Why do we wait so long in hospital emergency departments and for elective surgery?

Some situations can drive even the most patient person to meltdown. Try sitting in an emergency department for four hours on a Friday night with an injured relative. Or waiting two months for heart valve surgery, only for it to be cancelled at the last minute.

Waiting for emergency care, specialist appointments and “elective” procedures is not only inconvenient and frustrating, it can also be painful and detrimental to your health and well-being.

Spending on health care has grown rapidly in recent years. Approximately 10% of Australia’s gross domestic product (A$147 billion in 2012-2013) is invested in these services annually. Of this, just under A$60 billion was spent on hospital services.

So why do we wait so long for hospital care?

Waiting times

The latest available data shows that half of all patients were admitted for elective surgery within 36 days of being placed on a waiting list and 90% of patients were admitted within 262 days. This means 10% of people waited longer than eight-and-a-half months.

These figures hide a great degree of variability, with 50% of people based in Queensland being admitted for surgery in 28 days and longer waits in New South Wales (49 days).

Almost three-quarters (73%) of Australians visiting emergency departments were seen within four hours. But, again, there is variation across states (62% in the ACT and Northern Territory, and 79% in Western Australia).

While it’s unlikely to provide much comfort, Australians don’t wait as long as in some other publicly funded health systems.

The efficiency argument

Any economist will tell you that where there are finite resources, waiting lists can be a useful mechanism to enhance efficiency. They also ensure that someone really wants to access that service.

One-quarter of Australians visiting emergency departments aren’t seen within four hours. Pammy Pammy/Shutterstock

Mediating the flow of people into services ensures scarce resources (medical professionals, beds, equipment) are in use as much as possible and highly paid clinicians and expensive machinery are not going unused for long periods.

This is particularly helpful in areas where it is difficult to estimate future demand – for example, where a town grows rapidly due to migration.

Clinical need

Efficiency is only one of the reasons we wait. Clinicians prioritise patients based on the urgency of their treatment, so those in greatest need can be seen soonest.

Few of us waiting in the emergency department for a suspected broken foot believe we should take priority over someone who has just been in a serious motorcycle accident and is struggling to breathe. Emergency departments aren’t “first come first served” because you will still be alive (albeit in pain from your foot) in a few hours, but the motorcyclist may not be.

In emergency departments, individuals are triaged into five categories:

In relation to elective surgery, three categories are used:

Disability while waiting for surgery

The implications of waiting for surgery will depend on the procedure you are waiting for and a number of different life circumstances. Clinicians will apply judgements in different ways.

But how do we decide between someone who is classified as semi-urgent but is the primary carer for others, and someone who may have more urgent health needs but their waiting will not impact on others, or on their ability to work?

It’s not so clear cut. There is, however, evidence that longer waiting times for some procedures can result in greater costs for medication and poorer health outcomes for older groups.

A number of countries have experimented with approaches that attempt to make decisions about where individuals are placed on surgical waiting lists more transparent. Scoring approaches have been developed that seek to make the assessment process fairer.

But these kinds of approaches are unable to fully incorporate the differences and complexities of the lives we lead. And while they deal with the challenge of who goes where in the waiting line, they don’t actually reduce waiting times.

So what can be done to help?

Unfortunately, there isn’t just one solution when it comes to reducing waiting times.

Although many hospitals describe being financially stretched at the moment, it’s unlikely that providing additional money will solve this problem.

International evidence suggests that injecting more money into the health system will not get rid of waiting times. There are often more pressing needs within health systems. Even if resources are targeted at specific surgical procedures, for example, we may find an increase in demand because of reduced thresholds for treatment.

Some attempts have been made to incentivise people to take up private insurance so there is less demand on public hospitals. However, those who are able to take up private health insurance are typically healthier and wealthier, leaving those with complex and chronic illnesses relying on public hospitals.

Private health insurance hasn’t taken the pressure off the public system. Tyler Olson/Flickr

Many systems have attempted to make performance data more readily available and to benchmark waiting times or set maximum waiting time indications. But while data can be helpful in identifying areas where there are particular challenges, and targets can incentivise organisations into action, they can also have perverse incentives.

The well-publicised initiative that individuals should wait no longer than four hours to be seen in emergency departments, for example, has largely been successful in bringing down waiting times. However, resources have be directed at those in danger of “breaching” these targets. Patients have been unnecessarily admitted to hospital so they don’t continue to wait, but this may not be the most clinically appropriate or efficient outcome.

How we prepare, develop and support clinicians to make judgements about prioritising people’s treatment is crucial; it has profound impacts on the numbers of people referred for services. This is an issue that will continue to require attention, as will how we engage doctors in the management and leadership of health-care organisations more generally.

The sad truth is there isn’t a silver bullet that will resolve this problem. Although waiting can be irritating, shorter waits do ensure that we use resources appropriately and, without a dramatic increase in funding, are likely to stay.

The challenge is to ensure that waits do not get so long that they have a detrimental impact on the quality of lives for individuals.

This article is part of our series Hospitals in Australia. Click on the links below to read the other instalments: