Waiting Times for Health Services

3. The impact of waiting times on access and health outcomes

A body of evidence shows that long waiting times can have negative effects on access to care and health outcomes for patients.

3.1. Waiting times can be an important source on unmet care needs in some countries

One possible consequence of waiting times is that they can prevent patients from receiving the care they need, and thus contribute to unmet needs. A European-wide survey (EU-SILC) shows that only a relatively small share of people report unmet care needs due to health system reasons in most countries. The share varies from less than 1% in Austria, the Czech Republic, Germany, Luxembourg, the Netherlands, Spain, Switzerland and Hungary, to over 10% in Estonia in 2018. It reached 5% to 10% of the population in Greece and Latvia (Figure 3.1). However, among people reporting unmet needs for health system reasons, waiting times is the main reason given in nearly 50% of cases on average across these European countries, followed by financial reasons. In Nordic countries, Slovenia, the United Kingdom, Estonia, Lithuania, Poland, the Slovak Republic and Ireland, most people who report unmet needs cite waiting times as the main reason (Figure 3.2).1

Figure 3.1. Unmet care needs related to the health system are generally low in Europe

% of population with unmet care needs due to the health system

Source: European Union Statistics on Income and Living Conditions (EU-SILC) 2018 or latest year.

Figure 3.2. Waiting times are the main source of unmet care needs in several countries

% of health system unmet care needs due to waiting times and other reasons

Source: European Union Statistics on Income and Living Conditions (EU-SILC) 2018 or latest year.

3.2. Waiting times may result in inequalities in access

While access to care is supposed to be based on need and not ability to pay in publicly-funded health systems, there is evidence of a certain degree of inequalities in waiting times by socio-economic status in many OECD countries.

Using large administrative data, inequalities have been found across several elective procedures, such as cataract surgery, hip and knee replacement, and coronary bypass, in many countries, including Australia (Johar et al., 2013[7]; Sharma, Siciliani and Harris, 2013[8]), England (Laudicella, Siciliani and Cookson, 2012[9]; Moscelli et al., 2018[10]), Norway (Monstad, Engesaeter and Espehaug, 2014[11]; Kaarboe and Carlsen, 2014[12]) and Sweden (Tinghög et al., 2014[13]; Smirthwaite et al., 2016[14]). Possible explanations for these inequalities include that individuals with higher socio-economic status live in neighbourhoods with higher availability of health care providers, translating into easier access. They may also exercise more patient choice in looking for providers with shorter waits, engage more actively with the system and exercise pressure when experiencing long delays, and have better social networks (“know someone”).2

There is also evidence of socio-economic inequalities in waiting times from survey data. Using the Survey of Health, Ageing and Retirement in Europe (SHARE), Siciliani and Verzulli (2009[15]) provided evidence of socio-economic inequalities for specialist consultation in Spain, Italy and France, and for elective surgery in Denmark, the Netherlands and Sweden. Using survey data from Spain, Abásolo, Negrín-Hernández and Pinilla (2014[16]) found that people with higher income have shorter waiting times for diagnosis visits in publicly-funded systems, and that patients with lower level of education wait longer relative to those with higher educational attainments. Using survey data from Italy, Landi, Ivaldi and Testi (2018[17]) found that low education and income are associated with a higher risk of experiencing long waiting times for diagnostic and specialist visits.

3.3. Waiting times may worsen health outcomes

Beyond concerns about inequalities, another concern with rationing through waiting times is that the wait may worsen health outcomes for patients before and after the intervention. The evidence shows that this depends on the duration of the wait, the health problem (whether or not physical or mental health is likely to deteriorate quickly), and the ability of clinicians to prioritise.

A review of the literature for coronary bypass suggests that long waits may worsen symptoms and clinical outcomes following the operation (Sobolev and Fradet, 2008[18]). Waiting may also increase the probability of pre-operative death (while waiting) and unplanned emergency admission (Sobolev and Fradet, 2008[18]; Sobolev et al., 2012[19]). However, Moscelli, Siciliani and Tonei (2016[20]) did not find any evidence in England that waiting times for elective coronary bypass was associated with higher in-hospital mortality and only a weak association between waiting times and emergency readmission following a surgery.

Nikolova, Harrison and Sutton (2016[21]) found that long waits for patients in England on the waiting lists for common elective procedures reduce their health-related quality of life for hip and knee replacement while they are waiting, but not for other interventions such as varicose veins and inguinal hernia.

A review of the literature for mental health services found some evidence showing that shorter waiting times can have a positive effect on outcomes. Early access to services for some conditions, such as psychosis, has been shown to have a strong therapeutic benefit (Bird et al., 2010[22]; Reichert and Jacobs, 2018[23]). Similar impacts have been observed for children and adolescents seeking mental health services, where longer wait times can contribute to a higher rate of ‘no shows’, greater likelihood of disengaging from services during the therapeutic process, and possible worsening of the condition (Schraeder and Reid, 2015[24]; Westin, Barksdale and Stephan, 2014[25]; Kowalewski, McLennan and McGrath, 2011[26]).

Reducing psychiatric waiting times could also lead to efficiency gains and cost savings. A study in Los Angeles in a community mental health centre serving 30 000 people found that more rapid access to psychiatric services had positive impacts including ‘no shows’ to appointments falling by more than half – estimated to have led to cost savings of USD 44 000 in psychiatrist time – and reduced crisis hospitalisations (Williams, Latta and Conversano, 2008[27]). Where waiting for treatment is associated with deterioration in the person’s condition, there may be other economic costs, for example if the patient has poorer outcomes from treatment after having waited an extended period (Reichert and Jacobs, 2018[23]), or if their worsened condition prevents them from working (OECD, 2012[28]; Royal College of Psychiatrists, 2018[29]).

People seeking mental health support have also reported distress at long waiting lists for services, and being unable to access care in a timely way (Government Inquiry into Mental Health and Addiction, 2018[30]; Biringer et al., 2015[31]).

Notes

← 1.  Results from another European-wide survey carried out in 2014 (the European Health Interview Survey, EHIS) show greater levels of people reporting delay in getting an appointment for health care due to waiting times, ranging from about 4% of respondents in Norway to about 30% in Luxembourg. Part of the reason for these higher rates are that these survey results exclude those people who didn’t have any health care needs (OECD, 2019[55]).

← 2.  The study on coronary bypass by Moscelli et al. (2018[10]) also shows that inequalities are more pronounced when waiting times are long (e.g. above 150 days) but reduce proportionally (or more than proportionally) when waiting times reduce to shorter levels (60 days on average). This suggests that when waiting times are shorter, individuals with higher socio-economic status feel less pressured to identify mechanisms to avoid waiting.