Sustainability in surgery: implications for the future

Sustainability of Australian healthcare is not assured. Health costs as a fraction of GDP continue to outstrip inflation, as demands spike from an ageing population and prolonged health crises stretch budgets. Meanwhile, available resources plateau from reductions in the proportional taxpayer and private insurance base. To ensure a sustainable future, utilization of non-capital and capital resources in surgery need careful planning to maximize beneficence, mitigate workforce burnout and prepare for crises that further burden finite resources.

Sustainability of Australian healthcare is not assured. Health costs as a fraction of GDP continue to outstrip inflation, as demands spike from an ageing population and prolonged health crises stretch budgets. 1 Meanwhile, available resources plateau from reductions in the proportional taxpayer and private insurance base. 1 To ensure a sustainable future, utilization of non-capital and capital resources in surgery need careful planning to maximize beneficence, mitigate workforce burnout and prepare for crises that further burden finite resources.

Non-capital resources
Non-capital resources in surgery involves ensuring the needs of the workforce to provide surgical care to the community are met. Workforce planning has failed to co-ordinate the complete pipeline from training medical graduates to employment of surgeons in the public sector. This has created a challenge to ensure an appropriate workforce is present in an appropriate geographic distribution for equitable health care access.

Appropriate workforce
The surgical workforce is modelled by governments to meet future demands. However, there is no systematic co-ordination between the university sector that trains medical graduates, federal and state governments or RACS to plan public funding to Specialist Training Positions (STP) to match the number of medical graduates interested in surgical training. A lack of uniformity of points criteria for approved courses for Surgical education and training (SET) application set by different specialty training boards reduce transferability between specialties for junior trainees, prolongs entry and disincentivise diversity of prior experience in the applicants for surgical training which may not ultimately reflect the necessary scope of practice required to service the community. Consequently, a boost in medical graduate training without proportionate funding for surgical training or services has created unprecedented pressures on applicants for surgical training who take longer to enter training, face increased career uncertainty and are vulnerable to exploitation. 2,3 State and federal modelling vary, which creates a conflict between workforce demand at a local level and funding for workforce training which is done at a federal level.

Appropriate geographic distribution
Reduced access for younger fellows in the public sector incentivises additional post-fellowship training to qualify for highly specialized but limited metropolitan positions. Thus, fellows who complete training at an older age, with more academic qualifications, larger debt, less mobile families and reduced job opportunities in the public sector are incentivized to work in geographical regions with improved socioeconomic status, potentially increasing health care access inequity. 4 Limited prior exposure to rural practice, predominant subspecialty metropolitan training positions and poor networks to access senior support reduce preparedness to seek rural generalist roles. 5 In addition, without concurrent employment opportunities for partners in a small rural town, relocation is challenging. International Medical Graduates have been incentivized to fill this workforce shortage, however, while this solves the short-term problem it disincentivises against system wide change in surgical training to promote rural preparedness for domestic workforce. The pressures on the regional surgical workforce therefore grow unsustainably, worsening burnout and attrition. 6 Investment in training represents a large non-capital cost. However, reducing attrition and burnout ensures return on investment with estimated savings in the US of USD $6.3 billion. 7 Surgeons lost to the private system similarly represent a loss of value, raising the question whether taxpayer investment in workforce training is delivering equitable service provision and value to the community. 7

Capital resources
Paralleling untenable pressures on human resources is a critical unsurpassed demand on limited capital resources. As costs of new interventions rise and surgical budgets strain, health systems can respond by (i) reducing unnecessary cost by implementing value-based healthcare models, 8 (ii) ensuring stringent heath technology assessment of new interventions and (iii) mitigating conflicts of interests and industry pressures in adoption of new technology. In NSW public hospitals alone, up to 8855 procedures of questionable benefit are performed yearly, costing approximately AUD $99.3 million. 9 Opaque supply systems with poor stock visibility contribute to oversupply representing waste, or undersupply delaying timely care, as demonstrated by PPE shortages early in the COVID pandemic. Consumable costs vary by a factor of 10 between hospitals due to inconsistent contracts and reduced purchasing power due to the variety of surgeon-requested consumables. 10 Industry funded training for use of surgical interventions can create conflicts of interests which may drive key stakeholders in surgery to support funding models for health technology without evidence. Volume based funding incentivises matching metrics against key performance indicators (KPIs) that promote shorter term, less sustainable solutions. Value-based funding of health care may assist in mitigating these pressures.

Resource preservation by mitigating crisis
Crisis management increases demand on capital and noncapital resources and exacerbates health inequity. As seen during COVID-19, crises necessitate prioritization of acute health care, which has a disproportionate impact on non-urgent surgery. If the system is overwhelmed with numerous crises prolonging the impact of the shock to routine care, overcoming subsequent backlogs places unsustainable pressure on the workforce which impacts rural areas and areas with poor socioeconomic status due to limited workforce availability and high demand on public health services. Public-private partnerships globally have been utilized as a shortterm strategy to overcome backlogs but they divert money away  12 Steps must be taken to mitigate future crises but also address contribution from surgery to the problem. Operating theatres contribute 3-6 times the greenhouse gas compared to elsewhere in the hospital and 20-30% of the 42 000 tons of solid waste produce by Victorian public hospitals in 2019. 13,14 Reliance on single use plastics also has less-obvious value implications, including vulnerability to supply variation, illustrated by 2020's global shortage of sterilization wraps that threatened Australian surgical services.

Conclusion
Increasing concern about the sustainability of Australian surgical care necessitates measures to reduce waste as an economic and ethical priority. COVID-19 has provided a unique opportunity to press the reset button, examine areas of weakness and implement change ( Table 1). It is clear there are many opportunities to finding value in healthcarethe question is how. Solutions will be multifaceted, and in the words of General Boyd, should include 'People. Systems. Equipment! In that order!'