2008

400 National 350 Standar d (Cat 3)

s) 300 ay d (

e 250 m i t

g 200 n i t i Cat 2

wa 150 Cat 3 e ag r

e 100 v

A National 50 Standard (Cat 2)

0 Ex c is ion of Total hip Total knee Arthroscopy of Repair Removal of All other bunion and replacement replacement the knee procedures on internal fixation orthopaedic other toe shoulder and device of bone surgery def ormities elbow Surgery type

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 38 Waiting time - changes over time The median time to treatment for a category 2 excision of bunion and other toe deformity has increased over the past five years. In comparison, the median time to treatment for a category 2 hip or knee joint replacement has been reduced over the last three to four years. However, waiting times for these procedures still remain in excess of the clinically recommended waiting time of 90 days (Figure 4).

The reverse appears to be true for patients waiting for a category 3 excision of bunion and other toe deformity. The median time to treatment for this procedure seems to have decreased over the last three years while the median time to treatment for a category 3 hip or knee joint replacement has increased steadily over the last five years. On average, time to treatment for all category 3 orthopaedic surgery, is less than the clinically recommended waiting time of 365 days (Figure 5).

Figure 4. Median time to treatment for category 2 elective orthopaedic surgery in Victorian public hospitals, July 2003 to June 2008

180

160

140

s) 120 ay (d e

m 100 National Standard (Cat 2) ti

g 2003 - 04 n i t

i 2004 - 05

a 80 w

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d 60 e 2007 - 08 * M

40

20

0 Excision of bunion Total hip Total knee Arthroscopy of Repair Remov al of All other and other toe replacement replacement the knee procedures on internal fixation orthopaedic deformities shoulder and device of bone surgery elbow Surgery type

Source: July 2003 – June 2007: Department of Human Services Performance Reporting & Analysis Unit July 2007- June 2008: DHS Your Hospital website (http://serviceforip.webcentral.com.au/yourhospitals/median.asp) Note: Data for July 2003 – June 2007 represent the median time to treatment across all Victorian Hospitals. Data for July 2007- June 2008 were obtained by taking the average of the median time to treatment for hospitals for which data were available.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 39 Figure 5. Median time to treatment for category 3 elective orthopaedic surgery in Victorian public hospitals, July 2003 to June 2008

400 National Standard (Cat 3)

350

300 s) ay

d 250 ( e 2003 - 04 m i

t 2004 - 05 g 200 n

i 2005 - 06 t i

a 2006 - 07 w 2007 - 08 *

an 150 i d e M

100

50

0 Excision of Total hip Total knee Arthroscopy of Repair Remov al of All other bunion and other replacement replacement the knee procedures on internal fixation orthopaedic toe deformities shoulder and device of bone surgery elbow Surgery type

Source: July 2003 – June 2007: Department of Human Services Performance Reporting & Analysis Unit July 2007- June 2008: DHS Your Hospital website (http://serviceforip.webcentral.com.au/yourhospitals/median.asp) Note: Data for July 2003 – June 2007 represents the median time to treatment across all Victorian Hospitals. Data for July 2007- June 2008 were obtained by taking the average of the median time to treatment for hospitals for which data were available.

Waiting time - individual hospital data Individual hospital data are available for seven hospitals which provided data within the project time period. These included six metropolitan and one regional hospital. Hospital data have been de-identified.

The data are highly variable which is likely to reflect the complexity of impacts on waiting times and on delivery of elective surgical services across different Victorian public hospitals. In addition, the individual hospital data presented do not reflect activity in rural Victoria as the data provided relate mainly to metropolitan and one regional hospital. Few overall conclusions can be drawn about waiting time for elective foot and ankle surgery from the data presented. Individual hospital data were measured using the variable waiting time, as opposed to the variable time to treatment (Box 1).

The average waiting time for elective orthopaedic surgery compared with elective foot and ankle surgery across seven Victorian public hospitals is outlined in Figure 6 (category 2) and Figure 7 (category 3). Figure 6 indicates that three sites for which data were available, have a waiting time for category 2 elective orthopaedic surgery which is longer than the clinically recommended waiting time of 90 days. At three sites, foot and ankle elective surgery had longer waiting times than all orthopaedic elective surgery, and at four sites, foot and ankle elective surgery had a shorter waiting time than all orthopaedic elective surgery.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 40 Figure 6. Average waiting time for category 2 elective orthopaedic surgery. Snap shot of Victorian public hospitals*

250

200 s) ay d

( 150

e m i All orthopaedic t g 100 Foot and ankle in t i National Standard a (Cat 2) W 50

0 Site 1 Site 2 Site 3 Site 4 Site 5 Site 6 Site 7 Hospital

* Snap shot taken between September and December 2008

Figure 7 indicates that two sites for which data were available, have a waiting time for category 3 elective orthopaedic surgery which is longer than the clinically recommended waiting time of 365 days. At four sites foot and ankle elective surgery had longer waiting times than all orthopaedic elective surgery and at three sites, foot and ankle elective surgery had a shorter waiting time than all orthopaedic elective surgery.

Figure 7. Average waiting time for category 3 elective orthopaedic surgery. Snapshot of Victorian public hospitals*

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600 ) s

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g 300 Foot and ankle n i it a 200 W

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0 Site 1Site 2Site 3Site 4Site 5Site 6Site 7 Hospital

* Snap shot taken between September and December 2008

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 41 3.4 Number of people waiting for elective foot and ankle surgery

Figure 8 shows the number of people waiting on waiting lists at seven Victorian public hospitals. The number of cases waiting for foot and ankle elective surgery as a proportion of all orthopaedic elective surgery is between 7% and 24% (Site 1 – 13%; Site 2 – 24%; Site 3 – 9%; Site 4 – 23%; Site 5 – 9%; Site 6 – 7% and Site 7 – 16%). The reasons for the high number of cases waiting at Site 1 and Site 3 are not known. Similarly, the reasons for the low number of cases waiting at Site 4 are also not known.

Figure 8. Number of cases waiting for elective orthopaedic surgery and elective foot and ankle surgery. Snap shot of Victorian public hospitals*

1000 900 800 700 600 cases f All orthopaedic o 500 er

b 400 Foot and ankle m

u 300 N 200 100 0 Site 1 Site 2 Site 3 Site 4 Site 5 Site 6 Site 7 Hospital

* Snap shot taken between September and December 2008

3.5 Waiting times for an outpatient appointment

Waiting times for an outpatient appointment can also reflect the overall demand for surgery and can have a significant impact on overall waiting times for elective surgery. Data indicating waiting times for initial assessment in an outpatient department in Victorian public hospitals for a foot or ankle condition are limited. Waiting times for an orthopaedic outpatient appointment for any condition have been previously reported as between 6 months and 2 years12. This is consistent with data provided by three hospitals that indicate that the waiting time for an orthopaedic outpatient appointment is between 10 months (Site 3 and Site 7) and 2 years (Site 6).

Whilst limited, data from the mapping exercise and stakeholder consultations identified that a considerable proportion of patients referred to orthopaedic outpatients did not require or did not want surgery. Long waiting times for an outpatient appointment with an orthopaedic surgeon could be reduced through early and accurate identification of the need or otherwise for surgery and initiation of appropriate conservative management, both for those requiring surgery and those not requiring surgery. New initiatives such as the multidisciplinary foot and ankle clinic at Barwon Health and the podiatry led clinic at Northern Health aim to identify patients who would benefit from conservative management prior to seeing the surgeon. These initiatives have reported significantly shorter waiting times for an outpatient

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 42 appointment of between 2-4 weeks (Barwon Health) and 12 weeks (Northern Health). It is not known whether these services have had an impact on waiting times for surgery, however, in the case of Barwon Health, there is evidence that the services have transferred patients who do not require or are not suitable for surgery from the surgeon, leading to more efficient use of specialist surgeon services.

Individual hospital snap shot data are unable to detect trends in indicators such as waiting time and as such are limited in their ability to illustrate changes in relation to local initiatives to improve management of foot and ankle problems. Further detailed analysis of targeted individual hospital data would be required to demonstrate the impact of such initiatives.

Clinical decision-making occurs at several points, commencing with the podiatrist or GP, who will decide whether: • a case can be treated conservatively; • a surgical procedure is required that can be undertaken by the podiatrist or GP; or • the case needs to be referred for specialist surgical review.

If a referral for specialist surgical review is required, then the choice of specialist (i.e. orthopaedic surgeon or podiatric surgeon) will be based both on a clinical judgement and on the patient’s ability to pay. Consultations with referrers found that complex cases will tend to be referred to orthopaedic surgeons rather than podiatric surgeons.

Following specialist review, an orthopaedic surgeon or a podiatric surgeon will then make a further clinical decision about whether the case requires surgery or conservative treatment. Findings from the consultation phase indicate that regardless of whether the patient was reviewed by an orthopaedic surgeon or a podiatric surgeon the majority of cases were referred for conservative treatment. In one private orthopaedic surgeon clinic the rate of referral to conservative treatment was estimated to be around 90% and at a public hospital multidisciplinary foot and ankle clinic the rate of referral to conservative treatment was estimated to be around two thirds of all patients seen in the clinic.

3.6 Factors influencing demand for foot and ankle elective surgery

3.6.1 Increasing patient expectations Increasing patient expectations about health care can contribute to increased demand for foot and ankle surgery. One example is the demand for surgery for cosmetic reasons as in the case of an unsightly but otherwise asymptomatic bunion. Patient expectations are in part influenced by adequate communication between the patient and their doctor about appropriate expectations of available treatment options and their possible outcomes16.

Some orthopaedic surgeons consulted during the project reported that foot and ankle surgery does not have the same rates of patient satisfaction as other types of orthopaedic surgery such as hip and knee joint replacement surgery. They expressed that this may be because it is less effective at reducing pain and restoring function compared to, for example, hip and knee joint replacement surgery. Anecdotally, they reported an increased number of readmissions for foot and ankle surgery compared with other types of surgery as well as an increased number of complaints, and an increase in the rate of litigation when compared to other types of orthopaedic surgery.

Podiatric surgeons pose an alternative argument in relation to potential reasons for dissatisfaction, indicating that poor outcomes from foot and ankle surgery undertaken by orthopaedic surgeons is related to these surgeons’ levels of expertise and experience in foot and ankle surgery. There are no data to confirm the orthopaedic surgeons’ or podiatric surgeons’ views in this regard.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 43 Orthopaedic surgeons suggested that a potential reason for reduced patient satisfaction might be patients having high expectations of this type of surgery. Orthopaedic surgeons proposed patients’ high expectations of their surgery as a potential reason for reduced patient satisfaction. There was some recognition by orthopaedic surgeons that information regarding the likely outcome of surgery may not always be communicated effectively to the patient resulting in levels of patient satisfaction considerably lower than for other orthopaedic procedures. This has led to efforts to improve communication around foot and ankle surgery (Box 7).

Box 7. Using multimedia to improve patient consent for orthopaedic surgery17

Multimedia technology has been shown to be an effective tool to aid information delivery and retention during the informed consent process. Mr Andrew Beischer, a foot and ankle specialist orthopaedic surgeon has been involved in the development of multimedia information modules. Each interactive module is procedure specific and is viewed on a personal computer. 3D digital animation assists in providing information about: • pathology of the surgical condition; • pertinent details of the operative procedure; • expected post operative course; • likely benefits of the surgery; and • important possible consequences and complications of the surgery. The pace at which the information is presented is controlled by the patient who is able to scroll back and forth though the module as required. Patients are given the opportunity to clarify information or ask questions of the surgeon when they have finished viewing the module. Development of a multimedia module includes a review of the medical literature regarding current information about the expected outcome and potential complications of each surgical procedure, followed by focus groups of post surgery patients to determine their perception of what had been lacking in the information that they had been given in the traditional doctor-patient interaction prior to surgery. A randomised controlled trial comparing three methods of information delivery; multimedia module, pamphlet and a standardised verbal consultation with the surgeon, has demonstrated that multimedia improved the overall level of understanding as well as the duration for which the information was retained.

3.6.2 Availability of and access to conservative management options In some instances, limited availability of conservative management may lead to increased demand for surgery due to: • lack of conservative management leading to a worsening of a patient’s condition to the point where surgery is required; and • lack of conservative management options leading to surgical treatment being the only treatment available.

The degree to which limited availability of conservative management may influence demand for surgery could not be quantified as part of this project. However, the consultations did not find any evidence of a lack of access to or uptake of conservative management options in the metropolitan and major regional areas that were studied as part of this project – this may not be the case in other regional and rural areas.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 44

3.6.3 Population level influences Some of the most significant drivers for increased demand for foot and ankle surgery include population growth, the ageing population (refer Figure 9) and the increasing incidence of conditions such as osteoarthritis (OA), obesity and diabetes. These drivers are influenced by social, political and cultural factors which, whilst acknowledged were not explored in this project.

Figure 9. Victorian population and numbers of patients on elective surgery waiting lists by age group (Surgical Services Strategy, DHS)

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 45 4. Supply of foot and ankle surgery – current service model and workforce

Summary of Findings

A number of factors are known to influence the supply of elective surgery services, including theatre capacity, competing surgical priorities, inpatient capacity and workforce, amongst others. These factors vary considerably at a local level and interact in a complex way.

This project specifically explored factors influencing hospitals’ ability to meet the demand for foot and ankle surgery. It confirmed system factors such as theatre availability and competition for theatre time with emergency cases and other surgical specialties as significant barriers in some hospitals. Surgical skill shortage was also an issue at some but not all hospitals.

In Victorian public hospitals, foot and ankle surgery is performed predominantly by orthopaedic surgeons, some of whom have a special interest in foot and ankle surgery. Podiatric surgeons undertake foot and ankle surgery only within the private sector.

Limited data in terms of very long waiting times for complex foot and ankle surgery at one hospital, and general consultation with orthopaedic surgeons, point to a relative shortage of foot and ankle surgeons in the public sector. At the same time there is evidence of some spare capacity of foot and ankle surgeons in the private sector. The reasons for this imbalance appear to be related to a number of factors including insufficient operating theatre priority; inadequate outpatient facilities; remuneration opportunities for orthopaedic surgeons in the public sector being less than in the private sector (influencing the balance of public and private work undertaken by individual surgeons); and the current exclusion of podiatric surgeons from practice in the public sector. These factors interact in a complex way and resolution of any single factor is not likely to resolve the supply issue.

Whilst surgical workforce did not appear to be a major issue amongst the hospitals consulted during the project, a number of hospitals have sought to implement workforce solutions to meet demand at an outpatient level, where waiting times for specialist consultation may be prolonged and where there is scope to identify patients who may benefit from conservative management (Refer Section 5).

The contribution of system factors to the current supply of foot and ankle elective surgical services is variable across Victorian health services. Addressing the demand for foot and ankle surgery through an increase in theatre capacity would be a solution but any additional capacity would still be allocated based on clinical judgements about the relative urgency of the cases under consideration. Nevertheless, any increase in total operating theatre time would be likely to provide greater opportunities for the performance of more elective foot and ankle surgery.

4.1 Current service delivery in Victorian public hospitals – an overview

The project sought to establish the current service delivery model for foot and ankle elective surgery and related services such as outpatient services in Victoria. This section includes a profile of the service providers and an examination of the factors influencing service delivery.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 46 The most common pathway to foot and ankle surgery in Victorian public hospitals is via referral to a hospital orthopaedic outpatient clinic. Referrals are generally made by general practitioners, rheumatologists or emergency departments.

It is recognisied that referral patterns and source are influenced by funding models and may alter in line with changes to the funding model e.g. the proposed review of MBS.

Referrals are usually triaged for urgency and the patient is given an outpatient appointment. The patient attends their outpatient appointment and is assessed by the surgeon. If surgery is indicated, the patient is assigned an urgency category (Box 6) and placed on the elective surgery waiting list. If surgery is not indicated, the patient is referred for conservative management of their condition. In some instances, where public hospitals have limited outpatient services, patients are referred directly to an individual orthopaedic specialist who assesses prioritises and places the patient on the elective surgery waiting list directly from the surgeons’ private rooms (Figure 10).

Figure 10. Common public hospital service delivery model

Surgeon’s private Surgery

Waiting rooms Waiting

YES

Referral Does the patient want GP or require / suit Rheumatologist surgery? Emergency Dept

NO

Surgical Conservative Outpatient Management

Waiting clinic (orthotist, podiatrist, physio, GP)

Current foot and ankle related outpatient and surgical service delivery at 12 Victorian public hospitals is summarised in Table 14 which presents a profile of: • foot and ankle elective surgery services including the availability of day surgery facilities; and • outpatient services including general orthopaedic clinics, specialist orthopaedic foot and ankle clinics, general podiatry clinics and specialist podiatry clinics which represent clinics dedicated to foot and ankle issues that include podiatrists in multidisciplinary or advanced practice roles

The information in Table 14 illustrates that, while all the hospitals included in the analysis undertake orthopaedic surgery, only a small number have a dedicated foot and ankle theatre list. Similarly, while most hospitals have a general orthopaedic outpatient clinic, only two have an orthopaedic outpatient clinic dedicated to foot and ankle problems. While those data are not complete, they are consistent with the findings of the consultations with relevant stakeholders.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 47 Table 14. Profile of foot and ankle elective surgery related workforce, surgical and outpatient services at 12 Victorian hospitals 2008

Monash Royal Bendigo Geelong Goulburn Wangaratta Dandenong Moorabbin Northern St Vincent’s Western Austin Medical Melbourne Base Hospital Valley Base Hospital Hospital Hospital Hospital Hospital Hospital Centre Hospital Hospital Hospital Hospital

Dedicated foot and ankle - - X X - - X X X X theatre list ery rg

Su Day surgery facilities - - - - -

General orthopaedic X X clinic (limited) Foot and ankle X X X X X X X - X X orthopaedic clinic

General podiatry clinic X X X X X - X PPS PPS PPS PPS Outpatients Podiatry plus clinic X X X X X HRFC APPC HRFC HRFC HRFC HRFC MDFAC HRFC

PPS – Prioritised podiatry clinic meaning patients have to meet certain criteria usually high risk patients who require multidisciplinary input. HRFC – High risk foot clinic, APPC – Advanced practice podiatry clinic, MDFAC – Multidisciplinary foot and ankle clinic. ‘- ‘denotes data not provided within project timeframes.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 48 About half of the hospitals for which data were available had a high risk foot clinic (HRFC) which is a podiatry-led clinic dedicated to management of patients with impaired wound healing on their feet (Box 11). The term ‘high-risk’ refers to the degree of risk of lower limb amputation.

Five of the hospitals for which data were available had a prioritised podiatry clinic (PPC) which means that patients have to meet certain criteria to access the clinic - usually high risk patients who require multidisciplinary input. High risk in this context does not specifically refer to risk of lower limb amputation as it does for the HRFC.

The two other types of foot and ankle clinics identified included an advanced practice podiatry clinic at Northern Health (Box 9) and a multidisciplinary foot and ankle clinic at Barwon Health (Box 8). These are discussed further in section 5 of this report.

It should be noted that the term ‘advanced practice’ is applied to roles that are outside the scope of what is considered normal practice in the public sector, but within the legislative scope of the practitioner. To undertake an advanced practice role a podiatrist requires training and experience in addition to their entry-level qualification. Advanced practice roles allow the use of a podiatrist’s full scope of practice and enable more efficient and appropriate use of the existing skills in the workforce.

A related term is ‘extended scope’ which refers to roles that include tasks that are currently outside the legislative scope of practice. To undertake an extended scope of practice, practitioners require further training and credentialing in the required competencies. There are currently no extended scope podiatry roles in Victoria.

4.2 Current workforce

In Victorian public hospitals, foot and ankle surgery is performed predominantly by orthopaedic surgeons, some of whom have a special interest in foot and ankle surgery.

Orthopaedic surgeons are trained to undertake surgery on the spine, foot and ankle, knee, hip, hand, shoulder and elbow, as well as perform joint arthroplasty surgery, and surgery for trauma, tumours and paediatric musculoskeletal conditions. While orthopaedic surgeons are qualified to perform all procedures related to the foot and ankle, in practice the more complex foot and ankle procedures tend to be referred to orthopaedic surgeons with a special interest in foot and ankle surgery. The consultations indicated that in the private sector there is some spare capacity and that the sub-specialty is attracting more trainees. However, it was pointed out that these specialists, once trained, would also tend to move into private practice.

Management of patients with foot or ankle problems is also undertaken conservatively with the involvement of podiatrists and orthotists. The mapping exercise did not specifically assess these workforces outside the hospital setting, where much of the conservative management takes place.

Table 15 outlines the workforce involved in the provision of foot and ankle services at 12 Victorian public hospitals in 2008, including general orthopaedic surgeons, surgeons with an interest in foot and ankle surgery and podiatrists.

Currently in Victoria, there are 206 practising orthopaedic surgeons and 19 orthopaedic surgeons who indicate an interest in foot and ankle surgery. There are limitations in identifying foot and ankle specialist orthopaedic surgeons from the data currently available, as the interest in the specialty area is self-reported. Consultations with the Australian Orthopaedic Foot and Ankle Society indicate that the majority of foot and ankle surgery in Victoria is undertaken by some nine orthopaedic foot and ankle surgeons, with the majority in the private sector. Four of these are apparently not included in the data in Table 16.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 49 The limited data reveals that the availability of foot and ankle specialists in Victoria is largely confined to metropolitan areas. Of the 12 Victorian public hospitals included in the mapping exercise, the six hospitals that indicated they had an orthopaedic surgeon with an interest in foot and ankle surgery were all metropolitan hospitals. While general orthopaedic surgeons will perform most emergency foot and ankle surgery and some less complex procedures, the conduct of more complex foot and ankle surgery is often dependent upon the availability of specialist foot and ankle orthopaedic surgeons. Orthopaedic surgeons in rural and regional areas tend to refer complex foot and ankle cases to Melbourne for treatment.

Local workforce shortages can influence the waiting time for foot and ankle surgery at a particular site. For example, the elective waiting list for a single specialist foot and ankle surgeon at one metropolitan site was up to four years, due largely to competing emergency surgery.

Whilst specific data is limited, the consultations with orthopaedic surgeons and their representing bodies point to a relative shortage in the public sector of orthopaedic surgeons with an interest in foot and ankIe surgery. Whilst specific data are not available for surgeons with an interest in foot and ankle surgery, the Victorian Medical Workforce Survey 2000-2006 shows that in 2006 8.4% of orthopaedic surgeons worked in the public sector, 40.5% worked in private, and 51.2% worked in both public and private.

The consultations indicated that the relative shortage of orthopaedic foot and ankle surgeons working in the public system is due to their view that: • they do not believe that they are given sufficient operating theatre priority; and • remuneration in the public sector is less than in the private sector.

The consultations indicated that in the private sector there is some spare capacity and that the sub-specialty is attracting more trainees. However, it was pointed out that these specialists, once trained, would also tend to move into private practice.

Table 15. Profile of the workforce related to provision of foot and ankle services at 12 Victorian public hospitals - 2008

Orthopaedic Foot and Podiatrists Podiatric surgeons (N) ankle special (N) surgeons (N) interest surgeons (N) Dandenong Hospital 12 1 2 (1.4 FTE) 0 Monash Medical Centre 13 1 6 (1.2FTE) 0 Moorabbin Hospital 0 0 Northern Hospital Data not 0 3 (2.3 FTE) 0 available Royal Melbourne Hospital Data not 1 (0.2FTE) 2.7 FTE 0 available St Vincent’s Hospital Data not 1 4 (3.0 FTE) 0 available Western Hospital 15 1 4 (3.1FTE) 0 Austin Hospital 14 1 3 (1.6 FTE) 0 Bendigo Base Hospital 5 0 Data not 0 available Geelong Hospital 8 (3.1 FTE) 0 1 0 Goulburn Valley Hospital 3 0 2 (1.5FTE) 0 Wangaratta Base Hospital 4 0 0 0

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 50

Workforce distribution throughout Australia is also of interest to this project. Table 16 outlines the workforce numbers for orthopaedic surgeons in Australia in 2008.

The distribution of orthopaedic surgeons in Australia indicates that orthopaedic surgeons are disproportionately represented in South Australia (6.16 surgeons per 100,000 population) with the next highest ratio of orthopaedic surgeons to population being NSW at 4.69 surgeons per 100,000 population. The lowest ratio of orthopaedic surgeons to population is in the Northern Territory with less than one surgeon per 100,000 population.

Table 16. Workforce profile for orthopaedic surgeons in Australia, 2008

State Population Orthopaedic surgeons Orthopaedic (total) surgeons who indicate an interest in foot and ankle survey N N / 100,000 N pop. Victoria 5,246,079 206 3.93 19 New South Wales 6,926,990 325 4.69 48 South Australia 1,591,930 98 6.16 12 Western Australia 2,130,797 83 3.89 12 Queensland 4,228,290 174 4.12 19 Tasmania 495,772 14 2.82 0 Australian Capital Territory 340,818 18 5.28 2 Northern Territory 217,559 2 0.92 0 Australia (Total) 21,178,235 920 4.33 112 Source: Orthopaedic surgeon data: Australian Orthopaedic Association website – accessed (10/12/08) www.sport.gov.au/internet/main/publishing.nsf/Content/D0E469321C33F0C2CA257467001818FE/$File/20_08.pdf Planning and analysis unit, Service and workforce planning, Department of Human Services, October 2008

4.3 Other factors influencing the supply of foot and ankle surgical services

Factors other than workforce can influence the supply of foot and ankle elective surgery services which are discussed below and include: • theatre availability and competing priorities (such as the scheduling of emergency surgery); • other system factors (such as day surgery models or systems of patient prioritisation);

These factors, which are well recognised and have been previously described6, 16, are outlined in Figure 11. Supporting data are provided where available.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 51

Figure 11. Factors influencing the demand for and supply of elective foot and ankle surgery in Victorian public hospitals

SUPPLY DEMAND Influenced by: Influenced by: • workforce – surgeons and other • population growth

theatre staff • ageing population

• theatre availability • increasing incidence of chronic • competing priorities for surgery disease i.e. OA, obesity including unplanned • patient expectations (emergency) surgery • access to conservative • System factors such day surgery management

models or systems of patient • clinical decision-making

prioritisaion practices

4.3.1 Theatre availability and competing priorities The physical availability of theatres has a direct influence on the amount of elective foot and ankle surgery that can be undertaken. Theatre availability is influenced by localised infrastructure issues and the amount of funding made available to hospitals for infrastructure development.

In some cases theatre availability has been increased through targeted Federal and State Government funding aimed at increasing access to elective surgery (Box 3). For example, additional infrastructure has been provided to support implementation of additional elective surgery activity including: • a purpose built freestanding state-wide elective surgery centre at The Alfred; • two designated surgery centres at St Vincent’s Health and Austin Health; • new day surgery theatres at the Yarra Ranges Day Hospital; and • theatre re-development at Peninsula Health including two new theatres.

In some hospitals, provision of additional elective surgery is limited by existing theatre capacity despite the availability of additional funding from the Federal Government. For example, at one site it is estimated that theatres currently operate at 95% of capacity and so throughput is unable to be increased despite having enough surgeons to do the work. In addition, the establishment of dedicated state-wide elective surgery units was met with resistance by some surgeons who feel that issues should be dealt with locally.

In order to address limited theatre availability, some sites have successfully implemented government supported public private partnership arrangements; for example, at one site 90 foot procedures were performed at a private hospital. However, this arrangement created tension and dissatisfaction among some of the orthopaedic surgeons at the public hospital who felt that their patients should remain under their care and not be treated elsewhere.

As well as the physical availability of theatres, supply of foot and ankle elective surgery is influenced by the scheduling of surgery which needs to ‘compete’ with other types of elective orthopaedic surgery for which there is also great demand (Figure 3). Scheduling of foot and ankle surgery is influenced by demand for other types of surgery as well as the presentation and scheduling of unplanned (emergency) surgery.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 52

Figure 3 indicates that while waiting times for the most commonly performed foot and ankle procedure (excision of bunion or other toe deformity) are in excess of the clinically recommended waiting times, they are comparable to other orthopaedic conditions that also have long waiting times such as total hip joint replacement, total knee joint replacement and shoulder surgery.

These findings were supported throughout the mapping exercise and consultations with hospital staff who indicated that they did not consider foot and ankle elective surgery a greater priority than other orthopaedic elective surgery.

For these reasons, addressing the demand for foot and ankle surgery through an increase in theatre capacity could be seen as an option to manage demand. However, if foot and ankle elective surgery is not considered a priority, any additional theatre capacity would be allocated based on clinical judgements about the relative priority of other elective cases under consideration.

4.3.2 Other system factors Operating theatres do not function in isolation and the efficiency of operating theatres is closely related to the capacity of inpatient wards (including the availability of ICU beds), the emergency department and diagnostic services. Systems are influenced by system redesign such as the introduction of (among other things): • day surgery facilities, 23 hour procedure units and related models of care; • a State-wide elective surgery centre; • multidisciplinary or super clinics; and • systems of patient prioritisation.

While increasing day surgery capacity was identified in some of the consultations as a means of addressing demand for foot and ankle elective surgery, some surgeons indicated that it would be a more efficient use of theatre time to extend operating sessions to allow for some additional elective foot and ankle surgery than to move elective surgery to day surgery facilities.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 53 5. Initiatives to address demand for foot and ankle surgery

Summary of Findings

The project sought to investigate potential initiatives to meet the need for foot and ankle surgical services. Existing initiatives include examples of outpatient management strategies aimed specifically at patients with foot and ankle conditions including: • a multidisciplinary foot and ankle clinic at Barwon Health; • an advanced practice podiatry clinic at Northern Health; and • a multidisciplinary “super clinic” at Western Health.

The Barwon and Northern experiences suggest that long waiting times for an outpatient appointment with an orthopaedic surgeon can be reduced through early and accurate identification of the need for conservative management. It is not known whether these services have had an impact on waiting times for surgery, however, in the case of Barwon Health, there is evidence that the services have transferred patients who do not require or are not suitable for surgery from the surgeon, leading to more efficient use of specialist surgeon services.

Western Health used the availability of additional Commonwealth funds to create a multidisciplinary “super clinic” that was used to assess and treat all patients on its foot and ankle waiting list. This is more of an episodic solution to deal with a current problem but is a strategy that could be used in other facilities.

These models have demonstrated increases in efficiency through decreased waiting times for an outpatient appointment and a resultant increase in patient throughput. The consultation phase identified a general consensus for the creation of multidisciplinary clinics to manage demand for foot and ankle elective surgery.

One further proposal was to create a specialist centre for foot and ankle surgery to bring together a dedicated and specialised pool of clinicians that is able to deal efficiently with a large number of cases. Establishing the facility would require a significant injection of development funds.

The Barwon Health model has been identified as the preferred model as it incorporates workforce redesign to: • improve access to foot and ankle related services; and • increase the efficiency and effectiveness of the available health workforce through the optimal utilisation of skills.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 54 The project sought to investigate potential initiatives to meet the need for foot and ankle surgical services. Those identified have included: • outpatient reform initiatives; and • surgical workforce reform initiatives.

This section of the report describes these initiatives, including stakeholder views about wider implementation of such initiatives to address the demand for foot and ankle surgery.

Section 6 describes the potential role of podiatric surgeons as this was a significant driver of the project and was examined in some detail.

5.1 Outpatient workforce reform initiatives

Reform of outpatient services may involve workforce redesign and implementation of processes for referral and triage, early comprehensive assessment, evidence based multidisciplinary management and monitoring for deterioration. Current outpatient reform includes the implementation of advanced practice and multidisciplinary outpatient clinics, which have been implemented to optimise the management of patients with a variety of conditions, including osteoarthritis and shoulder conditions12, 14. There is evidence that advanced practice or multidisciplinary clinics can reduce the waiting time for an outpatient consultation12, 15.

The project identified a number of existing examples of outpatient initiatives aimed specifically at patients with foot and ankle conditions including: • a multidisciplinary foot and ankle clinic at Barwon Health (Box 8); • an advanced practice podiatry clinic at Northern Health (Box 9); and • a multidisciplinary “super clinic” at Western Health (Box 10).

Workforce redesign plays a significant role in the Barwon Health initiative as demonstrated by the decision-making practices around the need for conservative management being shifted from the surgeon to the multidisciplinary team in the foot and ankle clinic (Figure 12). In this way, workforce redesign aims to ensure the optimal utilisation of skills in order to increase the efficiency and effectiveness of the available health workforce. A major advantage of this approach is that it provides an integrated continuous service through which the clinical team is able to develop team skills and an effective working relationship.

The Barwon Health model has demonstrated a reduction in the number of patients referred to the surgeon which implies improved utilisation of specialist services. However, it is not known whether the service has had an impact on waiting times for surgery. Patient satisfaction has been assessed at Barwon Health and has been found to be high.

The Northern Hospital model (Box 9), which remains in a trial period, features assessment by a senior podiatrist, who is able to initiate conservative management prior to patients being subsequently reviewed in the orthopaedic clinic. The podiatrist in this clinic utilises the full scope of podiatry assessment and practice skills in undertaking this advanced practice role, enabling more efficient and appropriate use of the existing skills in the workforce. The Northern Hospital model comprises a restructure or redesign of traditional models of care in public hospitals.

Both examples, have demonstrated increases in efficiency through decreased waiting times for an outpatient appointment (2-4 weeks at Barwon Health and 12 weeks at Northern Health), and a resultant increase in patient throughput. The consultation phase identified a general consensus for the creation of multidisciplinary clinics to manage demand for foot and ankle elective surgery.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 55 Box 8. Multidisciplinary foot and ankle clinic – Barwon Health

A multidisciplinary foot and ankle clinic has been implemented at Barwon Health. The clinic was established in 2005 as part of the Orthopaedic Access Service, which includes similar clinics for low back and shoulder conditions. It is led by a physiotherapist and a GP and is co-located with the orthopaedic fracture clinic, providing an opportunity for consultation with the orthopaedic surgeon. Service Overview • The conditions seen at the foot and ankle clinic include bunions, hammer/claw toes, neuromas and foot and ankle sprains. • All referrals to the outpatient department are triaged and urgent cases are scheduled to see the surgeon within 2-4 weeks. All other patients attend the foot and ankle clinic before seeing the surgeon. • Patients are generally seen at the foot and ankle clinic within 4 to 6 weeks of referral (compared with up to 2 years for an orthopaedic outpatient appointment prior to the establishment of the Orthopaedic Access Service). • There is one clinic per fortnight with up to 8 – 10 patients seen per clinic. The clinic capacity was greater when the clinics were first established to deal with the backlog of patients. • Patients are assessed using standard assessment forms and referred for conservative management and/or to the surgeon as required, according to protocols. Outcomes • Early data indicate that approximately one third of patients seen at the clinic are referred on to the surgeon - the rest are conservatively managed. This is a higher rate of referral to the surgeon than other clinics i.e. referral of patients from the shoulder clinic to the surgeon is about 1 in 12. • Correspondence to GPs informs them of patient management undertaken in the clinic.

Figure 12. Workforce innovation – Allied health foot and ankle clinic (Barwon Health)

Surgery Surgical Outpatient

Waiting clinic Waiting

YES

Referral Allied Does GP health the patient want Rheumatologist foot & or require / suit Emergency ankle surgery? Dept clinic NO

Deferral from surgeon and conservative management (orthotist, podiatrist, physio, GP)

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 56 Box 9. Advanced practice* podiatry clinic – Northern Health

An advanced practice podiatry clinic is being trialled at Northern Health. The clinic was established in March 2007 and was based on a similar physiotherapy-led clinic for hip and knee joint conditions, which had been trialled the previous year. Service Overview • Referrals received by the orthopaedic outpatient clinic are triaged by an orthopaedic surgeon, and those with a non-urgent foot or ankle condition (i.e. category 2 or category 3) are directed to the advanced practice podiatry clinic. At this stage of the trial, these patients are also given an appointment with the orthopaedic surgeon. • The main conditions seen in the clinic include: bunions (42%), hallux rigidis, plantar fasciitis, digital deformities, soft tissue conditions, flat or high arches and osteoarthritis. • 89 patients have been seen in the advanced practice podiatry clinic with an approximate average waiting time of 3 months from the date of referral to assessment. • A senior (Grade 4) podiatrist assesses patients who have been referred. If a red flag is identified i.e. a patient has an urgent condition that had not initially been identified they are fast tracked to the surgeon. Alternatively the patient’s condition is conservatively managed while awaiting their appointment with the surgeon (usually around 3 months after their podiatry appointment). • Patients are then also assessed by an orthopaedic surgeon and the outcomes of both the surgeon’s and podiatrist’s assessments are compared to establish the degree of correlation. • The clinic is not co-located with orthopaedic clinics due to structural restraints but ideally the clinics would be co-located. • The conduct of the clinic is underpinned by evidence-based protocols that have been developed by the senior podiatrist. Outcomes • Patients will not be deferred from the surgeon until the trial has been evaluated. If it is found that the clinical assessment and decision-making of the podiatrist correlates highly with that of the surgeon, then patients assessed in the podiatry clinic as not requiring surgery, will be deferred from the surgeon. • The results so far indicate that the degree of correlation with regard to diagnosis is around 94%. The degree of correlation with regard to clinical decision-making has not yet been assessed.

* It should be noted that the term “advanced practice” does not mean “extended scope” as the podiatrist in this clinic, while a senior podiatrist, does not undertake an extended scope role.

A short-term targeted approach was taken by Western Health when it had access to Commonwealth funding to reduce waiting lists and established a multi disciplinary “super clinic” involving orthopaedic surgeons, physiotherapists and anaesthetists. All patients on the waiting list were assessed over a brief period of time and those needing surgery were able to be accommodated during an intensive period of surgery that coincided with the availability of a cohort of orthopaedic surgical registrars completing their training. The capacity to make assessments and to book patients into surgery immediately, as well as having operating theatres available over a period of days, led to the abolition of the foot and ankle waiting list suggesting that this approach is effective.

While this system provides an episodic solution to built-up demand, the clinical team needs to be re-established on each occasion. It also relies on a particular set of circumstances including the availability of clinicians and dedicated operating theatre resources.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 57

Box 10. Increased elective surgery capacity and the establishment of super clinics – Western Hospital

Western Health has recently sought to address long waiting lists for foot and ankle surgery as well as long outpatient waiting lists for these conditions. Federal funding has supported a significant increase in their surgery workforce, which has reduced the waiting list backlog. With this backlog addressed, ‘super foot and ankle clinics’ have been conducted on a number of occasions, based on auditing of the outpatient list. Over 100 patients may be seen at one of these clinics. The clinics see all orthopaedic patients but foot and ankle conditions are well represented because they have often been waiting for extended periods. The clinics are staffed by orthopaedic surgeons, physiotherapists, and an anaesthetist, which enables fast-tracking of patients i.e. patients are assessed for fitness for surgery and booked onto a waiting list at the same visit. By utilising the short stay unit at the Western Hospital, this initiative has helped to address the foot and ankle elective surgery backlog as many cases can be done as day cases. As a result the waiting list is very small at present owing to the increased capacity achieved with the federal funding.

Consultation with stakeholders identified some of the issues to be considered in establishing outpatient reform including: • engaging orthopaedic surgeons is an essential step when first establishing new clinics. Co-location of clinics helps to establish working relationships between health professionals; • podiatrists, as with all health professionals taking on an advanced practice role, require experience and training in addition to their entry-level qualification, and finding a person with the right skills and experience is important; • it is important that clinics are protocol driven to reduce the potential for conflict in terms of management approaches and decision-making. Protocols agreed to by all stakeholders engender support - in particular from surgeons; • these initiatives take considerable time and resources to establish and embed into routine practice and cannot be considered a short term option to manage demand for foot and ankle elective surgery.

While not considered a new initiative in foot and ankle services, podiatry-led high risk foot clinics were a feature at six of the 12 health services included in the mapping exercise (Table 14). High risk foot clinics were generally established in response to an identified need for better management of diabetic patients with a foot wound. The term “high-risk” refers to the degree of risk of lower limb amputation. Box 11 describes the high-risk foot clinic at Austin Health.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 58 Box 11. Podiatry led high risk foot clinic – Austin Health

The high-risk-foot clinic at Austin Health has been tailored over the years to better meet the specific needs of the target patient population and streamline continuity of care. Service overview • The service receives the majority of referrals from GP’s but also from the outpatient clinics, the inpatient wards and from Royal District Nursing Service. • If the referral indicates that the patient has a foot ulcer, then an appointment is made at the high-risk-foot clinic with minimal waiting time (0-2 weeks). All other patients are generally referred for management in the community. • There are two clinics per week. The Wednesday clinic is staffed by one podiatrist and runs simultaneously with Vascular outpatients clinic; the Friday clinic is staffed by three podiatrists, an orthotist and a nurse, and runs simultaneously with Endocrinology (Diabetes) outpatient clinic. • An average of 15-20 patients are seen at the Friday clinic (including around three new patients) and an average of eight patients are seen at the Wednesday clinic. In 2008, over 650 patients were seen in the Friday HRFC. • Patients are seen weekly (usually) and discharged upon resolution. Patients who have undergone amputation (minor or major) may be followed up in the Austin Amputee Podiatry clinic on a Wednesday. Patients may return if a new problem develops. • The clinics do not coincide with orthopaedic surgery clinics but an arrangement was established with a local private orthopaedic surgeon who visits the clinic on selected Fridays in order to facilitate multidisciplinary consultation regarding appropriate surgical cases. • The main reason for consultations with other specialists is impaired wound healing. If the cause of the impaired healing is thought to be vascular in nature then the patient will be referred to a vascular surgeon. If the cause is thought to be orthopaedic in nature then the patient will be referred to an orthopaedic surgeon. Occasionally both are involved. • The surgeon will review the patient in either their private rooms or in the Austin outpatient department and if surgery is indicated, the surgeon will waitlist the patient for surgery. If the patient has private health insurance, they can elect to have surgery privately in another hospital.

5.2 System redesign initiatives

Increased access to day surgery has been suggested as an option to address the demand for foot and ankle elective surgery as some of the more common foot and ankle elective surgery procedures such as toenail and bunion procedures may be suited to a day surgery model. However some surgeons indicated that it is a more efficient use of theatre time to extend sessions to allow for some elective surgery than to move elective surgery to day surgery facilities

While a day surgery model may provide additional surgical capacity, it requires implementation of a number of components of care in addition to day surgery facilities and staffing such as improved patient education regarding pain management and follow up procedures.

One further proposal that was raised during the consultations was to create a specialist centre for foot and ankle surgery. The example cited was the Victorian Plastic Surgery Unit. It would bring together a dedicated and specialised pool of clinicians that is able to deal efficiently with a large number of cases. It would also act as the leading training and research centre for clinicians who want to specialise in the treatment of foot and ankle disorders. Establishing the facility would require a significant injection of development funds. Partnering with a private hospital could make this a more attractive proposition for the department.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 59 6. The role of podiatric surgeons

Summary of Findings

A podiatric surgeon is a podiatrist who undertakes additional training under supervision of the Australasian College of Podiatric Surgeons. They practise almost entirely in the private sector, owing to system limitations such as. • State regulations which exclude podiatric surgeon from the definition of medical practitioner; • lack of access to surgical rights in public hospitals; • the limited number of private health insurers that provide rebates for services provided by podiatric surgeons (at present podiatric surgeons have admitting rights at fewer than ten out of approximately 540 private hospitals in Australia); and • lack of uniform or national access to prescribing privileges for the independent management of patients’ pharmacological needs.

In Victoria, two podiatric surgeons practise in the private health system; none practise in the public hospital system. Only one podiatric surgeon practises in the public health system in Australia (in South Australia).

The scope of practice of podiatric surgeons includes any surgical procedure of the foot and ankle, but the actual scope of practice is commonly self-limited to procedures involving the forefoot.

Employing podiatric surgeons as part of multidisciplinary teams (including podiatrists and physiotherapists) in public hospitals was strongly argued by podiatric surgeons as the preferred solution to meeting the current and future demand for foot and ankle surgery. Examples are also evident overseas of significantly greater involvement of podiatric surgeons in providing public surgical services. The consultations confirmed that the inclusion of podiatric surgeons as part of such teams would be a logical and optimal strategy.

There are however a number of impediments to this solution: • orthopaedic foot and ankle surgeons, general orthopaedic surgeons, other medical specialists and some podiatrists have concerns about the quality of the current podiatric surgery training program; • while hospital CEOs have the power to engage suitably credentialed professionals, it is highly unlikely that any would be prepared to pursue this path given the current views of medical specialists; • there is an insufficient number of podiatric surgeons in the system at the moment to make significant impact; and • podiatric surgeons would be competing for already scarce operating theatre time.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 60 6.1 Background

In Victorian public hospitals, surgical procedures on the foot and ankle are carried out predominantly by orthopaedic surgeons, some of whom have an interest in foot and ankle surgery. Surgery related to the foot and ankle is also performed by general practitioners and podiatrists (e.g. toenail surgery), vascular surgeons (e.g. amputations), paediatric orthopaedic surgeons (e.g. surgery for club foot) and general surgeons. In the private hospital system a small proportion of foot and ankle surgery (approximately 1.9%) is undertaken by podiatric surgeons5. Podiatric surgery is also performed in private practice, community health centres, day surgical centres and one public hospital7.

A podiatric surgeon is a podiatrist who undertakes additional training under supervision of the Australasian College of Podiatric Surgeons (ACPS).

There has been ongoing debate about the role of podiatric surgeons in the Australian health system. In a submission to The National Health and Hospital Reform Commission, the ACPS argues that health system reform should include increased utilisation of podiatric surgeons as part of broad based health workforce reform and that podiatric surgeons represent an example of existing workforce skills which can contribute to addressing the current issues facing the health system8. A recent report by Access Economics has also assessed the economic impact of increasing the utilisation of podiatric surgeons in Australia5.

The ACPS has identified a number of barriers that prevent increased podiatric surgeon workforce participation. These are further reflected in the Productivity Commission’s “Australia's Health Workforce” Report (2005)19 and include: • State regulations which exclude podiatric surgeon from the definition of medical practitioner; • lack of access to surgical rights in public hospitals; • the limited number of private health insurers that provide rebates for services provided by podiatric surgeons (at present podiatric surgeons have admitting rights at fewer than ten out of approximately 540 private hospitals in Australia); and • lack of uniform or national access to prescribing privileges for the independent management of patients’ pharmacological needs.

The ACPS has subsequently offered a number of recommendations to the National Health and Hospitals Reform Commission to improve the contribution of podiatric surgery including the recommendation that: “targeted funding be provided for health departments to employ podiatric surgeons to contribute to elective surgery waiting lists in a cost-effective manner”8.

The current project sought to describe the current and potential roles of podiatric surgeons in the public and private systems and to explore issues relating to the feasibility of workforce reforms involving podiatric surgeons.

6.2 Current podiatric surgeon workforce and service model

Table 17 describes the current podiatric surgical workforce and its distribution in Australia in 2008. Currently there are 25 fellows and 5 trainees of the ACPS. There are only three trained podiatric surgeons in Victoria. Each works in the private sector and uses their practices to train podiatric surgical registrars. There are currently three trainees in Victoria.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 61

Table 17. Workforce profile for podiatric surgeons in Australia, 2008

State Population Podiatric surgeons N N / 100,000 pop. Victoria 5,246,079 2 0.04 New South Wales 6,926,990 5 0.07 South Australia 1,591,930 7 0.44 Western Australia 2,130,797 8 0.38 Queensland 4,228,290 3 0.07 Tasmania 495,772 0 0 Australian Capital Territory 340,818 0 0 Northern Territory 217,559 0 0 Australia (Total) 21,178,235 25 0.11

The distribution of podiatric surgeons by state indicates that around two-thirds of all podiatric surgeons work in Western Australia (32%) and South Australia (28%) and that the ratio of podiatric surgeons to population in these states is at least five times greater than other states or territories. The reported reasons for this imbalance in the podiatric surgeon workforce distribution are historical and related to: • the availability of training which was initially only available in WA and SA; and • the availability of private health insurance refunds for podiatric surgeons which were not available in the Eastern states until 2004.

Referrals to podiatric surgeons come from three sources: • medical practitioner, mainly GPs or rheumatologists; • podiatrists; and • client self referral.

Podiatrists who refer to a podiatric surgeon can do so directly. However, if a podiatrist wishes to refer a patient to an orthopaedic surgeon, they need to do so via a general practitioner.

Consultations with private sector podiatrists indicated that their decision to refer to a podiatric or an orthopaedic surgeon was based upon: • where they believed the patient would receive the best quality care (complex cases or cases with complex co-morbidities were often referred to an orthopaedic surgeon); • patient preferences – the consultations found that while it is not necessarily an informed choice, patients tended to prefer orthopaedic surgeons as their preference was to see a medical specialist; and • the ability to pay private health costs.

While podiatrists tend to refer complex cases to orthopaedic surgeons there is no apparent concern about the level of competence of podiatric surgeons for other cases. In fact, the consultations with referring podiatrists found that they felt podiatric surgeons had a better understanding of foot problems than orthopaedic surgeons and were more likely to follow conservative treatment paths.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 62 There is only one podiatric surgeon currently employed in the public health sector, located in South Australia. It is understood that while being a member of the Department of Procedural Services, he does not work in a team environment with orthopaedic surgeons. He works one session per week in the public hospital and his trainee is able to work with him in both sectors. This service model is reflected in Figure 13. There is no indication that the use of podiatric surgeons in the public sector is likely to extend to other hospitals in South Australia. In all other Australian States podiatric surgeons practise only in the private health sector.

Figure 13. Service model – Podiatric surgery, Repatriation General Hospital, Daw Park, South Australia

Orthopaedic Orthopaedic Outpatients Surgery Waiting Waiting

Referral GP Rheumatologist Emergency Dept Triage

Podiatric Podiatric Outpatients Surgery Waiting Waiting

6.3 Qualifications

In order to ensure that there is an adequate workforce to meet the future needs for foot and ankle surgery, it is necessary to have professionals with qualifications that are deemed appropriate for the task. The consultations elicited a degree of disagreement about the adequacy of the training that is now being undertaken by both podiatric surgeons and other surgeons.

Podiatric surgeons are of the view that some foot and ankle surgery is being undertaken by surgeons who have not been trained in this specific area. Orthopaedic foot and ankle surgeons are of the view that podiatric surgeons do not have the breadth of training to enable them to deal with surgical complications.

Because there is no external definition of the standards and experience that must be achieved before certifying a professional to undertake foot and ankle surgery it is not possible to determine whether either of these views is correct.

Training program for orthopaedic surgeons To become an orthopaedic surgeon requires: • Completion of a medical degree; • Completion of the internship year and Post Graduate Year 2; and • Specialist surgical training in orthopaedics which takes five years. Specialising in foot and ankle surgery requires additional postgraduate fellowship training in foot and ankle surgery, which takes one year. Medical specialist surgical programs are accredited by the Australian Medical Council (AMC).

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 63

Box 12. Podiatric surgery at the Repatriation General Hospital, Daw Park, South Australia

Background There is the only podiatric surgeon operating in the public health system in Australia. He works at the Repatriation General Hospital in Daw Park, South Australia. The role developed historically in the 1980’s when the then head of podiatry developed an interest in podiatric surgery and began performing surgical procedures in outpatients and then extended his practice to inpatients. The role has continued to the present day and is currently funded partly as a teaching position by the University of South Australia (50%) and partly by the hospital (50%).

Scope of practice Podiatric surgery is generally limited to procedures of the forefoot including mainly: bunions; hammertoes; neuromas; ingrown toenails and exosectomies. The reasons for the limited scope of practice are partly political, partly due to workload (demand outstripping supply) and primarily because of the focus on procedures suited to day surgery.

Service model, capacity and waiting times Most referrals to orthopaedic outpatients for foot and/or ankle conditions are made by GPs or podiatrists. Referrals are assessed and triaged by the orthopaedic surgeon and appropriate cases are referred to the podiatric surgery outpatient clinic. Currently there is one podiatric surgery outpatient clinic per week assessing on average 3-4 new patients and 6 review patients. Some minor procedures are performed under local anaesthetic such as removal of ingrown toenails. There is one podiatric surgery theatre session per fortnight operating on 2-3 cases per session. There are currently between 50 – 100 people on the podiatric surgeon waiting list and the current waiting time is around 12 months. The major contributors to long waiting times are access to theatre time, anaesthetists, nursing staff and funding.

Advantages and disadvantages of working in the public sector Advantages include: • exposure to a more complex patient population which provides professional development and teaching opportunities for podiatric surgery trainees; • opportunities to collaborate with other medical specialists and allied health professionals; • less competition with orthopaedic surgeons because of reduced financial motivations and increased willingness of orthopaedic surgeons to divest themselves of work they don’t necessarily want to do; and • the opportunity to “pave the way” for other podiatric surgeons.

Disadvantages include: • poor remuneration compared with the private sector i.e. Andrew Van Essen is employed as an allied health professional even though he is performing podiatric surgery and is therefore paid significantly less than an orthopaedic surgeon. While podiatric surgeons are not looking for remuneration equal to that of orthopaedic surgeons, the current rates of pay are not viable in the long term; and • political issues in relation to acceptance by orthopaedic surgeons.

Overall, Andrew Van Essen believes that while podiatric surgeons may be considered “lesser trained” when compared with orthopaedic surgeons, they are: “equally, if not more capable in foot and ankle surgery and in fact have a better understanding of conservative management and how this can be integrated with or augment foot surgery” (Andrew Van Essen, Podiatric surgeon).

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 64 Training programs for podiatric surgeons To become a podiatric surgeon requires: • Completion of a bachelor’s degree in podiatry; • Clinical experience of two years; and • Concurrently with studying for a master’s degree in podiatry, Fellowship training under the supervision of the ACPS, which takes three years.

There is no equivalent to the AMC accreditation process for the podiatric surgical program offered by the ACPS.

Currently all of the training of podiatric surgeons is in the private sector, which limits the number and types of cases that can be used. All trainees are required to work in the UK or the US in order to have access to the broader range of cases that are seen in the public hospital systems. It is argued by podiatric surgeons that having access to public hospital practice would not only assist in alleviating the waiting lists for foot surgery, but would provide a better environment in which training can take place, not least because there would be the possibility of multidisciplinary experience. Podiatric surgeons believe and would wish to work in clinical teams with orthopaedic surgeons, as is the case in the US and the UK, and as has been the case when Australian podiatric surgeons have worked in the US and the UK.

A different training pathway from that of the ACPS is offered by the University of Western Australia. Podiatry courses are located in the School of Surgery within the Faculty of Medicine. A number of the first and second year subjects of the undergraduate degree (Bachelor of Podiatric Medicine) are common to the medical and dental degrees and students attend the same classes. For students wishing to specialise in podiatric surgery the University offers a postgraduate three-year coursework Doctorate of Clinical Podiatry degree focusing on either elective foot surgery (not ankle) or the management of high-risk foot problems (in the public hospital system). Having these courses located in a medical faculty and with a greater emphasis on medical content may allay some of the concerns that medical specialists express about the need for a more medically focused training program.

It should be noted that the consultations identified a firm view within the Australian orthopaedic surgery profession about inadequacy of the current training program for podiatric surgeons in Australia and that they would not wish to work with podiatric surgeons unless they perceive them as appropriately qualified. The Australasian College of Podiatric Surgery believes that its program is comparable to its international peers. It was not within the scope of this project for the consultants to undertake a detailed comparison of the ACPS and international training programs, although it was noted that there are different programs in the UK and the US and each of these has apparent differences from the ACPS one. In addition, there is now a new program based at the University of Western Australia which is also different from the ACPS program. This difference of opinion could be resolved by having the ACPS program externally accredited because that is likely to address the question of comparable standards and the appropriateness of the training.

6.4 Scope of practice and funding

There are no discipline-specific registration boards for either orthopaedic foot and ankle surgeons or podiatric surgeons. The Medical Registration Board of Victoria is responsible for medical practitioners and specialists (orthopaedic surgeons and other specialties) while individual hospitals credential specialists to provide certain services. The Podiatrists Registration Board of Victoria allows registered podiatrists to have their records annotated if they have completed the fellowship of the ACPS, but this does not affect the individual’s scope of practice. Within these regulatory environments individual practitioners are self-

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 65 regulating. It has been reported that the majority of surgery performed by podiatric surgeons is on the forefoot.

Medicare covers the cost of all procedures performed in public hospitals by surgeons employed by the public health system. Medicare covers 75% of the scheduled fee for procedures performed by surgeons in the private health system. The ‘gap’ payment (the remaining 25% of the scheduled fee) plus any additional charge by the surgeon is generally met by private health insurance or by the patient.

Podiatric surgeons may perform any surgical procedure of the foot and ankle. However, in practice the scope of podiatric surgeons is self-limited to those procedures with which they feel competent and appear to concentrate on surgery of the forefoot.

The Medicare Benefits Schedule does not apply to any service provided by a podiatric surgeon. Legislative amendments in 2004 made it possible for private health insurance funds to pay benefits for the services of 14 Commonwealth nominated accredited podiatrists. In Victoria prior to 2004, all costs associated with podiatric surgery, including hospital accommodation costs, had to be paid for in full by the patient.

6.5 Safety and effectiveness of podiatric surgeons

Safety and effectiveness of podiatric surgeon services is a key consideration in the debate regarding the role of podiatric surgeons. The literature in this area is limited. Two identified studies concluded that podiatric surgery was safe and effective however, the findings of these studies are limited as they did not include a comparison group20, 21. One study compared podiatric surgery with other surgical disciplines and found the results of podiatric surgery to be equivocal to the comparison group22 (Box 13).

Box 13. Studies investigating outcomes of podiatric surgery

Three identified studies have investigated the outcomes of podiatric surgery in terms of safety and effectiveness. • Bennett et al (2001) reported on a six-month prospective study that investigated the outcomes of foot surgery performed by Fellows of the ACPS, and found no significant adverse outcomes or unplanned re-admissions to the hospital20. • Kilmartin (2002) found podiatric surgery to be safe and effective and that the existence of podiatric surgery in a UK National Health Service Trust enhanced quality and range of care delivered by clinicians specifically trained in the conservative and surgical management of foot disorders21. • Butterworth et al (2008) concluded that podiatric surgery carried no greater risk of infection to the patient than other surgical disciplines, and results for Australia showed infection rates to be well within accepted industry standards as stated in recent literature22.

6.6 Cost effectiveness of podiatric surgeons

Access Economics undertook an economic impact analysis estimating the potential impact of improving access to podiatric surgeons in the Australian health sector. The project assessed the cost effectiveness and cost benefit of using podiatric surgeons to perform foot and ankle surgery compared with using orthopaedic surgeons. Key findings of the project were that: • podiatric surgery is less costly than orthopaedic surgery across all categories of procedure on average by $3,635 per procedure; and • in addition to the $3,635 per procedure saved in financial costs there is also a relative gain in well being worth $5,016 per procedure from podiatric surgery relative to orthopaedic surgery. Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 66

The report’s conclusions support the greater utilisation of podiatric surgeons in the Australian health system and cited benefits included: • substantial financial savings; • decreased waiting time for elective foot surgery; • increased productivity; • improved prevention of co-morbidities; and • a quicker return to an improved quality of life.

A critique of the Access Economics report suggests that some of the assumptions used to inform the economic analysis in the report may be flawed and as such the full economic benefits of podiatric surgeons outlined in the report should be considered with caution. It should be noted that the paucity of available data obliged the use of the assumptions.

The consultants believe that the report does not fully account for the complexities of the health system and has over simplified the issue of meeting demand for elective surgery into a workforce substitution issue, when in fact the range of factors that influence the supply of and demand for foot and ankle elective surgery are complex and variable, as highlighted in this report.

A strength of the report is that, although reducing the problem to one of workforce, it acknowledges that workforce solutions should aim to utilise current skills in the workforce most efficiently and introduce new skill sets to the health system as opposed to reinforcing restrictive, traditional models of practice in the health system.

Specific criticisms are discussed fully in Appendix 5 and include: • the definition of orthopaedic surgeons; • assumptions regarding the scope of podiatric surgical practice and the equivalence of service quality and safety; • the estimation of length of stay which ignores the contribution of patient and system related factors to length of stay; • the extrapolation of public sector data on waiting times to the private sector (and vice versa)( necessary due to the absence of existing data); • the extrapolation of productivity losses related to construction workers with a foot/ankle related condition to all patients with a foot/ankle condition; and • a perceived lack of consultation with health professionals and service providers outside the podiatric profession.

6.7 A possible workforce initiative - creating a multidisciplinary team (employing podiatric surgeons in public hospitals)

The employment of podiatric surgeons in public hospitals was strongly argued by podiatric surgeons as their preferred solution to meeting the demand for foot and ankle surgery. Ideally they would be part of a multidisciplinary team, including orthopaedic surgeons, podiatrists and physiotherapists.

The podiatric surgeons have suggested that a two-year pilot program be initiated to evaluate an alternative model for elective foot and ankle surgery. A podiatric surgeon and support team would be engaged by a public hospital to perform identified surgical and clinical procedures within a limited scope of practice and a governance and evaluation regime. The object would be to assess the effectiveness of quality of care and quality of life for patients undergoing elective foot and ankle surgery.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 67 As discussed above, there are a number of impediments to this solution: • orthopaedic foot and ankle surgeons, general orthopaedic surgeons, other medical specialists and some podiatrists have concerns about the quality of the current podiatric surgery training program; • while hospital CEOs have the power to engage suitably credentialed professionals, it is highly unlikely that any would be prepared to pursue this path given the current views of medical personnel; • there is an insufficient number of podiatric surgeons in the system at the moment to make significant impact; and • podiatric surgeons would be competing for already scarce operating theatre time.

The main impediment remains the perceived adequacy of the training program. This could be resolved by having the ACPS programme externally accredited.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 68 7. Roadmap for implementation of possible solutions

The project sought to: • identify and analyse a range of possible alternative solutions to enhance access to foot and ankle elective surgery; and • provide guidance to decision-making regarding possible alternatives to address the demand for foot and ankle surgery.

Section 5 identifies: • outpatient reform initiatives; and • surgical workforce reform initiatives.

Section 6 describes the potential role of podiatric surgeons as this was a significant driver of the project and was examined in some detail.

Both Sections further identify implementation strategies and barriers

Table 18 below summarises the preferred proposed solutions and implementation strategies, and provides an indication of the timeframes for these strategies.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 69 Table 18. Summary of proposed solutions and implementation strategies

Option Option Attributes Implementation Strategies

Description Benefits Limitations Short term Medium term Long term

Establishing A regular clinic Reduced waiting times Limiting exposure of Recruit appropriately Build up an evidence Build up an evidence multidisciplinary clinics assessing all foot and and access to a range orthopaedic and qualified staff. base to support base to support ankle problems in of conservative and podiatric surgical implementation. sustainability. order to triage patients surgical solutions. trainees to non- for the most effective operative cases. Identify facilities and timely treatment. preferably co-located Workforce may involve with orthopaedics. podiatrists, physiotherapists, podiatric surgeons, GPs; ideally collocated with orthopaedic clinics to provide access to surgical review as required.

Introducing advanced Providing capacity for Increasing the number Recruiting Identify the main Train staff in role Develop and support practice roles different members of of health professionals appropriately qualified clinical groups in foot extension while also extended practice the clinical team to able to assess and staff and ensuring and ankle surgery, engaging the clinical multidisciplinary work to the capacity of treat patients, thus that all team including podiatrists specialists to accept teams. their skills and clinical reducing waiting times. members recognise and podiatric the advanced practice abilities. and accept the surgeons, to concept as part of the clinical capacities and determine the degree clinical environment, Workforce may involve limitations of each to which their scope including the capacity advanced practice team member. of practice could be of different members podiatrists or, extended. of the team to make physiotherapists. effective clinical judgements.

Increasing theatre Availability of theatre Reducing waiting Requires additional Secure funding to Attract surgeons and capacity to cope with a greater times for surgery funding and the ready staff theatres. anaesthetists to the range of cases, generally and for availability of surgical public sector. including elective elective surgery more staff and

surgery. specifically. anaesthetists, nurses and related theatre staff.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 70 Option Option Attributes Implementation Strategies

Description Benefits Limitations Short term Medium term Long term

Increasing theatre Collect sufficient Provide additional capacity (cont) accurate data to funding to support the justify the use of engagement of theatre additional theatre staff. capacity for foot and ankle surgery.

Increasing the Attract more Increased surgical Funding constraints Inject funds to Build sufficient available orthopaedic orthopaedic surgeons capacity. may impede public support orthopaedic workforce numbers workforce for foot and to work in the public sector competing with appointments. for sustainability. ankle surgery sector. private sector salaries and conditions. Broader clinical team so that less complex cases can be performed by less specialised surgeons.

Establishing a podiatric Engage podiatric Increased surgical Although scope of Podiatric surgeons Podiatric surgeons Build sufficient surgeon workforce for surgeons as full capacity. practice would need prepare for national apply and gain (?) workforce numbers foot and ankle surgery members of the to be defined and registration and national registration, for sustainability. clinical team to work acknowledged, the accreditation. accreditation and S4 within established and Broader clinical team training of podiatric prescibing rights. accredited scope of surgeons would need so that less complex practice. cases can be to be accredited at a performed by less national level and the Address cultural specialised surgeons registration of such barriers/ resistance surgeons and their from medical scope of practice profession. defined.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 71 8. Conclusion

• The purpose of this project was to define delivery of foot and ankle surgery within public hospitals in Victoria; identify problems associated with this delivery and explore solutions to better meet demand for foot and ankle surgical services.

• Whilst the measures of demand for foot and ankle surgery are highly variable amongst Victorian hospitals, there are indications of a level of unmet need, and indications that the demand will continue to increase. The unmet need may be highest for complex foot and ankle surgery undertaken by more specialised surgeons but more specific data is required in this regard. These trends are not unique to foot and ankle surgery, but are shared by other elective orthopaedic surgery and elective surgery in general.

• The solutions identified in this Report are not equally applicable to all clinical settings, but they provide effective options for meeting foot and ankle surgical needs.

• A case has been made by podiatric surgeons that waiting lists could be alleviated by enabling them to work in public hospitals but several major impediments were identified which mitigate against this being an immediate solution. Many of these could be resolved by accreditation of the podiatric surgery training program by an appropriate external body.

• While employing podiatric surgeons in public hospitals may form part of an optimal long term solution, there are a number of potential short and mid term options to address foot and ankle surgery waiting lists in the public system including: o establishing multidisciplinary foot and ankle clinics (as at Barwon Health); o establishing “super clinics” (as at Western Health); and o increasing operating theatre time.

• The optimal solution may involve multidisciplinary clinics employing orthopaedic foot and ankle surgeons, podiatric surgeons, podiatrists, physiotherapists, orthotists and related allied health practitioners. However the project was unable to recommend this as a viable short term to medium term solution while concerns remain over the adequacy of podiatric surgical training. If this problem were resolved, through an appropriate accreditation and registration process, the optimal solution could become a reality, leading to clinical teams working closely together to have patients treated by the most appropriate member of the team based on effective clinical judgements.

• The information gathered in this project may also provide useful input into general planning for the delivery of elective surgery services in Victoria.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 72 9. Bibliography

1. Garrow A, Silman A, MacFarlane G. The Cheshire foot pain and disability survey: a population survey assessing prevalence and associations. Pain. 2004;110:378-84. Menz H, Gilheany M, Landorf K. Foot and ankle surgery in Australia: a descriptive analysis of the Medicare Benefits Schedule database, 1997-2006. Journal of the Foot and Ankle Research. 2008;8:1(10). 2. Hill C, Gill T, Menz H, Taylor A. Prevalence and correlates of foot pain in a population-based study: the North West Adelaide health study. Journal of Foot and Ankle Research. 2008;1:2. 3. Keysor J, Dunn J, Link C, Badlissi F, Felson D. Are foot disorders associated with functional limitation and disability among community-dwelling older adults? Journal of Aging and Health. 2005;17(6):734-52. 4. Menz H, Gilheany M, Landorf K. Foot and ankle surgery in Australia: a descriptive analysis of the Medicare Benefits Schedule database, 1997-2006. Journal of the Foot and Ankle Research. 2008;8:1(10). 5. The economic impact of podiatric surgery: Access Economics (for The Australasian College of Podiatric Surgeons); September 2008. 6. Victorian Surgical Services Strategy. Melbourne: Department of Human Services; 2008. Available from: http://www.health.vic.gov.au/surgery/sss- backgroundpaper0408.pdf. 7. What is podiatric surgery? Who are podiatric surgeons? What is the Australasian College of Podiatric Surgeons? : Australasian College of Podiatric Surgeons. Available from: www.acps.edu.au/PDF's/what%20is%20podiatric%20surgery1.pdf. 8. National Health and Hospitals Reform Commission Submission. Australasian College of Podiatric Surgeons; May 2008. 9. Demographics of Shoulder, Elbow, Wrist, Ankle, and Spinal Disc Arthroplasty. Supplementary Report. National Joint Replacement Registry, Australian Orthopaedic Association; 2008. Available from: http://www.aoa.org.au/docs/NJRRShoulderWrist08.pdf. 10. Hip and Knee Arthroplasty. Annual Report. National Joint Replacement Registry, Australian Orthopaedic Association; 2008. Available from: http://www.aoa.org.au/docs/NJRRAnnRep08_revd.pdf. 11. The state of our public hospitals. Canberra: Department of Health and Ageing; June 2008. Available from: www.health.gov.au/internet/main/publishing.nsf/Content/health- ahca-sooph-index08.htm. 12. Hawkins M, Landgren F, Osborne R. The Victorian Orthopaedic Waiting List Project Phase II – The Osteoarthritis Hip and Knee Service Pilot Implementation; 2007. 13. Planning and analysis unit, Service and workforce planning, Department of Human Services, October 2008. 14. Gurr J, Bower V, Walton T. Establishing a multi-disciplinary foot ulcer clinic – a practical approach. Australasian Journal of Podiatric Medicine. 2007;41(1):3-6. 15. Mangan J, Ashford R. A multidisciplinary approach to foot surgery waiting lists. The Foot. 1992;2(1):29-33. 16. Pencheon D. Matching demand and supply fairly and efficiently. BMJ. 1998;316:1665-7.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 73 17. Beischer A, Cornoiu A, de Steiger R, Donnan L, Richardson M. HIC 2006 and HINZ 2006: Proceedings; pages: 37-47. Westbrook, Johanna (Editor); Callen, Joanne (Editor); Margelis, George (Editor); Warren, James (Editor). Brunswick East, Vic.: Health Informatics Society of Australia, 2006. 18. National Health and Hospitals Reform Commission Submission: Australasian Podiatry Association (QLD); May 2008. 19. Submission to Productivity Commission Health Workforce Study: Australasian College of Podiatric Surgeons; July 2005. 20. Bennett P, Patterson C, Dunne M. Health-related quality of life following podiatry surgery. Journal of the American Podiatric Medical Association. 2001;91(4):164-73. 21. Kilmartin T. Podiatric surgery in a Community Trust; a review of activity, surgical outcomes, complications and patient satisfaction over a 4 year period. The Foot. 2002;11:218-27. 22. Butterworth P, Gilheany M, Tinley P. Postoperative infection rates in foot surgery: a clinical audit of Australian podiatric surgeons 2007 – 2008. Submitted to Australian Health Review. 2008.

Other references:

Australasian College of Podiatric Surgeons. Training Program. February 2004. Australasian College of Podiatric Surgeons. A comparison of the requirements for training as a foot surgeon in Australia, the USA and the UK: a discussion paper. February 2009. The University of Western Australia – http://www.surgery.uwa.edu.au/go/schools-and-centres/schools/school-of-surgery-and- pathology/units/podiatric-medicine/homepage United Kingdom http://www.feetforlife.org/cgi-bin/item.cgi?ap=1&id=521&d=pnd&dateformat=%25o-%25B United States of America http://www.aacpm.org/html/careerzone/require.asp http://www.aacpm.org/html/careerzone/career_training.asp

Borthwick AM. Challenging medicine: the case of podiatric surgery. Work, Employment and Society. 2000;14(2):369-83.

Issac A, Gwilym SE, Reilly IN, Kilmartin TE, Ribbans WJ. Interprofessional relationships between orthopaedic and podiatric surgeons in the UK. Annals of the Royal College of Surgeons England. 2008;90:663-70.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 74 Appendices

Appendix 1. Literature Review

(See supplementary document attached as a separate document)

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 75 Appendix 2. Membership and Terms of Reference of the Reference Group

Foot and Ankle Elective Surgery Feasibility Study

Reference Group Terms of Reference

Project Purpose

The purpose of this project is to explore solutions to better meet demand for foot and ankle elective surgery from a service and workforce planning perspective. In particular the project aims to: • Develop an accurate description of the current delivery of foot and ankle elective surgical services • Define the problems associated with the current delivery of foot and ankle surgical services • Identify and analyse a range of possible alternative solutions to enhance access to foot and ankle elective surgery, ensuring that current and potential workforce options are fully explored • Provide an evidence base to assist decision making regarding possible alternatives to address the demand for foot and ankle surgery.

Purpose of the Reference Group

To provide expert advice and guidance to support achievement of the project objectives by

1. reviewing project inputs and outputs and provide advice and guidance accordingly. 2. ensuring the project has undertaken broad, representative and effective stakeholder consultation.

Membership

Foot and ankle orthopaedic surgery Alison Taylor, Secretary of the Foot and Ankle representative Society of the Australian Orthopaedic Association Podiatric surgery representative Mark Gilheany, President of the Australasian College of Podiatric Surgery Education and training representative Adam Bird, Head of Podiatry School, Latrobe University Public hospital - Director surgery Clare Cully, Director of Surgery Western Health representative Public hospital – Director Allied health Debra Schulz, Director of Allied Health, Barwon representative Health Consumer representative Sue Viney DHS Workforce Innovation representative Susan Morgan, Manager, Workforce Innovation - Chair Kathleen Philip, Service and workforce planning

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 76

DHS Surgical services program Terry Symonds, Manager, Surgical Services representative Program TBC Consultants Peter Brooks, Australian Health Workforce Institute Brendan Maloney, Australian Health Workforce Institute Fiona Landgren, Project Health Catherine Jones, Project Health Vin Massaro, Massaro Consulting Lorraine Perry, Massaro Consulting

Secretary

• Agenda & Minutes to be circulated by the Secretary to Reference Group members

Quorum

• Half of the membership plus one

Meeting Frequency

• As required

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 77 Appendix 3. Data request sent to Victorian public hospitals for data pertaining to foot and ankle elective surgery and outpatient services

1. New patients

(include relevant dates to which data applies)

1.1 Mean number of new orthopaedic referrals per week

1.2 Mean number of new referrals for patients with foot or ankle problems per week

1.3 Mean number of new patients seen at consultant orthopaedic outpatients per week

1.4 Mean number of new patients with foot or ankle problems seen at consultant orthopaedic outpatients per week

2. Review Patients

(include relevant dates to which data applies)

2.1 Mean number of review patients seen at consultant orthopaedic outpatients per week

2.2 Mean number of review patients with foot or ankle problems seen at orthopaedic outpatients per week

3. Waiting list for orthopaedic outpatients

(include relevant dates to which data applies)

3.1 Total number of patients on waiting list for an orthopaedic outpatient appointment (Snap shot).

3.2 Number of patients on waiting list for an orthopaedic outpatient appointment with foot or ankle problems (Snap shot).

3.3 Mean (range) waiting time for orthopaedic outpatient appointment.

3.4 Mean (range) waiting time for orthopaedic outpatient appointment for patients with foot or ankle problems

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 78 4. Waiting list for surgery

(include relevant dates to which data applies)

4.1 Total number of patients on the waiting list for orthopaedic Cat 1 surgery by urgency category (Snap shot) Cat 2 Cat 3

4.2 Total number of patients on the waiting list for orthopaedic Cat 1 surgery with foot or ankle problems (Snap shot) Cat 2 Cat 3

4.3 Mean (range) waiting time for surgery (time to treat) for all Cat 1 days orthopaedic surgery Cat 2 days Cat 3 days

4.4 Mean (range) waiting time for surgery (time to treat) for Cat 1 days foot or ankle problems Cat 2 days Cat 3 days

5. Foot and ankle conditions requiring surgery – previous 12 months

Top 10 diagnoses requiring foot and ankle Separations Mean (range) surgery (previous 12 waiting time months) or (days) specific timeframe

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 79 Appendix 4. Foot and ankle procedures Victorian hospitals 2007 /2008

Source: Victorian Admitted Episodes Data Set (VAED)

No. (%) No. (%) episodes episodes Private Public Procedure code Procedure code description (n=6,886) (n=6,053) APPLICATION, INSERTION, REMOVAL Other application, insertion or removal procedures on ankle or foot 0 (0) 0 (0) 4970300 Arthroscopic lavage of ankle 0 (0) 0 (0) 4970601 Lavage of ankle 0 (0) 0 (0) INCISION Osteotomy of ankle or foot 412 (6.0) 136 (2.2) 4840615 Osteotomy of tarsal bone 24 (0.3) 5 (0.1) 4840915 Osteotomy of tarsal bone with internal fixation 11 (0.2) 9 (0.1) 4840002 Osteotomy of metatarsal bone 60 (0.9) 22 (0.4) Osteotomy metatarsal bone with internal 4840300 fixation 141 (2.0) 20 (0.3) 4840003 Osteotomy of toe 44 (0.6) 35 (0.6) 4840301 Osteotomy of toe with internal fixation 132 (1.9) 45 (0.7) Other incision procedure on ankle 299 (4.3) 91 (1.5) 4970000 Arthroscopy of ankle 178 (2.6) 26 (0.4) 4970600 Arthrotomy of ankle 30 (0.4) 41 (0.7) 4970302 Arthroscopic removal loose body of ankle 72 (1.0) 11 (0.2) 4970602 Removal of loose body of ankle 14 (0.2) 11 (0.2) 4970603 Division of ankle contractures 5 (0.1) 2 (0.03) Other incision procedure on foot 200 (2.9) 107 (1.8) 4980600 Subcutaneous tenotomy of foot 2 (0.03) 4 (0.1) 4980900 Open tenotomy of foot 69 (1.0) 72 (1.2) 4985400 Plantar fasciotomy 126 (1.8) 31 (0.5) 9055600 Tenolysis Achilles flexor/extensor tendon 3 (0.04) 0 (0) EXCISION Arthroscopic excision procedure on ankle 250 (3.6) 57 (0.9) 4970001 Arthroscopic biopsy of ankle 5 (0.1) 8 (0.1) 4970301 Arthroscopic trimming osteophyte ankle 75 (1.1) 20 (0.3) 4970304 Arthroscopic synovectomy of ankle 170 (2.5) 29 (0.5) Excision of bone of foot 455 (6.6) 172 (2.8) 4793301 Excision of exostosis of bone of foot 83 (1.2) 57 (0.9) 5033300 Excision of tarsal coalition 27 (0.4) 17 (0.3) 4840916 Ostectomy tarsal bone internal fixation 14 (0.2) 1 (0.02) 4840616 Ostectomy of tarsal bone 46 (0.7) 6 (0.1)

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 80 No. (%) No. (%) episodes episodes Private Public Procedure code Procedure code description (n=6,886) (n=6,053) 4840004 Ostectomy of metatarsal bone 157 (2.3) 41 (0.7) Ostectomy metatarsal bone with internal 4840302 fixation 32 (0.5) 9 (0.1) 4840005 Ostectomy of toe 71 (1.0) 32 (0.5) 4840303 Ostectomy of toe with internal fixation 25 (0.4) 9 (0.1) Amputation of ankle or foot 283 (4.1) 645 (10.7) 4433800 Amputation of toe 173 (2.5) 348 (5.7) 4435800 Amputation toe including metatarsal bone 91 (1.3) 256 (4.2) 9055700 Disarticulation through toe 0 (0) 0 (0) 4436100 Disarticulation through ankle 0 (0) 2 (0.03) 4436400 Midtarsal amputation 4 (0.1) 5 (0.1) 4436401 Transmetatarsal amputation 15 (0.2) 32 (0.5) Amputation ankle through malleoli tibia and 4436101 fibula 0 (0) 2 (0.03) Other excision procedure on ankle or foot 271 (3.9) 90 (1.5) 4981800 Excision of calcaneal spur 22 (0.3) 18 (0.3) 4986600 Neurectomy of foot 170 (2.5) 52 (0.9) 4985401 Plantar fasciectomy 44 (0.6) 17 (0.3) 4986000 Synovectomy of metatarsophalangeal joint 20 (0.3) 1 (0.02) 5031200 Synovectomy of ankle 15 (0.2) 2 (0.03) REDUCTION Closed reduction of fracture of calcaneum, talus or metatarsus 13 (0.2) 33 (0.5) 4760900 Closed reduction of fracture of calcaneum 1 (0.01) 3 (0.05) Closed reduction of fracture of calcaneum with 4760901 internal fixation 0 (0) 3 (0.05) Closed reduction of intra-articular fracture of 4761200 calcaneum 0 (0) 1 (0.02) Closed reduction of intra-articular fracture of 4761201 calcaneum with internal fixation 0 (0) 0 (0) 4760902 Closed reduction of fracture of talus 1 (0.01) 4 (0.1) Closed reduction of fracture of talus with 4760903 internal fixation 0 (0) 0 (0) Closed reduction of intra-articular fracture of 4761206 talus 0 (0) 0 (0) Closed reduction of intra-articular fracture of 4761207 talus with internal fixation 0 (0) 0 (0) Closed reduction of fracture of tarsometatarsal 4762100 joint 0 (0) 0 (0) Closed reduction of fracture of tarsometatarsal 4762101 joint with internal fixation 1 (0.01) 0 (0) 4763600 Closed reduction of fracture of metatarsus 8 (0.1) 8 (0.1)

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 81 No. (%) No. (%) episodes episodes Private Public Procedure code Procedure code description (n=6,886) (n=6,053) Closed reduction of fracture of metatarsus with 4763601 internal fixation 2 (0.03) 14 (0.2) Closed reduction of fracture of ankle or toe 98 (1.4) 378 (6.2) 4759700 Closed reduction of fracture of ankle 50 (0.7) 224 (3.7) Closed reduction of fracture of ankle with 4760000 internal fixation diats/fib/malus 27 (0.4) 64 (1.1) Closed reduction of fracture of ankle with 4760300 internal fixation x2 diats/fib/malus 8 (0.1) 25 (0.4) Closed reduction of fracture of phalanx great 4766300 toe 1 (0.01) 10 (0.2) Closed reduction fracture of phalanx great toe 4766301 with internal fixation 5 (0.1) 20 (0.3) Closed reduction of fracture of phalanx not 4767200 great toe 6 (0.1) 22 (0.4) Closed reduction of fracture of phalanx not 4767201 great toe with internal fixation 1 (0.01) 13 (0.2) Open reduction of fracture of calcaneum, talus or metatarsus 198 (2.9) 232 (3.8) 4763000 Open reduction of fracture of tarsus 2 (0.03) 1 (0.02) Open reduction of fracture of tarsus with 4763001 internal fixation 22 (0.3) 22 (0.4) 4761500 Open reduction of fracture of calcaneum 3 (0.04) 0 (0) Open reduction of fracture of calcaneum with 4761501 internal fixation 24 (0.3) 41 (0.7) 4761502 Open reduction of fracture of talus 0 (0) 0 (0) Open reduction of fracture of talus with internal 4761503 fixation 11 (0.2) 22 (0.4) Open reduction intra-articular fracture 4761800 calcaneum 4 (0.1) 0 (0) Open reduction intra-articular fracture 4761801 calcaneum with internal fixation 6 (0.1) 15 (0.2) 4761802 Open reduction intra-articular fracture of talus 0 (0) 0 (0) Open reduction intra-articular fracture of talus 4761803 with internal fixation 1 (0.01) 6 (0.1) Open reduction fracture of tarsometatarsal 4762400 joint 2 (0.03) 1 (0.02) Open reduction fracture tarsometatarsal joint 4762401 with internal fixation 18 (0.3) 22 (0.4) 4763900 Open reduction fracture of metatarsus 1 (0.01) 5 (0.1) Open reduction fracture metatarsus with 4763901 internal fixation 104 (1.5) 97 (1.6)

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 82

No. (%) No. (%) episodes episodes Private Public Procedure code Procedure code description (n=6,886) (n=6,053) Open reduction of fracture of ankle or toe 461 (6.7) 1,555 (25.7) 9055800 Open reduction of fracture of ankle 2 (0.03) 2 (0.03) Open reduction of fracture of ankle with 4760001 internal fixation diats/fib/malus 302 (4.4) 930 (15.4) Open reduction of fracture of ankle with 4760301 internal fixation x2 diats/fib/malus 136 (2.0) 569 (9.4) Open reduction of fracture of phalanx of great 4766600 toe 1 (0.01) 7 (0.1) Open reduction of fracture of phalanx of great 4766601 toe with internal fixation 10 (0.1) 25 (0.4) Open reduction of fracture of phalanx not great 4767202 toe 1 (0.01) 3 (0.05) Open reduction of fracture of phalanx not great 4767203 toe with internal fixation 9 (0.1) 19 (0.3) Closed reduction of dislocations of ankle or foot 5 (0.1) 96 (1.6) 4706300 Closed reduction of dislocation of ankle 3 (0.04) 57 (0.9) Closed reduction of dislocation of ankle with 4706301 internal fixation 1 (0.01) 2 (0.03) 4760906 Closed reduction of dislocation of calcaneum 0 (0) 0 (0) Closed reduction of fracture and dislocation of 4761202 calcaneum 0 (0) 1 (0.02) Closed reduction of fracture and dislocation of 4761203 calcaneum with internal fixation 0 (0) 0 (0) 4760904 Closed reduction of dislocation of talus 0 (0) 7 (0.1) Closed reduction of dislocation of talus with 4760905 internal fixation 0 (0) 0 (0) Closed reduction of fracture and dislocation of 4761204 talus 0 (0) 1 (0.02) Closed reduction of fracture and dislocation of 4761205 talus with internal fixation 0 (0) 0 (0) 4706900 Closed reduction of dislocation of toe 1 (0.01) 26 (0.4) Closed reduction dislocation of toe with 4706901 internal fixation 0 (0) 2 (0.03) Open reduction of dislocations of ankle or foot 10 (0.1) 28 (0.5) 4706600 Open reduction of dislocation of ankle 4 (0.1) 3 (0.05) Open reduction of dislocation of ankle with 4706601 internal fixation 1 (0.01) 6 (0.1) Open reduction of dislocation of calcaneum 4761505 with internal fixation 0 (0) 0 (0) Open reduction of fracture of calcaneum with 4761804 dislocation 0 (0) 0 (0) Open reduction of fracture of calcaneum with 4761805 dislocation and internal fixation 0 (0) 2 (0.03)

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 83 No. (%) No. (%) episodes episodes Private Public Procedure code Procedure code description (n=6,886) (n=6,053) 4761506 Open reduction of dislocation of talus 1 (0.01) 0 (0) Open reduction of dislocation of talus with 4761507 internal fixation 0 (0) 0 (0) Open reduction of fracture of talus with 4761807 dislocation and internal fixation 0 (0) 1 (0.02) 4707200 Open reduction of dislocation of toe 1 (0.01) 7 (0.1) Open reduction of dislocation of toe with 4707201 internal fixation 3 (0.04) 9 (0.1) REPAIR Repair of tendon, ligament of ankle or foot 486 (7.1) 203 (3.4) 4981200 Transfer of tendon or ligament of foot 28 (0.4) 8 (0.1) Transfer of anterior tibialis tendon to lateral 5033900 column 7 (0.1) 17 (0.3) Transfer of posterior tibialis tendon to 5034200 anterior/posterior foot 11 (0.2) 8 (0.1) 4970900 Stabilisation of ankle 327 (4.7) 70 (1.2) 4971800 Other repair of tendon of ankle 43 (0.6) 14 (0.2) 4972400 Secondary (delayed) repair of Achilles tendon 28 (0.4) 9 (0.1) 4972700 Lengthening of Achilles tendon 42 (0.6) 77 (1.3) Arthrodesis of ankle, foot or toe 618 (9.0) 254 (4.2) 4971200 Arthrodesis of ankle 128 (1.9) 63 (1.0) 4981500 Triple arthrodesis of foot 69 (1.0) 30 (0.3) 4984500 Arthrodesis of 1st metatarsophalangeal joint 318 (4.6) 119 (2.0) 5011800 Arthrodesis of subtalar joint 103 (1.5) 42 (0.7) Other repair procedure on ankle or foot 272 (4.0) 110 (1.8) 4980901 Open tenotomy of foot with tenoplasty 10 (0.1) 4 (0.1) Arthroscopic repair of osteochondral fracture 4970303 of ankle 2 (0.03) 2 (0.03) 4970305 Arthroscopic chondroplasty of ankle 109 (1.6) 11 (0.2) 4980000 Primary repair flexor/extensor tendon foot 19 (0.3) 59 (1.0) Secondary repair of flexor/extensor tendon 4980300 foot 1 (0.01) 1 (0.02) 4985700 Replacement metatarsophalangeal joint 48 (0.7) 17 (0.3) 4971500 Total arthroplasty of ankle 75 (1.1) 15 (0.2) 9059900 Other repair of ankle 8 (0.1) 1 (0.02) RECONSTRUCTION Reconstruction procedure on ankle or foot 50 (0.7) 14 (0.2) 4972401 Reconstruction of Achilles tendon 50 (0.7) 13 (0.2) 5033600 Reconstruction congenital vertical talus 0 (0) 1 (0.02) OTHER PROCEDURES Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 84 No. (%) No. (%) episodes episodes Private Public Procedure code Procedure code description (n=6,886) (n=6,053) Procedures for club foot 9 (0.1) 18 (0.3) 5032100 Release talipes equinovarus unilateral 1 (0.01) 8 (0.1) 5032700 Release talipes equinovarus bilateral 6 (0.1) 9 (0.1) Reverse release of talipes equinovarus 5032400 unilateral 0 (0) 1 (0.02) Reverse release of talipes equinovarus 5032401 bilateral 2 (0.03) 0 (0) Procedures for hallux valgus or hallux rigidus 1,191 (17.3) 427 (7.1) Correction of hallux valgus/rigidus arthroplasty 4982100 unilateral 101 (1.5) 44 (0.7) Correction of hallux valgus/rigidus arthroplasty 4982400 bilateral 16 (0.2) 5 (0.1) Arthroplasty valgus/rigidus with prosthetic 4983900 unilateral 20 (0.3) 5 (0.1) Arthroplasty valgus/rigidus w prosthetic 4984200 bilateral 8 (0.1) 0 (0) Correction of hallux valgus with transfer 4982700 tendon unilateral 17 (0.2) 2 (0.03) Correction of hallux valgus with transfer 4983000 tendon bilateral 0 (0) 1 (0.02) Correction of hallux valgus osteotmy 1st 4983300 metatarsal unilateral 496 (7.2) 270 (4.5) Correction of hallus valgus osteotomy 1st 4983600 metatarsal bilateral 261 (3.8) 56 (0.9) Correction of hallux valgus osteotomy 4983700 metatarsal and trasfer tendon unilateral 272 (4.0) 44 (0.7) Procedures for other toe deformities 351 (5.1) 175 (2.9) 4984800 Correction of hammer toe 86 (1.2) 37 (0.6) 4985100 Correction hammer toe with internal fixation 104 (1.5) 49 (0.8) 4984801 Correction of claw toe 44 (0.6) 33 (0.5) 4985101 Correction claw toe with internal fixation 107 (1.6) 49 (0.8) 5034500 Release of hyperextension deformity toe 10 (0.1) 7 (0.1) Toenail procedures 735 (10.7) 1,022 (16.9) 4790600 Debridement of toenail 8 (0.1) 8 (0.1) 4790601 Removal of toenail 52 (0.8) 112 (1.9) 4791200 Incision of foot for paronychia 1 (0.01) 0 (0) 4791500 Wedge resection of ingrown toenail 563 (8.2) 734 (12.1) 4791600 Partial resection of ingrown toenail 33 (0.5) 44 (0.7) 4791800 Radical excision of ingrown toenail bed 78 (1.1) 124 (2.0) Tumours of the foot & ankle 219 (3.2) 210 (3.5) 3123504 Excision of lesion(s) SSCT, foot 219 (3.2) 209 (3.5)

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 85 No. (%) No. (%) episodes episodes Private Public Procedure code Procedure code description (n=6,886) (n=6,053) Excision of lymphoedematous tissue leg and 4504803 foot 0 (0) 0 (0) 9060319 Sequestrectomy of metatarsus 0 (0) 1 (0.02) 9060320 Sequestrectomy of phalanx of foot 0 (0) 0 (0)

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 86 Appendix 5. The economic impact of podiatric surgery - Access Economics Report, September 2008 – an analysis

A report by Access Economics undertakes an economic impact analysis estimating the potential impact of improving access to podiatric surgeons in the Australian health sector.

The report assesses the cost effectiveness and cost benefit of using podiatric surgeons to perform foot and ankle surgery compared with using orthopaedic surgeons.

Key findings of the report are that: • podiatric surgery is less costly than orthopaedic surgery across all categories of procedure on average by $3,635 per procedure; and • in addition to the $3,635 per procedure saved in financial costs, there is also a relative gain in well being worth $5,016 per procedure from podiatric surgery relative to orthopaedic surgery.

The report’s conclusions support the greater utilisation of podiatric surgeons in the Australian health system and cite benefits including: • substantial financial savings; • decreased waiting time for elective foot surgery; • increased productivity; • improved prevention of co-morbidities; and • a quicker return to an improved quality of life.

A critique of the Access Economics report suggests that some of the assumptions used to inform the economic analysis in the report may be flawed and as such the full economic benefits of podiatric surgeons outlined in the report should be considered with caution. It is noted that the paucity of available data obliged the use of the assumptions.

One of the major criticisms of the report is that it does not fully account for the complexities of the health system and has over simplified the issue of meeting demand for elective surgery into a workforce substitution issue when in fact the range of factors that influence the supply of and demand for foot and ankle elective surgery are complex and variable.

A strength of the report however is that, although reducing the problem to one of workforce, the report acknowledges that workforce solutions should aim to utilise current skills in the workforce most efficiently and introduce new skill sets to the health system as opposed to reinforcing restrictive, traditional models of practice in the health system.

Specific criticisms discussed below include: • assumptions regarding the scope of podiatric surgical practice; • the definition of orthopaedic surgeons; • the estimation of length of stay which ignores the contribution of patient and system related factors to length of stay; • the extrapolation of public sector data on waiting times to the private sector (and visa versa) (necessary due to the absence of existing data); • the lack of evidence for quality of life and other outcomes following podiatric surgery, and more specifically a lack of evidence to support claims of equal or better outcomes of podiatric surgery when compared with orthopaedic surgery; • the extrapolation of productivity losses related to construction workers with a foot/ankle related condition to all patients with a foot/ankle condition; and

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 87 • a perceived lack of consultation with health professionals and service providers outside the podiatric profession.

The report may have benefited from the inclusion of an analysis of cost savings associated with the training requirements for podiatric surgeons compared with orthopaedic surgeons. On average it takes about 9-11 years to train a podiatric surgeon and about 12-15 years to train an orthopaedic surgeon (with an additional year of training to specialise in foot and ankle orthopaedic surgery). On this basis while podiatric surgeons may seem “lesser trained” it should be considered that they spend their 9-11 years of training becoming proficient exclusively in the area of foot and ankle, whereas the orthopaedic surgeon spends their 12-15 years of training becoming proficient in all areas of orthopaedic surgery.

1. Included procedures

The report includes 95 foot and ankle surgical procedures defined in the Medicare Benefits Schedule (MBS) (Access Economics page 10), however, podiatric surgeons perform only a proportion of these procedures (Bennet, 2007).

While podiatric surgeons are recognised under Federal legislation as being able to perform any surgical procedure of the foot and ankle, in practice, the scope of the podiatric surgeon is limited largely to the following procedures as described in a recent study by Bennet (2007):

Procedure type Procedure Orthopaedic • Excision and repair of bunion and other toe deformity procedures • Bunionectomy with soft tissue correction and arthrodesis • Repair of hammer toe • Repair of claw toe • Repair cocked up or overlapping toes • Exostosis • Enthesopathy of ankle and tarsus • Calcaneal spur Neurological • Excision of peripheral neuroma (Morton’s) procedures Procedures performed • Excision or destruction of lesion or tissue of skin and on the integumentary subcutaneous tissue system • Removal of nail, nail bed and/or nail fold • Radical excision of skin lesion • Excision debridement of wound, infection or burn

The scope of podiatric surgeon practice is usually self limited to those procedures with which they feel competent. The reasons for the limited scope of practice of the podiatric surgeon appear to be: • Under-exposure to more complex procedures as a result of restricted access to the public health system. The bulk of the work undertaken by podiatric surgeons consists of the types of procedures that can be performed in a private day surgery unit (Mark Gilheany – personal correspondence); and • lack of access to other health professionals such as general physicians, rheumatologists and vascular surgeons means that the scope of the podiatric surgeon is further limited to patients who do not have complex medical comorbidities (Mark Gilheany – personal correspondence). Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 88

Therefore an analysis based on equal performance of these procedures is flawed because in reality, whilst theoretically able to do so, podiatric surgeons do not perform all of these procedures.

2. Definition of orthopaedic surgeons

The cost benefit analysis involves a comparison of podiatric surgeons to orthopaedic surgeons however, as the report states, the definition of ‘orthopaedic surgeon’ is taken to include “all other surgeons with the exception of podiatric surgeons that also perform foot and ankle surgery” (Access Economics page 6).

The report does not differentiate between different types of surgical providers and the definition of orthopaedic surgeon includes all providers of foot and ankle surgery including orthopaedic surgeons, general surgeons, vascular surgeons, and general practitioners. Therefore a more accurate description of the analysis is that it is a comparison between podiatric surgeons and “all other health professionals that perform surgical procedures on the foot and ankle”.

3. Inputs to the economic modelling

3.1 Length of stay One of the main inputs to the economic modelling is length of stay. The report states that the length of stay for procedures performed by podiatric surgeons is on average 45.2% of the average length of stay for the same procedures performed by all surgeons (Access Economics page 31). It provides no analysis of the potential reasons for this.

This figure is based on unpublished hospital separation data from Western Australia for the period 2002 – 2007. The analysis compares the total number of bed days (2,678) divided by the total number of separations for foot and ankle procedures performed by podiatric surgeons (1,977) with the total number of bed days (91,067) divided by the total number of separations for foot and ankle procedures performed by all surgeons in the private sector (20,291) (Access Economics page 31). The data were limited to private sector data as podiatric surgeons currently only operate in the private sector.

While only private sector data are used to estimate length of stay, this estimate is extrapolated to the public system. This is problematic because the analysis ignores the contribution of patient and system related factors to length of stay, for example: • it is known that patients operated on by podiatric surgeons are a different patient population from patients operated on by “all surgeons” . Podiatric surgeons predominately operate on uncomplicated, often younger patients with no comorbidities (Bennet, 2007; Mark Gilheany – personal correspondence); • podiatric surgeons do not perform the same types of procedures as “all surgeons” as previously discussed. Podiatric surgeons usually perform less complex procedures that would result in a shorter length of stay than a more complex procedure; and • different systems of care operate in the private health system for example greater use of day procedure units.

The report provides no recognition or analysis of these or other factors that may impact on length of stay.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 89 3.2 Cost of waiting Another major input to the economic modelling was waiting times for surgery. The report states that “the productivity losses from waiting for orthopaedic surgery were estimated at $3,307 and $1,681 for podiatric surgery” (Access Economics page 3).

When estimating waiting times for surgery, the report estimates the average waiting time for an orthopaedic surgeon as 50 days based on the median waiting time for all orthopaedic surgery in Australia in 2006-07 (Access Economics page 8).

It then estimates the average waiting time for a podiatric surgeon to be 7 days. Box 1 explains how this estimate is reached.

Box 1. Estimating waiting times for podiatric surgery

Because there is no waiting time data available for podiatric surgery, a proxy waiting period has been estimated by Access Economics for podiatric surgeons as follows: “Butterworth et al (2008) estimate that nine podiatric surgeons across Australia performed 2,387 procedures in a 12-month period. This equates to around 265 procedures per surgeon per year. Given that a podiatric surgeon is capable of 1,250 procedures per year (NHS Trust UK, 2008)21, the wait time for surgery by a podiatric surgeon is assumed to be 7 days, which is 21.2% (265 procedures per annum / 1,250 possible) * 32 days, which is median wait time for all surgical specialties combined in Australia (AIHW, 2008)” (Access Economics page 32).

There are a number of flawed assumptions in the above analysis. Firstly the authors have extrapolated the median waiting time for all orthopaedic surgery in the public health system to a waiting time for all orthopaedic surgeons whereas in practice, waiting times differ significantly depending on: • the type of surgery; • the urgency of the surgery i.e. emergency surgery for trauma versus planned surgery; and • whether the surgery is being performed in the public or private sector, i.e. waiting times in the private sector are considerably less than in the public sector.

Secondly, while waiting times are dependent to some degree upon surgeon factors (i.e. when a specialist surgeon is required to perform a complex procedure), the most significant contribution to waiting times are related to system factors such as theatre availability, competing priorities for surgery including emergency surgery, capacity of inpatient wards including ICU and overall workforce availability. For this reason it is flawed to ascribe a waiting time to an orthopaedic surgeon.

There is only one podiatric surgeon operating in the public health system in Australia, at the Repatriation General Hospital in South Australia. This podiatric surgeon has a waiting time of 12 months for patients requiring foot surgery. This indicates that system factors contribute significantly to long waiting times and confirms that if you were to: a) substitute an orthopaedic surgeon in the public health system with a podiatric surgeon without changing any other variables; or b) add a podiatric surgeon to the public health system without changing any other variables. then the waiting times for the podiatric surgeon would be the same as that for the orthopaedic surgeon.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 90 3.3 Health complications and quality of life Another input to the economic modelling was health complications as a result of waiting for elective foot and ankle surgery. The report states that “studies have demonstrated that waiting for surgery may lead to further worsening of a patient’s condition including their overall physical and psychosocial wellbeing” (Access Economics page 33).

While it is probable that increased waiting results in reduced quality of life, there is no evidence to support this in relation to foot and ankle surgery. The evidence cited in the Access Economics report relates to patients awaiting surgery for hip joint replacement or diabetic foot complications. Anecdotally some orthopaedic surgeons report that the impact on quality of life of foot and ankle conditions is in general less that that of osteoarthritis of the hip requiring joint replacement surgery.

In addition, anecdotal evidence suggests that outcomes following foot and ankle surgery are poorer than and not comparable to outcomes following hip and knee joint replacement surgery which has been shown to be extremely effective at improving quality of life.

3.4 Health outcomes –this goes to underlying premises Although it was not included in the modelling, the report analyses the post surgical outcomes of podiatric surgery (Access Economics page 34). The report states that: “It was found that a number of domestic and international clinical audits23 had demonstrated that surgery performed by podiatric surgeons has the same quality of life and health outcomes (or better) as those performed by other surgeons. Some examples follow.

The report then cites the following studies (Box 2) (Access Economics page 35), none of which demonstrate that surgery performed by podiatric surgeons has better health outcomes than surgery performed by other surgeons. Two of these studies had no comparison group and two studies did have a comparison group and the outcomes of podiatric surgery was found to equivocal.

Box 2. Evidence for outcomes of podiatric surgery

• Bennett et al (2001) reported on a six-month prospective study that investigated the outcomes of foot surgery performed by Fellows of the ACPS, and found no significant adverse outcomes or unplanned re-admissions to the hospital. • Kilmartin (2002) found podiatric surgery to be safe and effective and that the existence of podiatric surgery in a UK National Health Service Trust enhanced quality and range of care delivered by clinicians specifically trained in the conservative and surgical management of foot disorders. • Butterworth et al (2008) concluded that podiatric surgery carried no greater risk of infection to the patient than other surgical disciplines, and results for Australia showed infection rates to be well within accepted industry standards as stated in recent literature. • Gilheany and Robinson (2008) reported on comparative skill sets, finding that podiatric surgeons possess a skill set comparable to orthopaedic surgeons in the examined area of great toe joint surgery.”

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 91 3.5 Productivity losses Productivity losses were estimated in part using data from a study of construction workers. Productivity losses for a population of construction workers would be greater than that for other populations that experience foot or ankle conditions i.e. workers with a sedentary occupation or elderly or young people who do not participate in the workforce.

4. Consultation

Finally, the report suffers from a lack of consultation with health professionals and service providers outside the podiatric profession. It relies heavily on podiatric literature and input from podiatric surgeons or podiatrists for assistance, research and expert input.

Exploring Solutions to Better Meet Demand for Foot and Ankle Surgical Services (June 2009) 92