We present data from patients who drew on their experiences (rather than quantifying length) of waiting times, and the impact this had on their perception of hospital services and staff. Our participants talked differently about ‘waiting for’ hospital appointments and surgery once referred, and ‘waiting in’ hospitals (e.g. waiting in emergency departments, waiting to see healthcare professionals once admitted) and how this differed between public and private hospitals. Participant’s perceptions of the reasons for and acceptance of ‘waiting for’ or ‘waiting in’ hospitals impacted their trust in various social systems (e.g. government, hospitals) and healthcare professionals working within hospitals. Although participants’ discussions of ‘waiting for’ and ‘waiting in’ hospitals may not map easily onto administrative definitions [
4], we provide contextual data to understand the impact of waiting times on patient experiences. It is important to provide this rich, contextual and meaningful data on the lived experiences of waiting in public and private hospitals, since “knowing more about what conditions produce trust and distrust, and why this matters, helps to craft the structure and financing of health care delivery in a manner that supports and enhances trust” [
38]. This may provide a more comprehensive picture of how waiting time shapes trust and consequential attitudes and health behaviours relevant to healthcare expenditure.
Differences in the experiences of ‘waiting for’ and ‘waiting in’ public and private hospitals
All participants made stark comparisons in terms of ‘waiting for’ and ‘waiting in’ public and private hospitals. The perceptions outlined in this section did not vary on the basis of the urgency of the treatment or surgery required by participants. Participants in public hospitals had experienced much longer waiting times for hospital appointments and for elective surgery. The main reason for most participants not purchasing PHI was the cost, and most would have liked to for the purpose of reducing waiting for treatment, but could not afford to. For example, HH said that she would consider taking out PHI to “avoid a hideously long waiting list” and that “we would then just make arrangements to pay for private options and then cop it sweet”. The term ‘cop it sweet’ suggests that HH would accept the financial consequences in terms of potentially not being able to afford other things in life as a result of paying for PHI. The main reason for choosing and paying for PHI was to reduce ‘waiting for’ times, as SC said, “I don’t want to hang around. I want action and I want it now. You’re not going to get that if you don’t have private health cover, otherwise you go on the waiting list”. Both of these participants talked about wanting to reduce the times ‘waiting for’ hospital care, and suggested that PHI would provide this for them – an indicator of trust in PHI, compared to the public system, to reduce times ‘waiting for’ hospital care.
One participant (SC) who had experienced care in both public and private hospitals described an incident waiting in a public hospital when she was left alone before a surgical procedure. Her remarks throughout her interview suggest that this experience decreased her trust in the public hospital system, not directly because of the quality of care, but because of the waiting and feelings of isolation. Similar comments were made by most public patients in this study, who rarely cited the quality of clinical care as their reasons for reduced trust, but were concerned about the lack of attention given to them while in hospital, making them question their trust in the system as opposed to the individual doctors and nurses. SC kept referring back to the ‘waiting in’ public hospital incident throughout the interview. Although she defended the doctors, her repeated references to waiting indicated that it had become an issue for her and had made her anxious regarding future hospital visits. She compared this experience to a similar situation of ‘waiting in’ a private hospital with a more favourable outcome, where she was checked on every hour and thus not left alone. Hence, this made the waiting manageable. The lack of contact and isolation is perhaps the key to her negative experience and loss of trust in public hospitals:
“..the fact that I got left, I suppose, is my main issue, I mean I was put in that room at six o’clock in the morning and I did not see anyone until I rang a bell at two o’clock in the afternoon because I had a throbbing headache from not eating, all day… It would have been nice to like – I don’t know, my experience in the private system was every hour or so they used to come in and say ‘how you going? You all right?’ You know, such and such will let you know and ‘it’s another few hours until you’ll be seen’ but there, they just left me and I never saw anybody until I rang this bell” (SC)
SC, along with many other participants, talked about how the isolation, feeling ‘forgotten’ and being bereft of information left them feeling less trusting of public hospitals. SC talked about how her previous experience makes her feel about future encounters in public hospitals:
“probably a little bit less confident because I am going in to have surgery again soon for a totally unrelated issue to this in July and I am a bit concerned because that’s through the public system again. I am a bit concerned whether – because this is a bit more major - whether I’m going to be treated like I was then and just left in a room to fend for myself or whether this is going to occur again so, yeah, it has got me a bit wary” (SC).
Another participant (JI) described his young daughter’s ‘
long’ and ‘
traumatic’ experience ‘waiting in’ a public hospital for surgery, and articulated how he would have been ‘
prepared ‘if he had just had some information:
I’d be better prepared and I’d make sure I’d got heaps of books for the kids and I’d just prepare them for the fact that they may be waiting for hours and hours” (JI).
On reflection of his daughter’s experience, JI identified the fault of the hospital, suggesting that the hospital practices could be improved: “I just think it could have been done more efficiently.” He favourably contrasted his daughter’s ‘waiting in’ private hospital experience to that in the public system, observing that it was, ‘streamlined,’ ‘efficient,’ and the nurses, ‘come out and tell you how it was going. It was a much more pleasant experience’ (JI).
For all participants, there was a general perception that nurses in public hospitals were busier,
“they don’t have time to chat” (MT), than the nurses in private hospitals, who were perceived as having more time to spend with patients, thereby improving the quality of care and reducing ‘waiting in’ the hospital:
“If you’re a patient in hospital and you need to see a nurse you don’t want to be waiting or you don’t think you want to be waiting. The nurses in the private sector are probably looking after less people than the nurses in the public….Probably not any better than the nurse in the public sector could but certainly quicker because they haven’t got as much to do I don’t think. If you ring your bell for a nurse to come if you can’t get out of bed and it takes half an hour you’re worrying about it. If the nurse can come within five minutes it’s less stressful” (GW).
This quote highlights GWs identification that nurses are ‘busier’ in public hospitals, but not necessarily providing poorer quality care and therefore not less trustworthy. In contrast to feeling isolated and forgotten while ‘waiting in’ public hospitals, a number of participants from public hospitals made assumptions about what it would be like to be treated in a private hospital, drawing on cultural expectations regarding privatisation. All public hospital participants assumed that both ‘waiting for’ and ‘waiting in’ would be shorter in the private system, that the hospitals would look nicer but interestingly that patients would be made to feel more ‘special’ in private hospitals. Although not explicit in the following quote, a question for future research relates to the extent to which such feelings of being ‘special’ impact positively on trust:
“I don’t think the quality of an operation would make a difference at all, I think it just may be longer queues in the public sector. Maybe also people like to feel, you know, as a private patient I guess maybe you’re made to feel more special; I don’t know and I haven’t been in the private care so I couldn’t really say” (MT).
Although participants with PHI talked about shorter ‘waiting in’ times and perceived superior service in private hospitals, this did not translate into perceptions of better clinical care. LK describes a common theme about the ‘service’ (e.g. speediness of service, friendliness of staff, time spent with health care professionals) being better but not necessarily the quality of clinical care. In this way, there is a level of trust in the efficiency of private hospitals but this does not necessarily lead to either an increase in trust in clinical care in private, or reduction in public, hospitals:
“Health care wise I don’t think so. I think you get better service. You get through straightaway sort of thing, you know? I mean private health cover is useful when you want elective operations or surgeries. I think the service is better but the health care, health care wise, not necessarily so” (LK).
Participants were reluctant to denigrate the care they received in public hospitals, irrespective of the urgency of their treatment or the length of their wait, but often followed positive comments (seemingly not wanting to appear distrusting of public hospitals) about the system with quasi-apologetic comments regarding services that they considered missing, such as information:
“Oh yeah, absolutely and the medical care was the best. I really – they couldn’t have done much more different with the medical care; that was all good. It was just the lack of information and again I found that the same with my daughter. You know, knowing what services were available, especially since I don’t have family in Australia, all this kind of - it would have been nice, even just a few booklets or something” (MT).
Whilst acknowledging the longer times in both ‘waiting for’ and ‘waiting in’ public hospitals, most public hospital participants were quick to defend and not question their trust in the public system, or at least the doctors and nurses working in the system. BM, a public patient, had been involved in a road accident and had been in an emergency department followed by emergency surgery. His experience was full of long ‘waiting in’ public hospitals to see a number of doctors, nurses and surgeons, but on reflection he was very philosophical regarding his treatment and expectations of the public hospital system:
“You have to think that there’s a minimum standard [in a public hospital] and that they will be able to fix you in some form and the individual talents of each one [doctors], well you’ve got no idea, simple as that” (BM)
. In this quote, BM trusts that public hospitals will meet a minimum standard of care and seems to reconcile the fact that patients in public hospitals have limited or no knowledge of the abilities or competence of doctors and experience longer ‘waiting in’ public hospitals, inferring a sense of pragmatic acceptance of public hospitals. BM went on to explain his lack of concern about the impact of longer ‘waiting in’ public hospitals. Although he had experience of public hospitals, he also had PHI and has used it for elective surgery and specialist appointments for his chronic conditions. In talking about the differences between ‘waiting in’ public and private hospitals, he was not concerned that public hospitals involved more waiting:
“In a private hospital say you were to push a bell, private hospital four minutes; public hospital seven, eight ‘what’s the problem?’ If you’re really in trouble you’ve got another … and it’s not as if it’s that critical, only if you’d fallen out of bed or something in which case the others around you would surely start hollering, so I don’t see it as a big deal” (BM).
In summary, (both public and private) had a high level of acceptance and understanding on ‘waiting in’ hospitals for emergency situations (as opposed to planned procedures), trusting that they would be taken care of: “Okay, they might be overflowing with people but if it was a serious thing they would eventually get round to you”. In emergency situations in public hospitals, participants talked about their internal struggle to justify the hospital that made them wait, often in pain and with little information, although they defended the system and in particular the doctors and nurses, resembling a ‘don’t bite the hand that feeds you’ philosophy. For example, “I think we are very lucky to have this system and that we’ve got at all…they were just so busy and I do understand. There was nothing they could do and it was just going to be one of those things”. In addition, a participant who was moved to different hospitals to deal with his fractured leg after an accident, was left in various rooms alone for hours and without adequate pain relief still managed to say “While I was in there I got put into – they were obviously so busy and I fully respect that we have a system here and I think we’re very lucky to have this system that we’ve got at all. We come in off the street, we’re looked after and we go home and the public side of things, I do fully respect that” (PW).
Waiting as ‘inevitable’
It was clear that ‘waiting for’ and ‘waiting in’ public hospitals were considered inevitable by public hospital participants, but not necessarily to perceptions of untrustworthy hospitals or healthcare professionals. The inevitability was based on knowledge, through the media, of tight government budgets, increased pressure on Department of Health budgets and thus less resources for public hospitals to perform all functions for all people in a timely manner. For example, BM said:
“The system pressures people. There’s a time pressure on everybody and that’s caused by lack of funds. That’s the ultimate driver on how we do things, isn’t it, how much money is available?....I could see that the time pressures that these guys have means that they don’t get the minute to sit and just go for thirty seconds ‘let’s just check everything’. I don’t have any grudge against them [the doctors]” (BM).
As the above quote reiterates, the inevitability of ‘waiting for’ public hospital appointments and the time pressures on doctors and nurses due to perceptions of inadequate staffing (resulting in less time with patients and more ‘waiting in’ hospitals) does not translate into negativity, blame or distrust of doctors. It is simply seen as a ‘problem of the system’, whereby the doctors and nurses are doing their best, fulfilling the role of trustworthy professional. Complaints about waiting were almost always countered by participant’s explaining that the staff were not to blame. However, this reluctance to distrust, creates a situation where if patient are stressed or isolated or needing information, they may not feel able to ask for things since they feel responsible for adding to already overburdened hospital staff. This may not be addressed during a single hospital admission, but over time could build up and become a source of distrust. This is demonstrated in the example below where the participant is initially protective of the public health system, describing a long and painful wait in the emergency department subsequent to fracturing his leg. He was fully cognisant of the pressures on the system during his treatment and initially forgiving:
“…I got shoved into a little room out the side, which was almost like a storage room – it was being used as a spare room basically - and every once in a while I’d press the beeper to say ‘I need this icepack refilled’ and they’d get around to doing it. It just seemed like I was in there for an eternity…. it took hours. It seemed like almost four hours and I felt like even right at the beginning there was no ice packs, there was nothing. They were just so busy and I do understand that but it was all the initial stuff. I think the fracture was a fracture, there was nothing they could do and it was just going to be one of those things (PW).
However, when the participant had left the hospital system he described feeling very angry regarding his disjointed follow-up care and fragmented rehabilitation in the public system. He blamed the lack of follow-up for his ongoing leg problems. Although this participant expressed that he had a trust in the doctors (as general standards ensure their quality), he said that he had to organise his own rehabilitation separately from the system, because the public system ‘will not care for you in these long-term problems’. Thus although he was prepared to be tolerant while in the hub of care (and thus information) once outside he felt isolated, left to fend for himself, and his trust in the system had eroded.
The perceived inevitability of longer waiting lists in the public system was given as an explanation for most private hospital participants to purchase PHI. For example, DM has PHI and fully expected to receive treatment with little or no ‘waiting for’ a private hospital appointment, and his expectations had not been let down, leading to trust. He stated that he felt lucky to have PHI:
“No matter how much money you poured into it, I think there’d always be some sort of a waiting list. You know the government just can’t do the whole – make everyone happy and just get them straight through. I just think I’m lucky that I’m able to have private insurance and can afford it and can get in early otherwise I’d have no option but to just go on the waiting list” (DM).
Whilst not attempting to justify the inevitable ‘waiting for’ public hospitals, most participants talked about the perceived equity of access to healthcare in the public system, whereby people with greater healthcare need would have a shorter wait and people with a lower need would have a longer wait. This is akin to the concept of vertical equity, which assumes higher access to services for people in greater need for those services, and vice versa. For example, GS is a public hospital participant, but perceives a needs-based waiting system:
“Well I don’t know much about it but my understanding is if you really need it like there’s waiting lists and you’ll be, like it’s sort of according to the need for it. So I figure if it was a major need for it I would get the operation” (GS).
In this quote, GS trusts that someone in the public hospital system is appropriately identifying different levels of urgency and then creating a needs-based waiting list, which he is comfortable in accepting. Another participant had waited for her surgery in the public system, and recognised and trusted the needs-based approach to waiting lists. She was happy with her care, rationalising that if it had been urgent or was causing more pain, then she would have moved up the list or would have been less accepting of ‘waiting for’ her surgery:
“I’d kind of reassured myself that he [the surgeon] did have the skills to do it, I was quite happy because he does mainly private work so I felt like I was almost getting private cover free, you know. And with the time, I may have felt differently if there’d had been a huge waiting period. It was like an ongoing issue, so it wasn’t like I urgently felt like I needed the surgery. I was like I could go on for a few months anyway so maybe that would have been different, if it was something that was causing a lot of pain” (LI).
Waiting as ‘bad for health’
One participant who did not have PHI articulated how she could queue jump if she had PHI and, in the quote below, stated that the process of waiting made her feel ‘inferior’:
“It’s all time in the public system, the waiting…Trying to get in, the waiting and waiting for…Well you’re sick all the time. You think, you know ‘if I was in private health I’d be - had the operation and I’d be right again’. That’s how you feel or ‘I’d have my’ – in X hospital you have to wait a long time for scans too…. you start to feel a bit inferior again. It takes a lot to make me feel inferior now but waiting does” (GW).
This point links to an earlier quote about people feeling ‘special’ in private hospitals, increasing their trust, whereas GW felt ‘inferior’, which could lead to lower trust in the hospital if this occurred over a longer period of time. For our participants, waiting highlighted the inequities of a society between ‘haves’ and ‘have nots’, and was seen to have negative health consequences. For many participants, the effect of waiting equated to increased stress, anxiety and worry: “If I had been a private patient I wouldn’t have had to wait all those months worrying about God knows what I had in my throat” (GW).
For most participants, the concerns over the negative health implications were exacerbated when it came to their children or older adults. Trust becomes an even more important issue in times of increased risk, which was the case when people talked about their children and older adults. In terms of older people, there was a perception that being on a long waiting list could not only lead to increased worry and anxiety, but to physical deterioration which would make the illness worse:
“their condition may deteriorate that by the time they go to have the procedure they may need a bigger procedure than if it could have been attended to earlier while they were still in reasonable condition. They’re likely going to be depressed, their recovery time will be longer and if whatever’s wrong with them is deteriorating more then I think it could be a bigger procedure” (CR).
Private hospital participants talked about their perceived responsibilities for their children, to reduce the likelihood of ‘waiting for’ hospital appointments or surgery. JM described her concern for her children and her desire that they will not have to be in a system where they will have to wait. This is not just as young children, but more a concern for them being vulnerable as they age and being in a health system with ‘
a really long queue. This suggests that ‘waiting for hospitals is even less acceptable when people have a ‘duty of care’ for others.
“It concerns me how vulnerable you might become as you get older in terms of an ageing population and being part of a really long queue system or not being able to get things attended to as quickly as you would like. I think that backs you into a corner to gravitate towards the private health system but at the same time the increasing costs of the private health system. If you’re unlucky or if things happen, I would be very grateful but sort of we’ve been very fortunate with my two children and my partner that no significant health issues have occurred – not to say they won’t in the future – and there’s always that unknown, that do you want that security blanket to know that if something goes wrong you will get attended to, you won’t be put in a queue” (JM).