tag:theconversation.com,2011:/uk/topics/waiting-lists-56667/articleswaiting lists – The Conversation2023-10-11T03:09:00Ztag:theconversation.com,2011:article/2150602023-10-11T03:09:00Z2023-10-11T03:09:00ZWith ACT and NZ First promising to overhaul Pharmac, what’s in store for publicly funded medicines?<p>Never before has Pharmac – the government’s medicine procurement agency and decision maker – featured so prominently in an election. </p>
<p>Many parties are pledging more funding, but two are promising to overhaul the agency as we know it. One proposal would link funding for medicines with measures of their impact on overall productivity (such as keeping people working).</p>
<p>But linking funding with productivity could jeopardise efforts to ensure equitable access and health improvements for all. Equity is a focus of <a href="https://link.springer.com/article/10.1007/s40258-023-00823-7">wider health reforms</a> and also a key recommendation in a <a href="https://www.health.govt.nz/system/files/documents/publications/pharmac-review-executive-summary.pdf">recent review</a> of Pharmac.</p>
<p>With patients <a href="https://www.medicinesnz.co.nz/fileadmin/user_upload/Publications/New_Zealand_s_Medicines_Landscape_2022-23.pdf">waiting</a> and sometimes <a href="https://www.stuff.co.nz/opinion/129976180/my-brother-is-dying-while-theres-a-drug-that-could-stop-this">dying while waiting</a> for new health technologies to be approved, there has been increasing media criticism of Pharmac’s various refusals and delays to medicines funding.</p>
<p>It is clear from the Pharmac review that the agency’s success at negotiating some of the lowest medicine prices in the world has come at the expense of delivering equitable and timely access to medicines for New Zealanders.</p>
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Read more:
<a href="https://theconversation.com/new-zealand-needs-urgent-action-to-tackle-the-frightening-rise-and-cost-of-type-2-diabetes-157581">New Zealand needs urgent action to tackle the frightening rise and cost of type 2 diabetes</a>
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<h2>More funding or a new system?</h2>
<p>Nearly every political party has a proposed solution. Given there are more than a hundred medicines on Pharmac’s <a href="https://connect.pharmac.govt.nz/apptracker/s/ranking-lists-for-funding-applications?reportType=OFI">Options for Investment</a> waiting list – deemed to deliver value and be funded if the budget allowed – promised funding increases will be welcome. But questions remain over whether this will stretch beyond merely “<a href="https://www.thepost.co.nz/a/nz-news/350080133/election-watch-bulk-1b-pharmac-keep-lights">keeping the lights on</a>”.</p>
<p>Labour is <a href="https://www.labour.org.nz/news-release_labour_pledges_billion_dollar_medicines_boost">promising to increase</a> Pharmac’s funding by NZ$1 billion over four years, with an extra $50 million for new treatments, rising to $100 million after two financial years.</p>
<p>National is <a href="https://assets.nationbuilder.com/nationalparty/pages/18436/attachments/original/1696286925/Better_Health_Outcomes.pdf?1696286925">promising an additional $724 million</a> over four years, plus $280 million ring-fenced to fund 13 cancer treatments. The party plans to fund these cancer drugs by reinstating the $5 prescription charge which the current government recently <a href="https://www.stuff.co.nz/national/health/300918032/free-medicines-as-5-prescription-charge-scrapped--this-will-save-people-pain">scrapped</a>.</p>
<p>The Greens <a href="https://www.raredisorders.org.nz/about-rare-disorders/rare-disorders-in-new-zealand/where-do-the-political-parties-stand/">say they would increase funding</a> for Pharmac but have not provided any dollar values. Likewise, Te Pāti Māori has <a href="https://www.maoriparty.org.nz/whanau_health">promised more funding</a>, but has not said by how much.</p>
<p>The Opportunities Party (TOP) has no stated policy, although it promises to <a href="https://www.top.org.nz/public-services">fully fund contraceptives</a>. No dollar value is given.</p>
<p>NZ First is <a href="https://www.nzfirst.nz/2023_policies">promising a new medicines-buying agency</a> and an additional $1.3 billion a year for life-saving medicines. </p>
<p>ACT has provided no specific funding promise, but has a policy it claims would ensure consistent and fair access to medicines. Essentially, the party proposes to overhaul regulatory approval processes and decision making.</p>
<p>Of all the party promises and offerings, however, it is ACT and NZ First that are promising something beyond funding increases – more akin to rewiring the whole house.</p>
<h2>Linking access to medicines with productivity</h2>
<p>ACT’s <a href="https://www.act.org.nz/a_strategy_to_ensure_consistent_and_fair_access_to_medicines">medicines strategy</a> is the most detailed of any party. It is also the most radical – likely a result of candidate Todd Stephenson, number four on the party list, having spent 15 years working in the pharmaceutical industry in Australia.</p>
<p>It requires the Ministry of Health to publish and regularly update a medicines strategy (a recommendation of the Pharmac review), and New Zealand’s medicines regulator MedSafe to approve within one week any drug or device that has been approved by two comparable international regulatory agencies. </p>
<p>ACT’s strategy calls for analysis to understand New Zealanders’ unmet needs, what new medicines offer, how other countries are managing cost, and what drives price changes. Given the Ministry of Health’s revised remit under the health reforms as the <a href="https://www.health.govt.nz/new-zealand-health-system/health-system-reforms">kaitiaki (or steward)</a> of the health system, this would fit well.</p>
<p>ACT then suggests performance bench-marking. This would require the ministry to publish evidence of the productivity gains from pharmaceutical funding decisions, and the productivity losses of waiting for treatments to be subsidised. The party also wants price performance to be compared with other countries. </p>
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<p>ACT has expressed an interest in including productivity in healthcare evaluations, and, <a href="https://www.1news.co.nz/2023/09/03/act-calls-for-productivity-focus-for-pharmac/">Stephenson has suggested</a> productivity should feature in the decision framework.</p>
<p>Other countries <a href="https://link.springer.com/article/10.1007/s40273-022-01221-y">consider productivity losses</a> by taking a societal perspective and including both direct healthcare costs and indirect productivity costs in evaluations. But this remains a much debated topic in the field of economic evaluation. </p>
<p><a href="https://ard.bmj.com/content/69/Suppl_1/i89.long">Productivity can either be valued</a> using the “human capital” approach (the amount of time lost due to illness, valued at the market wage) or the “friction cost” approach which takes into account unemployment and labour market reserves so workers can be replaced. </p>
<p>Irrespective of the approach, if a patient group happens not to be economically productive, then health technologies that target them may be deemed less cost-effective as there is no measurable productivity benefit of improving their health. </p>
<p>This became an issue in Sweden where the country’s societal perspective <a href="https://www.zefq-journal.com/article/S1865-9217(14)00183-4/fulltext">clashed with the principle of equal human value</a>. If Pharmac were to consider productivity, it would be important to ensure it does not discriminate against the young, old, those with chronic conditions, and those on benefits. That would risk exacerbating inequities.</p>
<h2>Outsourcing and bench-marking</h2>
<p>NZ First recently released a <a href="https://www.nzfirst.nz/2023_policies">seven-point plan for better healthcare</a>. It expands on the party’s “<a href="https://web.archive.org/web/20231003233705/https:/www.nzfirst.nz/2023_policies">performance not puffery</a>” idea by replacing Pharmac “with a new agency focused on patients’ health and recovery – not cost savings and lack of essential medicines”. </p>
<p>The party suggests bench-marking funding against the OECD average, funding a rapid access scheme for innovative medicines, and putting in timelines for the completion of reviews and decisions. NZ First also has a policy to “end MedSafe waste” by committing New Zealand to mutual recognition agreements with peer regulators. </p>
<p>The issue of outsourcing approvals was raised during the COVID pandemic. Then director-general of health Ashley Bloomfield’s <a href="https://www.beehive.govt.nz/sites/default/files/2021-06/Post%20Cabinet%20Press%20Conference%2021%20June%202021.pdf">response</a> was that evidence of safety and efficacy should be assessed in light of population demographics and healthcare delivery systems specific to Aotearoa New Zealand.</p>
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Read more:
<a href="https://theconversation.com/deciding-what-medicines-to-fund-shouldnt-be-a-private-affair-1387">Deciding what medicines to fund shouldn't be a private affair</a>
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<p>NZ First’s health spokesperson <a href="https://www.nzdoctor.co.nz/article/news/nz-first-gives-more-detail-plan-scrap-pharmac">has suggested</a> the evaluation and recommendation functions should be separated from the funding decision. </p>
<p>If Pharmac were not both the decision maker and funder (as is the case in England where the <a href="https://www.nice.org.uk/">National Institute for Health and Care Excellence</a> makes decisions and the <a href="https://www.nhs.uk/">National Health Service</a> funds them), this may undermine the agency’s credibility. The lack of a fixed budget would also undermine New Zealand’s strong negotiating stance.</p>
<p>ACT and NZ First are suggesting a new approach to decision making and procurement that, despite more funding, may increase inefficiencies and further embed inequities.</p><img src="https://counter.theconversation.com/content/215060/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paula Lorgelly receives funding from the Ministry of Health. </span></em></p>Most parties are promising more funding for the government drug-buying agency. But two likely coalition partners are suggesting a new – and possibly risky – approach to medicines procurement.Paula Lorgelly, Professor of Health Economics, University of Auckland, Waipapa Taumata RauLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2116802023-08-27T20:04:42Z2023-08-27T20:04:42ZDoes private health insurance cut public hospital waiting lists? We found it barely makes a dent<figure><img src="https://images.theconversation.com/files/544122/original/file-20230823-29-hhssuv.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/blur-image-patients-hospital-waiting-see-1142067620">Shutterstock</a></span></figcaption></figure><p>The more people take up private health insurance, the <a href="https://www.aph.gov.au/parliamentary_business/committees/senate/community_affairs/completed_inquiries/1999-02/pubhosp/report/c05">less pressure</a> on the public hospital system, including <a href="https://www.privatehealthcareaustralia.org.au/australians-sign-up-to-private-health-insurance-in-record-numbers-to-avoid-hospital-waiting-lists/#:%7E:text=%22Private%20health%20insurance%20is%20the,and%20keep%20pressure%20off%20premiums.">shorter waiting lists</a> for surgery. That’s one of the key messages we’ve been hearing from government and the private health insurance industry in recent years.</p>
<p>Governments <a href="https://www.privatehealth.gov.au/health_insurance/surcharges_incentives/index.htm">encourage us</a> to buy private hospital cover. They tempt us with carrots – for instance, with subsidised <a href="https://www.ato.gov.au/Individuals/Medicare-and-private-health-insurance/Private-health-insurance-rebate/">premiums</a>. With higher-income earners, the government uses sticks – buy private cover or pay the <a href="https://www.ato.gov.au/Individuals/Medicare-and-private-health-insurance/Medicare-levy-surcharge/">Medicare Levy Surcharge</a>. These are just some of the <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/delivering-australias-lowest-private-health-insurance-premium-change-in-21-years#:%7E:text=Home-,Delivering%20Australia's%20lowest%20private%20health%20insurance%20premium%20change%20in%2021,be%202.70%20percent%20in%202022">billion-dollar strategies</a> aimed to shift more of us who can afford it into the private system.</p>
<p>But what if private health insurance doesn’t have any meaningful impact on public hospital waiting lists after all?</p>
<p>That’s what we found in our <a href="https://melbourneinstitute.unimelb.edu.au/publications/working-papers/search/result?paper=4721936">recent research</a>. Our analysis suggests if an extra 65,000 people buy private health insurance, public hospital waiting lists barely shift from the average 69 days. Waiting lists are an average just eight hours shorter.</p>
<p>In other words, we’ve used hospital admission and waiting-list data to show private health insurance doesn’t make much difference.</p>
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Read more:
<a href="https://theconversation.com/private-health-insurance-is-set-for-a-shake-up-but-asking-people-to-pay-more-for-policies-they-dont-want-isnt-the-answer-210981">Private health insurance is set for a shake-up. But asking people to pay more for policies they don't want isn't the answer</a>
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<h2>What we did</h2>
<p>Our <a href="https://melbourneinstitute.unimelb.edu.au/publications/working-papers/search/result?paper=4721936">work</a> looked at data from 2014-2018 on hospital admissions and waiting lists for elective surgery in Victoria.</p>
<p>The data covered all Victorians who were admitted as an inpatient in all hospitals in the state (both public and private) and those registered on the waiting list for elective surgeries in the state’s public hospitals.</p>
<p>That included waiting times for surgeries where people are admitted to public hospitals (as an inpatient). We didn’t include people waiting to see specialist doctors as an outpatient.</p>
<p>The data was linked at the patient level, meaning we could track what happened to individuals on the waiting list.</p>
<p>We then examined the impact of more people buying private health insurance on waiting times for surgeries in the state’s public hospitals.</p>
<p>We did this by looking at the uptake of private health insurance in different areas of Victoria, according to socioeconomic status. After adjusting for patient characteristics that may affect waiting times, these differences in insurance uptake allowed us to identify how this changed waiting times.</p>
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<a href="https://images.theconversation.com/files/544142/original/file-20230823-23-lz4g5p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Man lying in hospital bed with oxygen mask, holding hands of female friend or relative" src="https://images.theconversation.com/files/544142/original/file-20230823-23-lz4g5p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/544142/original/file-20230823-23-lz4g5p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/544142/original/file-20230823-23-lz4g5p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/544142/original/file-20230823-23-lz4g5p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/544142/original/file-20230823-23-lz4g5p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/544142/original/file-20230823-23-lz4g5p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/544142/original/file-20230823-23-lz4g5p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">We looked at all people waiting for elective surgery.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-shot-wife-hands-family-praying-2344798261">Shutterstock</a></span>
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<h2>What we found</h2>
<p>In our sample, on average <a href="https://melbourneinstitute.unimelb.edu.au/__data/assets/pdf_file/0005/4721936/wp2023n09.pdf">44% of people</a> in Victoria had private health insurance. This is close to the national average of <a href="https://www.apra.gov.au/private-health-insurance-annual-coverage-survey">45%</a>. </p>
<p>We found that increasing the average private health insurance take-up from 44% to 45% in Victoria would reduce waiting times in public hospitals by an average 0.34 days (or about eight hours).</p>
<p>This increase of one percentage point is equivalent to 65,000 more people in Victoria (based on <a href="https://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/3101.0Main+Features1Jun%202018?OpenDocument">2018 population data</a>) taking up (and using) private health insurance.</p>
<p>The effects vary slightly by surgical specialty. For instance, private health insurance made a bigger reduction to waiting times for knee replacements, than for cancer surgery, compared to the average. But again, the difference only came down to a few hours.</p>
<p>Someone’s age also made a slight difference, but again by only a few hours compared to the average wait.</p>
<p>Given the common situation facing public and private hospitals across all states and territories, and similar private health insurance take-up in many states, our findings are likely to apply outside Victoria. </p>
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Read more:
<a href="https://theconversation.com/getting-an-initial-specialists-appointment-is-the-hidden-waitlist-99507">Getting an initial specialists' appointment is the hidden waitlist</a>
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<h2>Why doesn’t it reduce waiting lists?</h2>
<p>While our research did not address this directly, there may be several reasons why private health insurance does not free up resources in the public system to reduce waiting lists:</p>
<ul>
<li><p>people might buy health insurance and not use it, preferring to have free treatment in the public system rather than risk out-of-pocket costs in the private system</p></li>
<li><p>specialists may not be willing to spend more time in the public system, instead <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1111/1753-6405.12488">favouring working</a> in private hospitals </p></li>
<li><p>there’s a growing need for public hospital services that may not be available in the private system, such as complex neurosurgery and some forms of cancer treatment.</p></li>
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Read more:
<a href="https://theconversation.com/with-surgery-waitlists-in-crisis-and-a-workforce-close-to-collapse-why-havent-we-had-more-campaign-promises-about-health-182327">With surgery waitlists in crisis and a workforce close to collapse, why haven’t we had more campaign promises about health?</a>
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<h2>Why is this important?</h2>
<p>Government <a href="https://www.privatehealth.gov.au/health_insurance/surcharges_incentives/index.htm">policies</a> designed to get more of us to buy private health insurance involve a significant sum of public spending.</p>
<p>Each year, the Australian government spends about <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/delivering-australias-lowest-private-health-insurance-premium-change-in-21-years#:%7E:text=Home-,Delivering%20Australia's%20lowest%20private%20health%20insurance%20premium%20change%20in%2021,be%202.70%20percent%20in%202022">$A6.7 billion</a> in private health insurance rebates to reduce premiums.</p>
<p>In the 2020-21 financial year, Medicare combined with state and territory government expenditure provided almost <a href="https://www.aihw.gov.au/reports/hospitals/australias-hospitals-at-a-glance/contents/spending-on-hospitals">$6.1 billion</a> to fund services provided in private hospitals.</p>
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<p>There might be an argument for this public spending if the end result was to substantially take pressure off public hospitals and thereby reduce waiting times for treatment in public hospitals.</p>
<p>But the considerable effort it takes to encourage more people to sign up for private health insurance, coupled with the small effect on waiting lists we’ve shown, means this strategy is neither practical nor effective.</p>
<p>Given the substantial costs of subsidising private health insurance and private hospitals, public money might be better directed to public hospitals and primary care. </p>
<p>In addition, people buying private health insurance can skip the waiting times for elective surgery to receive speedier care. These people are often <a href="https://melbourneinstitute.unimelb.edu.au/__data/assets/pdf_file/0005/4682822/wp2023n08.pdf">financially well off</a>, implying unequal access to health care.</p>
<h2>What’s next?</h2>
<p>The Australian government is currently <a href="https://consultations.health.gov.au/medical-benefits-division/consultation-on-phi-studies/">reviewing</a> private health insurance.</p>
<p>So now is a good time for reforms to optimise the overall efficiency of the health-care system (both public and private) and improve population health while saving taxpayer money. We also need policies to ensure equitable access to care as a priority. </p>
<p>When it comes to reducing hospital waiting lists, we’ve shown we cannot rely on increased rates of private health insurance coverage to do the heavy lifting.</p>
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Read more:
<a href="https://theconversation.com/do-you-really-need-private-health-insurance-heres-what-you-need-to-know-before-deciding-93661">Do you really need private health insurance? Here's what you need to know before deciding</a>
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<img src="https://counter.theconversation.com/content/211680/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yuting Zhang receives funding from the Australian Research Council, Department of Veterans' Affairs, the Victorian Department of Health, and National Health and Medical Research Council. In the past, Professor Zhang has received funding from several US institutes including the US National Institutes of Health, Commonwealth fund, Agency for Healthcare Research and Quality, and Robert Wood Johnson Foundation. She has not received funding from for-profit industry including the private health insurance industry.</span></em></p><p class="fine-print"><em><span>Jongsay Yong and Ou Yang do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Governments spend billions of dollars every year to encourage us to take up private cover. But our research shows this does little to reduce pressure on the public system.Yuting Zhang, Professor of Health Economics, The University of MelbourneJongsay Yong, Associate Professor of Economics, The University of MelbourneOu Yang, Senior Research Fellow, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2107052023-08-07T20:02:24Z2023-08-07T20:02:24Z‘It’s soul-destroying’: how people on a housing wait list of 175,000 describe their years of waiting<figure><img src="https://images.theconversation.com/files/540968/original/file-20230803-29-4mxua0.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5296%2C3520&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Nationally, about <a href="https://www.aihw.gov.au/reports/housing-assistance/housing-assistance-in-australia/contents/households-and-waiting-lists#Waiting">175,000 households</a> are on the social housing waiting list. An individual usually has to be in “<a href="https://meteor.aihw.gov.au/content/269613%2520(Accessed%252019%2520April%25202023)">greatest need</a>” to get on the list. Even then, being listed does not mean you will be given the keys to a home any time soon.</p>
<p>This is especially so if an applicant is put on the general waiting list and not the priority list. In New South Wales in June 2022, for example, 57,550 were on the waiting list: 51,031 on the general waiting list and <a href="https://www.facs.nsw.gov.au/housing/help/applying-assistance/expected-waiting-times">6,519 on the priority list</a>. The NSW government <a href="https://www.facs.nsw.gov.au/housing/help/applying-assistance/expected-waiting-times">website</a> indicates people on the general waiting list can expect to wait ten years or more in most locations. </p>
<p>Even people on the priority list can wait a long time, especially if they <a href="https://www.tandfonline.com/doi/full/10.1080/19491247.2022.2132460?casa_token=KR6As6n8pJcAAAAA:YZ3vLWMlwUop37-oy-VVENBCfuezqi8gRSLY_cYNrhSeiWKB3xARu8LcHx459zQJ0VHcLhODEHW5A9c">have special requirements</a>, such as housing with no stairs.</p>
<p>For <a href="https://waitingforsocialhousing.com/2023/08/02/waithood-the-experiences-of-applying-for-and-waiting-for-social-housing/">our research</a>, we interviewed people on waiting lists in NSW, Queensland and Tasmania. Thirty interviewees were on the general waiting list and 49 on the priority list. The interviews covered various themes, but all of the interviewees were asked: “What words would you use to describe your wait for social housing?” This article focuses on their responses to this question.</p>
<iframe title="Households on public housing waiting lists in Australia" aria-label="Stacked Column Chart" id="datawrapper-chart-n6yQI" src="https://datawrapper.dwcdn.net/n6yQI/2/" scrolling="no" frameborder="0" style="width: 0; min-width: 100% !important; border: none;" height="400" data-external="1" width="100%"></iframe>
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Read more:
<a href="https://theconversation.com/yes-the-1-5-million-australians-getting-rent-assistance-need-an-increase-but-more-public-housing-is-the-lasting-fix-for-the-crisis-200908">Yes, the 1.5 million Australians getting rent assistance need an increase, but more public housing is the lasting fix for the crisis</a>
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<h2>Lives on hold</h2>
<p>Most interviewees found the endless waiting extremely challenging. It commonly left them feeling powerless, extremely stressed and unable to plan ahead.</p>
<p>Tania* in Queensland, who had escaped domestic violence, powerfully captured the perception of her life being put on hold:</p>
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<p>It sucks. […] They [state government housing department] just give you no answers […] It’s stopped our whole life. Running from him [her ex-partner] was hard enough, but asking them [the housing department] for help is ten times worse […] They don’t care. It’s pure and simple. They don’t care. Yeah, as I said, it’s like jail and they’re the screws, whatever they’re called. They’re the ones that run the jail.</p>
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Read more:
<a href="https://theconversation.com/i-left-with-the-kids-and-ended-up-homeless-with-them-the-nightmare-of-housing-wait-lists-for-people-fleeing-domestic-violence-187687">'I left with the kids and ended up homeless with them': the nightmare of housing wait lists for people fleeing domestic violence</a>
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<p>Zeynep, in her mid-70s, had been on the waiting list in Queensland for 13 years. Her response was particularly expansive:</p>
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<p>Yes, I’ve got a few words. Frustration, disappointment, nerve-racking, just being beside myself sometimes. Why do I have to do this? Why do I have to keep moving and packing and finding places? It’s soul-destroying, really.</p>
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<h2>A traumatising wait</h2>
<p>Single parents found the waiting particularly hard. Thea was in a shelter in Tasmania with her three children. The uncertainty of waiting had shaken her confidence.</p>
<blockquote>
<p>It’s been painful […] My anxiety has gone through the roof. It’s affected my mental health […] It makes me feel like I’m not good enough as a parent because I can’t provide a stable home for my children […] If it was just me, I could survive. But when I’ve got three little people that I’ve got to care for and provide for, that’s when it gets hard.</p>
</blockquote>
<p>Kylie’s description was similar. She has a child with a disability and had been on the NSW general waiting list for several years.</p>
<blockquote>
<p>It’s quite nerve-wracking. It’s quite depressing just for the uncertainty of everything, you know. I feel like so many thoughts that I have in my head I’m just trying to pick the best one. I would say […] it’s kind of traumatic as well, quite traumatic […] why can’t you support me to better my life in order for a child to have a better life and break that cycle, that generational cycle of poverty.</p>
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Read more:
<a href="https://theconversation.com/focus-on-managing-social-housing-waiting-lists-is-failing-low-income-households-120675">Focus on managing social housing waiting lists is failing low-income households</a>
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<p>In Tasmania, Basma and her three children were living in crowded transitional housing attached to a women’s shelter. She also described the waiting as traumatic. </p>
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<p>It’s trauma. It’s made my health go down. My children and I are always angry. […] It’s terrible.</p>
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Read more:
<a href="https://theconversation.com/getting-onto-the-wait-list-is-a-battle-in-itself-insiders-on-what-it-takes-to-get-social-housing-184838">'Getting onto the wait list is a battle in itself': insiders on what it takes to get social housing</a>
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<h2>Losing self-esteem and hope</h2>
<p>Interviewees said the endless waiting affected how they saw themselves. Jacqui was living in her car in regional NSW.</p>
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<p>I think it just it robs you of your pride and your dignity, your peace of mind and it leaves you psychologically exhausted […] being on that waiting list thinking that is today the day […] and then the call doesn’t come. It is like that loss of, you know, self-esteem and loss of hope […] So I think my words [to describe the wait] is my continual shame. You feel shame every day and other than that […] you have to deal with a loss of control over […] your position on the wait list. You have no control over anything.</p>
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<p>Many described a sense of hopelessness. Geoff in Sydney has to use a wheelchair and the house he was renting was totally unsuitable. He was despondent about ever getting suitable housing:</p>
<blockquote>
<p>I think the word is hopeless. You feel hopeless because you’ve done as much as you can to get the housing [department] to expedite your application, assuming that they have approved my application for priority housing, but there’s no interpretation of that as to what they mean by the priority.</p>
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Read more:
<a href="https://theconversation.com/ive-been-on-the-waiting-list-for-over-20-years-why-social-housing-suitable-for-people-with-disabilities-is-desperately-needed-193455">'I've been on the waiting list for over 20 years': why social housing suitable for people with disabilities is desperately needed</a>
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<p>After 20 months on the priority list, Lily was blunt about the impact on her sense of self:</p>
<blockquote>
<p>Yeah, you feel deficient. You feel forgotten. You feel really forgotten, yeah, and if you ring up and it’s about a number and even once they’ve got your file open I can’t remember being addressed by my name very much […] You feel a bit like an outcast.</p>
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<p>Josie also talked about being made to feel like a second-class citizen:</p>
<blockquote>
<p>Demoralising, because you’ve been trying to do the right thing and do everything that you’re asked. You try so many different approaches and you’re getting brick walls everywhere. And demeaning, because your situation is not properly recognised or catered for. So you almost start feeling like well, we can’t help you, but if you were good enough you wouldn’t be in this situation. [It’s] a nightmare, dreadful. I’ve never experienced anything like this before. Like never, ever, ever.</p>
</blockquote>
<p>Clearly, the long wait for social housing is devastating for many people. Day after day of not knowing makes everyday life extremely challenging. The shocking aspect is that the huge shortage of social housing means a substantial proportion of people on the general waiting list could be waiting forever.</p>
<p><em>* Pseudonyms have been used to protect the confidentiality of participants in the study.</em></p><img src="https://counter.theconversation.com/content/210705/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alan Morris receives funding from the Australian Research Council. </span></em></p>People on the general waiting list can wait a decade to be housed. Even those on the priority list may wait years. Asked how the wait affects them, their responses reveal devastating impacts.Alan Morris, Professor, Institute for Public Policy and Governance, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2029972023-06-30T14:09:06Z2023-06-30T14:09:06Z‘Dehumanising policies’ leave autistic people struggling to access health, education and housing – new review<figure><img src="https://images.theconversation.com/files/534448/original/file-20230627-31322-i8q760.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4160%2C3120&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Autistic people often don't receive the correct healthcare to meet their needs.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-many-people-waiting-medical-1033246597">toodtuphoto/Shutterstock</a></span></figcaption></figure><p><a href="https://www.cdc.gov/ncbddd/autism/data.html">Around 3% of people</a> are estimated to be autistic and it is a lifelong disability. Most autistic people experience the sensory world differently, such as places being too loud or too bright. We also typically communicate in a more direct way than is usual.</p>
<p>In the UK, the Equality Act 2010 means that autistic people should receive reasonable adjustments – meaning organisations must make changes to how they provide their services to remove environmental and social barriers. Despite this, autistic people often experience society as highly disabling. We die between 16 and 30 years younger than non-autistic people, and have a suicide rate <a href="https://journals.sagepub.com/doi/full/10.1177/1362361318764742">nine times higher</a>.</p>
<p>Autistic people are often misunderstood by non-autistic people who <a href="https://journals.sagepub.com/doi/10.1177/13623613221129123">fail to recognise</a> how autistic people show empathy. This misunderstanding is embedded in many government bodies, which can result in dehumanising policies and services that do not meet autistic people’s needs.</p>
<p><a href="https://library.oapen.org/handle/20.500.12657/63401">We reviewed</a> the evidence from a range of government and non-government research and reviews to understand how well autistic people fair in relation to government services. We looked at the areas described by William Beveridge, founder of the UK welfare state, as <a href="https://www.parliament.uk/about/living-heritage/transformingsociety/livinglearning/coll-9-health1/coll-9-health/#:%7E:text=By%20the%20outbreak%20of%20war,%2C%20disease%2C%20squalor%20and%20want.">“the five giants”</a>: health, education, employment, poverty and housing. Our findings, which focused on England and Wales due to differences relating to devolution, were bleak.</p>
<p><strong>1. Health</strong></p>
<p>Many government services designed to support autistic people are not available without diagnosis. However, in the UK, most autistic people <a href="https://journals.sagepub.com/doi/10.1177/13623613211059674">aren’t yet diagnosed</a>.</p>
<p>We found diagnosis waiting lists were long – for example, <a href="https://cavuhb.nhs.wales/our-services/integrated-autism-services/diagnostic-assessments-for-autism/">more then 20 months</a> for people served by the Cardiff & Vale health board in south Wales. Across England, between June 2021 and 2022, the waiting list for an autism assessment rose from <a href="https://digital.nhs.uk/data-and-information/publications/statistical/autism-statistics/july-2021-to-june-2022">88,000 people to more than 122,000</a>. </p>
<p>Even with a diagnosis, autistic people often don’t receive healthcare that meets their needs. Some people don’t even tell doctors they are autistic, because they expect to be treated badly. Of those who have told their GP, more than 75% said their GP didn’t make <a href="https://westminsterautismcommission.files.wordpress.com/2016/03/ar1011_ncg-autism-report-july-2016.pdf">any reasonable adjustments</a>, such as allowing extra processing time during appointments. </p>
<p>Being expected to phone to book appointments is also difficult for <a href="https://bmjopen.bmj.com/content/12/2/e056904">nearly two-thirds of autistic people</a>, yet many GP surgeries insist on phone calls to book appointments. Autistic people also report that clinical spaces <a href="https://www.ndti.org.uk/resources/publication/its-not-rocket-science">are painfully bright, busy and loud</a>, which can make it harder for us to explain what is wrong to the doctor.</p>
<p><strong>2. Education</strong></p>
<p>Autistic people often struggle in educational institutions because they rarely meet our needs. This can mean, for example, that autistic children are labelled as “troublemakers” by teachers, rather than disabled.</p>
<p>Despite autistic people accounting for only 3% of the population, around <a href="https://www.gov.uk/government/consultations/send-review-right-support-right-place-right-time">80% of those sent to pupil referral units</a> are autistic. This has lifelong effects, as <a href="https://lordchrisholmes.com/report-disabled-students-allowance-dsa/">only 8% </a> of students with a “statement of special educational needs” or an education, health & care plan progress to university, compared with 50% of non-disabled people. </p>
<p>For autistic people who do make it to university, the disabled students allowance (DSA) should pay for extra costs – but <a href="https://lordchrisholmes.com/report-disabled-students-allowance-dsa/">less than one-third </a>of eligible students get DSA. In addition, the support provided by universities is often <a href="https://www.tandfonline.com/doi/abs/10.1080/14703297.2020.1850320?journalCode=riie20">poor quality or absent</a>, leaving autistic students disadvantaged.</p>
<p><strong>3. Employment</strong></p>
<p>The UK’s <a href="https://www.legislation.gov.uk/ukpga/2009/15/contents">Autism Act 2009</a> says that autistic people should be supported to be able to work. However, autistic people are <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/disability/articles/outcomesfordisabledpeopleintheuk/2021">less likely to be in work</a> than non-autistic people. </p>
<p><a href="https://www.gov.uk/access-to-work">Access to work</a> is a UK government scheme to pay disabled people for the extra costs of working, but the application and claiming processes are complicated. Of the 42% of autistic adults who say they need help to access work, <a href="https://s4.chorus-mk.thirdlight.com/file/1573224908/61601577629/width=-1/height=-1/format=-1/fit=scale/t=443899/e=never/k=a402a7d4/nas_appga_report.pdf">only 12% are getting it</a>.</p>
<p><strong>4. Poverty</strong></p>
<p>Autistic people are <a href="https://doi.org/10.1108/AIA-01-2022-0004">more likely</a> to live in poverty than non-autistic people. <a href="https://edm.parliament.uk/early-day-motion/39649/dont-write-me-off-campaign">A 2009 report</a> found one-third of autistic people in the UK were not in paid work or getting benefits. One reason for this is that the benefits designed to stop disabled people living in poverty, such as the personal independence payment (PIP), can be hard to apply for, especially for autistic people. </p>
<p>And for people who manage to apply for PIP, autism falls within the “psychiatric disorders” category, which means they are <a href="https://www.gov.uk/government/statistics/personal-independence-payment-statistics-to-april-2022/personal-independence-payment-official-statistics-to-april-2022#pip-statistics-by-disabling-condition">least likely to receive the award</a> and most likely to lose their PIP upon renewal. </p>
<p><strong>5. Housing</strong></p>
<p>Around <a href="https://www.tandfonline.com/doi/full/10.1080/09687599.2021.2004881">12% of autistic people are homeless</a>. As rent typically costs far more than the amount of money awarded in housing benefit, and autistic people are less likely to be in work or have access to benefits, they are more likely to struggle to pay for housing. </p>
<p>This can be made worse by the “<a href="https://www.disabilityrightsuk.org/resources/bedroom-tax">bedroom tax</a>”, which is when tenants in social housing have their benefit reduced if they have spare bedrooms. This affects <a href="https://www.tandfonline.com/doi/full/10.1080/19491247.2021.1964253">single people under 35</a> especially, as they are only eligible for the <a href="https://england.shelter.org.uk/housing_advice/benefits/benefits_for_under_35s_in_shared_housing">shared accommodation rate</a>. Autistic people can find it hard to live with other people due to their sensory needs, and there are <a href="https://www.tandfonline.com/doi/abs/10.1080/14616718.2014.992681">few one-bedroom properties</a>. </p>
<p>Autistic people who do not have somewhere to live are more likely to be <a href="https://publications.parliament.uk/pa/jt201919/jtselect/jtrights/121/121.pdf.">placed in secure residential care</a>, where they are subjected to similar confines to people in prison, by staff who may have <a href="https://www.autism.org.uk/advice-and-guidance/stories/stories-from-the-spectrum-alexis-quinn">limited understanding of autism</a>. They can also be subjected to clinical “treatment” that has the same <a href="https://catalystjournal.org/index.php/catalyst/article/view/29579/23427">questionable origin</a> as <a href="https://www.stonewall.org.uk/everything-you-need-know-about-conversion-therapy">gay conversion therapy</a>, and which guidance states <a href="https://www.ingentaconnect.com/contentone/bild/ijpbs/2022/00000012/a00101s1/art00001?crawler=true&mimetype=application/pdf">should not be used</a>.</p>
<p>The research supporting this approach, known as applied behaviour analysis (ABA), is often riddled with <a href="https://www.frontiersin.org/articles/10.3389/fpsyg.2021.676303/full">undeclared conflicts of interest</a>. Those who experience ABA have been found to be <a href="https://www.emerald.com/insight/content/doi/10.1108/AIA-08-2017-0016/full/html">more likely to experience symptoms of post-traumatic stress disorder</a> (PTSD).</p>
<p>Worse, some autistic people in residential care have experienced <a href="https://www.theguardian.com/society/2019/mar/28/parents-of-former-mendip-house-resident-claim-they-were-misled-over-scale-of-abuse">abuse by staff</a>. In the most severe cases, <a href="https://www.theguardian.com/society/2018/may/30/seven-years-winterbourne-view-learning-disabled-people-abuse">autistic people have died</a> due to abusive and/or negligent treatment while in residential care. </p>
<h2>A cumulative impact throughout life</h2>
<p>In every area of government services, we found policies that failed to account for known autistic needs. These failures have a cumulative impact throughout life. A lack of accommodations in education leads to less likelihood of securing accessible employment and greater reliance on benefits and social housing. </p>
<p>To improve this, the policy-making process needs to be made accessible to disabled people so that services meet our needs. This could include ensuring that consultation processes reach out to a broader range of autistic people, and then meet their needs to submit evidence.</p>
<p>It is also important that policy-makers put evidence from the autistic community ahead of evidence provided by non-autistic “experts” who fundamentally misunderstand autism, can have conflicts of interest, and thus can not speak on our behalf. </p>
<p>Autistic lives depend on it.</p><img src="https://counter.theconversation.com/content/202997/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Aimee Grant receives funding from UKRI, the Wellcome Trust and the Research Wales Innovation Fund. We wish to thank Dr Gemma Williams and Richard Woods, co-authors of the chapter this article is based on.</span></em></p><p class="fine-print"><em><span>Kathryn Williams receives funding for her PhD studentship from the Economic and Social Research Council. She is affiliated with Autistic UK CIC, where she is a voluntary non-executive director. </span></em></p>A review of government services has found that autistic people are being failed in health, education, employment, poverty and housing.Aimee Grant, Senior Lecturer in Public Health and Wellcome Trust Career Development Fellow, Swansea UniversityKathryn Williams, PhD Candidate, Cardiff UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2005232023-03-16T00:00:40Z2023-03-16T00:00:40ZThe housing and homelessness crisis in NSW explained in 9 charts<p>Whatever the result of the New South Wales election on March 25, rising housing stress is a problem the new state government will have to confront.</p>
<p><a href="https://www.9news.com.au/national/domain-report-shows-rental-prices-shoot-up-australian-cities/ea06867b-5c30-479f-8d9b-3755d29f2981">Soaring rents</a> and an extraordinary <a href="https://www.abc.net.au/news/2023-03-11/australian-rental-vacancy-rates-lowest-since-before-pandemic/102079318">lack of rental vacancies</a> are intensifying <a href="https://www.ahuri.edu.au/research/brief/understanding-3040-indicator-housing-affordability-stress">housing stress</a> in <a href="https://www.9news.com.au/national/nsw-rental-affordability-how-much-you-need-to-earn-avoid-housing-stress-postcode-search/8eab1b7d-0884-41ce-979f-a3eaf68ba1e9">Sydney and elsewhere</a>. Many low-income households are spending well over 30% of their income on housing costs. </p>
<p>The numbers of people seeking help are pushing social housing and homelessness systems to the brink. </p>
<p>But how did these sectors end up in such a vulnerable place? And why are some of their problems worse than in other states?</p>
<h2>Population has outpaced social housing supply</h2>
<p>The stock of social housing in Australia has hardly changed in 25 years. It has fallen further and further behind the supply needed to keep pace with population growth.</p>
<p>Social housing accounted for more than 6% of occupied dwellings in 1996. By 2021, it was barely above 4%. Rather than reflecting active policy – such as large-scale privatisation or demolition – this is mainly a case of simple neglect.</p>
<iframe title="Supply of social housing stock in Australia since 1996" aria-label="Interactive line chart" id="datawrapper-chart-6Vl0x" src="https://datawrapper.dwcdn.net/6Vl0x/1/" scrolling="no" frameborder="0" style="border: none;" width="100%" height="400" data-external="1"></iframe>
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Read more:
<a href="https://theconversation.com/albanese-government-tackles-housing-crisis-on-3-fronts-but-theres-still-more-to-do-198509">Albanese government tackles housing crisis on 3 fronts, but there's still more to do</a>
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<p>At first sight, NSW did relatively well during the 2010s. Social housing stock apparently rose by 9% compared with 12% for population.</p>
<p>Unfortunately, this is a somewhat misleading impression. It reflects the NSW government’s <a href="https://www.pc.gov.au/ongoing/report-on-government-services/2023/housing-and-homelessness/housing/rogs-2023-partg-section18-housing-data-tables.xlsx">2016 decision</a> to widen its definition of social housing to include less-subsidised affordable rental housing managed by community housing providers. While this housing meets an important need for low-paid “essential workers”, it is no substitute for housing that very low-income earners can afford. </p>
<p>If not for this redefinition, the NSW chart would more closely resemble the national post-1996 picture.</p>
<iframe title="NSW social housing stock and population, 2011–2022" aria-label="Interactive line chart" id="datawrapper-chart-R8qKS" src="https://datawrapper.dwcdn.net/R8qKS/1/" scrolling="no" frameborder="0" style="border: none;" width="100%" height="400" data-external="1"></iframe>
<h2>Social housing supply</h2>
<p>Social housing construction numbers aren’t directly published in any official series but can be estimated from Australian Bureau of Statistics data on housing commencements. The 2010s began with a dramatic spike as the federal Rudd government <a href="https://formerministers.dss.gov.au/11367/social-housing-initiative-creates-jobs-is-value-for-money/">invested in social housing</a> as part of its emergency response to the Global Financial Crisis.</p>
<p>But then national and state governments largely stepped back from new social housing investment. NSW annual commencements ran at only 500-1,000 for most of the 2010s. This is less than half the <a href="https://blogs.unsw.edu.au/cityfutures/blog/2018/06/does-nsw-really-need-to-double-its-social-housing-output/">minimum number</a> needed to maintain social housing’s share of all housing.</p>
<iframe title="Social housing commencements in NSW, 2007-22" aria-label="Interactive line chart" id="datawrapper-chart-5beIp" src="https://datawrapper.dwcdn.net/5beIp/2/" scrolling="no" frameborder="0" style="border: none;" width="100%" height="400" data-external="1"></iframe>
<p><a href="https://cityfutures.ada.unsw.edu.au/documents/673/COVID-19_rental_housing_and_homelessness_impacts_-_FINAL.pdf">Unlike other states</a> such as Victoria and Queensland, the NSW government resisted calls for state-funded social housing investment as part of pandemic recovery plans in 2020 and 2021. In contrast with those states, NSW expects to achieve only a <a href="https://cityfutures.ada.unsw.edu.au/documents/673/COVID-19_rental_housing_and_homelessness_impacts_-_FINAL.pdf">minimal net increase</a> in social housing in the first half of the 2020s.</p>
<p>Not only is expected construction modest in scale, it is mainly associated with large-scale demolition of “obsolete” public housing to liberate land. Some is then sold to generate investment funds.</p>
<p>Unlike Victoria, the NSW government has continued to insist new social housing cannot be funded from general government revenue.</p>
<iframe title="Social housing construction pipelines, 2021-25" aria-label="Grouped Column Chart" id="datawrapper-chart-fMEP5" src="https://datawrapper.dwcdn.net/fMEP5/1/" scrolling="no" frameborder="0" style="border: none;" width="100%" height="400" data-external="1"></iframe>
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Read more:
<a href="https://theconversation.com/the-market-has-failed-to-give-australians-affordable-housing-so-dont-expect-it-to-solve-the-crisis-192177">The market has failed to give Australians affordable housing, so don't expect it to solve the crisis</a>
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<p>The trends are even more problematic than stock numbers suggest, because the system’s capacity to generate lettable vacancies continues to decline. Very few newly built properties are coming up for let. And the flow of existing tenancies being ended has dwindled as tenants struggle to find alternatives in the private rental market.</p>
<p>Social housing lettings in 2021-22 were down 13% compared with 2014-15. And a growing share of scarce lettings has to be devoted to priority applicants – those with the most urgent and severe needs. Priority lets grew by 37% over the past four years and made up nearly two-thirds of all lettings (64%) by 2021-22.</p>
<p>Vacancies remaining for non-priority applicants have almost halved since 2014-15 – down 47%.</p>
<iframe title="NSW social housing supply and letting to priority applicants" aria-label="Interactive line chart" id="datawrapper-chart-y85qM" src="https://datawrapper.dwcdn.net/y85qM/2/" scrolling="no" frameborder="0" style="border: none;" width="100%" height="400" data-external="1"></iframe>
<h2>Homelessness</h2>
<p>Many of those assigned priority status are homeless or at imminent risk of becoming homeless. The latest official statistics that directly measure homelessness are from the 2016 census when <a href="https://www.abs.gov.au/statistics/people/housing/estimating-homelessness-census/latest-release">38,000 people were homeless in NSW</a>. Relative to population, homelessness was higher than in any other mainland state.</p>
<iframe title="Trends in homelessness rates by state (territories excluded)" aria-label="Grouped Column Chart" id="datawrapper-chart-6b1iS" src="https://datawrapper.dwcdn.net/6b1iS/1/" scrolling="no" frameborder="0" style="border: none;" width="100%" height="400" data-external="1"></iframe>
<p>Measured by the average monthly caseload of specialist homelessness services agencies, homelessness has more recently been rising relatively slowly in NSW. It was up 5% in the four years to 2021-22 compared with 8% nationally.</p>
<p>But rising numbers are being turned away – <a href="https://www.aihw.gov.au/getmedia/8a0d042b-2f03-4887-ac13-75c9ba09536e/AIHW-HOU-331-Specialist-homelessness-services-data-tables-2021-22.xlsx.aspx">nearly 10,000 people in 2021-22</a> – up by 22% in three years. This suggests the system is increasingly overloaded.</p>
<p>The wider point is that homelessness is rising while social housing capacity is shrinking.</p>
<iframe title="Changes in numbers aided by specialist homelessness services" aria-label="Interactive line chart" id="datawrapper-chart-iEsRV" src="https://datawrapper.dwcdn.net/iEsRV/2/" scrolling="no" frameborder="0" style="border: none;" width="100%" height="400" data-external="1"></iframe>
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Read more:
<a href="https://theconversation.com/homeless-numbers-have-jumped-since-covid-housing-efforts-ended-and-the-problem-is-spreading-beyond-the-big-cities-194624">Homeless numbers have jumped since COVID housing efforts ended – and the problem is spreading beyond the big cities</a>
</strong>
</em>
</p>
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<p>After several years of stability or slight reductions, the social housing waiting list (excluding existing tenants) <a href="https://www.pc.gov.au/ongoing/report-on-government-services/2023/housing-and-homelessness/rogs-2023-partg-sector-overview-data-tables.xlsx">grew by 15% in 2021-22 to 52,000 households</a>. But annual snapshot statistics mask large numbers joining and leaving the list each year.</p>
<p>By <a href="https://cityfutures.ada.unsw.edu.au/documents/689/Waithood_final.pdf">our calculations</a>, 17,000 households newly enrolled on the NSW social housing register in 2020-21, nearly double the number given a tenancy. That’s another powerful measure of shortage. </p>
<p>Note that the rules on waiting list eligibility are strict. The weekly household income limit in 2022 was $690 – well below the full-time <a href="https://www.fairwork.gov.au/pay-and-wages/minimum-wages">minimum wage of $812.60</a>.</p>
<iframe title="Annual % change in NSW social housing waiting list" aria-label="Column Chart" id="datawrapper-chart-iiTPk" src="https://datawrapper.dwcdn.net/iiTPk/1/" scrolling="no" frameborder="0" style="border: none;" width="100%" height="400" data-external="1"></iframe>
<p>Far greater numbers of people are homeless or living with rental stress than are on the list. Many people who could qualify realise their chances are so slim it isn’t worth the trouble. Others drop off when they realise they face a wait of years or even decades.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/getting-onto-the-wait-list-is-a-battle-in-itself-insiders-on-what-it-takes-to-get-social-housing-184838">'Getting onto the wait list is a battle in itself': insiders on what it takes to get social housing</a>
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<p>Our <a href="https://cityfutures.ada.unsw.edu.au/social-and-affordable-housing-needs-costs-and-subsidy-gaps-by-region/">recent census-based analysis</a> shows there were well over 200,000 NSW households with an unmet need for social or affordable housing in 2021. Some 144,000 of them would probably qualify for social housing.</p>
<p>True, some of these needs could be met in other ways, such as a major increase in rent assistance. But even if that happened and if <a href="https://www.jennyleong.org/speech_ending_no_grounds_evictions">no-grounds evictions were outlawed</a> in NSW, private tenancies will remain far less secure than social housing. Arguably, that makes them fundamentally unsuitable for vulnerable people and low-income families.</p>
<iframe title="Current unmet need for social and affordable housing" aria-label="Bar Chart" id="datawrapper-chart-mo1QH" src="https://datawrapper.dwcdn.net/mo1QH/1/" scrolling="no" frameborder="0" style="border: none;" width="100%" height="193" data-external="1"></iframe>
<h2>What lies ahead?</h2>
<p>The extraordinary rent spike of 2021-2022 has been the main cause of rising housing need. This happened while immigration <a href="https://www.abs.gov.au/statistics/people/population/overseas-migration/latest-release">all but stopped during the pandemic</a>.</p>
<p>With migration rebounding, there is a <a href="https://www.afr.com/property/residential/unexpected-migration-pick-up-to-worsen-housing-shortfall-economists-20230306-p5cpwg">serious worry</a> rent inflation will continue to rage, placing even more low-income Australians in financial stress.</p>
<p>Somewhere on the horizon is modest help via the Albanese government’s <a href="https://theconversation.com/1-million-homes-target-makes-headlines-but-cant-mask-modest-ambition-of-budgets-housing-plans-193289">Housing Australia Future Fund</a>. The target is 30,000 new social and affordable dwellings over five years, with NSW likely to get a large share.</p>
<p>However, the HAFF legislation remains <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Economics/HousingPackageofBills">under review</a>. Even when new homes begin to flow through, numbers will be quite small relative to need.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/labors-proposed-10-billion-social-housing-fund-isnt-big-as-it-seems-but-it-could-work-174406">Labor's proposed $10 billion social housing fund isn't big as it seems, but it could work</a>
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<p>In NSW, party leaders are touting <a href="https://www.abc.net.au/news/2023-01-23/nsw-land-tax-and-stamp-duty-issue-debacle/101876910">rival plans</a> to assist first home buyers, but have long neglected arguably more serious policy challenges at the lower end of the housing market. Hundreds of thousands of households are struggling as a result.</p><img src="https://counter.theconversation.com/content/200523/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hal Pawson receives funding from the Australian Research Council (ARC), the Australian Housing and Urban Research Institute (AHURI), the Queensland Council of Social Service and Crisis UK. He is affiliated with Community Housing Canberra as a non-Executive Director</span></em></p>Why are some of the problems with housing stress and homelessness worse in New South Wales than in other states?Hal Pawson, Professor of Housing Research and Policy, and Associate Director, City Futures Research Centre, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1934552022-11-18T00:52:36Z2022-11-18T00:52:36Z‘I’ve been on the waiting list for over 20 years’: why social housing suitable for people with disabilities is desperately needed<figure><img src="https://images.theconversation.com/files/495302/original/file-20221115-25-9pieau.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4940%2C3167&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>One of the most common reasons people apply for social housing is because they or their immediate family members have a disability and they are unable to work. They need an affordable alternative to private rental housing that’s suitable for their disability-related needs.</p>
<p><a href="https://waitingforsocialhousing.com/">Our research</a> on the experiences and circumstances of people on the social housing waiting list has found many people with serious disabilities are not guaranteed access to social housing. The following three case studies, drawn from our interviews, illustrate how the <a href="https://www.ndis.gov.au/about-us/publications/quarterly-reports">long wait</a> for social housing makes their extremely difficult situations worse.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1589383350116298752"}"></div></p>
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Read more:
<a href="https://theconversation.com/not-just-ramps-and-doorways-disability-housing-is-about-choosing-where-how-and-who-you-live-with-183523">Not just ramps and doorways – disability housing is about choosing where, how and who you live with</a>
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<h2>Paul</h2>
<p>Paul* has serious mobility problems and requires a wheelchair. He lives by himself in Sydney. He had been on the social housing priority waiting list for just under a year and had no idea of how much longer he would have to wait. But the house he was living in was unsuitable. As Paul explained:</p>
<blockquote>
<p>“The nature of the accommodation has been assessed […] and it’s not suitable for me to live in […] There is a bathroom, but to do the shower you have to stand inside the tub […] so I can’t do that shower any more […] And the doors are not wide enough for the wheelchair to go through.”</p>
</blockquote>
<p>Access to the house is also difficult.</p>
<blockquote>
<p>“The condition of the [path] from the house going to the road it’s not good and it’s very difficult.”</p>
</blockquote>
<p>Paul is on the National Disability Insurance Scheme (NDIS) and eligible for an electric wheelchair. But he says:</p>
<blockquote>
<p>[T]hey won’t approve […] until I have a proper accommodation […] they want to make sure whether it’s going to be used in the house.“</p>
</blockquote>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1521235644739072000"}"></div></p>
<h2>Mark</h2>
<p>Two of Mark’s three children have complex mental and physical disabilities. His wife also has a disability. He gave up paid work 20 years ago to be their full-time carer. </p>
<p>Through community housing he found a subsidised private rental property. </p>
<blockquote>
<p>"We were there from 2002 until 2019 in the same house that was very not suitable for people with disabilities. It was just a three-bedroom normal house that was run down that as the kids grew up […] and my wife’s getting worse. The house was just absolutely not suitable […] for our situation.”</p>
</blockquote>
<p>His pleas for suitable social housing fell on deaf ears. In 2019 Mark felt he had to move.</p>
<blockquote>
<p>“I just couldn’t hack it anymore. The kids are getting bigger. It’s getting very hard for me to look after them cos I was the main carer and I have to shower them, toilet them, you know all that stuff, and you know the house was small […] sometimes they had to be in a wheelchair, [but] there was no wheelchair access. </p>
<p>"So eventually I just gave up and found a house that I’m renting now […] I’m paying private rent but being on priority housing I get subsidised from public housing […] It’s still not suitable, but it’s a bit bigger and a little bit better.</p>
</blockquote>
<p>Mark summed up his experience:</p>
<blockquote>
<p>"I’ve been on the waiting list for over 20 years without, you know, being given a public [housing] house or […] never offered suitable housing for our situation, and until today we’re still on the priority list.”</p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/getting-onto-the-wait-list-is-a-battle-in-itself-insiders-on-what-it-takes-to-get-social-housing-184838">'Getting onto the wait list is a battle in itself': insiders on what it takes to get social housing</a>
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<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1576771377771999238"}"></div></p>
<p>Despite the permanent nature of his family members’ disabilities, to continue receiving the rental subsidy Mark has to get forms filled in by a GP every six months. </p>
<blockquote>
<p>“There’s a lot of paperwork involved. Every six months you’ve got to bring bank statements […] you’ve got to bring medical certificates […] and the stress, and you know […] GPs these people don’t want to sit there filling up forms for three people. </p>
<p>"If I take my family and I go to a GP and say, ‘Listen, can you fill up these forms?”, they say, 'No mate, […] it’s too much work for me", and I’ve got that from my GP many times. You’ve got to beg the doctor, fight with the doctor […] and this is the life you live.“ </p>
</blockquote>
<h2>Pippa</h2>
<p>Pippa has an intellectual disability and lives with her carer who is also her partner. Despite being homeless at times, she has been on the waiting list for around 10 years.</p>
<blockquote>
<p>"They refused to put me on priority […] and I said, 'Yeah, but I don’t have anywhere to sleep. I don’t have a house or anything.’ And they basically just said, ‘Keep looking for private rental.’ We got 21 days of TA [temporary accommodation] and a little bit more during the whole year that me and my partner were homeless.”</p>
</blockquote>
<p>Although they eventually found a private rental property, the insecurity and her lack of disposable income are deeply unsettling.</p>
<blockquote>
<p>“I mean for me I think I need something more stable which would be [social] housing […] If it’s a place where I could kind of set my life up and you know get a job and not have to focus on, okay, the owner is going to sell or, you know, my rent’s going to go up […] if the owners sell tomorrow we would be back on the street cos there’s no way we could afford anything. There would be nowhere to go.”</p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/stability-and-security-the-keys-to-closing-the-mental-health-gap-between-renters-and-home-owners-179481">Stability and security: the keys to closing the mental health gap between renters and home owners</a>
</strong>
</em>
</p>
<hr>
<p>Pippa was scathing of the NSW Department of Communities and Justice – Housing.</p>
<blockquote>
<p>“The fact that Housing can’t even assist someone with a disability is very concerning […] I just think they don’t have the right kind of tools or people or anything to kind of handle someone with a disability […] they just have no idea at all.”</p>
</blockquote>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1587661653654446080"}"></div></p>
<p>The situations of Paul, Mark and Pippa (who is now on the priority list) starkly illustrate how not being able to get into social housing makes their lives even more challenging. Clearly, what is required is the urgent building of social housing that is suitable for people with different disabilities.</p>
<hr>
<p><em>* All the names used are pseudonyms to protect individuals’ privacy.</em></p><img src="https://counter.theconversation.com/content/193455/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alan Morris receives funding from The Australian Research Council.</span></em></p><p class="fine-print"><em><span>Jan Idle is employed though ARC funding.</span></em></p>A serious disability is one of the most common reasons people apply for social housing. The long wait for a suitable home just adds to the daily challenges they face.Alan Morris, Professor, Institute for Public Policy and Governance, University of Technology SydneyJan Idle, Research Officer, Institute for Public Policy and Governance, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1368352020-04-22T03:55:49Z2020-04-22T03:55:49ZElective surgery’s due to restart next week so now’s the time to fix waiting lists once and for all<figure><img src="https://images.theconversation.com/files/329614/original/file-20200422-82650-k0jniv.jpg?ixlib=rb-1.1.0&rect=14%2C0%2C4969%2C3325&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Monkey Business Images/Shutterstock</span></span></figcaption></figure><p>The near-total shutdown of elective surgery across Australia <a href="https://www.abc.net.au/news/2020-04-21/coroanvirus-national-cabinet-elective-surgery-ivf-to-resume/12168770">will end soon</a>, following National Cabinet consideration on Tuesday.</p>
<p>The shutdown was imposed to ensure there would be enough personal protective equipment (PPE) for doctors and nurses to manage a projected tsunami of COVID-19 patients in our hospitals.</p>
<p>But now there is a big backlog of Australians waiting for elective procedures.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/good-news-on-elective-surgery-but-dire-warning-on-the-economy-136745">Good news on elective surgery, but dire warning on the economy</a>
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</em>
</p>
<hr>
<p>Elective surgery waiting times are the bane of every state health minister’s life. Better ways to manage such procedures could be a major benefit from the shutdown and restart.</p>
<p>But we have to act quickly if we are to change how we manage these wait lists, as federal Health Minister Greg Hunt <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/elective-surgery-restrictions-eased">wants a staged reintroduction</a> to begin on April 27. </p>
<h2>Rethink priorities</h2>
<p>Currently, elective surgery is <a href="https://meteor.aihw.gov.au/content/index.phtml/itemId/598034">classified</a> as urgent (category 1), semi-urgent (category 2) and non-urgent (category 3). But different hospitals and different surgeons actually classify patients in different ways. </p>
<p>What’s worse is that some procedures are undoubtedly unnecessary, such as spinal fusion or removing healthy ovaries during a hysterectomy, and would provide no value for the patient, as <a href="https://theconversation.com/hospitals-have-stopped-unnecessary-elective-surgeries-and-shouldnt-restart-them-after-the-pandemic-136259">Adam Elshaug and I have argued before</a>.</p>
<p>Of course, not all of the backlog is low-value procedures. As states consider how to recommence elective surgery, they should seize this opportunity to introduce new systems, especially in metropolitan areas.</p>
<p>A properly managed elective procedures system should have three key elements:</p>
<ul>
<li><p>there should be a consistent process for assessing a patient’s need for the procedure, and ranking that patient’s priority against others</p></li>
<li><p>the team performing the procedure, and caring for the patient afterwards, should be highly experienced in the procedure</p></li>
<li><p>the procedure should be performed at an efficient hospital or other facility, so the cost to the health system is as low as possible.</p></li>
</ul>
<p>Unfortunately, Australia sometimes fails on all three measures.</p>
<h2>Stop the inconsistencies</h2>
<p>There is no consistent assessment process across hospitals. Even different surgeons in the same hospital seeing the same patient sometimes make different recommendations about the need for a procedure.</p>
<p>This means a patient lucky enough to be seen at hospital A may be assigned to category 2, but the same patient seen at hospital B might be assigned to category 3 and so have to wait longer.</p>
<p>Patient characteristics, such as <a href="https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-016-0302-3" title="Inequity in waiting for cataract surgery - an analysis of data from the Swedish National Cataract Register">gender</a> or <a href="https://link.springer.com/article/10.1186/1472-6963-12-268" title="Socioeconomic differences in waiting times for elective surgery: a population-based retrospective study">level of education</a>, also seem to inappropriately affect categorisation decisions.</p>
<p>High-volume hospitals and other facilities generally have <a href="https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-016-0376-4" title="Relationship between surgeon volume and outcomes: a systematic review of systematic reviews">better outcomes for a given procedure than low-volume centres</a>. And they are more efficient. </p>
<p>Yet most states ignore these facts. They have done little to <a href="https://www.dhhs.vic.gov.au/publications/targeting-zero-review-hospital-safety-and-quality-assurance-victoria">rationalise services</a> for the benefit of both the patient and the taxpayer.</p>
<h2>Time for change</h2>
<p>The large backlog of demand creates the opportunity for a new way of doing things. States should develop agreed assessment processes for high-volume procedures, such as knee and hip replacements and cataract operations, and reassess all patients on hospital waiting lists. </p>
<p>Reassessment could be done remotely using telehealth. Specialists in each area should be invited to develop evidence-based criteria for setting priorities. Where appropriate, patients should be diverted to treatment options other than surgery. </p>
<p>Private health insurers should be empowered to participate in <a href="https://grattan.edu.au/wp-content/uploads/2019/11/925-Saving-private-health-1.pdf">funding diversion options</a> so patients are able to have their rehabilitation at home rather than in a hospital bed.</p>
<p>A new, coordinated, single waiting list priority system in each state would enable all patients to know where they stand. A patient on the top of the list would be offered the first available place, regardless of whether it was closest to their home.</p>
<p>They could refuse the offer, without losing their place in the queue, if they wanted to wait for a closer location.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/329624/original/file-20200422-82645-jzlull.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/329624/original/file-20200422-82645-jzlull.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/329624/original/file-20200422-82645-jzlull.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=460&fit=crop&dpr=1 600w, https://images.theconversation.com/files/329624/original/file-20200422-82645-jzlull.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=460&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/329624/original/file-20200422-82645-jzlull.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=460&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/329624/original/file-20200422-82645-jzlull.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=578&fit=crop&dpr=1 754w, https://images.theconversation.com/files/329624/original/file-20200422-82645-jzlull.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=578&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/329624/original/file-20200422-82645-jzlull.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=578&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The health minister says it’s up to hospitals to decide which patients get to undergo elective surgery.</span>
<span class="attribution"><span class="source">Roman Zaiets/Shutterstock</span></span>
</figcaption>
</figure>
<p>The single waiting list should include both regional and metropolitan patients, to ensure as much as possible that city patients do not get faster treatment than people in regional and remote area. </p>
<p>Patients with private health insurance can <a href="https://www.healthdirect.gov.au/understanding-the-public-and-private-hospital-systems">opt to be treated as a private patient </a>in a public hospital. So the waiting list should include public and private patients, to prevent private patients gaining faster admission to public hospitals.</p>
<p>The system should be further centralised in metropolitan areas. The full range of elective procedures should not be re-established in every hospital. Some surgeons would need to be offered new appointments if elective surgery in their specialty was no longer being performed at the hospital where they previously had their main appointment.</p>
<h2>Private hospitals can help</h2>
<p>The private hospital system has taken a battering during the pandemic. <a href="https://www.theguardian.com/world/2020/mar/28/australias-private-hospitals-face-closure-after-coronavirus-causes-elective-surgery-ban">Private hospitals have effectively been closed</a>, and their viability may be under pressure.</p>
<p>States should consider signing contracts with private hospitals, at or below the <a href="https://www.ihpa.gov.au/what-we-do/national-efficient-price-determination">public hospital efficient price</a>, for elective procedures to be performed in these hospitals to help clear the elective surgery backlog.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/needless-treatments-spinal-fusion-surgery-for-lower-back-pain-is-costly-and-theres-little-evidence-itll-work-91829">Needless treatments: spinal fusion surgery for lower back pain is costly and there's little evidence it'll work</a>
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<p>As part of the new service model, states should bolster their <a href="https://www.mja.com.au/journal/2012/197/9/meta-analysis-hospital-home">hospital-in-the-home systems</a>. For many patients, rehabilitation at home or as an outpatient can produce <a href="https://www.mja.com.au/journal/2018/209/5/predictors-inpatient-rehabilitation-after-total-knee-replacement-analysis">better outcomes than in-hospital rehabilitation</a>.</p>
<p>The pandemic is not over yet and policymakers are right to be turning their minds to the transition back to something approaching business as usual. But the new, post-pandemic normal should be nothing like the old.</p>
<p>Physical distancing seems to be beating the virus, but the second victim might be health reform. Not wasting the crisis is the cliché on everyone’s lips. Australia has the chance to improve our elective surgery system. For the sake of taxpayers and patients, we should grasp it.</p><img src="https://counter.theconversation.com/content/136835/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities, as disclosed on its website.</span></em></p>The COVID-19 pandemic gives us a chance to improve our elective surgery system when it restarts.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1280062019-12-11T18:57:08Z2019-12-11T18:57:08ZAs simple as finding a job? Getting people out of social housing is much more complex than that<p>A <a href="https://www.aph.gov.au/Parliamentary_Business/Hansard/Hansard_Display?bid=chamber/hansardr/3d235a1c-91f8-4a9a-92b6-7ac7922cad16/&sid=0088">private member’s bill</a>, moved by Labor MP Josh Burns, recently called on the Australian government “to help build more affordable homes” in response to the <a href="https://theconversation.com/homelessness-soars-in-our-biggest-cities-driven-by-rising-inequality-since-2001-117833">growing homelessness crisis</a>. A premise of the bill is that a lack of social housing is a major cause of homelessness and increasing the supply is a key element of solving the problem. The government’s <a href="https://www.aph.gov.au/Parliamentary_Business/Hansard/Hansard_Display?bid=chamber/hansardr/3d235a1c-91f8-4a9a-92b6-7ac7922cad16/&sid=0086">response</a> was that one solution is to encourage social housing tenants to find paid work, so they can move into private rental housing.</p>
<p>The problem with this argument is it overlooks the major barriers to entering the private rental market for low-income households. It also does not excuse the failure to invest adequately in building more social housing.</p>
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<strong>
Read more:
<a href="https://theconversation.com/australias-social-housing-policy-needs-stronger-leadership-and-an-investment-overhaul-119097">Australia's social housing policy needs stronger leadership and an investment overhaul</a>
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</p>
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<p>There is certainly a shortage of social housing. About 140,600 applicants were on the waiting list for public housing and 8,800 households were wait-listed for state-owned-and-managed Indigenous housing <a href="https://www.aihw.gov.au/reports/housing-assistance/housing-assistance-in-australia-2019/contents/priority-groups-and-wait-lists#pg4">as at June 30 2018</a>. Another 38,300 applicants were waiting for mainstream community housing <a href="https://www.aihw.gov.au/reports/housing-assistance/housing-assistance-in-australia-2018/contents/priority-groups-and-wait-lists">as at June 30 2017</a> (the most recent publicly <a href="https://www.aihw.gov.au/reports/housing-assistance/housing-assistance-in-australia-2019/contents/priority-groups-and-wait-lists#pg4">available data</a>). Together, these tenure types comprise most of Australia’s social housing. </p>
<p>These figures exclude people temporarily suspended from waiting lists (e.g. social housing applicants in New South Wales who take up <a href="https://www.facs.nsw.gov.au/housing/policies/rent-choice-policy">Rent Choice private rental assistance</a>), who need social housing but <a href="https://www.monash.edu/news/articles/women-on-temporary-visas-vulnerable-to-family-violence2">are ineligible</a> and others not on waiting lists but still in need, such as <a href="https://www.ahuri.edu.au/research/final-reports/306">rough sleepers and very low-income households in housing stress</a>.</p>
<p>Tenure in social housing was once effectively <a href="https://www.ahuri.edu.au/research/final-reports/316">unlimited</a> provided tenants paid their rent and maintained their property. But waiting list pressures have led to a new approach. In his response to the private member’s bill, the assistant minister for community housing, homelessness and community services, Luke Howarth, <a href="https://www.aph.gov.au/Parliamentary_Business/Hansard/Hansard_Display?bid=chamber/hansardr/3d235a1c-91f8-4a9a-92b6-7ac7922cad16/&sid=0086">argued</a>:</p>
<blockquote>
<p>There needs to be more responsibility […] from state governments to help people who are able to get back into the workplace to then move on from social housing so that it will provide a flow-through effect for people currently on the waiting list.</p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/focus-on-managing-social-housing-waiting-lists-is-failing-low-income-households-120675">Focus on managing social housing waiting lists is failing low-income households</a>
</strong>
</em>
</p>
<hr>
<h2>Market realities</h2>
<p>Howarth’s argument is consistent with much state and territory policy. For example, the NSW <a href="http://www.socialhousing.nsw.gov.au/?a=348442">Future Directions policy</a> explicitly commits to “upskilling” tenants to enable them to live in private rental housing. </p>
<p>Tacitly overlooked in such “pathways” policies are the barriers to entering private rental. Across Australia <a href="https://www.anglicare.asn.au/our-work/research-reports/the-rental-affordability-snapshot">less than 26%</a> of private rental properties are affordable for households on a minimum wage. Less than 4% are affordable and appropriate for households on income support. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/growing-numbers-of-renters-are-trapped-for-years-in-homes-they-cant-afford-125216">Growing numbers of renters are trapped for years in homes they can't afford</a>
</strong>
</em>
</p>
<hr>
<p><a href="https://www.domain.com.au/news/tip-of-the-iceberg-complaints-alleging-discrimination-in-rental-market-rise-20170716-gxac9d/">Prejudice</a> and <a href="https://www.sheltersa.asn.au/site/wp-content/uploads/190430-Shelter-SA-Research-Report-on-Racial-Discrimination-in-Private-Rental-FINAL.pdf">discrimination</a> against tenants perceived to pose a greater risk to landlords’ investments make access even more difficult. </p>
<p>Low-income households in the private rental market also face insecure tenure. “No-grounds terminations” are permitted in all states and territories except Tasmania and, from July 1 2020, Victoria (except at the end of the first fixed term). </p>
<p>Under “no grounds” termination, landlords can evict tenants for no stated reason at the end of a fixed-term lease and at any time on a periodic lease. Fear of retaliatory eviction makes it <a href="https://www.pc.gov.au/research/completed/renters/private-renters.pdf">less likely tenants will assert their legal rights</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/an-open-letter-on-rental-housing-reform-103825">An open letter on rental housing reform</a>
</strong>
</em>
</p>
<hr>
<h2>Employment as a pathway</h2>
<p>Even if private rental access and affordability were certain, many social housing tenants are not in a position to undertake employment. In 2017–18, about <a href="https://www.aihw.gov.au/reports/housing-assistance/housing-assistance-in-australia-2019/contents/summary">398,900 households were in social housing in Australia</a>. Many of them relied on the disability support pension (21%) or the age pension (19%) as their main source of income. </p>
<p>Long-standing <a href="https://www.aihw.gov.au/reports/housing-assistance/housing-assistance-in-australia-2019/contents/priority-groups-and-wait-lists">targeting</a> of social housing to greatest need means tenants are disproportionately likely to have low educational qualifications and limited marketable skills. They face considerable employment challenges, not the least of which is <a href="https://www.ahuri.edu.au/research/final-reports/166">stigmatisation</a>. </p>
<p>It is also worth considering what “employment” realistically looks like for social housing tenants seeking to enter or re-enter the workforce. It’s likely to be as <a href="https://theconversation.com/labour-in-vain-casualisation-presents-a-precarious-future-for-workers-8181">casualised labour</a> in the <a href="https://theconversation.com/uber-might-not-take-over-the-world-but-it-is-still-normalising-job-insecurity-127234">gig economy</a>. </p>
<p>As social policy researchers Greg Marston and Catherine McDonald have <a href="https://www.ingentaconnect.com/content/tpp/ben/2007/00000015/00000003/art00003">argued</a>, we cannot assume exiting welfare for the labour market leads automatically to social and economic security. Precarious, intermittent, low-wage employment does not offer a sound basis for sustaining a private tenancy.</p>
<p>Of course, social housing tenants should be supported to find work and to move out of social housing if they want to. But the evidence would suggest tenant choice is not the motivation here. Rather than creating “pathways” as a way of managing social housing waiting lists, governments would have greater impact on the housing crisis if they invested much more in social housing. </p>
<p>Between 2011 and 2016, <a href="https://www.launchhousing.org.au/site/wp-content/uploads/2018/05/LaunchHousing_AHM2018_Report.pdf">government spending on social housing decreased 7%</a>, from A$1.42 billion to A$1.32 billion. This has contributed to a <a href="https://theconversation.com/australia-needs-to-triple-its-social-housing-by-2036-this-is-the-best-way-to-do-it-105960">backlog of 433,000 dwellings</a> in Australia’s social housing supply. That’s predicted to grow to a shortage of 727,000 dwellings by 2036. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australia-needs-to-triple-its-social-housing-by-2036-this-is-the-best-way-to-do-it-105960">Australia needs to triple its social housing by 2036. This is the best way to do it</a>
</strong>
</em>
</p>
<hr>
<p>In addition to providing <a href="https://cityfutures.be.unsw.edu.au/documents/522/Modelling_costs_of_housing_provision_FINAL.pdf">more social and affordable</a> housing, governments must act on the systemic problems in the private rental market. This includes developing <a href="https://everybodyshome.com.au/our-campaign/a-better-deal-for-renters/">nationally consistent tenancy legislation</a> to provide more protection for tenants, including against no-grounds evictions, and providing the resources to properly enforce such laws.</p><img src="https://counter.theconversation.com/content/128006/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Hartley receives funding from the Department of Communities and Justice and Homelessness NSW. Chris is on the Operation's Group for the Everybody's Home Campaign and the Executive Team of The Constellation Project. </span></em></p><p class="fine-print"><em><span>Kathleen Flanagan receives funding from the Australian Housing and Urban Research Institute and the Australian Research Council. </span></em></p>Helping tenants find work supposedly creates a pathway into private rental housing, freeing up social housing for others. Private rental costs and the situations of many tenants make that unrealistic.Chris Hartley, Research Fellow (Housing and Homelessness) at the Centre for Social Impact, UNSW SydneyKathleen Flanagan, Research Fellow & Deputy Director, HACRU, University of TasmaniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1048622018-10-30T02:58:44Z2018-10-30T02:58:44ZWaiting for better care: why Australia’s hospitals and health care are failing<figure><img src="https://images.theconversation.com/files/242387/original/file-20181025-71038-17bngcx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Health is the largest single component of state government expenditure.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/245905492?src=jhlWisgjKa449M1gf5-h5A-1-61&size=huge_jpg">Shutterstock/hxdbzxy</a></span></figcaption></figure><p><em>This week we’re exploring nine different policy areas across Australia’s states, as detailed in Grattan Institute’s State Orange Book 2018. Read the other articles in the series <a href="https://theconversation.com/au/topics/state-of-the-states-2018-61464">here</a></em>.</p>
<hr>
<p>Australia has a good health system by international standards, but it has to get better. Half of all patients across Australia wait more than a month for an elective hospital procedure, such as a hip replacement. This is in addition to waiting for an outpatient visit so they can be added to the elective procedure wait list. </p>
<p>“Elective” here doesn’t mean the patient can do without the procedure – they may be in pain or having trouble moving around while waiting. Elective simply means it doesn’t have to be done immediately and can be scheduled.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/to-keep-patients-safe-in-hospitals-the-accreditation-system-needs-an-overhaul-101513">To keep patients safe in hospitals, the accreditation system needs an overhaul</a>
</strong>
</em>
</p>
<hr>
<p>About 9% of people in New South Wales and about 25% in South Australia wait more than a year for public dental services, such as fillings, extractions and root canals. </p>
<p>Physicians report nearly one-third of patients with an acute mental illness wait more than eight hours in hospital emergency departments.</p>
<p>The Grattan Institute’s <a href="https://grattan.edu.au/report/state-orange-book-2018/">State Orange Book 2018</a> charts the performance, maps a route to improvement, and recommends penalties for states that fail to meet waiting list targets. </p>
<h2>Why hospitals are always key state election issues</h2>
<p>Health is the largest single component of state government expenditure in every state of Australia, and <a href="https://grattan.edu.au/report/budget-pressures-on-australian-governments-2014/">has been growing rapidly</a>. About two-thirds of <a href="https://www.aihw.gov.au/reports/health-welfare-expenditure/health-expenditure-australia-2015-16/contents/summary">state government health spending</a> – excluding transfers from the Commonwealth – is on public hospitals. </p>
<p>Just over half the population does not have health insurance and so relies on public hospitals for all their care. Even for people with private insurance, public hospitals are their principal source of emergency care. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/242391/original/file-20181025-71017-1e527cl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/242391/original/file-20181025-71017-1e527cl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=449&fit=crop&dpr=1 600w, https://images.theconversation.com/files/242391/original/file-20181025-71017-1e527cl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=449&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/242391/original/file-20181025-71017-1e527cl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=449&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/242391/original/file-20181025-71017-1e527cl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/242391/original/file-20181025-71017-1e527cl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/242391/original/file-20181025-71017-1e527cl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Even Australians with private health insurance use public emergency departments.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/270431723?src=CRCnZ-2UKKWBIUb0mQBTmg-1-12&size=huge_jpg">Annette Shaff/Shutterstock</a></span>
</figcaption>
</figure>
<p>State governments are responsible for public hospitals, so hospital care is always a key issue in state elections. It is therefore no surprise state governments love to tell us how much they are doing for public hospitals, and election campaigns are often jam-packed with promises of new or expanded hospitals.</p>
<p>The politicians, at least in states with growing populations, are right that more beds are needed. What matters for the public, though, is not how many beds there are, but whether there are enough. One way of measuring that is waiting times, and here the picture isn’t as rosy as campaigning politicians would like us to believe.</p>
<h2>Waiting for elective hospital procedures</h2>
<p>It’s bad enough half of all patients across Australia wait more than a month for an elective procedure from the time they were booked. What’s worse is that about 10% wait more than six months. </p>
<p>In our smallest state, Tasmania, 10% of patients wait about a year. In the biggest state, NSW, the situation is almost as bad. </p>
<p><strong>This graph shows the waiting time (days) for elective procedures, 2012-13 to 2016-17, for the 10% of patients who wait longest (orange) and the median (maroon):</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/242860/original/file-20181030-76384-o3lxkt.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/242860/original/file-20181030-76384-o3lxkt.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/242860/original/file-20181030-76384-o3lxkt.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=393&fit=crop&dpr=1 600w, https://images.theconversation.com/files/242860/original/file-20181030-76384-o3lxkt.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=393&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/242860/original/file-20181030-76384-o3lxkt.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=393&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/242860/original/file-20181030-76384-o3lxkt.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=494&fit=crop&dpr=1 754w, https://images.theconversation.com/files/242860/original/file-20181030-76384-o3lxkt.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=494&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/242860/original/file-20181030-76384-o3lxkt.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=494&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Grattan Institute/Australian Institute of Health and Welfare</span></span>
</figcaption>
</figure>
<p>Publicly reported data focus on elective procedure or elective surgery waiting times, but there is another important wait: from the time a patient is referred to the hospital to the time they are seen in an outpatient clinic. This is sometimes called the <a href="https://theconversation.com/getting-an-initial-specialists-appointment-is-the-hidden-waitlist-99507">“hidden waiting list”</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/getting-an-initial-specialists-appointment-is-the-hidden-waitlist-99507">Getting an initial specialists' appointment is the hidden waitlist</a>
</strong>
</em>
</p>
<hr>
<p>For the patient, the wait for an appointment with an outpatient clinic matters – it delays diagnosis and treatment. Yet these waits are not publicly reported in NSW, Western Australia, the Australian Capital Territory or the Northern Territory. And the states that do report outpatient clinic wait times do not use consistent measures. </p>
<p>Our state and territory governments should strengthen hospital accountability to reduce combined outpatient and inpatient waiting times. There should be clear consequences and penalties for failure to meet targets.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/242392/original/file-20181025-71026-19w3hop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/242392/original/file-20181025-71026-19w3hop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/242392/original/file-20181025-71026-19w3hop.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/242392/original/file-20181025-71026-19w3hop.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/242392/original/file-20181025-71026-19w3hop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/242392/original/file-20181025-71026-19w3hop.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/242392/original/file-20181025-71026-19w3hop.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">First you have to wait to get on the waiting list. Then you get booked in for your procedure.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/counting-down-days-calendar-110130863?src=e7fmSXAl-CJ1LfyBpfMKeg-1-2">Shutterstock/cvm</a></span>
</figcaption>
</figure>
<h2>Waiting for public dental care</h2>
<p>The <a href="http://www.coaghealthcouncil.gov.au/Portals/0/Australia%27s%20National%20Oral%20Health%20Plan%202015-2024_uploaded%20170216.pdf">COAG Health Council</a> (made up of Commonwealth, state and territory health officials) says current funding for public dental services allows for treatment of only about 20% of the eligible population. </p>
<p>The remaining 80% have to wait for long periods, pay for relatively expensive care in the private sector, or go without care entirely.</p>
<p>Waiting times vary significantly among states. And in several states, notably Vic and SA, <a href="https://www.pc.gov.au/research/ongoing/report-on-government-services/2018/health/primary-and-community-health">waiting times have got longer in recent years</a>.</p>
<p>Boosting public dental services will improve people’s health and reduce the strain on hospitals. </p>
<p>In 2015-16, there were <a href="https://www.aihw.gov.au/getmedia/acee86da-d98e-4286-85a4-52840836706f/aihw-hse-201.pdf.aspx?inline=true">67,266 hospital admissions for potentially preventable dental conditions</a> – more than one-fifth of all hospital admissions for potentially preventable acute conditions.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/poor-and-elderly-australians-let-down-by-ailing-primary-health-system-100586">Poor and elderly Australians let down by ailing primary health system</a>
</strong>
</em>
</p>
<hr>
<p>Unforgivably, our state governments have not delivered on a 2012 commitment to monitor waiting times for public dental care through a National Healthcare Agreement performance indicator. Data inconsistencies mean it is <a href="https://www.aihw.gov.au/getmedia/df234a9a-5c47-4483-9cf7-15ce162d3461/aihw-den-230.pdf.aspx?inline=true">not possible to reliably compare public dental waiting lists</a> across states and territories. </p>
<p>NSW does not provide data on public dental waiting lists at all, citing concerns about the potential for misleading comparisons. The only comparable data we have is from an Australian Bureau of Statistics sample survey, which shows more than 10% of patients across the country wait more than a year for public dental care. </p>
<p><strong>This graph shows the proportion of people who waited more than a year for public dental services:</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/242862/original/file-20181030-76402-11wzj6r.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/242862/original/file-20181030-76402-11wzj6r.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/242862/original/file-20181030-76402-11wzj6r.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/242862/original/file-20181030-76402-11wzj6r.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/242862/original/file-20181030-76402-11wzj6r.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/242862/original/file-20181030-76402-11wzj6r.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=491&fit=crop&dpr=1 754w, https://images.theconversation.com/files/242862/original/file-20181030-76402-11wzj6r.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=491&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/242862/original/file-20181030-76402-11wzj6r.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=491&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Notes: The figures in smaller states should be regarded as approximate; the percentages are of those who have been seen, and do not include those still waiting at the time of the survey.</span>
<span class="attribution"><span class="source">Grattan Institute/Australian Bureau of Statistics</span></span>
</figcaption>
</figure>
<h2>Waiting for mental health care</h2>
<p>Campaigners say Australia has reached a “tipping point” on access to mental health care. Physicians report nearly one-third of patients with an acute mental illness wait more than eight hours in emergency departments. </p>
<p>We know this does damage: long waits for access to community mental health services can result in poorer outcomes for patients, as a condition may be harder to control the longer it persists. Long waits may also place additional pressure on families or friends who face the consequences of their friend or family member’s behaviour. </p>
<p>Yet there is no information about the adequacy of community mental health services in Australia. The 2017 <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/mental-fifth-national-mental-health-plan">National Mental Health and Suicide Prevention Plan</a> only tracks the use of services, not their adequacy. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/more-australians-can-stay-healthier-and-out-of-hospital-heres-how-55746">More Australians can stay healthier and out of hospital – here's how</a>
</strong>
</em>
</p>
<hr>
<p>In contrast, Canadian governments have agreed that a <a href="http://www.highperforminghealthcaresystems.com/content/25550">wide range of mental health and addictions indicators</a> will be collected and reported from 2019. </p>
<p>Australian voters should demand their state governments do the same thing. We should wait no longer for a better health system.</p><img src="https://counter.theconversation.com/content/104862/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities as disclosed on its website. The State Orange Book 2018, from which this article draws, was supported by a grant from the Susan McKinnon Foundation.</span></em></p>Australians are waiting too long for elective surgery, dental care and treatment for mental health. It’s no wonder health is a vote-changer.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/995072018-07-15T18:46:52Z2018-07-15T18:46:52ZGetting an initial specialists’ appointment is the hidden waitlist<figure><img src="https://images.theconversation.com/files/227295/original/file-20180712-27042-lmlv0h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">States compare wait times differently so it's hard to judge the scale of the problem. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>The <a href="http://www.abc.net.au/news/2018-07-01/patients-waiting-more-than-16-years-for-hospital-treatment-in-sa/9929146">recent release</a> of specialist outpatient waiting times by the new South Australian government caused outrage when it was revealed some patients had been waiting more than 16 years for an appointment. </p>
<p>This is not a new problem. A <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Completed_inquiries/1999-02/phealth_first/report/c02">2000 Senate Committee Report</a> cited consumer concerns about long outpatient waiting times, as did the <a href="http://www.parliament.qld.gov.au/documents/tableoffice/tabledpapers/2005/5105t4447.pdf">2005 Forster report</a> into Queensland’s health system.</p>
<p>Access to timely care is the cornerstone of an efficient and effective health-care system. Delays decrease patient satisfaction, prolong periods of pain and discomfort, and create uncertainty for patients. Worse, a patient’s health might deteriorate while waiting with an undiagnosed condition. </p>
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Read more:
<a href="https://theconversation.com/which-are-better-public-or-private-hospitals-54338">Which are better, public or private hospitals?</a>
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<h2>Room for improvement</h2>
<p>Historically, much of the conversation on waiting times at public hospitals has been about elective surgery. While efforts <a href="https://www.aihw.gov.au/reports/hospitals/ahs-2016-17-elective-surgery-waiting-times/contents/table-of-contents">to report</a> and <a href="https://www.nsw.gov.au/news-and-events/news/shorter-wait-times-for-elective-surgery/">reduce</a> waiting times for elective surgery have been established nationwide, these figures only account for the time from a specialist appointment to the date of surgery. </p>
<p>This obscures the sober reality of even longer waits from GP referral leading up to the initial specialist appointment. This unreported wait is known as the <a href="https://www.theage.com.au/national/victoria/outpatients-wait-four-years-data-20100620-yp75.html">“hidden” waitlist</a>. </p>
<p>Currently, the quantity and quality of publicly available data on outpatient specialist clinics vary significantly between states, making it difficult to do national comparisons. Victoria has the most <a href="http://performance.health.vic.gov.au/Home/Category.aspx?CategoryKey=138#Anchor">comprehensive data</a>, reporting waits for the average patient, as well as how long the 10% of patients with the longest waits spent on the list for each specialty and urgency category. </p>
<p>While <a href="http://www.performance.health.qld.gov.au/Hospital/SpecialistOutpatient/99999">Queensland</a> and <a href="http://outpatients.tas.gov.au/clinicians/wait_times">Tasmania</a> have also published data on all referral categories, they use different measures. <a href="https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/about+us/our+performance/specialist+outpatient+waiting+time+report">South Australia</a> has only published average wait times for non-urgent referrals. </p>
<p>States also use different urgency categories to triage outpatient referrals. In Victoria, referrals are stratified into two categories based on queuing theory, which suggests the most efficient form of prioritisation is one with the fewest possible categories. Meanwhile, other states (WA, Tasmania and Queensland) function with <a href="https://www.qld.gov.au/health/services/hospital-care/waiting-lists">three priority categories</a>. </p>
<p>These different approaches to reporting make it impossible to compare states. Some 10% of patients wait more than three months in many Queensland clinics, and more than two months in Victoria.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/227271/original/file-20180712-27030-1a94b0s.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/227271/original/file-20180712-27030-1a94b0s.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/227271/original/file-20180712-27030-1a94b0s.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=443&fit=crop&dpr=1 600w, https://images.theconversation.com/files/227271/original/file-20180712-27030-1a94b0s.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=443&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/227271/original/file-20180712-27030-1a94b0s.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=443&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/227271/original/file-20180712-27030-1a94b0s.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=557&fit=crop&dpr=1 754w, https://images.theconversation.com/files/227271/original/file-20180712-27030-1a94b0s.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=557&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/227271/original/file-20180712-27030-1a94b0s.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=557&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Five comparable specialties in Queensland & Victoria with the longest waits.</span>
<span class="attribution"><a class="source" href="http://www.sourceurl.com">Queensland Health Quarterly information for Specialist Outpatient 2018, Victorian Health Services Performance Statewide Performance Data. Note: The clinically recommended wait time for Urgent (Category 1) patients is <30 days. The 90th centile wait time is the within which 90% of patients attended their first appointment.</a>, <span class="license">Author provided</span></span>
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<h2>Why do such long wait times exist?</h2>
<p>The number of specialists available and the hours they choose to work in public hospitals affect the number of clinic appointments available. In aggregate, <a href="https://www.healthpolicyjrnl.com/article/S0168-8510(13)00076-6/fulltext">48% of specialists</a> work across both public and private sectors, 33% work only in public and 19% work only in private practice.</p>
<p>A <a href="https://www.publish.csiro.au/ah/ah15228">study</a> revealed that on average, orthopaedic surgeons and rheumatologists spend more than 70% of their time in private practice. Private practice generally offers higher incomes to doctors.</p>
<p>With such long wait times, patients who can afford it may turn toward <a href="https://www.mja.com.au/system/files/issues/206_04/10.5694mja16.01297.pdf">private specialist services</a> to skip the queue, leaving patients who cannot afford the <a href="https://www.smh.com.au/national/it-s-outrageous-doctors-slam-practice-of-blackmailing-patients-20180526-p4zhoe.html">high out-of-pocket costs</a> charged by specialists to wait. </p>
<p>The burden of <a href="http://www.abc.net.au/news/health/2018-05-28/how-out-of-pocket-medical-costs-can-get-out-of-control/9592792">out-of-pocket</a> costs also falls disproportionately on those with multiple diseases, the least disposable income and <a href="https://www.mja.com.au/journal/2013/199/7/cant-escape-it-out-pocket-cost-health-care-australia">older households</a>, excluding them from accessing more timely care in the private sector.</p>
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<strong>
Read more:
<a href="https://theconversation.com/explainer-why-do-australians-have-private-health-insurance-38788">Explainer: why do Australians have private health insurance?</a>
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<h2>What can be done?</h2>
<p><a href="https://www2.health.vic.gov.au/Api/downloadmedia/%7B8946077D-7254-493F-B5C7-7886DD5ACE16%7D">Some health services</a> have implemented <a href="https://www.publish.csiro.au/ah/pdf/AH16275">strategies</a> to reduce outpatient waiting times. This can include using more <a href="https://www.publish.csiro.au/AH/AH16206">allied health services</a> where appropriate. For example, <a href="http://brochures.mater.org.au/brochures/mater-hospital-brisbane/orthopaedic-physiotherapy-screening-clinic">using physiotherapists</a> to see patients in orthopaedic clinics can help patients get non-surgical treatment for their condition earlier. </p>
<p>Other good solutions include a <a href="https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2011/vol-124-no-1347/article-cariga">non-contact first specialist appointment</a>, where a specialist looks at a patient’s clinical notes and sends their recommendation to the referring GP.</p>
<p>States need to address long outpatient waits. And they need to be accountable for doing so.</p>
<p>We need better data on outpatient specialist clinics accessible in all states. Ideally, the data reported would be based on a national standard, as we currently do for <a href="https://www.aihw.gov.au/reports/hospitals/australian-hospital-statistics-national-emergency/contents/table-of-contents">elective surgery and emergency services</a>.</p>
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<strong>
Read more:
<a href="https://theconversation.com/are-private-patients-in-public-hospitals-a-problem-79910">Are private patients in public hospitals a problem?</a>
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<p><em>Tessa Tan, Grattan Institute Intern and Bachelor of Medicine student contributed to this article.</em></p><img src="https://counter.theconversation.com/content/99507/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities as disclosed on its website.</span></em></p>Reports often talk about surgery wait times, but the time to actually see the specialist for the first time is the hidden waitlist.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.