Although the healthcare system of Australia is considered one of the best in the OECD, it experiences certain challenges that need to be addressed by carefully tailored healthcare policies. For example, it faces the issues of increased demand for medical services, increased healthcare costs, complex health conditions, and inequities, which urge the country to improve the performance of its healthcare system (Dixit and Sambasivan, 2018). A review conducted by Dixit and Sambasivan (2018) revealed that one of the major issues with Australian healthcare facilities is long waiting times for elective surgeries. This problem is related to two main concerns for policymakers identified by the researchers: performance improvements and resource allocation (Dixit and Sambasivan, 2018). Long waiting lists can influence performance by negatively affecting patient outcomes, and they may be a sign of inadequate resource allocation. Therefore, there is a need for policymakers to address the problem of reducing waiting time in Australian hospitals. This paper aims to propose a research project to address the health policy question of what factors lead healthcare facilities to have increased waiting times for elective surgery.
The Australian healthcare system experiences an increase in waiting times in both emergency departments (ED) and elective surgery. According to the report compiled by the Australian Medical Association (AMA, 2021), only 67% of patients presented to the ED in 2019-2020 were seen within the recommended period of 30 minutes, while the target percentage is 80%. Another national target is that 90% of ED admissions should leave the ED within four hours: they should be either discharged or referred to another hospital for treatment (AMA, 2021). However, in Australia, only 69% of patients left the ED within four hours after admission (AMA, 2021). Although one may assume that a decline in the number of patients received on time in Australian public hospitals has been caused by the COVID-19 pandemic, this assumption would be unlikely because Australia has been experiencing such a decrease since 2014-2015.
In elective surgery, waiting times have also been increasing in recent years, even before the COVID-19 pandemic began. In 2019-2020, only about 75% of category 2 patients underwent their surgery within the recommended period of 90 days (AMA, 2021). However, according to AMA (2021), many patients have been waiting for a certain period of time before being added to the official waiting list, and this phenomenon is called the “hidden waitlist.” Despite AMA’s advocacy, this hidden list is still not being published, which leads to a lack of transparency of public healthcare data. Overall, the data reported by AMA shows that Australian public hospitals experience an increase in waiting times in EDs and elective surgery, and this increase is caused by factors other than COVID-19.
Long waiting times have negative consequences for patient outcomes and quality of life. They can lead to prolonged suffering from illnesses and disabilities (Tsui and Fong, 2018). Recent studies have cited the consequences of long waiting times for elective surgeries aimed at treating such prevalent health conditions as a cataract and total joint replacement. Huang-Lung et al. (2021) explored the costs of hidden waitlists for patients waiting for cataract surgery in Australia. They found that, in such patients, long waiting times could lead to an increased risk of falls and fall-related injuries, a loss of driver’s license, social isolation, and aggravated depressive symptoms (Huang-Lung et al., 2021). Tsui and Fong (2018) researched the factors contributing to long waiting times in patients in need of total joint replacement. The scholars revealed that, in such individuals, prolonged waiting times could lead to worsening pain and fatigue, a loss of self-confidence, and negatively affected social relationships. In addition, the effectiveness of surgery after waiting for it for a long time could be decreased (Tsui and Fong, 2018). Given the adverse effects of long waiting times on patient health outcomes, it is crucial to develop and implement policies to address this issue.
Research reveals multiple policy options intended to reduce waiting times in public hospitals. A review conducted by Bachelet, Goyenechea, and Carrasco (2019) showed that four common options were increased funding, restructuring the referral process, strategies of score-based prioritization, and inducing private health insurance. However, the researchers also revealed that all the policies were highly dependent on the country context, which means that there was no general policy that could be applied to any setting (Bachelet, Goyenechea, and Carrasco, 2019). This evidence emphasizes the need for investigating country-specific factors leading to long waiting lists to craft policies applicable to the context of the Australian healthcare system.
As was identified during the literature review, the issue of long waiting times in Australia has been researched only from patients’ perspective. The study conducted by Ward et al. (2017) aimed to explore patients’ experiences while waiting for treatment in EDs and for elective surgery and specialist appointments. Researchers also attempted to reveal the implications of these experiences for public trust in hospitals and healthcare professionals. The results showed that waiting times in public hospitals were longer than in private hospitals, but patients perceived this phenomenon as unavoidable (Ward et al., 2017). Although patients may not like waiting for surgery for a long time, they accept it, and their trust in public healthcare is not undermined because they believe hospitals do their best under the conditions of limited resources (Ward et al., 2017). Yet, the findings showed that individuals experienced increased stress and anxiety when long waiting times were concerned with the treatment required by children and older people (Ward et al., 2017). Thus, although long waiting times are accepted by patients to a certain extent, they are still perceived as a problem that needs to be addressed, especially when it comes to treating children and the elderly.
No recent studies that would explore the factors contributing to long waiting times for elective surgery in Australian public hospitals have been found during the literature review. However, one study conducted by Tsui and Fong (2018) in Hong Kong sheds some light on this question. Tsui and Fong (2018) identified five factors leading to long waiting times for elective surgery of total joint replacement: the pattern of the disease, patients’ decisions, resources, the length of hospital stay, and healthcare manpower. In particular, the length of stay can affect waiting times by reducing or increasing the turnover of hospital beds. As for resources, Tsui and Fong (2018) note that not only underfunding leads to long waiting times but also certain patient behaviors, such as non-attendance. When patients do not attend appointments or surgeries, this leads to the underutilization of available healthcare resources. This research shows that factors contributing to long waiting times can be multifaceted, so it is necessary to identify them to ensure that healthcare policies target the right issues.
The rationale for the proposed research project comes from the provided evidence. First, the problem of long waiting times has been present in the Australian healthcare system since 2014-2015, meaning that it stems from certain system inefficiencies rather than the adverse effects of the recent pandemic. Second, evidence shows that prolonged waiting times for elective surgery lead to negative consequences for patients’ physical and mental health. Third, there is no current research that would identify factors leading to increased waiting times in Australian healthcare. This issue has been investigated only from the patients’ perspective, but there is also a need to gain an insight into the problem from the position of healthcare professionals and managers. The findings of the proposed study may contribute to the body of knowledge related to long waiting times in public hospitals and inform healthcare policies aimed at reducing waiting times in the Australian healthcare system.
Aim of the Investigation and the Research Questions
This section will describe the aim and research questions of the proposed research project. According to Thomas and Hodges (2010), the research aim should be broad and general, reflecting the overarching purpose of the investigation, while research questions should be more detailed, uncovering specific topics related to the aim. Based on the provided background, the aim of this proposed project will be to identify factors associated with long waiting times for elective surgery in Australian public hospitals. The factors identified during the research will be further used to provide recommendations to policymakers regarding issues that have to be addressed through healthcare policies to achieve a decrease in waiting times in Australian public hospitals.
The research questions will be based on the study conducted by Tsui and Fong (2018), who identified factors contributing to long waiting times in Hong Kong. These findings will be used as a starting point for this research project because they will allow for discovering whether the same factors are present in Australian public hospitals. However, since Australian public hospitals may experience the influence of factors specific to their country context, an additional question will be added to identify any other factors not mentioned in Tsui and Fong’s (2018) study. Thus, the six research questions will be as follows:
- What is the effect of the types of diseases and disease patterns on waiting times for elective surgery in Australian public hospitals?
- How are patients’ decisions related to waiting times for elective surgery in Australia?
- How does the length of hospital stay influence waiting times for elective surgery in Australia?
- What is the effect of allocation and use of healthcare resources on waiting times in Australian public hospitals?
- How does healthcare manpower affect the waiting times for elective surgery in Australia?
- What are additional factors leading to long waiting times, as revealed by Australian healthcare professionals and managers?
Description of Approach and Application of Systems Perspective
This research will use an interpretivist approach to explore the question of what factors are associated with long waiting times for elective surgery in Australian public hospitals. According to Sarantakos (2013), interpretivism is a qualitative research framework that aims to discover human experiences of specific social phenomena. However, the key purpose of an interpretivist approach is not to simply find people’s experiences but to interpret them in order to understand their meanings (Punch, 2016; Sarantakos, 2013). Applying this method to the proposed research project may help identify the challenges experienced by healthcare professionals and managers when managing hospital waitlists. In addition, this approach will help contribute to the existing body of knowledge by exploring factors associated with long waiting times from the perspective of healthcare professionals and managers.
The interpretivist approach will be informed by a systems perspective on health policy research. According to Gilson (2012), a systems approach aims to understand how societies are organized in an attempt to achieve common health goals and how various actors interact in pursuit of attaining policy outcomes. In other words, a systems perspective is focused on different stakeholders’ contributions to the development and implementation of healthcare policies. In the presented issue of long waiting times, the key stakeholders are patients and their families, healthcare professionals and managers, the government, and insurance companies. Patients and their families suffer from the physical and mental consequences of prolonged waiting times. Healthcare professionals are responsible for performing elective surgeries within the recommended period of time. Healthcare managers feel pressure to reduce waitlists under the conditions of increased demand. Insurance companies affect whether patients can afford elective surgery. Finally, the government is responsible for allocating funds and developing policies to address issues in the healthcare system.
Among the mentioned stakeholders, the proposed research aims to discover healthcare professionals’ and managers’ perspectives on the problem of long waiting times. First, this is because this issue has already been explored from the patients’ perspective but has not been investigated from the viewpoint of healthcare professionals. Second, healthcare workers and managers are key actors responsible for implementing healthcare policies in practice. Therefore, the challenges experienced by them when managing waitlists for elective surgery should be understood and included in respective policies. Finally, the interpretivist approach to this research project will allow for identifying how different system factors such as resource allocation, length of hospital stay, and patient decisions affect the management of waitlists in Australian public hospitals. Taking a systems perspective to policy research is important because it enables researchers to discover how different actors interact within a healthcare system and influence the performance of this system (Gilson, 2012). In this regard, the importance of the proposed research is that it may shed light on how healthcare professionals and managers influence the performance of the healthcare system in terms of waiting times for elective surgery and what they identify as challenges on the path toward better performance.
The proposed research project will utilize a qualitative research method. The data will be collected through in-depth interviews with healthcare professionals and managers in Australian public hospitals. Semi-structured interviews will be employed because they enable researchers to keep respondents on the topic and ask open-ended questions to gain a deep insight into the research question. Since the proposed project aims to identify factors associated with long waiting times for elective surgery from the perspective of healthcare professionals and managers, semi-structured in-depth interviews seem to be a justified method. They will allow for discovering experiences and challenges of key stakeholders directly involved in the implementation of policies targeted at managing waitlists. The interviews will take place at public hospitals, and each interview will be recorded and transcribed. Convenience sampling will be used to recruit participants, and a total number of 10 respondents selected among healthcare professionals and managers will be used in interviews. After qualitative data is collected, interview transcripts will be analyzed using thematic content analysis to identify common themes related to factors associated with long waiting times in Australian public hospitals.
The theoretical framework on which the research will be based includes the queueing theory, which is generally applied when studying waiting times in hospitals. According to this theory, patients enter the healthcare system at a rate not depending on the system’s state (Osundina and Opeke, 2017). Further, they wait in a queue because the facility is temporarily engaged. The order in which patients are served usually depends on the priority system applied in the facility (Osundina and Opeke, 2017). The priority in which patients receive treatment may influence their waiting times as lower-priority patients may wait longer. This framework also considers how many service providers are available for patients, what is the capacity of the system, and how patients leave the system after services have been provided.
Project Feasibility and Limitations
The project is planned to be completed over six months, with data collection, analysis, and reporting being allocated two months each. In order to ensure that the research meets ethical standards, respondents will be informed about the purpose of the research, and informed consent will be obtained from each of them before conducting interviews. The proposed study will have some limitations that should be considered when analyzing data. First, since the qualitative method has been selected, the results of the study will not be generalizable to the larger population. The choice of convenience sampling leads to the same limitation as it does not involve randomization. Finally, in-depth interviews rely on self-reporting, which may lead to subjective or incorrect information.
Australian Medical Association (2021) Public hospital report card 2021.
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Gilson, L. (2012) Health policy and systems research: a methodology reader. Geneva: World Health Organization.
Huang-Lung, J. et al. (2021) ‘The true cost of hidden waiting times for cataract surgery in Australia’, Public Health Research & Practice, advance online publication. doi: 10.17061/phrp31342116
Osundina, K.S. and Opeke, R.O. (2017) ‘Patients’ waiting time: indices for measuring hospital effectiveness’, International Journal of Advanced Academic Research, 3(10), pp. 1-18.
Punch, K.F. (2016) Developing effective research proposals. Los Angeles: Sage.
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Tsui, Y. and Fong, B.Y.F. (2018) ‘Waiting time in public hospitals: case study of total joint replacement in Hong Kong’, Public Administration and Policy, 21(2), pp. 1727-2645. doi: 10.1108/PAP-10-2018-009
Ward, P.R. et al. (2017) ‘‘Waiting for’ and ‘waiting in’ public and private hospitals: a qualitative study of patient trust in South Australia’, BMC Health Services Research, 17(333), pp. 1-11. doi: 10.1186/s12913-017-2281-5